Beruflich Dokumente
Kultur Dokumente
College of Nursing
Presented to:
MRS. GISSELLE CHARADE A. ZAMORA, R.N.
Presented by:
MR. MICAH NOEL I. PERPETUA
MR. JONI S. PURAY
MS. MA. PRINCESS H. GCCAE SANTILLAN
MS. ARNIKKA B. RUBIA
MR. RIEL R. SEGURA
BSN – 3H
GROUP 4
TABLE OF CONTENTS
PART PAGE
Acknowledgement………………………………………………………………….…
Introduction……………………………………………………………………………
Objectives…………………….……………………………………………………….
Patient’s Data………………………………………………………………………….
Genogram……………………………………………………………………………..
Family History………………………………………………………………………..
Developmental Data…………………………………………………………………...
Physical Assessment……………………….…………………………………………..
Complete Diagnosis……………………………………………………………………
Anatomy and Physiology………………………………………………………………
Etiology…………………………………………………………………………………
Symptomatology…………………………………………………………….………….
Pathophysiology…………..……………………………………………………….……
Doctor’s Order……………………………………………………………………..……
Diagnostic Examiation.………………………………………………………………….
Drug Study………………………………………………………………………………
Procedural Report……………………………………………………………………….
Nursing Theories…………………………………………………………………………
Nursing Care Plans……………………………………………………………………….
Discharge Planning……………………………………………………………………….
Prognosis…………………………………………………………………………………..
Conclusion…………………………………………………………………………………
Recommendation………………………………………………………………………….
Bibliography……………………………………………………………………………….
Acknowledgement
appreciation primarily to Mr. Police for allowing them to have his case as
during the entire exposure. Moreover, he was also very patient with them
while providing them sufficient information regarding him and his case.
Furthermore, they are grateful to Anna for being supportive and also
for giving them an opportunity to learn more regarding her husband’s case
The staff nurses are also acknowledged for their kind accommodation.
Their humility in sharing some of their knowledge was great help to the
made the student nurses efficient in rendering nursing care towards the
valued patients.
The student nurses would also like to thank Ma’am Gisselle Charade A.
Zamora, R.N. for giving them the appropriate orientation and facilitation on
their first exposure to St. Joseph. She had been very patient and
experience that made them further appreciate the “journey of our being.”
Sir Anselmo Lafuente, R.N., their substitute clinical instructor at St. Joseph
ward at DMSF Hospital, for guiding and inspiring them with his remarkable
holistic teachings that encouraged them not only to be better nurses, but as
well as better individuals. May they find the right path towards God, as he
The student nurses would also like to thank their respective families
they are doing; for the financial and moral support and for understanding.
Thank you for the love. The group would also like to extend their gratitude to
the Perpetua family for welcoming them into their home and for securing
And above all, they are very thankful to the Almighty Father for gracing
them with His wonderful blessings. He is their ultimate strength and hope.
They pray for His loving guidance as they continue their journey in their
nursing careers.
INTRODUCTION
liquid continually secreted by the liver. The bile in turn emulsifies fats and
enough, the gallbladder is an organ that people can live without. Perhaps,
this fact contributes to the laxity of the majority. The gallbladder tends to be
taken for granted – ignored of the proper care and conditioning. Lifestyle
together with heredity, sex, race and age are just some factors that leave a
in the gallbladder. This later causes irritation and is probably the leading
cause of inflammation. Cholecystitis affects women more often than men and
is more likely to occur after age 40. People who have a history of gallstones
among individuals from sub-Saharan Africa and Asia. It affected 20.5 million
Hospitalizations total up to 636,000 in the same year and over 500,000 have
(http://digestive.niddk.nih.gov/statistics)
The student nurses have chosen this case as they see it fit for the peri-
Moreover, despite the cholecystitis’ low incidence, they would like to give
credit and to know more of the nature and function of the gallbladder. Much
often this small organ is not given importance. Thus they are in a pursuit for
interesting since it does not always affect only females and elderly. It can
affect everyone. It can be alarming since many people are confused and
they too are predisposed to lifestyle modification – especially diet and food
preferences which can contribute to the disease. With this study, the student
nurses hope to apply their learning in taking care not only of their patients
management that will be given. Through this, they are hoping that they will
be able to find the right plan of care and sound interventions, not forgetting
the patient’s rights as a person. All in all, these will help them to become
nurses shall have devised objectives that will guide them for the proper
GENERAL OBJECTIVES
Cognitive
The student nurses’ first main goal is to gain knowledge through the
completion of the case study and to impart this learning to Mr. Police and to
those directly and indirectly involve with the completion of this case.
