Our Lady of Fatima University - Valenzuela Campus College of Nursing

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OUR LADY OF FATIMA UNIVERSITY -VALENZUELA CAMPUS

COLLEGE OF NURSING

“Case Study: Cholecystitis/Cholelithiasis Disease”

A Drug Study Submitted to the Faculty of College of Nursing

Our Lady of Fatima University

Valenzuela City Campus

In Partial Fulfilment of the Requirements in NCMA 316

Related Learning Experience

For the Degree of Bachelor of Science in Nursing

Presented by:

BSN 3Y2 – 5

Group 3

Leader: Roque, Khristine Mae


Members:
Baya, Jeremiah
Calderon, Monique
Casillano, Honeywell
Encila, Reginald
Rodriguez, Christine Mae
Tajonera, Ingrid
Tuazon, Cathy
GENERAL OBJECTIVE:
This case study aims to obtain additional information about Cholecystitis and Cholelithiasis. This
will serve a comprehensive clinical case study and will be providing precise nursing procedures and
proper responsibilities. This study is designed to recognize medical principles that are related to the said
case.

SPECIFIC OBJECTIVES:

 This study aims to formulate a comprehensible background and epidemiology about


Cholecystitis/Cholelithiasis.

 This will also discuss the patient’s background, family history and medical history that may be vital
to the condition

 To determine the signs and symptoms, predisposing factors and precipitation factors that contribute to
the present illness of the client.

 To present the laboratory and diagnostic results ordered to the patient and formulate a propriate
nursing interventions

 To deliver an effective and appropriate nursing diagnosis regarding the patient’s condition and give a
corresponding nursing care plan

 To make various nursing interventions for the general care of the patient

 To classify the different medications prescribed to the patient for treating his condition

 To provide a discharge planning to patient with Cholecystitis/Cholelithiasis


I. INTRODUCTION
Cholecystitis is an inflammation of the gallbladder. The gallbladder is a small, pear-shaped organ
located on the right side of your abdomen, underneath the liver. This could be acute or chronic that causes
pain, tenderness, and rigidity of the upper right abdomen and a possibility to radiate to the midsternal
area/ right shoulder. This can also be accompanied with nausea, vomiting, and signs of inflammation.
The gallbladder holds a digestive fluid called bile that is to be released into small intestine.
|In most cases (90%), gallbladder stone obstructs bile outflow in a calculous cholecystitis. If the
bile stays in the gallbladder, it will initiate a chemical reaction. Autolysis and edema will occur, the blood
vessels in the gallbladder are now compressed, compromising its vascular supply. Perforation of the
gallbladder with gangrene may occur. Bacteria also contributes in having cholecystitis, this involves
organisms that are generally enteric or organisms that typically live in the GI tract and include
Escherichia coli, Klebsiella species, and Streptococcus.
Acalculous cholecystitis is the inflammation of the gallbladder without the obstruction by the
presence gallstones (10% ) of the case. Usually occurs after major surgical procedures or severe trauma.
Bile stasis and increased viscosity of the bile are also thought to play a role. The occurrence of acalculous
cholecystitis with major surgical procedures or trauma makes its diagnosis difficult.
Signs and symptoms of cholecystitis may include:
• Severe pain in the RUQ
• Pain that radiates to the right shoulder and back
• Tenderness of the abdomen when touched
• Nausea
• Vomiting
• Fever
Cholecystitis signs and symptoms usually arise after a meal, mostly a large or fatty one.

