Beruflich Dokumente
Kultur Dokumente
Case Study
of
CHOLEDOCHOLITHIASIS
Submitted by:
Castanar, Aimelyn C.
Coquia, Benjamin III S.
Cortez, Christian Jay B.
Dumlao, Jennifer M.
Gabriel, Rutzki S.
Justo, Jonalyn V.
Mamucod, Madel S.
Marcos, Shierly Luz D.
Natividad, Manuelito A.
Pasamba, Janine P.
Group B3
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TABLE OF CONTENTS
I. Introduction…………………………………………………………………1
II. Nursing Process……………………………………………………………..3
A. Assessment
1. Personal Data……………………………………………………3
2. History of Past Illness…………………………………………...6
3. History of Present Illness………………………………………..6
4. Physical Assessment
i. 13 Areas of Assessment……………………………………..6
5. Diagnostic and Laboratory Procedures……………………...….17
6. Anatomy and Physiology……………………………………….22
7. Pathophysiology
i. Book Based…………………………………………………24
ii. Client Based………………………………………………...25
B. Planning
1. Nursing Care Plan………………………………………………26
C. Implementation
1. Medical Management…………………………………………...34
2. Drug Study……………………………………………………...38
3. Diet……………………………………………………………...43
4. Activity or Exercise……………………………………………..45
5. Surgical Management…………………………………………...48
6. SOAPIE…………………………………………………………50
D. Evaluation
1. Patient’s Daily Program in the Hospital………………………...57
2. Discharge Planning……………………………………………...58
III. Conclusion…………………………………………………………………..59
IV. Recommendation……………………………………………………………59
V. Bibliography………………………………………………………………...60
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ACKNOWLEDGEMENT
The group would like to thank almighty God for giving us strength and courage to fulfill
this case study.
The group wishes to extend a sincere thank you to the talented Dean of our college, and
level coordinators for being the contributors and reviewers of this case study, who provide many
valuable and very helpful ideas, and suggestions. To our clinical instructor for this case study
Ms. Mylene Romero for her attention to detail that promoted an excellent outcome, and to our
fellow 3rd year students, for their questioning minds and motivation for this case study. And also
the group would like to thank to our parents that serves as our seeking light and reflections, and
for allowing us to pursue this case study and have our overnight for almost a week. And finally,
to our panelist for sharing their knowledge, for us to have a beautiful new designs of our selected
case.
GROUP B3
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I. INTRODUCTION
Choledocholithiasis is the presence of gallstones in the common bile duct. This condition
causes jaundice and liver cell damage, and is a medical emergency, requiring the endoscopic
retrograde cholangiopancreatography (ERCP) procedure or surgical treatment. A tendency for
this disease can be inherited.
Doctors can use a blood test of alkaline phosphatase, bilirubin and cholesterol to diagnose
choledocholithiasis. However, ultrasound demonstrating an enlarged common bile duct is the test
of choice.
Treatment involves removing the stone using ERCP. Typically, the gallbladder is then
removed, an operation called cholecystectomy, to prevent a future occurrence of common bile
duct obstruction.
Gallstones are more common among women after 40 years of age and among certain groups
of people, such as Native Americans. They are uncommon in children and young adults. The risk
factors for gallstone formation include increased age, obesity, a typical Western diet, and a
family history of gallstones.
About 15% of people with gallstones will develop stones in the common bile duct, the small
tube that carries bile from the gallbladder to the intestine. Risk factors include a previous medical
history of gallstones. However, choledocholithiasis can occur in people who have had their
gallbladder removed. (http://www.umm.edu/ency/article/000274.htm)
In the United States, the incidence rate for gallstones is approximately 40% in individuals
older than 60 years. In individuals undergoing cholecystectomy for symptomatic cholelithiasis,
8-15% of patients younger than 60 years have CBD stones, compared to 15-60% of patients
older than 60 years. (http://emedicine.medscape.com/article/172216-overview)
The incidence of cholelithiasis increases after the age of 40 years, affecting 30% to 40% of
the population by the age of 80 years. Four times more women than men develop cholesterol
stones and gallbladder disease; the women are usually older than 40, multiparous, and obese. The
incidence of stone formation rises in users of oral contraceptives, estrogens and clofibrate; these
substances are known to increase biliary cholesterol saturation. The incidence of stone formation
increases with age as a result of increase hepatic secretion of cholesterol and decrease bile acid
synthesis. In addition, there is an increase risk because of malabsorption of bile salts in patients
with gastrointestinal disease or T-tube fistula or in those who have had ileal resection or bypass.
The incidence also increases in people with diabetes. (endnote 11th edition by brunners and
suddarth’s, volume 2)
In the Philippines, there were 131 males (18%) and 609 (82%) females, with a female ratio
male 4.6:1. Benign lesions comprised 99% (mean age 36), mostly chronic cholelithiasis (97%)
and acute cholelithiasis which constituted 15 cases only (2%), malignant lesions comprised only
7 cases for example 1% of all lesions (mean age 65).
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(http://www.thedoctorsdoctor.com/diseases/gallbladder_chronic_cholelithiasis.htm#epidemiolog
y)
As the group go on with our weekly duty at the Tarlac Provincial Hospital, the group
observed a case of choledocholithiasis. So, as nursing students, the group decided to study this
kind of case. The significance of studying this case is to enhance or broaden our knowledge as
well as the patient’s who are suffering this disease and also to those people who are in high risk
of having this disease for us to share our knowledge for the primary prevention and simple
interventions of the disease.
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Objectives:
Comprehensive understanding about the condition will formulate a good perception and
information to both patients and nurse in dealing and exploring such kind of disease. These
objectives will help to attain such benefits in knowledge and skills to identify
Choledocholethiasis.
General
Enhance understanding regarding Choledocholethiasis and together factual data and
current trends in regards to the condition
Specific
Establish rapport with the client thus enhancing communication skills and to be able to
gather pertinent information to the client and significant others.
Know and apply corresponding intervention regards to post-op Choledocholithotomy
surgery.
Evaluate effectiveness of the nursing intervention rendered.
Perform continuous physical assessment in order to gather pertinent information the
disease condition.
A. ASSESSMENT
1. Personal Data
a. Demographic Data:
Name : Mr. D
Age : 51 yrs. Old
Sex : Male
Civil Status : Married
Occupation : Farmer, Construction Worker
Religious Affiliation : Roman Catholic
Role Position in the Family : Head of the family
Address : Ramos, Tarlac
Date & Place of Birth : Toledo Ramos, Tarlac
Nationality : Filipino
Usual Source of Medical Care : none
Chief Complaint : Abdominal Pain
Diagnosis : choledocholithiasis secondary to
ruptured gall bladder
Date of Admission : February 9, 2009
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b. Environmental status
According to Mr. D, they regularly clean their own house that is bungalow and
made of pure concrete. Their house has 3 bedrooms and in the living room they have
appliances television, radio and electric fan. Their house is located near in the farm with their
relatives. Drainage system is open. Source of water is forced pump.
