I

INTRODUCTION

Description of the Disease

The gallbladder is a small pear-shaped organ which aids in the digestive
process. Its function is to store and concentrate bile - a digestive liquid continually
secreted by the liver. The bile in turn emulsifies fats and neutralizes acids in partly
digested food. Despite its importance in the digestion of fat, many people are
unaware of their gallbladder. Fortunately 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 room for gallbladder complications to occur.
As defined, cholecystitis is the inflammation of the gall bladder. It came from
the greek word cholecyst which means gallbladder and the suffix itis which
means inflammation. The inflammation occurs mainly because of an obstruction of
the cystic duct by a stone. Blockage of the cystic duct with gallstones causes
accumulation

of

bile

in

the gallbladder and

increased

pressure

within

the

gallbladder. Concentrated bile, pressure, and sometimes bacterial infection irritate

and damage the gallbladder wall, causing inflammation and swelling of the
gallbladder. Inflammation and swelling of the gallbladder can reduce normal blood
flow to areas of the gallbladder, which can lead to cell death due to insufficient
oxygen. Not everyone who has gallstones will go on to develop cholecystitis. People
with history of gallstones are at high risk for having cholecystitis, as well as those
who are obese and those with sedentary lifestyle. The most common presenting
symptom of cholecystitis is upper abdominal pain. However, this may appear
asymptomatic, initially. Physical examinations may reveal fever, tachycardia, and
tenderness in the RUQ or epigastric region, often with guarding behaviour.

Recent Trends, Innovations, and/ or Refinements in Treatment

Robotic Scarless Gallbladder Surgery [ ScienceDaily (Dec. 11, 2012) ]
Yassar Youssef, M.D., is the first surgeon in Baltimore City to perform gallbladder
surgery using just one incision and the da Vinci Surgical System. Because the single
1 | Page

incision of about an inch is made in the patient's navel, he or she is left without a
noticeable scar. Additional patient benefits are less pain, less blood loss and a faster
recovery compared even with minimally invasive gallbladder removal that requires
multiple incisions. This is good news for the one million Americans who need their
gallbladders removed each year, most of whom are candidates for this single-site,
robotic approach.
More than any other hospital in Maryland, Sinai Hospital has made technologic
investments in its da Vinci Surgical System; in addition to having da Vinci Single-Site
instruments that enable Youssef to perform gallbladder removal, the hospital has
two da Vinci units, an extra console allowing two surgeons to operate in tandem on
a patient, and other advanced instruments. Sinai's sister hospital, Northwest, also
has its own da Vinci Surgical System. Youssef has plans to train other surgeons on
the da Vinci, including those in Sinai's surgical residency program. Sinai Hospital is a
part of LifeBridge Health, one of the largest, most comprehensive providers of
health services in northwest Baltimore. LifeBridge Health also includes Northwest
Hospital, Levindale Hebrew Geriatric Center and Hospital, Courtland Gardens
Nursing & Rehabilitation Center, and related subsidiaries and affiliates.
Statistics (Local & International)
About 10-20% of Americans have gallstones, and as many as one third of
these people develop cholecystitis. On the other hand, Indian and Scandinavian
people have the highest prevalence of cholecystitis, it affected 20.5 million people
with a record of approximately 7,000 deaths in 2012. Hospitalizations total up to
636,000 in the same year and over 500,000 have undergone cholecystectomies.
In the Philippines alone, 5, 073, 040 people are affected by the disease last 2011.
Generally, the incidence of cholecystitis increases with age and it is 2-3 times more
frequent in females than in males.

Objectives of the Study

A. General Objective
2 | Page

After the entire hospital rotation at Rafael Lazatin Memorial Medical Hospital, the
student nurses will be able to:

Know and understand the disease process and concept of Cholecystitis.

B. Specific Objectives
After the entire hospital rotation at Rafael Lazatin Memorial Medical Hospital, the
student nurses will be able to:

Cognitive

Review the Proper Physical Assessment (IPPA) and how to do them efficiently;

Understand

the

Disease

Process:

the

causes,

effects,

management, treatment, and possible preventions;

Determine the Pathophysiology of the condition with their rationale for

occurrence of each manifestation;

Determine why certain management and medications are given and provided
for the condition;

Understand how and why certain diagnostic tests are done for the condition,
and

Review the concepts about the Anatomy and Physiology with regards to the
disease condition.

Psychomotor

Perform proper physical assessment (IPPA) to the patient efficiently;

Perform thorough health history from patient and significant others;

Participate in the course of care of patient;

Provide health teachings to the patient about certain interventions in the

maintenance of healthcare.

Affective

3 | Page

Establish rapport and therapeutic interaction with the patient and significant
others to obtain necessary information and positive compliance to care being
provided;

Provide care and health teachings necessary for the betterment of the
condition of the patient.

Share the learning acquired to co-student-nurses to increase awareness and

help them if ever they will encounter patient with the same condition.

I.

NURSING

HISTORY

Biographic Data
This is a case of a 46 years old Filipino named Mr. Naguit who was born on the
27

th

day of February 1967. He is currently living at Angeles City.

The client is

married and has six children and one grandchild all of which lives under the same
roof with him and his wife.

The clients main language for communication is

Kapampangan but he also knows how to speak Tagalog and English as well.
As stated by the patient, he experienced dizziness and an intolerable sharp
stabbing pain in his abdominal area on the day of his hospitalization which made
him decide to go to the hospital. He was brought by his wife and was admitted at
Ospital Ning Angeles last November 19,2013 at 7:45pm with the diagnosis of
Cholecystitis; Anemia to be considered under the care of the admitting physician
Dr. Balajadia.

Past Medical History

During the one on one interview of the student nurse with the client, the
client stated that he has complete immunization as child and had experienced only

4 | Page

a couple of minor illnesses for the past years such as cough, common colds, and
fever.
The patient had no record of previous hospitalizations and that this was his
first time to be confined in a hospital. Although on the year of 2008, he had
experienced an accident wherein he fell down from the stairs in the Grotto in
Bamban, Tarlac which gave him a sprain in his left foot but the client said that it was
not that serious and did not required hospitalization.
Lifestyle
Our client usually wakes up at 5:00 in the morning so as to help his wife
prepare his children to go to school, after which he gets ready to go to work as well.
He works 8 hours a day as a driver of dump trucks under the management of the
government. He walks to and from his work which basically becomes his daily form
of exercise. The patient eats 3 times a day, breakfast, lunch and dinner respectively,
and he mentioned that he loves to eat food high in cholesterol such as Fried Pork,
and Chicharon. He said that he is not picky when it comes to food but he enjoys
eating and get to eat a lot when hes eating fatty foods because it gives the food
more flavor and makes it savory.
He has no vices, although he used to smoke and drink, according to him he
decided to stop smoking five months ago and was able to continue that change until
now. As for his alcohol consumption, the client said that he only drinks alcoholic
beverages during special occasions but in light to moderate consumption only. One
of his ways to manage stress is to play with his grandchild,who for the client, gives
joy to the whole family and brighten up everyones day in the Naguits residence.

