Our Lady of Fatima University - Valenzuela Campus College of Nursing
Our Lady of Fatima University - Valenzuela Campus College of Nursing
Our Lady of Fatima University - Valenzuela Campus College of Nursing
COLLEGE OF NURSING
Presented by:
BSN 3Y2 – 5
Group 3
SPECIFIC OBJECTIVES:
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
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
Nationality: Filipino
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.
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.
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.
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.
IV
Skin: Rash.
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
IMPRESSION:
Cholethiasis
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.
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
Etoricoxib To treat
120g p.o. B.I.D. pain and
inflammation
- 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.
Dependent:
2. Administere
d
medications
as
prescribed:
Medication
• 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.
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.
• 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 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
• Encouraged the client to pray and have time to communicate with God.