They have pets, dogs and cat that live outside their house.
c. Lifestyle
Mr. D likes planting vegetables in their backyard during his leisure time. He
usually eat foods rich in fats like meats cooked with oil, fried fish, and vegetables. He is fond
of drinking alcohol, and verbalizes that they usually eat “chicharon” as their pulutan. In terms
of rest pattern Mr. D only sleeps for about 7-8 hours every night. Usually he sleeps at 7:00
p.m. and wakes up at 3:00 a.m. He usually drinks coffee every morning and sometimes in
afternoon while having some chat with his friends. At 4:00 AM he’ll eat his breakfast. After
his morning routine he go to work and go home at 6:00 p.m. He spend his day doing his
work.
d. Social Status
. The patient spends his time during weekends with his family and friends by
doing his favorite routine which is planting. The family lives in their own house along with
their relatives. There is no conflict between the family members. Whenever some issues or
problem arises, they handle it by talking about it in a calm and respectful manner.
According to the patient, he is not anymore active in community activities or
project because he doesn’t have any time to join and participate.
e. Psychologic Status
According to the client he often experience fatigue in some of his work. But
concluded that it is just normal because of the type of his work. It was his goal to provide all
the necessary things needed by his family. He believes he will only achieve this goal if he
will look forward and treat his family as his only treasure. And whenever life doesn’t go well
with his plans, he gets a little depressed. He always thinks about his family problems
specifically financial accountabilities.
Whenever he is anxious, he usually had conversations and seeks some advises with
his wife.
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FAMILY HISTORY OF HEALTH AND ILLNESS
N/ N
/ N
LEGEND: A N/
/
A A
A
= Male
= Female
8 7 7 8 7 7 7
= deceased male 0 5 4 2 9 7 5
A&W HPN A&W N/A DM A&W A&W
= deceased female
= the patient
As = Asthma N
N 5 5 4 4 4 4 4 4 4 3
A&W = Alive and well /
B 6 A 1 9 8 6 5 4 3 0 8
C = Choledocholithiasis N/A A&W N/A C A&W DM HPN A&W A&W HPN A&W A
DM = Diabetes Mellitus
HPN = Hypertension
NB = Newborn
N/A = not applicable
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2. History of Past Illness
Mr. D had experienced childhood illnesses such as cough and cold, mumps at the
age of 9 years old, chicken pox when he was 12 years of age. The patient verbalized that he
cannot remember if he completed his immunization during his childhood. It was in the month
of December when he experienced the first onset of pain in his right upper quadrant while he
was eating and concluded that it was just an ulcer. He said that the pain lasted for five
minutes and reoccur after a minute with the same area, he said he never prompted to seek
medical help. And he said he never take any over the counter drugs to relieve pain. But
instead he only sat or lied until the
pain relieves.
During the two months duration before his hospitalization, the pain still occur
once week, but still the patient can tolerate it until the time when he was eating the pain again
arises in his right upper quadrant and he said that the pain was continues without any interval
that makes him decided to take consultation at Tarlac Provincial Hospital. But when he
arrived, his gallbladder was already ruptured according to his physician. So he was directly
brought to operating room and Cholecystectomy was done.
4. Physical Assessment
13 AREAS OF ASSESSMENT
SOCIAL STATUS
Mr. D is 51 years of age, and was married. They make decision for the family together;
they are a type of nuclear family. According to him, he never experiences any intimate
family violence. They located in a compound area and most of his neighbors are his relatives.
He originally lives at Ramos Tarlac City. He proudly said that he has no conflict with people
around him, although some misunderstanding happened to him, but he tries to solve it in a
good manner like talking to them calmly. When he feels stress, he just takes rest and sleep.
His hobbies are planting vegetables on their backyard, listening to music and sometimes
chatting with his friends and neighbors. He denies any membership of any social
organization; he doesn’t attend any barangay assembly. He is a Roman Catholic, but he
rarely attends holy Mass due to lack of time, he mentioned that he only attends mass twice a
year. He denied drug abuse. He was fond of smoking and drinking alcohol.
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Interpretation
He has a good relationship with family and relatives and also with his neighbors which is
an indication of good social stability. He does his responsibility as a good husband for his
wife and responsible father to his childrens. He is able to cope or handle social conflicts. He
has a good spiritual status. He has lack of interest with regards to the social organization.
Body function can affect by drugs and tobacco because he is fond of using it.
MENTAL STATUS
Mr. D is comfortably positioned flat on bed. He is restless due to pain on his right upper
quadrant abdomen. He can do his activity of daily living but sometimes needs assistance. His
facial expressions are inappropriate with his feelings and mood of conversation. The patient
is sometimes stiff due to pain episodes he experience because of the operation done to him.
He usually moves slowly and carefully with minimal assistance. She wears loose and light
clothing appropriate for his condition. He is not well groomed with uncombed hair and has
clean and trimmed nails and pale in appearance.
• Level of consciousness
Post-operative
After the said operation, Mr. D were able to respond with the questions given to him,
with an appropriate answer, and was able to do eye contact while answering.
• Mood
Post-operative
Upon assessing Mr. D, he cooperates attentively with appropriate mood. He talks with
us calmly with low voice. But he also verbalizes that after he had the operation he was at
times moody and was selective with the topic, and questions to be discussed. The patient also
mentioned that after his operation he easily gets tired and so he was not able to answer some
of our questions at that time.
Mr. D was able to expresses his thoughts and feelings. He is willing to answer our
questions appropriately and sometimes he also asked related questions related on the topics
being discussed to him and share his ideas and experiences in life to the group.
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• Cognitive Abilities
Post-operative
Mr. D shown awareness to about his present condition, about the treatment and surgical
procedure he undergone. He is aware regarding the people around him and the time and place
where he is. He is also able to recall significant events in his life.
Interpretation
Mr. D responds well and can answer appropriately. He is also aware about the time and
the place where he was. Based on the data gathered he possesses the appearance; thought
processes, mood and was conscious at the time of monitoring. He also interacts upon
assessment and interview with appropriate mood. But due to his condition as he undergoes
surgical procedure, his movements were sometimes limited and thus he needs assistance to
attain his needs.
EMOTIONAL STATUS
Post-operative
Mr. D expresses and verbalizes his emotions and feelings during the interview; he seems
uncomfortable because of the pain episodes he feels after the operation. He said that his
stress though he was resting and sleeping. Despite of his condition he still possesses a brave,
relaxed attitude. He approached us in a kind attitude. He is fully supported by his family as
we see that he is cared by his siblings and children. And he also verbalize that he was able to
accept his present condition.