Within the 5 days span of duty, the student nurses will be able to:
• Gather significant data from the patient’s chart which includes the
system.
• Research on the possible causes and also the symptoms the patient
In this aspect, the student nurse’s goal is to apply all what they have
learned during the process of completing this case study to improve nursing
care that will meet Mr. Police’s need for the improvement of his general
welfare.
Within the 5 days span of duty, the student nurses will be able to:
• Formulate nursing care plans and apply them to satisfy the patient’s
• Make a discharge plan for the patient using M.E.T.H.O.D and validate
Affective
knowledge, another goal is that the student nurses will be able to empathize
with the current situation of the patient and to gain some values like the
Within the 5 days span of duty, the student nurses will be able to:
information about the patient which includes the medical and family
data from the patient’s chart and to his family and etc.; and for the
Personal Data
Sex: Male
Nationality: Filipino
Occupation: PNP
Clinical Data
VS upon admission:
BP –120/90 mmHg R – 28 cpm P – 109 bpm Temp
– 36.5˚C
Dad A B Mo 3 4 5 6
1 ħ
BB 1 BB 2
Legend:
ħ: Hypertensive
±: Unknown cause of death
Ø: Suicide
Δ: Died of childhood illness
†: Deceased
HEALTH HISTORY
A. Family Background
Mr. Police is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children.
But his younger sister died of a childhood illness at the age of three
years old, he could not recall. He grew up at General Santos City where
the relatives of his mother live. When Mr. Police was a first year high
school, his parents got separated because of third party. He lived with
his mother and Mrs. Mom’s live-in partner at Davao City, while his
father returned to Leyte where his other relatives live. With his
Because Mr. Police had been away from the relatives of his father, he
does not know any significant disease they have or had. He doesn’t
the paternal side. On the other hand, what he only knows is that the
eldest sister of her mother has hypertension, and that his grandfather
Currently, Mr. Police has been married to Anna for 15 years. They met
at Mandug, Davao City, where Mr. Police had been assigned at work
before. The couple had difficulty conceiving a child because Anna has
B. Personal Background
because he couldn’t find a job with the course he had, he had six-
On his rest day, he stays in their house and on the evening, goes with
his friends and has a drinking session. He enjoys watching TV, and
children are to Anna. But he enjoys playing with them sometimes and
describes him. He has a set of close friends who are also policemen like
every Sundays but is a Sto. Niño devotee. Every January, he goes back
Niño fiesta.
Mr. Police has been a smoker since he was 20 years old. His wife said
stopped because his friends also decided to stop. With regards to his
meat, and could not sleep without eating such. He also eats lots of
and other pica-pica. Moreover, he does not eat vegetables but eats all
he had to have a sick leave from his work. Moreover, Anna also has to
watch over him and she has to leave the children under the care of her
elder sister for a while. Moreover, Anna is worried of the effect of the
operation to the health of her husband. But she is hoping that because
control over his health, that he would cease drinking and smoking.
Furthermore, Anna is also expecting that her husband would regain his
Mr. Police experienced common illness such as colds, cough, and fever
during his childhood. He also had chicken pox during his childhood.
However, he could not recall at what age he got the disease and as
with an FBS result of 7.8 mmol/dL. They were having an annual check
advised to control his diet and have a regular exercise but he was not
given any maintenance drug. Moreover, he was not compliant with the
doctor’s advice.
Two years ago (2007), he was admitted to Davao Medical Center due to
the VS taking at the emergency room. He was admitted for one day
doctor advised him to cease smoking and drinking alcohol, and as well
as to avoid over fatigue. He stopped smoking, but only for two months.
and vomiting. The pain was tolerable so he did not seek medical
so he also didn’t mind to take any pain relievers. Until three days prior
to admission, patient had severe right upper quadrant pain, which was
of the abdomen, pain is elicited. He had also lost his appetite because
of the pain. His scleras were also slightly icteric during admission and
GENERAL SURVEY
46 year old Filipino male, was lying in bed, asleep; with an IVF # 3
right metacarpal vein; with epidural catheter; with Jackson Pratt drain;
coherent when awaken; with complain of pain at the incision site, with
gown. Respiratory distress was not noted. Aside from that, he weighs
85 kg and stands 5’5” and has a body mass index of 31.18 which
34.9.
VITAL SIGNS
T= 36 °C
SKIN
Skin was warm to touch, slightly dry, rough, and with good skin turgot.
with nevi noted on the right side of the nose. Patient was not cyanotic.
Skull size was normocephalic. Skull and face were symmetrical with an
equal distribution of hair. Hair was black in color with fair amount of
white and gray strands, short, dry, and fine. There was no dandruff or
depressions noted.