EPIDEMIOLOGY
Gallbladder disease occurs in both men and women. The risk of gallbladder disease increases in
women, obese people, pregnant women, and patients in their 40s. Cholecystitis happens to 3–10% of
cases of abdominal pain worldwide.
II. PATIENT’S PROFILE

Name: A.B.C

Gender: Male

Age: 50 years’ old

Birth date: August 15, 1971

Birth place: Tarlac

Civil Status: Single

Address: Pasay City

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: College Graduate

Date of Consultation: Feb 21,2021

Time of Consultation: 7:00 AM

Admitting Diagnosis: Cholecystitis R/O Cholelithiasis

Chief Complaint: Abdominal Pain w/ yellowish discoloration of the skin

III. COURSE IN THE WARD


Day 1:
Patient A.B.C. was admitted February 21, 2021 at East Avenue Medical Center at 7:00 am, with a
chief complaint of feeling bloated, nausea and vomiting, fever of 39.4, abdominal pain of 7/10, with
jaundice and skin pruritus; vital signs are BP 150/90 mmHg, T-39.4 c, PR 98 bpm RR 20 cpm Then,
hooked to D5PLR 1L at 120 cc/hr while an order for HBT Ultz, ERCP, CBC with platelet count, PT PTT,
Urinalysis, CXR, Lipid Profile, FBS, Bilirubin, Na and K. Hgt every 6 hours 6-12-6-12. NPO temporarily
and resume diet after surgery to clear liquid diet to low fat, diabetic diet. Medications are given: Ciprobay
200mg TIV 30 mins prior to OR (ANST), Vitamin K injection prior OR. Piperacillin tazobactam (Zosyn)
4.5 g IV q8h, Omeprazole 40 mg TIV OD 8am, Kalium durule 2 tabs then 1 tab TID 8am, KCl 40 meqs
incorporated to present IV, Ketorolac 30g TIV q 8 hours x 2 doses, Etoricoxib 120g p.o. B.I.D. Patient is
strictly monitors Vital signs: Every 4 hours and watches out for any signs of bleeding and infection.

Day 2:

At exactly 7:00am, the nurse recorded the vital sign of the patient who received the medications. Post-
op care includes semi-fowler’s position, IVF, pain monitoring, diet of low fat for, ambulation after 24
hours post op.

IV. ANATOMY & PHYSIOLOGY

The gallbladder is a pear-shaped organ that stores about 50 ml of the bile produced by the liver until the
body needs it for digestion. It is about 7–10cm long in humans and is dark green in color.

 It is located in the right side of the body beneath


the liver.

 Store’s bile that digests fats and vehicle for


bilirubin to exit our body to stool.
Liver creates or produced the bile
Liver and gallbladder work together for the bile.