Present History of Illness

Chief Complaint: Dizziness and Abdominal Pain on the RUQ
A month prior to admission, Mr. Naguit experienced right upper quadrant pain
associated with a sense of bloatedness and dizziness. The pain was tolerable so he
5 | Page

did not seek medical attention yet. He also said that he had an increased level of
pain tolerance so he also didnt mind to take any pain relievers. Until three days
prior to admission, patient had severe right upper quadrant pain, which was said to
be intolerable. Moreover, when pressure is applied on the RUQ 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 he was positive with Murphys sign. Ultrasound
revealed cholecystitis, so patient was advised admission and operation.

Character: When interviewed, the patient experienced sharp stabbing pain on the
Right Upper Quadrant of the abdomen.
Onset: The onset of pain was sudden.
Location: The pain was located on the Right Upper Quadrant of the patients
abdomen.
Duration: According to the patient, the pain lasted for minutes.
Severity: The pain was severe and intolerable wherein he could no longer perform
his Activities of Daily Living.
Pattern: According to the patient, the pain was intermittent.
Associated Factors: According to Mr. Naguit, when the pain occurs, he would then
suffer from weakness and dizziness.
Family History of Illness
As stated by the client, both his parents died due to Diabetes Mellitus, and he
also have a family history of Asthma traced back to his grandfather in his mothers
side. He also stated that two of his siblings are Hypertensive and his grandfather in
his fathers side died due to Hypertension.

II.

PHYSICAL ASSESSMENT

Nurse Patient Interaction (November 21, 2013)

At around 8 am, physical survey was done. Mr. Naguit, a 46 year old male
was received lying in bed, conscious, coherent and awake with an IVF of #4 PNSS
6 | Page

1L, at the level of 500 cc, KVO, infusing well at his left hand. Patient was on NPO and
complains of pain, with a pain scale of 7/10. Patient was in good grooming wearing
white shirt and maong pants.
Vital Signs taken are as follows:

FINDINGS

IMPRESSION
Normal

PULSE RATE

120/80
mmHg
79 bpm

RESPIRATORY RATE

16 cpm

Normal

TEMPERATURE

37.1 C
/axilla

Normal

BLOOD PRESSURE

Normal

Skin:
Skin was warm to touch, slightly dry, rough, and with good skin turgor.
Neither jaundice nor cyanosis observed.

No bruises or discolorations

observed. No edema noted.

Head:

Skull and face were symmetrical with an equal distribution of hair. Hair was
black in color. There was no dandruff or infestation present. No lesions,
lacerations, tenderness, masses and depressions noted.

Eyes:

The client has straight normal eye condition; with slight icteric sclera.
Pupil is brown in color and equal in size; reactive to light and accomodation.
Have thin eyebrows.

Ears:

Skin color is same as facial skin, auricle aligned with outer canthus of eye,
mobile, firm, and not tender; pinna recoils after it is folded; presence of
cerumen noted.

Nose:

7 | Page

Nose is uniform in color and has slight discharges; there are no masses or
tenderness upon palpation.

Mouth and Throat:

Lips are pale; tongue is at the center and has no discharge; Oral cavity has
no sores and lesions.

Neck

Neck was symmetrical with no masses or swelling noted. No jugular vein

distention was noted. Range of motion was normal and moves easily without
discomfort upon rotation, flexion, extension and hyperextension.

Thorax and Lungs:

Respiratory rate was 16 cycles per minute with regular breathing pattern.
Symmetrical chest expansion was observed during respiration. No use of
accessory muscles during breathing observed. Chest wall was intact; no
tenderness and

masses noted.

Uniform temperature

also noted. No

adventitious breath sounds heard upon auscultation. No cough present. No

dyspnea, hemoptysis, hiccups noted.
Abdomen:

Abdomen was slighty enlarged and globular when patient was in supine
position. Tenderness noted on the right upper quadrant when
palpated.

Genito- Urinary:

Unable to perform inspection in the genitourinary region. However, patient

verbalized that he had not seen any discharges from her genitalia nor
presence of papules or ulcerations. The patient voided with a yellow colored
urine.

Back & Extremities:

8 | Page

Symmetrical shoulder movement observed during respiration. Spine was

located at the midline with no discrepancies noted. Shoulders, arms, elbows
and forearms were free from nodules and deformities. Upper extremities were
not edematous. Radial and brachial pulses were present. Hip joint and thighs
were symmetrical with no deformities present. No edema noted at both legs.
No inflammation noted in the lower extremities

9 | Page

IV.

DIAGNOSTICS

AND

LABORATOR Y RESULTS

HEMATOLOGY

Diagnostic/
Laboratory
procedures

Hemoglobi
n

Date
ordered/
Date
result(s)
in:

DO: 11-1713
DR: 11-1713

Indication(s
)
or
Purpose(s)

To measure
protein used
by red blood
cell
to
distribute
oxygen
to
the
other
tissue
and
cell in the
body

Result

87

Normal
value
(units
used in
the
hospital)
140180gm/L

There is low
hgb
level.
The patient is
possible
to
have anemia.
This indicates
that
the
patient
has
poor blood's
ability
to
carry oxygen
throughout
his body.

0.40-0.54
L/L

There is low
hct
level.
This means
that there is
insufficient
blood volume
composed of
RBCs, which
are
the
responsible
for carrying
oxygen in the
body.

63
DO: 11-2013
DR: 11-2013

Hematocrit

DO:
13
DR:
13

11-1711-17-

To measure
the amount
of blood that
is occupied
by the red
blood cell

0.26

0.19
DO:
13
DR:
13

11-20-

Analysis
and
Interpretati
on of
Results

11-20-

10 | P a g e

RBC count

DO:
13
DR:
13

DO:
13
DR:
13
WBC Count

DO:
13
DR:
13

11-1711-17-

11-20-

To measure
the number
of red blood
cells
per
volume
of
blood
and
determine
for presence
of
polycythemi
a,
dehydration,
and anemia.

3.03

To determine
infection/
inflammation
& also to
determine
and evaluate
the
bodys
physiologic
capacity to
resist
and
overcome
infection.

15.0

4.56.3x10
12/L

2.21
Decreased
level of RBC
may indicate
presence of
anemia.

11-20-

11-1711-17-

Decreased
level of RBC
may indicate
presence of
anemia.

5-10 x
10/L

The elevated
value of the
WBCs
is
indicative of
a
bacterial
infection
which
may
be due to the
inflamed
gallbladder.

.40-74%

Neutrophil
level is above
normal
range.
It
could
suggest that
there is a
presence of
viral
infection,
tissue
necrosis,

12.6
DO:
13
DR:
13
Neutrophils

DO:
13
DR:
13

11-2011-20-

11-1711-17-

To determine
possible
presence of
infections
and
tissue
necrosis

0.81

0.76

11 | P a g e

DO:
13
DR:
13

acute stress
response or
bacterial
infection.

11-2011-20-

Neutrophil
level is above
normal
range.
It
could
suggest that
there is a
presence of
viral
infection,
tissue
necrosis,
acute stress
response or
bacterial
infection.

Lymphocyt
es

DO:
13
DR:
13

11-1711-17-

To determine
the presence
of
viral
infection and
inflammation

0.19

19-48%

The
results
are
within
normal
range.

0.24
DO:
13
DR:
13
Platelet
Count

11-20-

The result is
within normal
range.

11-20-

DO: 11-1713
DR: 11-1713

Responsible
or
blood
clotting, thus
preventing
blood loss.