FACE
EYES
Mr. Police did not use any corrective aids such as glasses or contact
lacrimal duct openings were evident at the nasal side of the upper and
lower lids. Blinking reflex was present. Skin around the eyes was intact
dark brown. His pupils were equal within 1-2 mm diameter in size and
both eyes. Nystagmus, strabismus and lid lag were not evident.
EARS
Ears were symmetrical with same size bilaterally and color consistent
with face. Pinnas were free from lesions, masses, swelling, redness,
tenderness, and discharges and were in line with the eyes. External
canals were clear with no cerumen seen. No inflammation, masses,
discharges and foreign bodies noted. Gross hearing acuity was good.
NOSE
upon palpation.
MOUTH
Mouth was proportional and symmetrical. Lips were rust colored and
yellowish in color with some dental caries noted. Right upper first
premolar tooth was absent. Tongue was in central position and moves
NECK
vein distention was noted. Range of motion was normal and moves
without deviation.
BREAST
noted. Both axilla were free of lesions rashes, and infections. Lymph
hiccups noted.
HEART
auscultation.
ABDOMEN
supine position; with slightly soaked, intact dressing on the right upper
quadrant with Jackson Pratt drain. Pulsations were not visible. The
abdomen had hypoactive bowel sounds of two bowel sounds per
minute. Tenderness noted on the right upper quadrant near the incision
site.
GENITO –URINARY
patient verbalized that he had not noted any discharges from his
arms, elbows and forearms were free from nodules, deformities and
atrophy. Range of motion was not limited. Neither pallor nor bone
pulses were present. Hip joint and thighs were symmetrical with no
noted in the lower extremities. Range of motion was active and not
limited.
DEFINITION OF COMPLETE DIAGNOSIS
CHOLECYSTITIS
duct.
Health Sciences
CHOLELITHIASIS
Health Sciences
ANATOMY AND PHYSIOLOGY
HEPATOBILLARY TREE
LIVER
A. Location and size of the liver- largest gland in the body, weighs
ligament
2. Right lobe- forms about five sixths of the liver; divides into
C. Bile ducts
1. Small bile ducts form right and left hepatic ducts
hepatic duct
1. Glucose Metabolism
process gluconeogenesis
2. Ammonia Conversion
3. Protein Metabolism
-stores vitamin A, D, E, K
6. Drug Metabolism
7. Bile Formation
function
GALLBLADDER
The gallbladder (or cholecyst, sometimes gall bladder) is a small
organ whose function in the body is to harbor bile and aid in the
digestive process.
Anatomy
• The cystic duct connects the gall bladder to the common hepatic
• The common bile romero duct then joins the pancreatic duct, and
duodenal papilla.
• The fundus of the gallbladder is the part farthest from the duct,
Microscopic anatomy
The different layers of the gallbladder are as follows:
• The gallbladder has a simple columnar epithelial lining
(lamina propria).
connective tissue.
and cystic ducts. During this time the gallbladder concentrates bile
occurs. Bile is thereby denied its normal exit from the body in the
pigments with a yellow hue enters the blood and is deposited in the
tissues.
concentrated than when it left the liver, increasing its potency and
hemoglobin from the red blood cell is broken down from biliverdin,
this bilirubin is still called free bilirubin. As it passes through the liver,
free bilirubin is released from its albumin carrier molecule and moved
this form, it passes through the bile ducts into the small intestine. In
the normal level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory
bilirubin.