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Interpretation
Mr. D has the ability to manage stress by means of expressing his thoughts and feelings
of willingness to participate in our group. He has positive coping mechanism because he
approached our group in a kind manner. He possess ability to recognized an accept condition.
Therefore his emotional status is in normal state.
SENSORY PERCEPTION
Post-operative
• Sense of Sight
The patient is able to read with the use of his reading glass with a visual acuity of
30/30. His external eyes were symmetrical in shape and size, have no lesion and no bleeding
found. His sclera is yellowish in color whole his conjunction in pinkish. The patient can raise
both eyelids asymmetrically. His pupils are black and round.
• Sense of Smell
The patient’s nose is on the midline, it is symmetrically in shape and the nostrils are
intact. He is able to distinguish different color like alcohol, perfume or cologne and different
scent of fruits provided like orange.
• Sense of Hearing
Our group performed a hearing test in order to check if the patient had a good sense of
hearing by whispering words about 3 inches away from the ear and asked him to repeat the
words that were spoken to him to check if he really hear the words. The patient is able to
answer questions correctly that means his hearing ability is good. No bleeding, wounds, or
lesions are found on his external ear.
• Sense of Taste
Tongue and oral cavities are symmetrical and no lesions or abnormalities were found.
The patient was able to determine taste of salty, sweet, sour, and bitter taste.
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Standard and Norms
Patient should be able to sense the different kind of tastes like sweet, bitter, sour, and salty.
(Health Assessment by Mary Elle Zator Estes,2006)
• Pain Sensation
The patient is able to response with the pain sensation when we pinched his skin. And he was
able to determine if the object is sharp or not and can able to determine if the object is smooth or
rough.
Interpretation
Regarding the patient’s sense of perception, before and after his operation, there is no
problem found except with his sense of sight because he is using reading glasses whenever he
read. It only means that his visual acuity is not in normal. Other than that’s he already possesses
normal perception in other areas.
MOTOR STABILITY
Post-operative
Mr. D cannot tolerate heavy movement. He was moderately weak. He needs assistance when
ambulating and eating. He moves slowly in changing his position when he sleeps and rest.
Over-all Appearance: The patient should be able to stand on the bedside via independent
ambulation. Structural effects should be absent. There should be no outward indications of
discomfort during rest, weight bearing, or joint movement.
Posture: In standing position the torso and head are upright. The arms hang freely from the
shoulders. The feet are aligned and the toes point forward. In sitting position both feet should
be placed firmly on the floor surface, with toes pointing forward.
Gait and Mobility: Walking is initiated in one smooth, rhythmic fashion. The patient should
remain erect and balanced during all stages of gait. (Estes, Mary Elen Zator. (2006),Health
Assessment and Physical Examination (3rd Edition
Interpretation
The patient’s motor stability is not normal because he cannot stand on the bedside, and
independently ambulate himself and needs assistance in doing his ADL.
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BODY TEMPERATURE
Reference:
Estes, Mary Elen Zator. (2006)
Health Assessment and Physical Examination (3rd Edition
RESPIRATORY STATUS
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02-20-2009 10 am 26 cpm Tachypneic
2 pm 30 cpm Tachypneic
4pm 29 cpm Tachypneic
6pm 24 cpm Tachypneic
10 pm 28 cpm Tachypneic
02-21-2009 6 am 24 cpm Tachypneic
10 am 30 cpm Tachypneic
2 pm 33 cpm Tachypneic
02-22-2009 5 am 26 cpm Tachypneic
02-23-2009 5 am 25 cpm Tachypneic
Analysis:
Patient was tachypneic, as a result of his compensatory mechanism of his heart (post op).
CIRCULATORY STATUS
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Standard and Norms
Normal blood pressure varies with age. As a person ages, blood pressure generally
increases. The normal blood pressure of an adult is 120/80 mmHg. Normally baroreceptors
(Receptors that are located in the walls of most of the great arteries that sense hypotension and
initiate reflex vasoconstriction and tachycardia to bring the blood pressure back to normal) help
a patient to maintain a normal blood pressure when changing from supine from a sitting or
standing position. Processes increasing cardiac output, such as exercise, will normally increase
blood pressure. Pulse pressure is normally 30 – 40 mmHg. Normal pulse rate also varies with
age. The normal pulse rate of an adult is 60 – 100 BPM. The heart rate normally increases during
periods of exertion. Normal pulse rhythm is regular with equal intervals between each beat. The
pulse volume is normally the same with each pulse beat. A normal pulse volume can be felt with
a moderate amount of pressure of the fingers and obliterated with greater pressure. Capillary
refill is an indicator of peripheral circulation. Normal capillary refill may also vary with age, but
the color should not return to normal within 2 -3 seconds. (Health Assessment by Mary Elle
Zator Estes)
Analysis:
Based on the standard and norms the patient is hypotensive but he is able to tolerate his
condition as evidenced by not experiencing dizziness and body weakness.
NUTRITIONAL STATUS
The patient weighs 60 kg and 5’7” in height. The patient was on high protein diet. He
was given an IV fluid of D5LRS to maintain fluid and electrolytes balance in his body. He eats
three times a day and take some snacks between the periods of eating hours. And was fond of
eating foods rich in fats such as fried fish, meats cooked with oil.
BMI=weight in kg
Height in m2
=60 kg
(1.7018)2
= __60__
2.89612324
= 20.75
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BMI
<16 malnourished
16-19 underweight
20-25 normal
26-30 overweight
31-40 moderately to severely obese
>40 morbidly obese
Interpretation
With regards to Mr. D’s nutritional status, it appears that he is able to meet her nutritional
needs and can tolerate all type of foods. There are no known problems associated with his
nutrition and any drug or food allergies. He’s weight is suited with the height.
ELIMINATION STATUS
Post-operative
Mr. D verbalizes that he usually urinates 3 times within the shift and it is characterized by
dark yellow in color. He reported absence of defecation for 2 days, but was able to defecate once
daily with clay color stool for the next three days. Also, he verbalizes that he never felt any pain
during urination and defecation. He was also inserted with T-tube, with 250 cc in the first duty
and 230 cc for the next day characterized by coffee ground in color and slimy, without any stain
of blood.
Interpretation
With regards to the patient’s elimination status, it appears that his urine output is in normal
ranges. He experienced constipation in two days and was normally defecated for the next three
days of our monitoring.
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REPRODUCTIVE STATUS
Mr. D has three children. He is happily married to his wife and still enjoying his life with his
family.
Interpretation
The patient is sexually healthy but not as active like on her early age. It because of his
condition and age, his reproductive activities was decreased.
Post-operative
After the said operation, Mr. D was complaining of difficulty in getting sleep. He usually
sleeps for only 5-6 hours and it was not continuous because of the doctor and nurses rounds,
including the onset of pain in his right upper quadrant which has an interval of 10-15 minutes.