205

236
DO: 11-2013
DR: 11-2013

150-400%
x 0 q/L

Results show
that Platelet
is
in
the
normal range
this
means
that
there
are
less
chances
of
developing
hemorrhage.
Results show
that Platelet
12 | P a g e

is
in
the
normal range
this
means
that
there
are
less
chances
of
developing
hemorrhage.
Blood Type

DO:
13
DR:
13

11-2011-20-

A blood
type is used
to
classify
blood based
on
the
presence or
absence
of
inherited ant
igenic
Substances
on
the
surface
of red blood
cells (RBCs).

Type A
RH
(D):
Positive

Patients
blood type is
type A, RH
positive.

Nursing Responsibilities
Before

During

After

Check for the specific

test ordered by the
doctor.
Explain the test and why
is it needed.

Ensure that the blood

sample is not taken from a
vein in the hand or arm
with an intravenous line.
Hemodilution
with
intravenous or plasma will
lower the hematocrit value
falsely.

Instruct the SO to apply

pressure to the puncture
site until bleeding stops.
Assess
for
hematoma
formation.
Document
the
test
performed

Explain to the patient

that it is normal for the
patient to feel pain and
some discomforts while
performing
the
procedure.
Explain to the client that
an amount of blood will
be extracted from the
brachial arm.

13 | P a g e

BLOOD CHEMISTRY

Diagnostic/
Laboratory
procedures

Blood Urea
Nitrogen
(BUN)

Date
ordered/
Date
result(s)
in:

Indication(s
)
or
Purpose(s)

Result

Normal
value
(units
used in
the
hospital)

Analysis and
Interpretatio
n of Results

DO: 11-2013
DR: 11-2013

To
assess
renal
functions
and
the
ability
of
kidneys
to
excrete urea
and protein.

Traditional:
30.0

Traditional:
9- 20mg/dl

S.I:
10.71

S.I:
3.27.1mmol/L

SGPT
(Serum
Glutamic
PyruvicTransaminas
e)

DO: 11-2013
DR: 11-2013

SGPT is a
specific
indicator of
liver
dysfunction.

S.I:
37.0

S.I:
21-72 ul/l

The result is
within normal
range.

BUA

DO: 11-2013
DR: 11-2013

Determines
how
much
uric acid is
present
in
your blood.
The test can
help
determine
how
well
your
body
produces

Traditional:
15.4

Traditional:
3.58.5mg/dl
S.I:
208-506
umol/L

An increase in
the level of
BUN indicates
a
impaired
kidney
function.

S.I:
916.3

An increase in
the level of
BUN indicates
an
impaired
kidney
function.

14 | P a g e

and removes
uric acid.
HBsAg
(Hepatitis B
surface
antigen
screening)

DO: 11-2013
DR: 11-2013

Diagnosis of
acute,
recent,
or
chronic
hepatitis
B
infection

Non
Reactive

Non
Reactive

Non
Reactive

Non
Reactive

Determinatio
n of chronic
hepatitis
B
infection
status

ANTI- HCV
Screening

DO: 11-2013
DR: 11-2013

Diganosis of
Hepatitis
C
Virus.

Nursing Responsibilities
Before

During

After

Check for the specific

test ordered by the
doctor.

Wipe with cotton balls and

alcohol the site where
insertion is done

Instruct the SO to apply

pressure to the puncture
site until bleeding stops.

Tell the SO when the needle

will be inserted for them to
get prepared
Explain the test and why
is it needed.

Assess
the
site
hematoma formation.

for

15 | P a g e

Inform that there are no

food or fluid restrictions

Document
performed.

the

test

Inform that the test

requires blood sample,
tell who will do the test
and when
Tell that there will be
discomfort
from
the
needle
that
will
be
inserted and pressure
from the tourniquet.
If the patient is being
treated
for
infection,
advise that the test will
be
repeated
several
times to maintain the
progress.

Explain to the client that

an amount of blood will
be extracted from the
brachial arm.

ULTRASOUND REPORT

Purpose

Result

Interpretation

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WHOLE
ABDOMINAL
ULTRASOUND

Medical test that uses highfrequency sound waves to

capture live images from
the inside of your body,
which help the military
detect planes and ships
also allows doctor to see
problems
with
organs,
vessels, and tissues without
needing
to
make
an
incision.

Right Liver Lobe: 14.0 x 11.8 x 10.5 cm

Left Liver Lobe : 3.98 x 4.95 x 3.71 cm
Gallbladder
: 8.10 x 2.65 cm
Spleen
: 11.2 x 3.68 cm
Pancreas
: 0.95 x 1.12 x 0.69cm (H x
B x T)
Right Kidney
: 9.47 x 4.44 cm
Cortical Thickness: 1.69 cm
Left Kidney
: 9.62 x 5.21 cm
Cortical Thickness: 1.99 cm
Prostate
: 2.81 x 2.86 x 2.79cm (11.7
grams)

Obstructed
biliary
disease with the
presence of stones
in the cystic duct.
Intrahepatic
ducts
are dilated and gall
bladder
is
distended. Consider
Chocystitis.

The liver and spleen are slightly enlarged.

It has smooth contour and homogenous
parenchymal echo pattern.
The gallbladder is slightly dilated. The walls
are thickened (o.58 cm) There are several
high lever echoes noted within, measuring
an average of 0.49cm. The cystic duct is
10mm
with
an
11mm
shadowing
calcification at the proximal segment.
Pancreas is normal in size. Parenchymal
echopattern is uniform. Pancreatic ducts
are not dilated.
Urinary bladder is adequately distended.
No intravesical echoes seen. The prostate
gland is not enlarged. Parenchymal
echopattern is homogenous.

Nursing Responsibilities (Whole abdominal Ultrasound):

Preprocedural Care:
1.
2.
3.
4.

Check for the specific test ordered by the doctor.

Check for materials needed.
Secure a laboratory request.
Explain the procedure to the SO.

5. Inform that there the patient is not allowed to eat and can only drink
with small amount of water in taking medicines.
6. Inform the patient about the procedure. Tell him/her that there will be
no discomfort while doing the procedure.
17 | P a g e

During the test patient care.

1.

Assisting to adhere to standard precautions.

2.

Provide emotional support.

3.

Assist the patient and the physician during the procedure

Postprocedural Care:
1. Obtain results and secure it to the patients chart.
2. Refer the results to the physician.
3. Document the test performed.

URINALYSIS

Diagnostic/
Laboratory
procedures

URINALYSIS

Date
ordered/
Date
result(s)
in:

DO: 11-1713
DR: 11-1713

Indication
(s)
or
Purpose(s
)

The
diagnostic
test
is
performed
for
the
general
evaluation
of
the
patients
health.
It
helps
in
identifying
metabolic
and
systemic
diseases or

Result

Color: Yellow

Normal
value
(units
used in
the
hospital
)
Straw to
dark
yellow

Transparency
Slightly
turbid

Clear

pH: 6.5
(Acidic)

pH 6.5
8.0

Analysis and
Interpretation
of Results
Result
indicates
normal finding.

Result
may
indicate
the
presence
of
particulate
matters such as
bile, bacteria, pus
and hemolysis.
Result
indicates
normal
finding.
Freshly
voided
urine is normally
somewhat acidic

18 | P a g e

disorders
that affect
the kidney
and
urinary
tract.
Urinalysis
is ordered
to identify
any
deviation
that
may
indicate
the
diagnosis
of
the
patient.