When food goes down to stomach


It became chyme, when it lives stomach
Chyme passes to duodenum and it have a duct that senses
fats in chyme
When gallbladder senses the fats it contracts
Which results in releasing bile down to cystic duct
common bile duct down to duodenum to assist
digesting fats.
V. PATHOPHYSIOLOGY
VI. GORDONS FUNCTIONAL PATTERN
Predisposing
PrecipitatingRightFactors
sided
Factors
Endolymph Chamber Periylmph hearing loss
Chamber
AgeWhirling Sensation
Smoking
Stress (+) Family History
Mother side: Migraine
Excess intake of salt in diet.
Before admission During Admission
1. Health Perception/ He claimed she doesn’t get sick The patient knows the risk of
Health Management often. Every time he had a fever taking over the counter
and disturbance in his stomach, medications and the importance
he self-medicated with of consultation. He did not
paracetamol, Kremil S and smoke and drink alcohol during
Buscopan and no consult was hospitalization. The patient is
done. As an additional self- taking/receiving the following
treatment for the pain, he medications as prescribed by the
frequently ate lugaw. He also doctor: Ciprobay 200mg TIV 30
had a complete immunization mins prior to OR (ANST),
when he was a child. He Vitamin K injection prior OR.
claimed that he drinks alcohol, Piperacillin tazobactam (Zosyn)
smoke 1 stick of cigarette every 4.5 g IV q8h, Omeprazole 40
after meal and denied using mg TIV OD 8am, Kalium
drugs. durule 2 tabs then 1 tab TID
8am, KCl 40 meqs incorporated
to present IV, Ketorolac 30g
TIV q 8 hours x 2 doses,
Etoricoxib 120g p.o. B.I.D.
2. Nutritional Metabolic According to the client, he The client ate a nutritious food
usually ate rice, vegetables, and given by the hospital to meet his
meat for breakfast, lunch and nutritional needs and to make
dinner. He also loves to eat fatty him healthier. He also no longer
foods since childhood especially eats fatty foods because fatty
chicken skin, chicharon and foods are not good for his
lechon. condition.
3. Elimination Pattern He claimed that he defecated The patient defecates a light-
once a day with brown and colored stools and passes dark
formed stool. He had not urine.
experienced any difficulties in
defecation and she never used
any laxatives and stool
softeners. She said she urinated
3 times a day with yellow urine
and has no foul smell. He did
not experience any
difficulties in voiding.
4. Activity Exercised According to his history of past The patient is performing
illness, he does exercise such as passive ROM exercises.
walking and running.
5. Cognitive- Perceptual According to the patient, he The patient is oriented in time
does not have any problems in place and person.
hearing, sight, and as well as in
memory.
6. Sleep and Rest She always goes to bed around The patient usually sleeps
11 in the evening and she often anytime of the day but mostly
wakes up at 6 in the morning to awake due to pain in the
get ready to go to work by 8 am stomach. The patient sleeps an
average of 8 hours per day.
7. Self-perception/ Self She often socialized with her She socializes with her friends
concept friends after work and if there is when they are visiting on the
an occasion. hospital, and he often talks to
his family. She believes that she
can recover from her illness.
8. Role- Relationship The patient is living in her The patient is confined in the
permanent address in Pasay city. hospital due to his condition and
She has good relationships with stomach pain. She has good
his family and neighbors. relationships with his family, to
the doctors, and nurses.
9. Sexually- Reproductive The patient is not active when it The patient is not engaged in
comes to sexual interactions. any sexual activity.
10. Coping tolerance/ Stress The patient’s coping tolerance is The patients coping tolerance is
tolerance sometimes taking 1 stick of to sleep and rest to forget
cigarette a day or whenever slightly the pain and stress she
stressed. experiences. She said she
sometimes interacts with her
family if she feels stress.
11. Value/ Belief The patient is always praying The patient always brings his
before sleeping and after waking bible with a rosary in the side of
up, she usually attends the her bed.
Sunday mass with the family.

VII. PHYSICAL ASSESSMENT:

Head ● No lesions are present in the patient


● Normocephalic
● Headache (7/10)

Eyes ● Pupils are equally round and reactive to


light and accommodation
● pallor palpebral conjunctiva
● Yellowish discoloration in the sclera

Mouth, Throat and Neck ● Lips are dry


● Tongue is at the midline and pale in color

Chest ● Symmetrical chest expansion


● No retraction
● No difficulty of breathing noted

Heart ● Increase heart rate due to fever.

Abdomen ● Abdominal distention


● Abdominal tenderness in the right upper
abdominal quadrant
● Rebound tenderness (positive Blumberg
sign)
● A palpable abdominal mass in the right
upper abdominal quadrant (positive
Courvoisier's sign)
● Guarding may be present
● (+) abdominal pain (7/10)

Skin ● Hot to touch (fever)


● Yellow discoloration of the skin
● Skin pruritus
● Skin is dry

VIII. DRUG STUDY

Drugs Mechanism Indications Contraindications Side effects Nursing


of action and Rationale Responsibilities

Generic Name: Synthetic Use to treat - Hypersensitivity to No side • Monitor urine pH;
quinolone serious ciprofloxacin or effects seen it should be less than
Ciprofloxacin that is a bacterial other quinolones nor 6.8, especially in the
Hydrochloride broad- infection experienced older adult and
spectrum -Syphilis by the patients receiving
Brand Name: bactericidal Rationale: patient. high dosages of
agent. Given to patient -Viral infection These are ciprofloxacin, to
Cipro bay Inhibits because of potential side reduce the risk of
DNA- Cholecystitis -Tendon effects. crystalluria.
Classification: gyrase, an R/O inflammation or
enzyme cholelithiasis tendon pain GI: • Monitor I&O ratio
Anti-infective necessary that leads to and patterns: Patients
for bacterial infection - Myasthenia gravis Nausea, should be well
Dosage DNA evidenced by vomiting, hydrated; assess for
replication fever of 39.4 -Atrial Fibrillation diarrhea, S&S of crystalluria
200mg and some and WBC of 15 cramps.
aspects of 000/mm3 -Uncorrected
Frequency: transcription hypokalemia CNS: • Educate patient to
, repair, Headache, report any tendon
30 minutes prior to recombinati vertigo, inflammation and
OR (ANST) on, and malaise, pain. The drug
transpositio seizures should be
Route: n (especially discontinued
with rapid IV
TIV infusion). • Report nausea,
diarrhea, vomiting,
Skin: and abdominal pain
Rash, or discomfort.
phlebitis,
pain,
burning,
pruritus, and
erythema at
infusion site.