Observable signs of inadequate sleep are still seen on the patient such as eyebags, frequent
yawning and sometimes irritable.
Interpretation
In terms of rest and sleep pattern of the patient, it appears that he has a disturbed sleeping
pattern and inadequate sleep before and after the operation due to pain he experienced and
unfamiliarity of the environment. He only have 5-6 hours of sleep at night, this is indicate that
Mr. D sleep pattern is not normal.
The color of his skin is brown. No rashes found in the incision site and reddish in color.There
is no bed sores found. Hairs are well distributed in black color. Nail plate is clear, firm and the
tissue surrounding the nails are intact with no lesion. The skin of the patient is slightly dry and
when you pinched, it takes 2 seconds to turns back to its original state.Some skin damage is
found due to IV insertion, Lab test such as CBC and operation that was done (cholecystectomy).
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Standard and Norms
Normally, the skin is uniform whitish pink or brown color, defending on the patient race.
Exposure to sunlight results increased pigmentation of an exposed area. Normally, there are no
areas of bleeding. No skin lesions should be present except for freckles, birthmarks or moles,
which may be flat or elevated. The skin is dry with minimum of perspiration. Moisture also
varies with changes in environment, muscular activity, and body temp. stress and activity levels.
Skin surface temp. should be warm and equal bilaterally. Skin surface should be non tender. It
should be smooth, even and firm except where there is significant hair growth. When the skin is
released, it should returns to its original contour rapidly. Edema should no be present. Terminal
hair is found in the eyebrows, eyelashes and scalp, and in the axilla and pubic areas after puberty.
Males may experience a certain degree of normal balding and may also develop terminal facial
and chest hair. The scalp should be pale white to pink in light skinned individuals and light
brown in dark skinned individuals. There should be no signs of infestations or lesions. Dandruff
may be present. Hair may feel thin, straight course, thick or curly. It should be shiny and resilient
when traction is applied and should no come out in clumps in your hands. Normally, the nails
have a pink cast in light skinned individuals and are dark brown in dark skinned individuals. It
should be smooth and slightly rounded or flat. Curve nails are normal variant. Nail thickness
should be uniform throughout, with no brittle edges. The angle of the nail bed should be
approximately 160 degrees. It should be firm on palpation. (Health Assessment by Mary Elle
Zator Estes)
Interpretation
The patient has a poor skin turgor. Dryness of the skin was observed and it can be a sign of
dehydration also it may reflects on his age.
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5. Diagnostic and Laboratory Procedures
371g/L 310-360g/L
• MCHC • Increased MCHC value
indicates hemorrhage
272g/L 140-440g/L
• Plt • Within normal values.
20
Diagnostic/ Date Ordered Indications/ Purposes Results Normal Values Analysis and
Laboratory Interpretation
Procedures
Hematology February 17, 2009 The CBC is used for the
• WBC following purposes: 12.0 4.1-10.9 • Increased WBC
•as a preoperative test to indicates
ensure both adequate inflammatory and
oxygen carrying capacity infectious processes
and hemeostasis
•to identify persons who
may have an infection
• Gran •to diagnose anemia 9.0 2.0-7.8 • Increased gran
•to identify acute and (neutrophil)
chronic illness, bleeding indicates acute
tendencies, and white infection or
blood cell disorders such inflammatory
as leukemia processes.
•to monitor treatment for
• RBC anemia and other blood 3.62 4.20-6.30 • Decreased level of
diseases. RBC indicated
hemorrhage.
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• MCHC 372g/L 310-360g/L • Increased MCHC
indicates
hemorrhage
Nursing Responsibilities
Before:
1. Check for the doctor’s order.
2. Discuss the importance of the procedure.
3. Explain to the client how to participate to the procedure.
After:
1. Apply pressure on the site for 5-10 minutes after the procedure.
2. Have the patient take a rest after the procedure.
3. Encourage patient to eat foods rich in iron such as beans, green leafy vegetables and meats.
22
Diagnostic/ Date Ordered Indications/ Purposes Results Normal Values Analysis and
Laboratory Interpretation
Procedures
Blood Chemistry February 20. 2009 • Measurement of the
• CHON blood levels of other 50g/L 60-78 g/L
elements regulated in
part by the kidneys
• Albumin can also be useful in 20g/L 32-45g/L • Decreased albumin
evaluating kidney indicates
function. malabsorption.
• Globulin
30g/L 23-35g/L • Within normal
values.
Nursing Responsibilities
Before:
1. Check for the doctor’s order.
2. Discuss the importance of the procedure.
3. Explain to the client how to participate to the procedure.
After:
1. Apply pressure on the site for 5-10 minutes after the procedure.
2. Have the patient take a rest after the procedure.
23
Diagnostic/ Date Ordered Indications/ Purposes Results Normal Values Analysis and
Laboratory Interpretation
Procedures
Serum February 13, 2009 • To determine
Electrolytes electrolyte and acid-
>Sodium base imbalances. 145.5mmol/L 136-142mmol/L • Increased sodium
indicates dehydration,
excessive IV sodium,
insufficient water
intake or impaired
renal function.
Nursing Responsibilities
Before:
1. Check for the doctor’s order.
2. Discuss the importance of the procedure.
3. Explain to the client how to participate to the procedure.
After:
1. Apply pressure on the site for 5-10 minutes after the procedure.
2. Have the patient take a rest after the procedure.
3. Instruct patient to increase fluid intake.
6. Anatomy and Physiology
The common hepatic duct is the duct formed by the convergence of the right hepatic duct
(which drains bile from the right functional lobe of the liver) and the left hepatic duct (which
drains bile from the left functional lobe of the liver). The common hepatic duct then joins the
cystic duct coming from the gallbladder to form the common bile duct.
The liver is also the largest gland in the human body. It lies below the diaphragm in the thoracic
region of the abdomen. It produces bile, an alkaline compound which aids in digestion, via the
emulsification of lipids. It also performs and regulates a wide variety of high-volume
biochemical reactions requiring very specialized tissues.
The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the
body is to store bile and aid in the digestive process.
The cystic duct is the short duct that joins the gall bladder to the common bile duct. It usually
lies next to the cystic artery. It is of variable length. It contains a 'spiral valve', which does not
provide much resistance to the flow of bile. Bile can flow in both directions between the
gallbladder and the common hepatic duct and the (common) bile duct. In this way, bile is stored
in the gallbladder in between meal times and released after a fatty meal.
Bile, which is synthesized in the liver, is carried to the right and left hepatic ducts, which
converge along with the Cystic duct to form the common hepatic duct. There it enters the
superior end of the common bile duct and either empties into the second (and retroperitoneal)
part of the duodenum, or enters the cystic duct to be stored in the gallbladder.