ETIOLOGY AND SYMPTOMATOLOGY
Precipitating Factors:
Liver cells secrete Liver cells Liver excrete Liver excrete Invasion Calcium enters Liver excrete
cholesterol into bile also secrete relatively high conjugated of bile passively some
along with bile salts proportion of bilirubin into bacteria along with other unconjugated
phospholipid in the cholesterol in the bile electrolytes bilirubin into
form of unilamellar bile bile
vesicles
A
Unconjugated
Residual vesicles Some of the The bacteria Bilirubin tends to
Bacterial
unilamellar hydrolyze form insoluble
hydrolysis
vesicles dissolve conjugated precipitates with
of lecithin
bilirubin calcium
Formation of Release of
mixed micelles fatty acids Formation of
Increase in Calcium
unconjugated Bilirubinate
bilirubin
The cholesterol A fatty acids forms Black Pigment
carrying capacity of complex with calcium Gallstones
the micelles and
residual vesicles is
exceeded
Attraction Bacteria
of release
Leukocytes lytic Formation of
Bile is enzyme
supersaturated with Calcium
cholesterol Bilirubinate
leukocytes
hydrolyze
Formation of bilirubin Brown Pigment
Crystals conjugates Gallstones
and fatty
acids
Nucleation of
cholesterol crystals
Cholesterol
Gallstones
Mixed Stones
CHOLELITHIASIS
Gallstone tries to go
out of the gallbladder
Cholestasis
Release of phospholipase Disruption of mucous
from the epithelium of the coat of the gallbladder
gallbladder epithelium
Prolong Cholestasis Absence of Bile in ↑ levels of Hydrolization of lecithin Damages mucosal cells
the duodenum bilirubin/bile into lysolecithin due to detergent action of
pigments in the
bile salts
circulation
Hepatomegaly
S/S Indigestion,
Vit ADEK
deficiency, gray
Fibrosis Irritation of the
stools
S/S jaundice, gallbladder wall
ecteric sclera,
Liver Cirrhosis pruritus, dark
urine
Release of prostaglandins
within the gallbladder wall
Fibrous nodules distorts the S/S Biliary Colic,
architecture of the liver Tenderness, Murphy’s
sign, nausea and
vomiting, fever, ACUTE M
Resistance to K elevated wbc, anorexia CHOLECYSTITIS
portal blood flow
Increase pressure
in hepatic portal
vein
IF TREATED: IF NOT TREATED
Portal Hypertension Open Cholecystectomy
Laparoscopic
Cholecystectomy
Litotripsy
Z Ursodeoxycholicacid Bacteria invade the External surface
injured gallbladder of the
through the blood, gallbladder is
lymphatic or bile ducts scarred and
form adjacent organs layered by
(Empyema of the fibrinous
gallbladder) exudates and
GOOD PROGNOSIS distended
Increased Intraluminal
pressure
Ischemia
Ulcerations of the
mucosa
Necrosis
Gangrenous
Cholecystitis
Free Perforation Localized Perforation
Cholecystoenteric
fistula formation
Ischemia
Dehydration Necrosis
Hypovolemic shock
Generalized Peritonitis
Sepsis
S/S fever,
Septic Shock chills,
tachycardia
DEATH
Z
Increased
intracranial pressure
Brain Hernation
Hepatic Coma
DEATH
M
Chronic Cholecystitis
Extensive
dystrophic
calcification of the
gallbladder wall
(Porcelain bladder)
Growth of
gallbladder
carcinoma
Metastasize to the
liver
Secondary Liver
Cancer
K
DOCTOR’S ORDER
Chest PA
Clinical Indication: Chest X-ray is done to diagnose pulmonary disease
and diseases of the mediastinum and bony thorax. This test also gives
valuable information on the condition of the heart, lungs,
gastrointestinal tract and thyroid gland.
Nursing Responsibilities:
- Explain to the patient that the chest x-ray will be used for
screening, diagnosis and evaluation of change in his
respiratory system.
- Explain the nature of the procedure to the patient
- Instruct the patient to remove all metal objects between
his neck and chest and change to hospital gown.
- Instruct the patient to take a deep breath and exhale; then
he is required to take another deep breath but hold it while
the picture is taken.
- Tell patient that the procedure takes only a few minutes.
- Inform the patient regarding the result of the test.
ECG Result
(April 27, 2009)
Rate: 25 min
PR interval: 0.10second
Rhythm: Sinus
QRS: 0.08second
Axis: +15°
QTc: 0.44seconds Position Intermediate
Nursing Responsibilities:
Inform patient on why and how the test is done. Tell him that
this is not an invasive procedure, painless and a safe test.
Place patient in a supine position in the bed or table.
Prepare the skin (shave if there is excess hair) by applying
contact paste or prejelled discs.
Place the electrodes accurately.
Inform the patient regarding the result.
Reference Clinical Nsg
Exam Result Interpretation
Range Indication Responsibility
Blood Chemistry (April 27, 2009)
FBS 6.84 4.20 – Fasting blood Above normal - Explain that
6.40 sugar test level, indicates a blood
mmol/L measure the diabetes. sample will
amount of be taken from
glucose in the the hand or
blood and to arm and that
detect any the sample
disorder of will be
glucose evaluating
metabolism. the amount
of sugar
present in the
blood that
may indicate
diabetes and
evaluate if
metabolic
derangement
has resulted
by the
disease.
-Instruct the
client not to
eat or drink
anything, 12
hours prior to
taking the
test. He can
just drink
water.
-Administer
Omeprazole
400 mg tab,
1 tab OD to
suppress
gastric acid
secretion,
preventing
hyperacidity
since the
patient will
be on NPO for
12 hours.
3.
Continuously
monitor fluid
balance
through daily
weights and
intake and
output
recordings.