Drugs Mechanism of Indications Contraindications Side effects Nursing


action and Responsibilities
Rationale

Generic Name; New carbanion Used to - Contraindicated No side effects •Monitor patient
model that treat and to patient seen nor constantly. Severe
Phytonadione mimics the prevent low hypersensitivity to experienced by reactions,
(Vitamin K) proton levels of vitamin K the patient. including fatalities,
abstraction from certain These are have occurred
Brand Name; the gamma substances - Severe liver potential side during and
position of (blood disease effects. immediately after
Mephyton protein-bound clotting IV injection
glutamate. factors) GI:
Classification This is the that your Gastric upset. •Monitor Lab tests:
essential step body Baseline and
Vitamin leading to naturally Metabolic: frequent PT/INR.
carboxylation produces. Hype
Dosage: and activation These rbilirubinemia, •Monitor
of the blood- substances kernicterus. therapeutic
10 mg/ml clotting proteins help your effectiveness
blood to Respiratory: which is indicated
Frequency: thicken and by shortened PT,
stop Dyspnea and INR, bleeding, and
Immediately prior bleeding sensation of clotting times, as
to OR normally. chest well as decreased
constriction hemorrhagic
Route: Rationale: tendencies.
Given
SubQ because
diet
restriction
and
antibiotic
cause
vitamin K
deficiency
which will
increase
patients
risk for
bleeding
during
surgery.

Drugs Mechanism Indications Contraindication Side effects Nursing


of action and s Responsibilities
Rationale

Generic The beta- Treatment Contraindicated in No side effects •Monitor lab


Name: lactamase of patients seen nor tests: C&S prior
inhibitors are moderate- hypersensitive to experienced by to first dose of
Piperacillin/ recognized as to- severe piperacillin, the patient. the drug; start
Tazobactam substrates for infection tazobactam, These are drug pending
the beta- caused by penicillins, potential side results.
Brand Name: lactamases susceptible cephalosporins, or effects.
produced by organisms beta-lactamase •Monitor
Zosyn bacteria. This inhibitors such as CNS: hematologic
allows the R: Given to clavulanic acid and Headache, status with
Classification: actual beta- patient sulbactam. insomnia, prolonged
Beta- lactams to because of fever. therapy (Hct and
lactamase attack the bacterial Hgb, CBC with
inhibitor bacterial cell proliferation GI: differential and
wall by due to Diarrhea, platelet count).
Dosage: binding to obstruction constipation,
penicillin of stones in nausea, •Monitor patient
4.5 g binding the duct vomiting, carefully during
proteins dyspepsia the first 30 min
Frequency: after initiation of
Skin: the infusion for
q8h (8am- Rash, pruritus, signs of
4pm- 12am) hypersensitivit hypersensitivity
y reactions.
Route:

IV

Drugs Mechanism Indications Contraindication Side effects Nursing


of action and s Responsibilities
Rationale

Generic An anti- Given to Contraindicated in No side •Monitor urinalysis


Name: secretory patient patients effects seen for hematuria and
compound because of hypersensitive to nor proteinuria.
Omeprazole that is a acid reflux omeprazole experienced
gastric acid cause by by the
Brand Name: pump chronic Hypocalcemia patient. •Report severe
inhibitor. gallbladder These are diarrhea; drug may
Losec Suppresses disease/ re potential need to be
gastric acid attack of side effects. discontinued.
Classification: secretion by acute
Proton pump inhibiting the cholecystitis CNS:
inhibitor H+, K+- (Bloating, Headache,
ATPase nausea and dizziness,
Dosage: enzyme vomiting). fatigue.
system in the
40mg parietal cells R: To relieve GI:
vomiting Diarrhea,
Frequency: abdominal
pain,
OD nausea,
mild
Route: transient
increases in
TIV liver
function
tests.