The duodenum is largely responsible for the breakdown of food in the small intestine. Brunner's
glands, which secrete mucus, are found in the duodenum. The duodenum wall is composed of a
very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely
retroperitoneal. The duodenum also regulates the rate of emptying of the stomach via hormonal
pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in
response to acidic and fatty stimuli present there when the pyloris opens and releases gastric
chyme into the duodenum for further digestion. These cause the liver and gall bladder to release
bile, and the pancreas to release bicarbonate and digestive enzymes such as trypsin, lipase and
amylase into the duodenum as they are needed.
The pancreatic duct, or duct of Wirsung, is a duct joining the pancreas to the common bile
duct to supply pancreatic juices which aid in digestion provided by the "exocrine pancreas". The
pancreatic duct joins the common bile duct just prior to the ampulla of Vater, after which both
ducts perforate the medial side of the second portion of the duodenum at the major duodenal
papilla.
The stomach is a highly acidic environment due to hydrochloric acid production and secretion
which produces a luminal pH range usually between 1 and 2 depending on the species, food
intake, time of the day, drug use, and other factors. Combined with digestive enzymes, such an
environment is able to break down large molecules (such as from food) to smaller ones so that
they can eventually be absorbed from the small intestine. A zymogen called pepsinogen is
secreted by chief cells and turns into pepsin under low pH conditions and is a necessity in protein
digestion.
The pancreas is a dual-function gland, having features of both endocrine and exocrine glands.
• Endocrine
The part of the pancreas with endocrine function is made up of a million cell clusters called islets
of Langerhans. There are four main cell types in the islets. They are relatively difficult to
distinguish using standard staining techniques, but they can be classified by their secretion: α
cells secrete glucagon, β cells secrete insulin, cells secrete somatostatin, and PP cells secrete
pancreatic polypeptide.
The islets are a compact collection of endocrine cells arranged in clusters and cords and are
crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of
endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with
blood vessels, by either cytoplasmic processes or by direct apposition. According to the volume
The Body, by Alan E. Nourse, the islets are "busily manufacturing their hormone and generally
disregarding the pancreatic cells all around them, as though they were located in some
completely different part of the body."
• Exocrine
In contrast to the endocrine pancreas, which secretes hormones into the blood, the exocrine
pancreas produces digestive enzymes and an alkaline fluid, and secretes them into the small
intestine through a system of exocrine ducts. Digestive enzymes include trypsin, chymotrypsin,
pancreatic lipase, and pancreatic amylase, and are produced and secreted by acinar cells of the
exocrine pancreas. Specific cells that line the pancreatic ducts, called centroacinar cells, secrete a
bicarbonate- and salt-rich solution into the small intestine.
PATHOPHYSIOLOGY BOOK BASED
RISK FACTORS
Non-modifiable: Modifiable:
• FEMALE • ↑FAT
• FERTILITY Intake
• FORTY YEARS
OLD and ABOVE
GALLSTONE IN BILE
DUCTS
IN LIVER
BILE STASIS
RUPTURE OF
GALLBLADDER CHOLECYSTITIS
Modifiable: Non-modifiable:
HIGH FAT DIET 51 YEARS OLD
↑ BILIARY CHOLESTEROL
SATURATION
CRYSTALLIZATION OF
BILE CHOLESTEROL
GALLSTONE IN BILE
DUCTS
BILE STASIS
BACTERIAL GALLBLADDER AND
PROLIFERATION DUCT INFECTION
S/SX
>Pain in right hypochondriac region
>feeling of fullness
>nausea and flatulence
CHOLEDOCHOLETHIASIS
RUPTURED GALL
BLADDER
CHOLECYSTECTOMY
Complications:
• PAIN ON INCISION SITE
• ↑RESPIRATORY RATE
• ↓BLOOD PRESSURE
• CLAY COLORED STOOL
• DISTURBED SLEEP PATTERN
Nursing Care Plan # 1
POST-OPERATIVE
Nursing Diagnosis:
Risk for infection r/t
broken skin.
Nursing Care Plan # 4
POST-OPERATIVE
ASSESMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
S> Ø > Vague, uneasy > Within the Independent: > After the shift,
feeling of shift, the patient >Facilitate development > Trust is necessary before the patient
O>Expressed discomfort or will as a trusting relationship patient and family can feel acknowledged
concerns due to dread acknowledge with patient and family free the open personal lines feelings and
change in life accompanied by feelings and and communication with identify healthy
events autonomic identify healthy hospice team and address ways to deal with
> restlessness response. ways to deal sensitive issues. them.
> worried about with them.
his condition >Provide open, >Promotes and encourage
> unpleasant nonjudgmental dialogue about feelings and
thoughts about environment. Use concerns.
any event related therapeutic
to death or dying communication skills.
> feelings of
hopelessness >Encourage verbalization >Patient may feel
of thoughts and concerns supported expression of
Nursing and accept expressions of feelings by understanding
Diagnosis: sadness and anger. that deep and often
Anxiety r/t conflicting emotions are
change in health normal in this situation.
status.
>Reinforce teaching > Patient/SO’s benefit from
regarding disease process factual information. Honest
and treatments and answer promotes trust.
provide information as
requested. Be honest; do
not give false hope while
providing emotional
support.
Nursing Care Plan # 5
POST-OPERATIVE
NURSING RESPONSIBILITIES
Before:
1. Inspect each container. Read the label. Ensure solution is the one ordered and is with in the expiration date.
2. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter. Any container which
is suspect should not be used.
3. Use only if solution is clear and container and seal are intact.
After:
1. Watch for infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation
and hypervolemia.
2. Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent
monitoring of electrolytes levels is essential.
3. Monitor the regulation of the IVF.
4. Check for any signs of any infiltration complication in the IV site.
Medical Management/ Date Ordered/ General Description Indication/ Purposes Client Reaction to
Treatment Performed Treatment
Date Changed/ Date
Continued
D5LR 1L regulated @ Date ordered: hypertonic. 5% Dextrose This Solution is None
30 gtts/min. February 20, 2009 in Lactated Ringer’s indicated for use in
Date performed: Injection is sterile, non- adults and pesiayric
February 20, 2009 pyrogenic and contains patients as a source of
Date Changed: no bacteriostatic or electrolytes, calories and
February 21, 2009 antimicrobial agents. water for hydration.
Date replaced: This product is intended
February 21, 2009 for intravenous
administration.
NURSING RESPONSIBILITIES
Before:
1. Inspect each container. Read the label. Ensure solution is the one ordered and is with in the expiration date.
2. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter. Any container which
is suspect should not be used.
3. Use only if solution is clear and container and seal are intact.
After:
1. Watch for infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation
and hypervolemia.
2. Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent
monitoring of electrolytes levels is essential.