Sp. Gr.: 1.020

1.005
1.035

Result is within
normal range.

Albumin: +3
Trace

Negative
()

Functional
albuminuria may
be present during
acute illness but
is just temporary.
This may also
indicate
Renal
disease

Sugar:
Negative ()

Negative
()

Result
indicates
normal finding.

MICROSCOPIC FINDINGS
Pus cells:
0.2/hpf
Epithelial
Cells:
Few

None

Result
may
indicate
urinary
tract
infection
alterations
in
kidney function.

19 | P a g e

NURSING RESPONSIBILITIES:
Pre procedural care:
1. Check the doctors order.
2. Explain to the patient and SO the procedure and purpose of
urinalysis.
3. Provide clean specimen cup.
4. Explain to the patient to obtain midstream urine.
5. Advise the patient to wash urinary meatus prior to collecting the
specimen to avoid contamination.
6. Inform the patient that there is no fluid and food restriction
needed.

20 | P a g e

7. Refrigerate the specimen if analysis will be delayed longer than 1

hour.
During the procedure patient care:
1. Provide privacy throughout the procedure
2. Collect the urine in a clean specimen cup.
3. Label the specimen cup properly.
Post procedural care:
1. The specimen should be delivered to the laboratory within 1
hour.
2. Obtain results and secure it to the chart.
3. Refer the results to the physician.
V.

THE

PATIENT

AND

HIS

ILLNESS

Anatomy and Physiology

Figure 1.0 Biliary System

THE BILIARY SYSTEM

21 | P a g e

The biliary system consists of the organs and ducts (bile ducts, gallbladder,
and associated structures) that are involved in the production and transportation of
bile. The transportation of bile follows this sequence:

When the liver cells secrete bile, it is collected by a system of ducts

that flow from the liver through the right and left hepatic ducts.

These ducts ultimately drain into the common hepatic duct.

The common hepatic duct then joins with the cystic duct from the
gallbladder to form the common bile duct, which runs from the liver to
the duodenum (the first section of the small intestine).

However, not all bile runs directly into the duodenum. About 50
percent of the bile produced by the liver is first stored in the
gallbladder, a pear-shaped organ located directly below the liver.

Then, when food is eaten, the gallbladder contracts and releases

stored bile into the duodenum to help break down the fats.

Functions of the Biliary System

The biliary system's main function includes the following:
22 | P a g e

a. to drain waste products from the liver into the duodenum

b. to help in digestion with the controlled release of *bile

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile
salts), required for the digestion of food. It is secreted by the liver cells to perform
two primary functions, including the following:
a. to carry away waste products, and
b. to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Without
adequate bile, our body cannot metabolize fats which can result in a deficiency of
the fat-soluble vitamins (A, D, E and K). We may also have problems digesting the
essential fatty acids. Amongst other symptoms we could have trouble utilizing
calcium, have dry skin, peeling on the soles of your feet, etc. One way we can tell
we have trouble digesting fats is if we have excessive burping that starts shortly
after eating a meal that has fat in it. We might feel nauseous or experience gas and
bloating. Bile, which is excreted from the body in the form of feces, is what gives
feces its dark brown color.

GALLBLADDER

The gallbladder is a small pouch that sits just under the liver. The gallbladder (or
cholecyst or gall bladder) is a small non-vital organ that aids in the digestive
process and stores bile produced in the liver. It stores bile produced by the liver.
After meals, the gallbladder is empty and flat, like a deflated balloon. Before a meal,
the gallbladder may be full of bile and about the size of a small pear.

23 | P a g e

The adult human gallbladder stores about

50 mL (1.7 US fluid ounces / 1.8 Imperial
fluid ounces) of bile, which is released
when food containing fat enters the
digestive tract, stimulating the secretion
of cholecystokinin (CCK). The bile,
produced in the liver, emulsifies fats in
partly digested food. After being stored in
the gallbladder, the bile becomes more
concentrated than when it left the liver,
increasing its potency and intensifying its
effect on fats. Most digestion occurs in
the duodenum.

In response to signals, the gallbladder squeezes stored bile into the small intestine
through a series of tubes called ducts. Bile helps digest fats, but the gallbladder
itself is not essential. Removing the gallbladder in an otherwise healthy individual
typically causes no observable problems with health or digestion yet there may be a
small risk of diarrhea and fat malabsorption.

COMMON BILE DUCT

The common bile duct is a tube-like anatomic structure in the human

gastrointestinal tract. It is formed by the union of the common hepatic duct and the
cystic duct (from the gall bladder). It is later joined by the pancreatic duct to form
the ampulla of Vater. There, the two ducts are surr ounded by the muscular
sphincter of Oddi.
When the sphincter of Oddi is closed,
newly synthesized bile from the liver is
forced into storage in the gall bladder.
When open, the stored and concentrated
bile exits into the duodenum. This
conduction of bile is the main function of
the common bile duct. The hormone
cholecystokinin, when stimulated by a
fatty meal, promotes bile secretion by
increased production of hepatic bile,
contraction of the gall bladder, and
relaxation of the Sphincter of Oddi.

24 | P a g e

CYSTIC DUCT
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.

COMMON HEPATIC DUCT

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.

Precipitating Factors:
Predisposing Factors: PATHOPHYSIOLOGY
(Book Based)
Diet
Gender
Medications and Oral Contraceptives
Age
Obesity
Race
Rapid Weight Loss
Heredity
Spinal Cord Injury
Pregnancy
Liver cells secrete
Primary Biliary Cirrhosis
Liver excrete Diabetes
The bacteria
Liver
Calcium
Unconjugated
Liver excrete
enters
Mellitus
cholesterol into bile
relatively high Hemolytic
hydrolyze
excrete
bile
passively
some
tends
Syndromes 25 | P a Bilirubin
along with
ge
Liver Some
cells of the
Increase in
Bacterial
Invasion
Formation
proportion of Ileal
conjugated
Disease,
conjugated
Resection and Bypass
unconjugated
along
to form
withof
phospholipid in the
also
unconjugate
hydrolysis
of
Calcium
unilamellar
Infection into
cholesterol in Biliary
bilirubin
bilirubin
bilirubin
insoluble
other into
form of unilamellar
Release of
Formation of
secrete
d bilirubin
of lecithin
Residual
bacteria
Bilirubinate
vesicles
the
bile
bile
precipitates
electrolytes
vesicles
fatty acids bile
mixed micelles
bile salts
vesicles

The cholesterol
carrying capacity
of the micelles
and residual
vesicles is
exceeded
Bile is
supersaturated
with cholesterol

Formation of
Crystals

Nucleation of
cholesterol
crystals

fatty acids
Black
forms
complex
Pigment
with
calcium
Gallstones

Attraction
of
Leukocyte
s
leukocyte
s
hydrolyze
bilirubin
conjugate
s and
fatty

Bacteria
release
lytic
enzyme

Formation of
Calcium
Bilirubinate

Brown
Pigment
Gallstones

Cholesterol
Gallstones

Mixed
Stones

26 | P a g e

CHOLELITHIASIS

Gallstone tries to
go out of the
gallbladder

Obstruction of the
common bile duct by
gallstones
(Choledocholelithiasi
s)