4. Evaluate
for increased
fluid volume
manifested by
edema,
decreased
urine out put,
neck vein
distention,
dyspnea and
hepatomegaly
.
Total 33.3 2.0 – 21.0 The Above normal Explain the
Bilirubin umol/L measurement range, may purpose and
Direct 7.6 0.0 – 3.4 of bilirubin is indicate the
Bilirubin umol/L important in obstructive procedure of
Indirect 25.7 2.0 – 17 evaluating jaundice of the test.
Bilirubin umol/L liver function, which is a
and hemolytic result of Tell patient
anemia. A obstruction of that 10ml
NORMAL level the common venous blood
of total bile duct or is to be
bilirubin reules hepatic ducts collected
out any due to stones before he
significant or neoplasm. eats his
Above normal
impairment in breakfast.
range, may
the excretory
indicate
function of the Inform
choledocholithi
liver or patient
asis.
excessive regarding the
Above normal
hemolysis of test result.
range, may
red blood
indicate
cells.
hemolytic
Differentiation
anemia.
of bilirubin is
done to
determine
which of the
problems
above is the
cause of the
elevation of
total bilirubin.
An in crease in
Uric Acid 0.497 0.2 – 0.4 Uric acid is Above normal Explain the
umol/L formed from range, could be purpose and
the breakdown associated with the
of nucleonic nitrogen procedure of
acids and is an retention and the test.
end product of with increase in
purine urea, creatinine Inform the
metabolism. and other non- patient
Measurement protein regarding the
of uric acid is nitrogenous result.
most substances in
commonly in the blood. May Monitor
evaluation of indicate a patient’s
renal failure, decreased intake and
gout and renal function. output so as
leukemia. to determine
if he has a
decreased
renal
function.
Alkaline 228 64 – 306 This enzyme Within normal Explain the
Phosphatas U/L test is used range purpose and
e chiefly as an the
index of liver procedure of
and bone the test.
disease when
correlated with Inform the
other clinical patient
findings. In regarding the
liver disease, result.
the blood level
rises when
excretion of
this enzyme is
impaired as a
result of
obstruction in
the biliary
tract.
Albumin 55.4 38 – 51 This test can Above normal Explain the
g/L help range, may purpose and
determine if a indicate renal the
patient has disease. procedure of
liver disease the test.
or kidney
disease, or if Inform the
the body is not patient
absorbing regarding the
enough result.
protein.
Ultrasound Report
(04/27/09)
Ultrasound Report
(This report is based on sonographic findings and must be correlated
clinically.)
Impression:
> Cholecystitis with bile sludge formation and suggestive
hydrophoric change. Cannot entirely rule out calculus in the
cystic duct
> Sonographically normal liver and biliar ducts
Mode of Action: Blocks the transport of calcium into the smooth muscle
cells lining the coronary arteries and other arteries of the body. Since
calcium is important in muscle contraction, blocking calcium transport
relaxes artery muscles and dilates coronary arteries and other arteries
of the body. By relaxing coronary arteries, amlodipine is useful in
preventing chest pain (angina) resulting from coronary artery spasm.
Relaxing the muscles lining the arteries of the rest of the body lowers
the blood pressure, which reduces the burden on the heart as it pumps
blood to the body. Reducing heart burden lessens the heart muscle's
demand for oxygen, and further helps to prevent angina in patients
with coronary artery disease.
Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Administer drug without regard to meals.
4. Monitor patient’s vital signs carefully while adjusting drug to
therapeutic dose.
5. Instruct patient to take drug with meals if stomach upset
occurs.
6. Instruct him to take drug exactly as prescribed by his
physician.
7. Tell patient that he may experience some side effects brought
upon by the drug.
8. Instruct him to report intolerable side effects so management
can be done.
9. Instruct him to eat frequent small meals if vomiting occurs.
10.Oral care if patient vomits.
11.Instruct him to adjust lighting, noise and temperature if he
experiences headache and report if it is intolerable so that
medication may be given.
12.Instruct him to report any adverse effects that he may
experience.
Generic Name: Vitamin K
DRUG INTERACTION:
Cholestyramine, mineral oil: may inhibit Gi absorption of vitamin
K
Oral anticoagulants: decreased anticoagulant effect
Antibiotics: may inhibit vitamin K production leading to bleeding
NURSING RESPONSIBILITIES :
1. Assess for contraindication.
2. Assess for baseline data.
3. Monitor protime during treatment; monitor for bleeding,
pulse and BP.
4. Teach patient not to take other supplements, unless
directed by prescriber, to take this medication as directed.
5. Tell patient that he may experience side effects brought
about by the drug and to report intolerable ones so as
prompt interventions be done.