3. Watch for sings and symptoms of potassium intoxication include paresthesias of the extremeties, are flexia, muscular or
respiratory paralysis, mental confusion, weakness, hypotension, cardiac arrhythmias, heart block, electrocardiographic
abnormalities and cardiac arrest.
4. Monitor the regulation of the IVF.
5. Check for any signs of any infiltration complication in the IV site.
Nursing Responsibility:
BEFORE:
1. Ask the patient if he is allergic to sea foods or iodine.
2. Explain to the patient the procedure to prevent or reduce anxiety
3. Monitor VS prior to procedure.
AFTER:
1. Patient should remain on bed after the procedure.
2. Monitor VS.
3. Assess for any bleeding on the incision site.
Medical Date ordered/Date General Description Indication/Purpose Client Reaction to the
Management/Treatment Preformed/Date Treatment
Change/Date Continued
> Peritoneal lavage February 9,2009 > involves the For the cleaning of None
instillation of 1 L of excess materials (dye)
warmed LR’s or normal left during
saline solution in to the cholandiogram.
abdominal cavity.
Nursing Responsibility:
BEFORE
1. Explain to the patient the procedure to prevent or reduce anxiety
2. Monitor VS prior to procedure
AFTER:
1. Secure tunings of the lavage in a drainage bottle to avoid leak.
2. Monitor the amount and characteristics of the secretions.
3. Monitor VS and signs of infection such as redness in the area of insertion and any purulent discharges.
ii. Drugs
NAMES OF DRUG DATE ROUTE ADMIN. & GEN. ACTION, MECH. INDICATION/S, CLIENT RESPONSE
ORDERED/DATE DOSAGE & OF ACTION PURPOSES TO MED W/ ACTUAL
TAKEN/GIVEN, DATE FREQUENCY OF S/E
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date Ordered: 750 mg IVP every 8 Chemical Effect: Perioperative >No usual allergic
>Cefuroxime February 9, hours >Inhibits cell wall prophylaxis response
Sodium 2009 synthesis promoting
osmotic instability
Brand Name: Date Taken: usually bactericidal.
>Kefurox, Zinacef
February 9, Therapeutic Effect:
Pharmacologic 2009 > Hinders or kills
Class: susceptible bacteria
>Cephalosporin including many
gram positive
Therapeutic Class: organism and
>Antibiotic enteric gram
negative bacilli.
NURSING RESPONSIBILITIES
BEFORE:
Check for doctor’s order.
Assess patient’s infection before therapy and regularly thereafter.
Before giving first dose, obtain specimen for culture and sensitivity tests.
Before giving first dose, ask patient about previous reactions to cephalosporins or penicillin.
Assess patient’s and family’s knowledge of drug therapy.
Instruct patient to take drug exactly as prescribed, even if he feels better
DURING:
Instruct patient to take oral drug with food to enhance absorption.
Explain that tablets may crushed, but drug has bitter taste that difficult to mask even with food.
AFTER:
Tell patient to report any adverse reactions immediately.
Be alert for adverse reactions and drug interactions.
NAMES OF DRUG DATE ROUTE ADMIN. & GEN. ACTION, MECH. INDICATION/S, CLIENT RESPONSE
ORDERED/DATE DOSAGE & OF ACTION PURPOSES TO MED W/ ACTUAL
TAKEN/GIVEN, DATE FREQUENCY OF S/E
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date ordered: 100mg IVP q 8° Chemical action: > Moderate to > Patient is free
>Tramadol February 12, >Unknown; moderately severe from pain.
Hydrochloride 2009 centrally acting pain
synthetic analgesic
Brand Name: Date taken: compound not
> Ultram February 12, chemically related
2009 to opioids that is
Pharmacologic thought to bind to
class: opioid receptors and
Opioid agonist inhibits reuptake of
norepinephrine and
Therapeutic class: serotonin.
Analgesic
Therapeutic effect:
>Relieves pain
NURSING RESPONSIBILITIES:
BEFORE:
Check for doctor’s order.
Assess patients pain before starting therapy and regularly thereafter to monitor the drugs effectiveness.
AFTER:
Monitor patient for drug dependence.
Be alert for adverse reactions and drug interaction.
For better analgesic effect, give drug before onset of intense pain
Monitor CV and respiratory status.
Tell ambulatory patient to be careful when getting out of bed and walking
NAMES OF DRUG DATE ROUTE ADMIN. & GEN. ACTION, MECH. INDICATION/S, CLIENT RESPONSE
ORDERED/DATE DOSAGE & OF ACTION PURPOSES TO MED W/ ACTUAL
TAKEN/GIVEN, DATE FREQUENCY OF S/E
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date ordered: > 1 amp IVP q 8° Chemical effect: > Duodenal or > No response
> Ranitidine HCl February 9, > Competitively gastric ulcer
Brand Name: 2009 inhibits action of H2
> Zantac at receptor sites of
Pharmacologic Date taken: parietal cells,
class: February 9, decreasing gastric
>H2-Receptor 2009 acid secretion.
Antagonist
Therapeutic class: Therapeutic effect:
>Antiulcerative > Relieves GI
discomfort
NURSING RESPONSIBILITIES
BEFORE:
AFTER:
Be alert for adverse reaction and drug interaction
NAMES OF DRUG DATE ROUTE ADMIN. & GEN. ACTION, MECH. INDICATION/S, CLIENT RESPONSE
ORDERED/DATE DOSAGE & OF ACTION PURPOSES TO MED W/ ACTUAL
TAKEN/GIVEN, DATE FREQUENCY OF S/E
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date ordered: > 500 mg IVP q 8° Chemical effect: > To prevent > Patient is free
> Metronidazole February 9, > Direct-acting postoperative from infection as
Brand Name: 2009 trichomonazide and infection evidenced by
> Flagyl amebicide that temperature within
Pharmacologic Date taken: works at both normal range
Class: February 9, intestinal and
> Nitroimidazole 2009 extraintestinal sites
Therapeutic Class:
> Antibacterial; Therapeutic effect:
antiprotozoal, > Hinders growth of
amebicide selected organisms,
including most
anaerobic bacteria
and protozoa
NURSING RESPONSIBILITIES
BEFORE:
Check for doctor’s order.
Tell patient not to use alcohol or drugs that contain alcohol during therapy and for at least 48 hours after
therapy is completed
Urge patient to complete full course of therapy even if he feels better
DURING:
Tell patient that metallic taste and dark or red-brown urine may occur
AFTER:
Be alert for adverse reaction and drug interactions
NAMES OF DRUG DATE ORDERED/DATE ROUTE ADMIN. & GEN. ACTION, MECH. INDICATION/S, CLIENT RESPONSE TO
TAKEN/GIVEN, DATE DOSAGE & OF ACTION PURPOSES MED W/ ACTUAL S/E
CHANGED/DATE FREQUENCY OF
DISCONTINUED ADMIN
Generic Name: Date ordered: > 30 mg 1 amp. IVP Chemical effect: > Short- term > Patient is free
> Ketorolac February 9, q 8 > May inhibit management of pain from pain
2009 prostaglandin
Brand Name: synthesis
> Acular Date taken:
Pharmacologic February 9, Therapeutic effect:
Class: 2009 > Relieves pain and
> NSAID inflammation
Therapeutic Class:
> Analgesic, anti-
inflammatory
NURSING RESPONSIBILITIES
BEFORE:
Check for doctor’s order.