Obstruction of the
cystic duct by
gallstones

Cholestasis

Prolong
Cholestasis

Release
Disruption
of of mucous
phospholipase
coat of from
the gallbladder
the
epitheliumepithelium
of the
gallbladder
Absence of Bile
in the duodenum

levels of
bilirubin/bile
pigments in the
circulation

Hydrolization
of lecithin
Damages
mucosal
cells due to detergent
into lysolecithin
action of bile salts

Hepatomegaly

Fibrosis

Liver Cirrhosis

S/S
Indigestion,
Vit ADEK
deficiency,
gray stools

S/S jaundice,
ecteric sclera,
pruritus, dark
urine

Irritation of the
gallbladder wall

27 | P a g e

Fibrous nodules distorts

the architecture of the
liver
Resistance to
portal blood flow

Increase
pressure in
hepatic portal
Portal Hypertension

S/S Biliary Colic,

Tenderness,
Murphys sign,
nausea and
vomiting, fever,
elevated wbc,

IF TREATED:

Release of prostaglandins
within the gallbladder
wall
ACUTE
M
CHOLECYSTITIS

IF NOT TREATED

Open Cholecystectomy
Laparoscopic
Cholecystectomy
Litotripsy
Ursodeoxycholicacid

GOOD PROGNOSIS

Bacteria invade
External
the
injured
surface
gallbladder
of the
through
gallbladder
the blood,is
lymphatic
scarred
or bile
and
ducts form
layered
adjacent
by
organs
fibrinous
exudates and
(Empyema
of the
distended
gallbladder)

Edema, hemorrhage and

suppuration of the
gallbladder wall

28 | P a g e

Compression of
blood vessels

Increased
Intraluminal pressure

Compromised blood
flow to the mucosa
and lymphatic stasis

Ischemia

Ulcerations of the
mucosa

Necrosis

Gangrenous
Cholecystitis

29 | P a g e

Free Perforation

Localized
Perforation

Adhesion to an
adjacent hollow
viscus
(duodenum)

Pericholecystic abcess

Cholecystoenteri
c fistula
formation
Gall stone induced
intestinal
obstruction
(gallstone ileus);
drainage of bile into
adjacent organs;
entry of air and
bacteria into the

As the intestine
becomes
congested, its
ability to absorb
food and fluids
decreases

Cut off the blood

supply to the
affected portion
of your intestine

Ischemia

30 | P a g e

Dehydration

Necrosis

Hypovolemia

Perforation in
the intestinal
wall

Hypovolemic
shock
Generalized Peritonitis

Sepsis

Septic Shock

S/S fever, chills,

tachycardia

DEATH

31 | P a g e

Liver failure

Liver is unable to
convert the
protein byproduct
ammonia into
urea

Shunting of blood
into the splenic vein

Spleen enlarges to
compensate
decreased liver
function

Blockage
Increase
or increase
pressure in
pressure inperitoneal
the portalcapillaries
vein
causes blood to backflow to
the different vessels located
near the esophagus and GIT
Fluid shifting from
the portal vein to the
peritoneal cavity

32 | P a g e

Splenomegal
y

Ammonia enters
general circulation

Increase in size
decreases the
spleens ability to
function properly or
loss of function

Morphologic
changes in
astrocytes

Astrocytes may
undergo Alzheimer
type II astrocytosis

Astrocytes become
swollen

Development of a
large pale nucleus,
a prominent
nucleolus, and
margination of
chromatin

HEPATIC
ENCEPHALOPATHY

S/S
Asterixi
s

Increases in blood
waste product since
spleen is not able
to properly destroy
RBCs
Death
S/S
Thrombocyto
penia,
anemia,
leukopenia

Gastroesophageal
Varices

Ascites

Rupture Invasion of
bacteria from
the blood, or
Hypovolemilymph or
a
through the
bowel wall
Hypovolemic
Spontaneous
shock
Bacterial Peritonitis
Death
Sepsis
S/S Fever,
diarrhea,
abdominal
Septic
pain
Shock
Death

S/S Anorexia, Nausea,

Liver tenderness,
Jaundice

33 | P a g e

Cerebral edema

Increased
intracranial
pressure

Brain Hernation

Hepatic Coma

DEATH

Synthesis of the Disease:

Cholecystitis is defined as inflammation of the gallbladder that occurs most
commonly because of an obstruction of the cystic duct from cholelithiasis. It is
caused by an obstruction of the cystic duct, leading to distention of the gallbladder.
As the gallbladder becomes distended, blood flow and lymphatic drainage are
compromised, leading to mucosal ischemia and necrosis.

Predisposing Factors:
Gender: Women have twice the risk as men of developing cholesterol gallstones
because estrogen increases biliary cholesterol secretion. Before puberty this risk is
negligible, and beyond menopause the increased risk disappears.
34 | P a g e

Age: The incidence increases with age. Less than 5-6% of the population under age
40 have stones, in contrast to 25-30% of those over 80.
Race: Prevalence highest in North American Indians, Chilean Indians, and Chilean
Hispanics, greater in Northern Europe and North America than in Asia, lowest in
Japan; familial disposition; hereditary aspects
Heredity: Family history alone imparts increased risk, as do a variety of inborn
errors of metabolism that lead to impaired bile salt synthesis and secretion or
generate increased serum and biliary levels of cholesterol, such as defects in
lipoprotein

receptors

(hyperlipidemia

syndromes),

which

engender

marked

increases in cholesterol biosynthesis.

Pregnancy: Pregnancy is an independent risk factor for cholesterol gallstones. The
risk increases with increasing parity, especially with more than two children. During
pregnancy, elevated estrogen and progesterone levels increase biliary cholesterol
secretion. Elevated progesterone also inhibits gallbladder contractility. 40% of
women develop biliary sludge in their gallbladder and 12% of women form their first
stones during pregnancy. The incidence of gallstones is higher in women with
multiple pregnancies.

Precipitating Factors:
Diet (High Fat, High Sodium): Increased intake of calories, refined carbohydrate,
cholesterol, and saturated fats has all been postulated to cause cholesterol
gallstones. Patients with cholesterol gallstones secrete a greater fraction of dietary
cholesterol into bile than do normal subjects.
Medications

and

Oral

Contraceptives:

Hypolipidemic

agents

(clofibrate,

gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion

increase the risk of cholesterol gallstones by twofold to threefold. Competitive
inhibitors
(lovastatin,

of

3-hydroxy-3-methylglutaryl

simvastatin,

pravastatin)

coenzyme

decrease

biliary

(HMGCoA)

reductase

cholesterol

saturation.