6. Instruct patient to report symptoms of bleeding: bruising,
nosebleeds, bleack tarry stools, hematuria.
7. Stress the need for periodic lab tests to monitor
coagulation level.
8. Instruct patient to report adverse effect that he may
experience.
Generic Name: Midazolam HCl
Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Monitor level of consciousness before, during and for at least
2 – 6hours after administration.
4. Carefully monitor VS during administration.
5. Keep patient on bed for 3hours, not to permit ambulation
upon administration.
6. Teach him that the drug helps him to relax and will make him
sleep, and the drug is a potent amnesiac and he will not
remember what has happened on him.
7. Instruct him to take the drug exactly as prescribed.
8. Instruct him to avoid alcohol, or sleep – inducing, or OTC
drugs before receiving the drug.
9. Tell patient that he may experience side effects brought upon
by the drug.
10.Instruct patient to report adverse effects that he may
experience.
Generic Name: Cefoperazone Na 1 g, Sulbactam Na 0.5 g
Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Give direct IV dose slowly (over 1 to 2 minutes).
4. Monitor BP carefully during IV administration.
5. Monitor for extrapyramidal reactions, and consult physician if
they occur.
6. Keep diphenhydramine injection readily available incase of
extrapyramidal reactions.
7. Have phentolamine readily available in case of hypertensive
crisis (most likely to occur with undiagnosed
pheochromocytoma).
8. Tell patient that he may experience side effects brought upon
by the drug.
9. Instruct patient to report involuntary movement of the face,
eyes or limbs, severe depression, severe diarrhea.
10.Provide a safe environment if restlessness, involuntary muscle
movement occur.
Generic Name: Ranitidine
Nursing Responsibilities:
1. Assess for contraindications.
2. Assess for baseline data.
3. Tell patient that he may experience side effects brought upon
by the drug.
4. Instruct him to report side effects that are intolerable.
5. Control environment (temperature, lighting) if sweating or
CNS effects occur.
6. Encouraged small frequent meals if vomiting occurs.
7. Oral care for dry mouth and vomiting.
8. Encourage him to increase oral fluid intake.
9. Instruct patient to report adverse effects that he may
experience.
Generic Name: Ketorolac tromethamine
Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Infuse slowly as a bolus over no less than 15 seconds.
4. Administer with ranitidine to avoid ulceration.
5. Tell patient that he may experience side effects brought upon
by the drug.
6. Encouraged oral fluid intake to avoid dry mucous membrane.
7. Provide comfort measures if headache occurs.
8. Instruct to report intolerable side effects for prompt
intervention.
9. Instruct to report signs of bleeding such as black tarry stool,
weakness and dizziness upon standing.
10.Instruct to report if he experiences adverse effects.
Generic Name: Bupivacaine
Classification: Anesthesia
Brand Name:
Nursing Responsibilities:
1. Assess for contraindication.
2. Assess for baseline data.
3. Do not administer unless solution is clear and container is
undamaged. Discard unused portion.
4. Monitor knee-jer reflex before repeated parenteral
administration. If it is suppressed, do not administer the drug
for it may cause respiratory center failure.
5. Administer with caution if flushing and sweating occurs.
6. Have calcium gluconate readily available if signs and
symptoms of hypermagnesemia occur.
7. Tell patient that he may experience some side effects brought
about by the drug and instruct him to report intolerable side
effects so as prompt intervention be done.
8. Oral care when vomiting occurs.
9. Volume for volume replacement when excessive bowel
movement and vomiting occurs to replace the loss fluid.
10.Instruct patient to report adverse effects immediately.
Procedural Report
on Open Cholecystectomy
Definition
Cholecystectomy is the excision (removal) of the gallbladder.
Discussion
Note:
“open” cholecystectomy.
Type of Anesthesia
• General anesthesia
applied.
Skin Preparation
axilla to the pubic symphysis and down to the table on the sides.
Procedure
grasped (generally with a Pean clamp). The cystic duct, cystic artery,
and common bile duct are exposed. The surgeon must be aware of
exiting a stab wound and secured to the skin with a stitch. The wound
or skin staples.
Draping
• 4 folded towels and a laparotomy sheet
Equipment
ordered
• Suction
• Laser (e.g., Nd: YAG laser fiber or pulsed dye) when requested
Instrumentation
Supplies
• Antiembolitic hose
• Basin set
• Suction tubing
Hemovac™), optional
available
Avitene™, available
Nursing Responsibilities
Preoperative
medicolegal reasons.
• The nurse conveys to the patient that he will act as the patient’s
radiopaque dye.