Skin: Rash.

Drugs Mechanism Indications Contraindica Side effects Nursing


of action and tions Responsibilities
Rationale

•Monitor for and


Generic Name: Potassium Potassium Contraindicat No adverse report signs of
chloride is chloride is ed in patients effects seen on symptoms of nausea
Potassium used to used to patients.
hypersensitive and vomiting
Chloride prevent or to prevent or to to potassium
treat treat low chloride and -Weakness •Monitor I&O ratio
Brand Name:
low blood levels of its -Hypotension and pattern in
Kalium Durule levels of potassium
components patients receiving
potassium -Nausea
the parenteral drug.
(hypokalemia Rationale:
) -Vomiting If oliguria occurs,
Potassium
Pharmacologic -Hyperkalemia stop infusion
Chloride
class: -Abdominal promptly and notify
given to the
discomfort physician.
Potassium salts patient to
prevent
Dosage: hypokalemia
2 tabs now then 1 because
tab Cholecystitis
increase
Route: potassium
loss through
P.O
that vomiting
Frequency: that causes
potassium
TID 8am 1pm
6pm
Drugs Mechanism Indications Contraindica Side effects Nursing
of action and tions Responsibilities
Rationale
Generic Name: May inhibit Use the Contraindicat No adverse •Monitor BP
prostaglandin lowest ed in patients effects seen on frequently before
Ketorolac effective
synthesis to with patients. allowing patient to
Tromethamine dose for the
produce anti- previously ambulate
shortest -Headache
Brand Name: inflammatory demonstrated
, analgesics duration hypersensitivi •Keep the patient
Toradol consistent -Edema supine while patient
and ty to ketorolac -Hypertension
with is receiving IV
Therapeutic antipyretic tromethamine
individual therapy.
class: effects. patient . -Nasal
treatment discomfort •Monitor glucose
NSAID goals. level closely
-Rhinitis
Pharmacologic because beta
R:
class: -Throat blockers may mask
Ketorolac irritation certain sign and
NSAID
was given to symptoms of
Dosage: patient to hypoglycemia
stop the
30g body's
Route: production of
a substance
Oral that causes
pain, fever,
Frequency:
and
TIV q 8 hours x 2 inflammation
doses

Drugs Mechanism Indications Contraindications Side Nursing


of action and effects Responsibilities
Rationale

Generic Name: Like any Short-term Contraindicated in No Assess client for


Arcoxia other COX-2 treatment of patients with: adverse history of allergic
selective moderate Hypersensitivity to effects reaction to arcoxia
Brand Name: any component of
inhibitor pain. seen on or for previous
Etoricoxib Etoricoxib this product. patients. heart failure, heart
selectively -Congestive heart attack, bypass
Classification: inhibits failure (NYHA II- surgery, angina,
Rationale: IV). -Stomach
NSAID isoform 2 of peripheral arterial
To relieve ache
cyclooxygena disease, or transient
abdominal -Patients with
Dosage: se enzyme -Diarrhea ischemic attack.
hypertension whose
(COX-2), pain.
120g blood pressure has -Monitor blood
preventing -
not been adequately pressure regularly
production of Constipati
Route: controlled. while taking this
prostaglandin Pregnancy. on,
P.O medication.
s (PGs) from -
Frequency: arachidonic Headache -Take medication
acid. with a glass of
B.I.D. to start at -Feeling water to avoid
6am tomorrow x 4 tired or dehydration.
doses dizzy,
-Arcoxia may be
- taken regardless of
Palpitatio food intake.
ns and
increased -Stop the
blood medication
pressure. immediately if
gastrointestinal
lesions occur.