Estrogen therapy is associated with an increased risk of developing cholesterol

35 | P a g e

gallstones. Oral contraceptive steroids increase biliary cholesterol secretion and

saturation but do not affect gallbladder motility.
Obesity: Obesity is strongly associated with increased gallstone prevalence. The
risk is proportional to the increase in total body fat. Obese people synthesize more
cholesterol in both hepatic and nonhepatic tissues, transport it to the liver, and
secrete more of it into the bile, leading to bile that is often greatly supersaturated
with cholesterol.
Rapid Weight Loss: Obese patients undergoing rapid weight loss (1-2% of body
weight or approximately 1-2 kg/week), either by very low caloric dieting or gastric
stapling, have a 25-40% chance of developing gallstones within 4 months. During
rapid weight loss, biliary cholesterol saturation increases acutely as cholesterol is
mobilized from adipose tissue and skin and secreted into bile.
Spinal Cord Injury: Patients with spinal cord injury have 10% incidence of forming
gallstones within the first year after injury. This high risk, which is 20 times normal,
is believed to be secondary to abnormal gallbladder motility and probably biliary
hypersecretion of cholesterol from the progressive reduction in body mass.
Primary Biliary Cirrhosis: Patients with primary biliary cirrhosis have an increased
prevalence of gallstones. Stone analysis has not been performed, but the elevated
cholesterol saturation of bile in these patients suggest that they form cholesterol
stones.
Diabetes Mellitus: Despite obesity and increased total body cholesterol synthesis
and decreased gallbladder motility seen in patients with diabetes, diabetes mellitus
itself does not appear to be an independent risk factor for cholesterol gallstone
disease.
Hemolytic

Syndromes:

Inherited

hemolytic

anemia,

sickle

cell

disease,

sphericytosis, thalassemia, chronic hemolysis associated with artificial heart vavles,

and malaria dramatically increase the risk of pigment stone formation because of
increased biliary secretion of total bilirubin conjugates, especially bilirubin
monoglucoronide, at the expense of the bilirubin diglucuronide, the predominant
conjugate in healthy individuals.

36 | P a g e

Ileal Disease, Resection and Bypass: Patients with ileal dysfunction have a
strikingly increased risk for developing gallstones. Gallstones develop in 30-50% of
patients with ileal Chrons disease; the risk correlates positively with the extent and
duration of ileal dysfunction, Although ilieal disease or resection leads to cholesterol
supersaturation and cholesterol stone formation in some patients , careful studies
now show that most patients with ilieal dysfuncyion form black pigment, not
cholesterol stones.
Biliary Infection: Brown pigment stones are frequently found in the intrahepatic
bile ducts and are always associated with infection by colonic organisms usually
E.coli,

or

parasitic

infestation

(Ascaris

lumbricoides,

or

other

helminthes).

Intraductal stones developing after cholecystectomy are invariable associated with

bile stasis, biliary tree infection, and/or retained suture material.

Signs and Symptoms:

Biliary Colic/ Moderate to Severe Pain: The most common symptom is in pain
the right upper part of the abdomen or epigastrium. This can cause an attack of
abdominal pain, called biliary colic, which: develops quickly, is severe, lasts about
one to three hours before fading gradually, isn't helped by over-the-counter and
isn't helped by passing wind. The pain may radiate to the back, right scapula or
shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is
caused by the functional spasm of the cystic duct when obstructed by stones,
whereas pain in acute cholecystitis is caused by inflammation of the gallbladder
wall.
Tenderness: Palpation of the abdomen frequently elicits localized tenderness in the
right upper quadrant which is associated with guarding and rebound tenderness.
Murphys Sign: The patient with acute inflammation of the gallbladder might have
a positive Murphys sign, which is inspiratory arrest during deep palpation in the
right upper quadrant.

37 | P a g e

Nausea and Vomiting: These signs and symptoms may accompany a gallbladder
attack. Pain is usually accompanied by nausea and vomiting.
Fever and chills: Gallstones sometimes get trapped in the neck of the gallbladder
and can cause persistent pain that lasts more than several hours and is
accompanied by fever, also due to the irritation and inflammation of the gallbladder
wall. Fever occurs in about one third of people with acute cholecystitis. The fever
tends to rise gradually to above 100.4 F (38 C) and may be accompanied by chills
Loss of appetite and Anorexia: The pain often begins suddenly following a large
or rich meal. People tend not to eat, especially fatty or oily foods, in order not to
experience that pain. Fat absorption is also impaired for the lack of bile salts, As a
result, rapid loss of weight and anorexia can occur.

Non-Modiable Factors:
PATHOPHYSIOLOGY

(Client Based)

Age: The client is a 46 Years Old

man

Modifiable Factors:
Diet: The clients eats fatty foods rich in
cholesterol.
Eg: Chicharon, Lechon Kawali, etc.

Increased Bile
Cholesterol
38 | P a g e

Supersaturati
on of Bile

Irritation of the
gallbladder
Surface changes

Formation of
small
crystals

Increased mucous
secretion

Crystals
enlarges to
visible stones

Increased
mucous
secretion

Obstruction of
Cystic Duct

Affectation and Obstruction

of the
Common Bile Duct

Bacterial
invasion

Liver
39 | Impairment
Page

Inflammation
Increase
d WBC

RUQ pain
(+) Murphys
sign

JAUNDICE ANEMIA

CHOLECYSTITIS

Synthesis of the Disease:

Gallstones can form anywhere in the biliary tree, however the point of origin is
within the gallbladder. Gallstones develop when an individual eats too much fatty
and salty foods that causes an increase in bile cholesterol, therefore, causing an
irritation of the gall bladder. The surface changes within the gallbladder and mucous
secretion increases as a form of a compensatory mechanism. The bile, however,
becomes more viscous making hard for the gallbladder to contract and secrete bile.
Small crystals form and enlarges into visible stones. These stones or what we
commonly call gallstones tries to get out of the gallbladder. The stone then passes
on the cystic and common bile ducts which later on causes an obstruction. Since
there is an obstruction, the gallbladder can no longer secrete bile causing
indigestion, vitamin A,D,E and K deficiency and gray stool. There will also be an
increase in the levels of bilirubin/bile pigments in the circulation, thus, making the
40 | P a g e

sclera and the skin yellowish in color. Also, this obstruction causes an irritation in
the gallbladder wall, and an inflammatory response happens through the release of
prostaglandins. When prostaglandins are released, symptoms such as tenderness,
RUQ pain, murphys sign, nausea, vomiting, anorexia and an elevated wbc
happens/manifests. Thus, cholecystitis happens.

Predisposing Factors:
Age: The incidence increases with age. Less than 5-6% of the population under age
40 have stones, in contrast to 25-30% of those over 80.

Precipitating Factors:
Diet (High Fat, High Sodium): Increased intake of calories, refined carbohydrate,
cholesterol, and saturated fats has all been postulated to cause cholesterol
gallstones. Patients with cholesterol gallstones secrete a greater fraction of dietary
cholesterol into bile than do normal subjects.
Signs and Symptoms:
Tenderness: Palpation of the abdomen frequently elicits localized tenderness in the
right upper quadrant which is associated with guarding and rebound tenderness.
Murphys Sign: The patient with acute inflammation of the gallbladder might have
a positive Murphys sign, which is inspiratory arrest during deep palpation in the
right upper quadrant.
Nausea and Vomiting: These signs and symptoms may accompany a gallbladder
attack. Pain is usually accompanied by nausea and vomiting.
Loss of appetite and Anorexia: The pain often begins suddenly following a large
or rich meal. People tend not to eat, especially fatty or oily foods, in order not to
experience that pain. Fat absorption is also impaired for the lack of bile salts, As a
result, rapid loss of weight and anorexia can occur.

41 | P a g e

Gray Stool. When bile accumulates the liver, bile flow is decreased causing its
absence in the duodenum and insufficient amount of bile may lead to excretion of
gray stools.
Indigestion. Indigestion is a sign that indicates the presence of gallstones. This
happens usually when pain on the Right Upper Quadrant is felt.