• Inform the patient of the scheduled date and time of the surgery
shoes)
• The patient may have fear and anxiety regarding the surgical
perioperative events.
necessary.
• Decrease fear
Intraoperative
tract.
(considered contaminated)
as necessary.
procedure.
• Know the name and use of the instrument and handle the
instrument individually
• The scrub person sets up the instruments on the back table for
the surgeon.
• Scrub person takes care to make certain that the saline or dye
calculi)
gallbladder bed.
Postoperative
• Assess the patient: appraise air exchanges status & note skin
information.
shock
Reference
The patient last April 30, 2009 was on status post cholecystectomy.
Cholecystectomy was done to remove the gallbladder. Incision was
made. To have an effective wound healing and prevent complications,
vital signs was monitored. Patient was encouraged to take a rest. To
regain structure and function, the body needs to restore structural
integrity through repair and healing. It is very important to take note of
the discharges, its quantity and characteristic. Aseptic technique in
wound dressing was applied to prevent possibility of infection. In
addition, to promote healing, antibiotics was also given.
Jean Watson
Faye Abdellah
8. Promote bedrest,
allowing patient to assume
position of comfort.
® Bedrest in Fowler’s
position reduces
intraabdominal pressures;
however, patient will
naturally assume least
painful position.
6. Provide safe
environment such as giving
assistance in sitting and
transferring from bed to
chair or chair to bed and
use of wheelchair if
possible.
®Avoids accidental injuries
and falls.
7. Encourage early
ambulation. Support
abdomen when
ambulating.
®Early ambulation
prevents postop
complications. Splinting
provides incisional support/
decreases muscle tension
to promote cooperation
with therapeutic regimen.
Provide adequate rest
periods in between
activities.
®To prevent fatigue.
8. Administer antibiotics.
®Necessary for treatment
or prohylaxis for abscess or
infection.
9. Monitor laboratory
studies such as WBC
® Leukocytosis reflects
inflammatory process such
as abscess formation or
development or peritonitis
or pancreatitis.
Date/ Cues Need Nursing Objectives of Nursing Interventions Evaluation
Time Diagnosis Care
April S/O: Surgical H Risk for Within an 8 hr 1. Monitor vital signs. Note Goal met.
30, incision at E infection care, the client onset of fever, chills,
2009 right upper A related to will be able to: diaphoresis, changes in Within the
quadrant L presence of mentation, and complaints span of care,
3- T surgical incision 1. Be free of of increasing abdominal temperature
11pm H purulent pain. remained
®The skin is drainage or ®Suggestive of presence of normal,
P the first line of erythema; be infection/ developing patient was
E defense against afebrile sepsis, abscess or not afebrile.
R infection. Any peritonitis. No purulent
C break in its drainage
E continuity may 2. Practice good hand noted.
P allow washing and aseptic wound
T microorganisms care.
I to enter the ®Reduce risk of spread of
O body which in bacteria.
N turn can cause
- the infection, 3. Inspect incision and
H and since the dressings. Note
E patient had characteristics of drainage
A undergone from wound.
L cholecystectom ®Provides early detection
T y, there is a of developing infectious
H break of process and monitor
continuity of resolution of pre-existing
M the skin, which peritonitis.
A may contribute
N to the 4.Administer antibiotics
A development of ®May be given
G future prophylactically or to
E infections. reduce number of
M multiplying microorganisms
E Source: in the presence of infection
N to decrease spread and
T Mattson Porth, seeding of the abdominal
Essentials of cavity.
P Pathophysiolog
A y Concepts of 5. Use sterile gloves for
T Altered Health wound care. Practice
T Status, aseptic technique.
E Lippincott ®Prevents invasion of
R Williams and bacteria or microorganisms
N Wilkins, 2007 at site and eventually
prevents possible infection.
6. Instructed to maintain
clean dry clothes
preferably cotton fabric
®Skin friction caused by
stiff or rough clothes leads
to irritation of fragile skin
and increases risk for
infection.
9. Provide a cool
environment. Adjust air
conditioner as preferred by
the client.
® Hot room temperature
induces sweating which
may inhibit the healing of
wound and eventually
cause moisture at the area
delaying the healing
process.
Discharge Planning
Medicines:
• Tramadol
• Ketorolac
• Ranitidine
• Sulperazone
Mr. Police should comply with the medications he has been prescribed
with in order to aid in the recovery state after surgery. With regards to his
drugs, their side effects and their adverse effects. If he experiences any
Exercise:
weeks duration time for recovery. Once home, it is possible to tire more
resumed after about a week. Patient must follow his surgeon's advice about
driving. He shouldn't drive until he is confident that he could perform an
Treatment:
Now that the patient had his gallbladder removed, the rest is up to him. It is
important to rest and let the body recover after surgery. Consequently, to
prevent other complications, he must have his lifestyle and diet modified.