IX. DIANOSTICS AND LABORATORY EXAMS

ULTRASOUND HBT
RESULT:
The gallbladder is larger in size measuring around 12cm x 5cm. Wall is thickened (>3 mm). There are
intraluminal echoes seen (gall bladder stones) the largest measuring around 1.02 cm.
IMPRESSION:
Gallstones (more than 5) with cholecystitis

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY


RESULT:

IMPRESSION:
Cholethiasis

COMPLETE BLOOD COUNT


REFERENCE RESULT INTERPRETATION
VALUE
RBC 4.2 – 5.4 million/ uL 4.2 million/ uL Normal
Hgb 12-16 g/dl 14 g/dl Normal
Hct 37- 47% 40% Normal
WBC 5,000 - 10,000 uL 18000 uL Increased due to
presence of
inflammation
Neutrophil 40-60%/L 75% Increased due to
presence of
inflammation
Lymphocyte 20-40%/L 45% Increased due to
presence of
inflammation
Platelet 150,000- 400,000 250,000 mm3 Normal
mm3

URINALYSIS
Reference Value Result Significance
Color Pale yellow-amber Yellow Normal
Clarity Clear to slightly hazy Clear Normal
Specific gravity 1.005-1.030 1.010 Normal
Glucose Negative Negative Normal
Ketones Negative Negative Normal
pH level 5.0- 8.0 6.0 Normal
Protein Negative Negative Normal
Blood Negative Negative Normal
Bilirubin 0 to 0.2 mg/dL 4 mg/dL Increased as bile stasis
triggers release of liver
enzymes along with
serum bilirubin
Urobilinogen 0.2- 1.0 EU/dl 0.2 Normal
Nitrite Negative Negative Normal
Leukocyte Ester Negative Negative Normal

CHEST XRAY
RESULT:

Findings: Both lungs are clear and expanded with no infiltrates. There is no pleural effusion or
pneumothorax. The visualized skeleton is normal. Heart size is normal.

Impression: No active disease

SODIUM BLOOD TEST


Reference Value Result Significance
136.00 - 142.00 mmol/L 130. 00 mmol/L Low this is due to vomiting.

POTASSIUM BLOOD TEST


Reference Value Result Significance
3.80 - 5.00 mmol/L 3. 00 mmol/L Low this is due to vomiting.

LIPID PROFILE
Reference Value Result Significance
Total Cholesterol 150 – 200mg/dL 220 mg/dL High
Triglyceride 30 – 150 mg/dL 190 mg/dL High
HDL – C Less than 50 39 mg/dL Normal
mg/dL
LDL - C less than 100 130 mg/dL High
mg/dL

Reference Value Result Significance


PT 11-13.5 sec 12 sec PT result is within normal
range
26 sec PTT result is within normal
PTT 25- 38 sec
range

FASTING BLOOD SUFAR TEST


Reference Value Result Significance
Less than 100 mg/dL (5.6 160 mg/dL High. Patient is diagnosed with
mmol/L) diabetes mellitus type 2.