NURSING CARE PLANS

Problem 1: Acute Pain
Cues
Subjective Cues:
>Masakit ku po
atchan anyang
purmero ok pa pero
ekune talaga abata
kaya pepa confine
naku. as verbalized
by the patient.
Objective Cues:
>Pain Scale of 7/10
>Facial mask of pain
>Muscle guarding
when right abdomen
is palpated and when
trying to change bed
position

Nursing Diagnosis
>Acute Pain related
to inflammation and
distortion of tissues
as evidenced by
patients
verbalization of
biliary colic, facial
mask of pain,
guarding behavior,
autonomic responses,
self-focusing and
narrowed focus.

Scientific Explanation
Obstruction of the
cystic duct that leads to
further complication
making the gallbladder
wall irritated or
damaged causing
inflammation
(Cholecystitis) that
disrupts the movement
and distortion of
tissues. This will
activate nociceptor in
the dermis and tissues.
The receptor sends an
impulse to CNS for
interpretation that
triggers pain perception
causing acute pain.

Planning
After 4 hours of
nursing
interventions the
client will be able
to:
>Decrease the
pain (from pain
scale of 7/10 to
5/10) or control
pain as client
demonstrates use
of relaxation skills
as indicated for
individual
situation.

Intervention
>Provide comfort
measures (e.g.
repositioning, touch.)

R
>To prom
pharmac
managem

>Encourage the client of

relaxation techniques
such as focused
breathing, imaging etc.

>To distr
reduce te

>Review procedures /
expectations and tell
client when treatment
may cause pain.
>Encourage diversional
activities.

>Autonomic
responses
>Self-focusing
>Narrowed Focus
>Vital Signs
BP: 120/80mmHg
Temp: 37.1C
PR: 79 bpm

42 | P a g e

> To redu
the unkn
associate

>To distr
reduce te

RR:16 cpm

Problem 2: Activity Intolerance

Cues
Subjective Cues:
>Manibat midala
ku hospital
mangalambut naku.
As verbalized by the
patient.
Objective Cues:
>Difficulty in
changing bed
position
>Generalized
weakness
>Limited range of
motion
>Needs assistance
when doing ADL
(e.g. going to toilet,
changing clothes.)
>Vital Signs
BP: 120/80mmHg
Temp: 37.1C
PR: 79 bpm
RR:16 cpm

Nursing Diagnosis
>Activity Intolerance
related to general
weakness.

Scientific Explanation
>Activity intolerance is
affected by any disorder
that impairs the ability
of the nervous system,
musculoskeletal
system, cardiovascular
system, respiratory
system and vestibular
apparatus.

Planning
After 4 hours of
nursing
interventions the
client will be able
to:
>Identify
alternative ways
to maintain
desired activity
level.

Intervention
>Ask the client about the
usual level of energy.

>Identify factors, such as

age and painful
conditions.
>Instruct the client in
unfamiliar activities and
in alternate ways of
doing familiar activities.
>Discuss with client/SO
the relationship of illness
/ debilitating condition to
inability to perform
desired activities.

>Identify and discuss

symptoms for which
client need to see
medical assistance or
evaluation.

43 | P a g e

R
>To iden
problems
of client
ability to
activities

>This co
the desire
activity.

>To cons
promote

>Unders
relations
with acce
limitation
opportun
of practic

>Providi
for timel

Problem 3: Risk for deficient Fluid Volume

Cues
Subjective Cues:
>Manawa ku pong
danum As
verbalized by the
patient.

Nursing Diagnosis
Risk for deficient
fluid volume related
to inadequate fluid
intake

Objective Cues:
>Dry skin

Scientific Explanation
Deficient Fluid Volume
is decreased
intravascular,
interstitial, and/or
intracellular fluid. This
refers to dehydration,
water loss alone
without change in
sodium.

>General weakness
>Dry lips
>Vital Signs
BP: 120/80mmHg
Temp: 37.1C
PR: 79 bpm
RR:16 cpm

Planning
After 4 hours of
nursing
intervention the
client will be able
to:

>Demonstrate
behaviors or
lifestyle changes
to prevent
development of
fluid volume
deficit.

Intervention
>Evaluate nutritional
status, noting current
intake, type of diet.

R
>It can n
fluid inta

>Monitor I/O balance,

being aware of altered
intake or output.

>To ensu
picture o

>To prov
>Establish individual
fluid needs / replacement
schedule.
>Provide supplemental
fluids, as indicated.

>Fluids m
this mann
unable to
is NPO f
when rap
resuscita

Intervention
>Provide explanations
of/reasons for test
procedures and
preparation needed.

R
>Informa
decrease
reducing
stimulati

>Review disease
process/prognosis.

>Provide
base from

Problem 4: Knowledge Deficit

Cues
Subjective Cues:
>Nanu wari
talagang kundisyun
ku? As verbalized
by the patient.
Objective Cues:

Nursing Diagnosis
Deficient knowledge
related to condition,
prognosis, treatment,
self-care and
discharge needs.

Scientific Explanation
There is this presence
of knowledge deficit
due to some unfamiliar
information that causes
some confusion to the
client that needs to be
discussed.

Planning
After 4 hours of
nursing
intervention the
client will be able
to:
>Verbalize

44 | P a g e

>Frequently asking
question about his
condition, treatment
and diet.

understanding of
disease process,
prognosis and
potential
complications.

Discuss hospitalization
and prospective
treatment as indicated.
Encourage questions,
expression of concern.

can make
choices.
commun
support a
diminish
promote

>Review drug regimen,

possible side effects.

>Gallsto
necessita
therapy.

>Worried gaze

>Instruct patient to avoid

food/fluids high in fats
or gastric irritants.

>Suggest patient to limit

gum chewing, sucking
on straw/ hard candy or
smoking.

Type of IVF

General Description

Indication/
Purposes

Date
Ordered/D
ate
Started/Da
te
Changed

Clients
Response to
Treatment

45 | P a g e

>Prevent
recurrenc
attacks.

>Promot
which ca
distentio

5% Dextrose in
Lactated
Ringers
Solution
(D5LRS)

Plain
Normal
Saline Solution
1L

Lactated Ringer's and

5% Dextrose Injection,
USP is a sterile,
nonpyrogenic solution
for fluid and electrolyte
replenishment and
caloric supply in a single
dose container for
intravenous
administration

Normal Saline is asterile,

nonpyrogenicsolution for
fluid
andelectrolytereplenish
ment.-It contains
noantimicrobial agents.

Used to supply
water and
electrolytes
such as
calcium,
potassium,
sodium
chloride

Used because
it has little to
no effect on
the tissues
and makes the
patient feel
hydrated.

Date
Ordered:
November
19, 2013
Date
Started:
November
19, 2013
Date
Changed:
Novermber
20, 2013

No allergies
were noted and
inflammation on
the site of
infusion. Intact
and infusing

Date
Ordered:
November
20, 2013

well. No pain
verbalized by

Date
Started:
November
20, 2013

the patient.