Health Teachings:
• On discharge, the nurse must advise about caring for the stitches,
given by his physician. Remind him to complete the full course of the
antibiotic treatment.
walking. Avoid doing strenuous activities which could slow down his
recovery.
side-effects.
Out-patient Care:
• a fever develops.
antibiotics
Diet:
high risk of developing heart disease, diabetes and disorders of the nervous
drastic lifestyle and dietary changes. They should limit the intake of
saturated fat and avoid the consumption of alcoholic beverages. Also, they
should eat smaller amounts of food during a single meal. People who have
had gall bladder removal surgery are advised to eat around 5 or 6 smaller
meals a day instead of 2 or 3 usual meals. Considering the fact that the
help of the gall bladder, operated patients also need to take vitamin and
PROGNOSIS
Computation:
No. of categories rated POOR (1) + No. of categories rated FAIR (2)
+
= 6 + 12
=18/7
=2.57
1-1.6 =POOR
1.7-2.3 =FAIR
2.4-3.0 =GOOD
General Prognosis:
The general prognosis of the client is good. This means that the client
has a good chance of recovering from his illness.
Conclusion
Generally, the student nurse’s one week exposure and duty at the
care and promoting holistic wellness to their clients. It reminded them again
tasks.
After five days of exposure at St. Joseph (3C) ward, the student nurses
has identified and understood the causative factors of cholecystitis, its signs
Upon learning his case, it challenged and motivated them to work hard to
gallbladder stones. It occurs when a stone blocks the cystic duct, which
carries bile from the gallbladder. Predisposing factors can include heredity,
age, sex and race. With the presented factors that cannot already be
modified, one has to take action towards preventing the disease to happen.
The only one who can help yourself is you alone. With the proper knowledge
about the nature of the disease as well as its preventive measures along with
responsibility and sense of will, one can surely direct himself away from the
complications.
Our gallbladder is not to be taken for granted. There have been reports
empyema of gallbladder).
“No matter how the disease has already reached an alarming incidence rate or not, it is
a duty of every human person to take care of his own body, not just for the sake of other people
that depend on him, but most especially for himself ~ a primary obligation that he must fulfil.”
Recommendation
thoroughly studying Mr. Police’s case, the group has come up with the
following recommendations:
To the client:
on the healthcare team. More than anything else, there must be willingness
to recover on the part of the patient. With this, he must carry out his
his thoughts and feelings to his medical attendants, such as his nurses,
his part thus, hindering his recovery or yet understand that the things that
his nurses is doing for him is for his own good and betterment in life. He is
much as he can through complying with the treatment being given to him
and through continuing his rehabilitation process so that the chances of his
against the disease. The family members should be involved with his
present. More than that, they should give their emotional support to boost
educated with the basic facts about the patient’s condition so that they will
understand his condition better. Not only that, they should always asked the
always ready to lend a helping hand. Through this, they would be able to
know how to manage and meet his needs when he is discharged from the
To the group
Maintain practicing teamwork and unity within the group so that better
group members. If one is done with the task, try to help the others and
contribute something that would make the work better. Being calm is always
It is not through a single effort that you learn the entirety of a certain
with the necessary knowledge that will help you in your endeavors especially
this that you can provide the quality and holistic nursing care that patients
need. You should realize that your patients are also humans, though suffering
approaching them so that you can be of help in the best way you can.
Nursing students of AdDU should be committed to the goal of being men and
women for others. They should not only appreciate the concepts during
lecture session but should also positively digest the experiences they get
providing the best exposures to its nursing students. The faculty and staff
cheaper, less invasive and more aesthetic procedure is preferred. The group
would like to comment on the success of the emergence of new studies and
• http://www.nottingham.ac.uk/nursing/sonet/rlos/bioproc/resources.html
• http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html
• http://www.le.ac.uk/pa/teach/va/anatomy/case5/frmst5.html
• http://digestive.niddk.nih.gov/statistics
Edition
• Deglin, Judith H., Vallerand, April H. Davis’s Drug Guide for Nurses, 10th
• Yearbook 1996.
USA: The
USA:Lippincott,
o Williams and Wilkins 2006.
Philadelphia.
o 4th edition.
Thomson
CA, USA.
• Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne
C.
ed. Vol.1.
Care
Pennsylvania,2006.
Williams &
o Wilkins, 2007.
• MIMS, 108th ed. CMPMedica Asia Pte Ltd, Singapore, 2004.
Health States.