Assess patient’s pain before and after drug therapy
Explain that drug is intended for short-term management
AFTER:
Advise patient to report persistent or worsening pain.
Teach patient to re4cognize and immediately report signs and symptoms of GI bleeding.
iii. Diet
TYPE OF DIET DATE ORDERED, GENERAL DESCRIPTION INDICATION/S, SPECIFIC FOODS CLINT RESPONSE
DATE PURPOSE/S TAKEN AND/OR REACTION
STARTED,DATE TO THE DIET
CHANGED
Diet as tolerated Date ordered: It is a normal diet It serves as a basis Rice, meat, The patient accepts
February 19, planned to provide the for the vegetables and the ordered diet and
2009 recommended daily modifications of fruits. he was able to eat
allowance for essential therapeutic diets in the served foods. It
Date Started: , nutrients but designed to the hospital. is good to the
February 19, meet the caloric needs patient’s appetite
2009 of a bedridden or and meets the
ambulatory patients caloric need. He
Date Changed: whose condition does understands and
February 20, not require any dietary appreciates the
2009 modification for benefits of the diet.
therapeutic purposes. Diet tolerated
High protein diet Date ordered: Diet that prescribes a It is used in post 2 egg white, and The patient accepts
February 20-23, specific level of protein operative patients meat the ordered diet and
2009 fraction or amino acid For rapid tissue he was able to eat
repair. the served foods. He
understands and
Date Started: , appreciates the
February 20, benefits of the diet.
2009 Diet tolerated
Date Changed:
February 24,
2009
Low fat Date ordered: Diet that prescribes a To prevent Lean or grilled meat The patient tries to
February 20-23, specific level of fat for aggravation of and fish. eat the served food
2009 patients whose condition accumulation of fats and understands the
requires a small amount in the common bile benefits of the diet
Date Started: , of fat fraction. duct. in his condition.
February 20, Diet tolerated.
2009
NURSING RESPONSIBILITIES
Before:
1. Emphasize the importance of the diet
2. Discuss the food sources included in the diet.
3. Explain to the client the purpose of the diet.
After:
1. Assess the client’s response to the diet.
2. Assess the client’s understanding about the diet.
TYPES OF EXERCISE DATE ORDERED, DATE GENERAL DESCRIPTION INDICATIO/S, PURPOSE/S CLIENT’S
STARTED, DATE RESPONSE/REACTION TO
CHANGED. THE ACTIVITY/EXERCISE
Deep Breathing Date ordered: Deep breathing is a Breathing exercises can Participate willingly in
Exercises February 19-23, 2009 relaxation technique that be used to optimize gas the activity.
can be self-taught. Deep exchange, promote lung
Date Started: , breathing releases expansion, minimize Patient verbalizes
February 19, 2009 tension from the body atelectasis, decrease alleviated pain sensation
and clear the mind, dyspnea, and promote and serves as an
Date Changed: improving both physical secretion removal effective relaxation
February 24, 2009 and mental wellness. especially after technique.
prolonged inactivity.
We tend to breathe Understands and
shallowly or even hold appreciates the benefits
our hold our breath of the exercise
when we are feeling
anxious
Range of Motion Date ordered: Maximum possible Strengthens muscle to Participate willingly in
Exercise February 19-23, 2009 movement for a joint. prevent muscle atrophy the activity.
Normal muscle strength or weakness among
Date Started: , for complete voluntary patients who mostly Understands and
February 19, 2009 range of motion. confined on bed. appreciates the benefits
of the exercise
Date Changed: Promotes blood
February 24, 2009 circulation.
Participate willingly in
Date ordered: Increases mobilization, the activity.
Daily walking activity February 23, 2009 strengthens muscle and
Walking with bilateral promotes balance. Understands and
Date Started: , equal strengths. Activity appreciates the benefits
February 23, 2009 to maintain balance of the exercise
NURSING RESPONSIBILITIES:
DEEP BREATHING EXERCISE
BEFORE:
1. Explain the procedure to gain patients cooperation.
2. Discuss the benefits of the exercise
DURING:
1. Help the client perform deep breathing exercise.
2. Advise to rest between activities.
AFTER:
1. Encourage to perform exercise at last 1 hour before every meal.
2. Encourage verbalization of increased comfort.
DURING:
1. Help the client perform deep breathing exercise.
2. Advise to rest between activities.
3. Ensure the patient’s safety.
AFTER:
1. Encourage to perform active ROM exercise at last 1 hour before every meal.
2. Encourage verbalization of any pain after the activity
3. Encourage verbalization of increased comfort.
DURING:
1. Assist the patient or advise the patient to perform daily walking activities with the assistance of SO’s.
2. Advise to rest between activities.
3.Ensure the patient’s safety.
AFTER:
1. Encourage daily walking activities.
2. Encourage verbalization of any pain after the activity
3. Encourage verbalization of increased comfort.
v. Surgical Management
Name of Procedure Date ordered/Date General Description Indication/Purpose Client Reaction to the
Preformed Operation
Choledocholithotomy February 9,2009 Operation to make an Removal of stones on Reduce anxiety
incision on the common the common bile duct.
bile duct to remove
gallstones.
Nursing Responsibility
BEFORE:
1. Secure consent
2. Explain to the patient the procedure.
3. Monitor VS.
4. NPO post midnight.
AFTER:
1. Maintain patient flat on bed for 8 hours.
2. Monitor for bleeding on the incision site.
3. Monitor Vs.
4. NPO until positive flatus.
Name of Procedure Date ordered/Date General Description Indication/Purpose Client Reaction to the
Preformed Operation
Choledochostomy February 9, 2009 Making an incision in Removal of stones Reduce anxiety
the common duct,
usually removal of
stones. After the stones
have been evacuated, a
tube is usually inserted
into the duct for
drainage of bile until
edema subsides.
Nursing Responsibility
BEFORE:
1. Secure consent
2. Explain to the patient the procedure.
3. Monitor VS.
4. NPO post midnight.
AFTER:
1. Maintain patient flat on bed for 8 hours.
2. Monitor for bleeding on the incision site.
3. Monitor Vs.
4. NPO until positive flatus
Name of Procedure Date ordered/Date General Description Indication/Purpose Client Reaction to the
Preformed Operation
Cholecystectomy February 9, 2009 Making an incision for Removal of gallbladder Reduce anxiety
the removal of
gallbladder
SOAPIE # 1
POST-OPERATIVE
P: Within one hour of appropriate nursing intervention, the patient’s pain scale will alleviate
from 7/10 to 3/10.