X. NURSING CARE PLANS

Assessment Nursing Background Planning Intervention Rationale Evaluation


Diagnosis Knowledge
Subjective: Acute Pain Irritation of Short term: Independent: After 30 mins
related to the Gall of nursing
“Sobrang inflammation bladder wall After 30 mins 1. Observed and 1. Assists in intervention
sakit ng and tissue ↓ of nursing documented location, differentiating cause the patient
tyan ko dito necrosis as Increased Gall intervention severity and character of pain, and
sa bandang evidence by bladder lumen the patient of pain provides Reported that
taas sa narrowed pressure, will: information about pain is
kanan” as focus, reports Decrease disease progression controlled from
of pain 7/10, Report pain is and resolution, 7/10 to 4/10
verbalized blood flow to
autonomic relieved/ development of
by the gall gladder
responses controlled complications and After 8 hrs of
patient. (elevated BP Ischemia, gall from 7/10 to effectiveness of nursing
and Temp) bladder 4/10 interventions intervention
Objective: necrosis, the patient will:
inflammation, After 8 hrs of
Reports of loss of gall nursing 2. Obtained, 2. Serves as a Verbalized
pain 7/10 bladder intervention monitored, and baseline data and methods that
structural the patient recorded the vital serves as a display provide relief
Facial integrity will: signs snapshot of what’s
grimace/ ↓ going inside the Demonstrated
mask of Bacterial Verbalize body the use of
pain invasion and methods that relaxation
transmural provide relief 3. Promoted bed rest 3. Reduces low skills and
Guarding inflammation in low fowler’s intra-abdominal diversional
behaviour of gall bladder Demonstrate position pressure activities as
Irritation of use of indicated for
relaxation individual
Self parietal
skills and 4. Controlled 4. Cool situation.
focusing peritoneum,
diversional environmental surroundings aid in
stimulates activities as temperature minimizing dermal Demonstrated
VS: somatic indicated for discomfort methods that
T- 39. 4 C nerves individual provide relief
BP- 150/90 ↓ situation. 5. Encouraged use of 5. Promotes rest,
mmHg Persistent relaxation techniques. redirects attention, After 7 days of
RUQ Pain Demonstrate Provided diversional and may enhance nursing
methods that activities coping intervention,
provide relief the patient
reports his pain
Long term: 6. Maintained NPO 6. Removes gastric ranges on a
statues, secretions that scale of 1/10
After 7 days inserted/maintained stimulates release of
of nursing NG suction as cholecystokinin and Goal was met.
intervention, indicated gallbladder
the patient contractions
will be free
from pain Dependent:
from 7/10 to
2/10 or no 7. Administered
pain at all medications as
prescribed.
 Ketorolac 30g  To relieve
TIV q 8 hours x 2 pain from
doses gallbladder
distention

 Etoricoxib  To treat
120g p.o. B.I.D. pain and
inflammation

Assessment Nursing Background Planning Intervention Rationale Evaluation


Diagnosis Knowledge

Subjective Deficient Inflammation After 2 hours After 2 hours


data: fluid of the of nursing - Monitored and -Decrease in of nursing
volume gallbladder interventions, document vital signs circulating blood interventions,
“Nagsusuka related ↓ the client will especially BP and volume can cause the client was
ako, to be able to HR. hypotension and able to
madalas vomiting associated with maintain tachycardia. maintained
kaapag as gallstones. adequate fluid adequate fluid
katapos ko evidenced ↓ volume as volume as
kumain” as by poor evidenced by -Commence a fluid -To monitor patient evidenced by
verbalized skin turgor obstruction of moist mucous balance chart, fluid volume moist mucous
by the and dry the bile membranes monitoring the I&O accurately and membranes
patient. skin and outflow and good skin of the patient. effectiveness of and good skin
lips. ↓ turgor action to prevent turgor.
dehydration.
Objective calculous
data: cholelithiasis Therefore, the
↓ - Assessed - Signs of goal was met.
-Dry skin skin/mucous dehydration are also
and lips cholecystitis membrane, peripheral detected through the
-Poor skin r/o pulses, and capillary skin
turgor cholelithiasis refill.
-Vomiting ↓
-
tachycardia The patient’s - Monitored for signs -Continued
manifest and symptoms of vomiting may cause
nausea and increased or dehydration.
vomiting continued nausea or
↓ vomiting
(Risk)
Fluid Deficit
-Performed frequent -To decrease
oral hygiene dryness and of oral
mucous membranes;
reduces risk for oral
bleeding.

-Provided skin and -Skin and mucous


mouth care. membrane are dry,
with decreased
elasticity because of
vasoconstriction and
reduced intracellular
water.

- Eliminated noxious -To reduces


sights or smells from stimulation
environment. of vomiting center.

- Provides
- Increased fluid hydration.
intake. Replacing increased
insensible fluid
losses.