I: > Offered divertional activities such as reading newspaper or magazines, socialization with
others
> Provided comfort measures such as backrub and changing position every 2 hours.
E: >After one hour of appropriate nursing intervention, the patient’s pain scale will alleviated
from 7/10 to 3/10 as evidenced by:
a. can move freely b. verbalized increase level of comfort
SOAPIE # 2
POST-OPERATIVE
P: > Within 2 to 3 hours of appropriate nursing intervention the patient will be able to
demonstrate increase activity tolerance
>Emphasized adequate intake of fluids at least 1500-2000 ml and nutritious foods such as
vegetables and fruits .
>Encouraged to maintain positive attitude; suggest use of relaxation techniques such as deep
breathing exercise.
>Provided emotional support and encouragement to the client to gradually increase activity.
E: > After 2 to 3 hours of appropriate nursing interventions the patient had demonstrated activity
tolerance as evidence by:
a. verbalization of patients mobility progression.
b. demonstration of patients positive attitudes towards activities.
c. patients wide understanding about the importance of activity tolerance.
SOAPIE # 3
POST-OPERATIVE
S>
P> Within 8 hours of appropriate nursing intervention, the patient will be free from manifesting
signs and symptoms of infection such as swelling, redness..
I >Inspected the skin for pre-existing irritation, redness, swelling or burning sensation.
E> After 8 hours of appropriate nursing intervention, the patient is free from signs and
symptoms of infection as evidenced by:
a. afebrile
b. (-) redness, swelling, burning sensation
SOAPIE # 4
POST-OPERATIVE
S> Ø
P> Within the shift, the patient will acknowledge feelings and identify healthy ways to deal with
them
> Encouraged verbalization of thoughts and concerns and accept expressions of sadness and
anger.
>Reinforced teaching regarding disease process and treatments and provide information as
requested. Be honest; do not give false hope while providing emotional support.
E> After the shift, the patient acknowledged feelings and identify healthy ways to deal with
them.
SOAPIE # 5
POST-OPERATIVE
P: After 3 hours of nursing interventions the patient will verbalize understanding of therapeutic
needs.
· Emphasized importance of maintaining low fat diet, eating small frequent meals, gradual
reintroduction of foods or fluids containing fats over 4 to 6monthperiod.
· Informed patient that loose stools may occur for several months.
· Identified signs and symptoms requiring notification of healthcare provider like dark urine,
jaundiced color of eyes or skin, clay colored stools.
E: · After 3 hours of nursing interventions the patient was able to verbalize understanding of the
disease process.
D. EVALUATION
Daily program 1st Day 2nd Day 3rd Day 4th Day 5th Day
(Feb 19 2009) (Feb 20 2009) (Feb 21 2009) (Feb 22 2009) (Feb 23 2009)
Nursing Problems
• Temperature: • Temperature: • Temperature: • Temperature: • Temperature:
5 am-36.5 °C 10 am-37.2 °C 6 am-37 °C 5 am-36.7 °C 5 am-37 °C
10 am-37.2 °C 2 pm-37.5 °C 10 am-37 °C
2 pm-37.5 °C 4pm-37.5 °C 2 pm-37.4 °C
4pm-37.5 °C 6pm-37.4 °C
6pm-37.4 °C 10 pm-36.5 °C
10 pm-36.5 °C
• Pulse Rate: • Pulse Rate: • Pulse Rate: • Pulse Rate: • Pulse Rate:
5 am-70 10 am-71 6am-72 5 am-70 5 am-69
10 am-65 2 pm-74 10 am-75
2 pm-73 4pm-77 2 pm-69
4pm-79 6pm-76
6pm-76 10 pm-75
10 pm-72
Exercise Range of motion Range of motion Range of motion Range of motion Range of motion
2. Discharge Planning
i. General condition of the patient upon discharge
It was February 24, 2009, when the patient was discharge. He was able to
sit on bed without assistance. He was able to consume all the food on the tray. He
is still with his t-tube intact.
The doctor ordered the patient for OPD follow-up after one week, regular
cleaning, changing of dressings at the insertion site. The patient was also advised
to continue low fat and low sodium diet.
ii. METHOD
T: > Ø
H: >
• Encouraged to continue high protein diet, low fat-low sodium
diet.
Discipline is one of the major factors needed by the patient with choledolithiasis. He
must be able to know on how to tolerate his foods particularly the limitations of fats and
cholesterol intake which are one of the major factors that lead for the formation of stones in the
gallbladder`. Proper balance nutrition is a good practice for the alleviation and minimal
occurrence of this kind of disease.
With regards to the patients medical and surgical managements, occurrence of problems
such as risk for infection prior to surgery may be prevented by means of proper cleaning of the
incision site and medications should be taken as prescribed with proper dosages to avoid any of
its adverse or side effects.
As we work this kind of study, the group gained wide knowledge and understanding
about Choledolithiasis, the problems related to this condition and the different management that
should be prioritized in order for us to have positive outcomes in nursing problems. Good nurse-
patient relationship was also established as we conduct this study. This study helps us to identify
measures to prevent complications of the disease and also for them to have understanding about
this condition and to practice independent implementation for this kind of disease
IV. RECOMMENDATION
As nursing students, we should have wide knowledge about our patient’s condition in
order for us to give appropriate managements. So we group B3 recommend to our patient to
maintain proper diet that is high in protein for faster tissue repair and low salt-low fat diet to
prevent aggravation of disease. Drinking sufficient water for at least 8 glasses or more, may also
be helpful for proper circulation of nutrients that patient’ take.
Patient should always be practice proper intake of his medication and must always obtain
proper hygiene especially on the insertion site of the t-tube to prevent secondary infections. Any
abnormalities or adverse effects should report to the physician immediately. Patient should also
practice independence to promote sense of well-being.
V. BIBLIOGRAPHY
BOOKS:
Ackley, Betty J. and Ladwig, Gail B., Nursing Diagnosis Handbook, 7th Edition, 2006.
Estes Zator, Mary Ellen. Health Assessment and Physical Examination, 3rd Edition, 2006.
Ignativicius and Workman. Medical- Surgical Nursing, Collaborative and Critical Thinking
Vol. 1 and 2, 2004.
Kozier, Erb, Berman, Synder. Fundamentals of Nursing, Concepts, Process and Practice,
7th Edition, 2004.
Smeltzer, Suzanne C. and Bare, Brenda G., Medical- Surgical Nursing, Vol. 2 10th
Edition, 2004.
Website
http://www.umm.edu/ency/article/000274.htm
http://emedicine.medscape.com/article/172216-overview