- Provided Drop situations
comfortable where patient can
environment by experience
covering patient with overheating to
light sheets. prevent further
fluid loss.

- Aided the patient if Dehydrated patients


he or she is unable to may be weak and
eat without assistance, unable to meet
and encourage the prescribed intake
family or SO to assist independently.
with feedings, as
necessary.

Dependent:

1. Administere Fluids are


d IV fluids necessary to
as prescribed maintain hydration
status. 
- D5LR 1L x
120cc/hr

2. Administere
d
medications
as
prescribed:

- Omeprazole To relieve vomiting


40 mg TIV
OD 8am

XI. DISCHARGE PLANNING

Medication

• Advised the patient to take the medicines prescribed by the doctor:

 Omeprazole 40 mg TIV OD 8am


 Kalium durule 2 tabs then 1 tab TID
 Etoricoxib 120g p.o. B.I.D

• Told patient to do not wait until the pain is severe before he takes his medicine. Tell caregivers if
his pain does not decrease.

• Educated the patient on how to take his medicine and what medicine and how much he should
take. Advised the patient to be sure to know how, when, and how often to take it.

 The patient can take non-prescription medications to relieve pain, unless his doctor tells him not
to. Acetaminophen and ibuprofen are examples of non-prescription pain medications.

Environment/Exercise
• Maintaining a healthy weight and engaging in physical activity can reduce gallbladder pain and
decrease the amount of gallbladder pain attacks. Usually, the patient has no complications and is
able to resume normal activity within a few weeks.

• Advised patient to do exercises like walking and go up and down stairs. Regular physical activity
can reduce cholesterol levels and help prevent gallstones from forming. Though small, gallstones
can cause serious inflammation, pain, and infection. They can also grow to larger sizes.

• Reinforce pain control and deep-breathing exercises until the incision is completely healed.

Treatment

• Advised patient to keep all appointments with his healthcare provider. His healthcare provider
needs to monitor his condition.

• Practice 10 deep breaths every hour and 2 coughs every hour, (for at least 12 hours a day), while
awake for the first week after surgery to reduce the risk of lung problems or pneumonia. When
coughing, be sure to place a pillow over the incision and gently press inward to reduce the
pressure (from coughing) on your incision.

• Applying heat can be soothing and relieve pain.

Health Teaching

• Told patient to avoid submerging the abdomen in the bathtub for the first 48 hours.

• Explained to the patient the possibility of abdominal and shoulder pain caused by the instillation
of carbon dioxide so that if the pain occurs, he will not experience unnecessary anxiety about a
heart attack.

• Educated the patient to not lift heavy objects (more than 8 pounds) for the first 4 weeks. Also
avoid pushing, pulling or abdominal pressure for these first 4 weeks.

• Following a 3 to 5-day hospital stay for an open cholecystectomy, instructed the patient on the
care of the abdomen wound, including changing the dressing and protection of any drains.
Observation/Out-patient

• Advised the patient to seek care immediately if the following symptoms shows like severe pain in
the abdomen, chest pain or trouble breathing and urinate less than usual.

• Instructed the patient to watch the incisions for signs of infection.

• Contact your healthcare provider if the following occurs; have a fever or chills, have nausea or
vomiting, a decreased appetite, pain when you urinate and if the skin or eyes turn yellow.

Diet

• Encouraged to eat fewer refined carbohydrates and less sugar.

• Encouraged to eat more foods that are high in fiber, such as: fruits, vegetables, beans and peas,
whole grains, including brown rice, oats, and whole wheat bread.

• Encouraged to eat healthy fats, like fish oil and olive oil, to help your gallbladder contract and
empty on a regular basis.

• Instructed to avoid the following foods such as; vegetable oil, peanut oil, refined white foods,
foods high in fat, processed foods. (Foods with trans fats, like those in processed or commercially
baked products, can also be harmful to gallbladder health. Avoiding refined white foods, like
white pastas, breads, and sugars, can protect your gallbladder)

Spiritual

• Advised patients to express feelings to family members.

• Encouraged the client to pray and have time to communicate with God.

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