VI. PATIENT AND HIS CARE: INTRAVENOUS

THERAPHY
PATIENTS DAILY PROGRESS IN THE HOSPITAL
Admission
(Nov.19,2013)

Day2
(Nov.20,2013)

Day3
(Nov.21,2013)
46 | P a g e

Nursing Problems:
1. Acute pain
2. Activity
intolerance
3. Imbalance nutrition:
Less than body
requirements
4. Knowledge deficit

Vital Signs

TEMP.
PR (bpm)
RR(bpm)
BP(mmHg)

36.7 C
88
20
100/60

D5LRs 1L

2. Drugs
Omeprazole
Meperidine
Hydrochloride
Metoclopramide
Ceftriaxone Sodium
Ursodiol
Lactulose

37.1 C
79
16
120/80

Hematology
Blood chemistry

Diagnostic and Laboratory

Procedure
Medical Management:
1.IVF

36.9 C
85
18
110/70

D5LRs 1L
PNSS 1L
PNSS 1L

PNSS 1L

Soft Diet
3. Diet

NPO except medication

NPO

CBR w/ BRP

CBR w/ BRP

May sit up on bed

4.Activities

PATIENT AND HIS CARE: DIET

47 | P a g e

Type of
Exercise

General
Description

Indication /
Purposes

Clients Response and/or

Reaction to the Diet

Complete
Bed Rest with
Bathroom
Privileges

Patient should be
on bed most of the
time to decrease
oxygen
demand
and to lessen the
feeling of pain but
he can go to the
bathroom
when
needed.

This was ordered

to
conserve
energy, promote
recovery
and
provide rest to
prevent
fatigue
and feeling of
pain. It is also
ordered
to
decrease oxygen
demand.

The patient was kept in bed most

of the time and was able to
conserve energy through bed
rest as evidenced by patients
verbalization
of
decreased
fatigue and weakness.

May sit up on
bed

A type of exercise
wherein the patient
is
being
Repositioned every
1-2 hours.

To
improve
circulation,
to
prevent
venous
stasis,
thrombophlebitis,
respiratory
complications and
skin breakdown.

Patient did not manifest pain in

the calf upon dorsiflexion on the
foot
and
maintained
skin
integrity.

PATIENT AND HIS CARE: ACTIVITY

Type of Diet

General
Description

Indication /
Purposes

Date
Ordered

Clients
Response
and/or
Reaction to
the Diet

48 | P a g e

NPO (Nothing
Per Orem)

NPO orders are nothing

per orem diets which
means that the patient
is not allowed any type
of food or drink.

To assess the
clients
lab
results
without any
variance
of
affected food.

November
19, 2013

Administration of
IVF
prevented
the patient from
dehydration. The
patient
cooperated well
with
the
prescribed diet.

Soft Diet

This is to introduce a
diet that is easy to
digest and allow the GI
tract to be adjusted
with limitation of foods
rich in fats.

Soft diet was

ordered
to
allow the GI
tract
to
receive foods
that are easy
to digest so
as to prevent
gastric
irritation and
to
promote
easier
digestion

November
21, 2013

GI
discomfort
like
abdominal
pain
was
lessened
because of the
decreased
contraction
of
the gallbladder

CLIENTS DRUG THERAPHY

Name

Brand Name:
Prilosec,
Rapinex,
Zegerid, Losec.
Generic
Name:
Omeprazole.

Dosage,
Route
and
Frequenc
y
Dosage
>40mg
Route
>
Intravenou
s

General Action

>Thought to be a
gastric pump
inhibitor in that it
blocks the final
step of acid
production by
inhibiting the
H+/K+ ATPase

Indication /
Purpose

Date ordered,
Date
performed,
changed or
D/C

>Short term
treatment of active
duodenal ulcer.

Date Ordered:
November 19,
2013

>with clarithomycin
to treat duodenal
ulcer associated
with H.pylori.

Date
Performed:
November 19,
2013

49 | P a g e

Clients
Response t
the
medicatio
with actua
side effect
CNS:
Headache,
Dizziness

GI: Abdomin
Pain, Anorex

Hematolog

Classification:
Proton Pump
Inhibitor

Frequenc
y
>Once a
day

system at the
secretory surface
of the gastric
parietal cell. Both
basal and
stimulated acid
secretions are
inhibited.

>Short-term
treatment of active
benign gastric
ulcer.

Date Changed:
N/A
Discontinue:
N/A

:
Hemolytic
Anemia

Misc:
Pain, fatigue
malaise.

>Long-term
treatment of
hypersecretory
conditions.
>Reduce risk of
upper GI Bleeding
in critically ill
clients.

Name

Brand Name:
Demerol

Dosage,
Route
and
Frequenc
y
Dosage
>25mg

General Action

>One-tenth as
potent an
analgesic as

Indication /
Purpose

Date ordered,
Date
performed,
changed or
D/C

>Analgesic for
moderate to severe
pain.

Date Ordered:
November 19,
2013

50 | P a g e

Clients
Response t
the
medicatio
with actua
side effect

No side
effects wer

Generic
Name:
Meperidine
Hydrochloride

Route
>
Intravenou
s

Classification:
Narcotic
Analgesic

Frequenc
y
>As
needed

Name

Dosage,
Route
and
Frequenc
y

morphine. Its
analgesic effect is
only one-half when
given PO rather
than parenterally.
Has no antitussive
effects and does
not produce
miosis. Less
smooth muscle
spasm,
constipation, and
antitussive effect
than than
equianalagesic
doses of morphine.

General Action

Date
Performed:
November 19,
2013

manifeste
by the clien

Date Changed:
N/A
Discontinue:
N/A

Indication /
Purpose

Date ordered,
Date
performed,
changed or
D/C

51 | P a g e

Clients
Response
the
medicatio
with actua
side effec

Brand Name:
Reglan,
Maxolon.
Generic
Name:
Metoclopramid
e.
Classification:
Proton Pump
Inhibitor

Name

Dosage
>12mg
Route
>Intraven
ous
Frequenc
y
>As
needed

Dosage,
Route
and
Frequenc

>Stimulates motility
of upper GO tract
without stimulating
gastric, biliary or
pancreatic
secretions; appears
to sensitize tissues
to action of
acetylcholine;
relaxes pyloric
sphincter, which
when combined with
effects on motility,
accelerates gastric
emptying and
intestinal transit;
little effect on
gallbladder or colon
motility; increase
lower esophageal
sphincter pressure;
has sedative
properties.

General Action

>Short term
therapy for adults
with symptomatic
GERD who fail to
respond to
conventional
therapy.
>Stimulation of
gastric emptying
and intestinal
transit of barium
when delay
emptying interferes
with radiologic
examination of the
stomach or small
intestine.

Indication /
Purpose

Date Ordered:
November 19,
2013
Date
Performed:
November 19,
2013

CNS:
Fatigue,
Headaches
and dizzines

GI: Nausea,
Gastrointest
al
hemorrhage

Date
Changed:
N/A
Discontinue:
N/A

Date ordered,
Date
performed,
changed or

52 | P a g e

Clients
Response
the
medicatio

y
Brand Name:
Rocephin

Dosage
>1g

Generic
Name:
Ceftriaxone
Sodium

Route
>Intraven
ous

Classification:
Cephalosporin

Frequenc
y
>q8

D/C
> Works by
inhibiting the
mucopeptide
synthesis in the
bacterial cell wall.
The beta-lactam
moiety of Ceftrixone
binds to
caboxypeptidases,
endopeptidases, and
transpeptidases in
the bacterial
cytoplasmic
membrane. These
enzymes are
involved in cell-wall
synthesis and cell
division. By binding
to these enzymes,
Ceftriaxone results
in the formation of
defective cell walls
and cell death.

>Intra-abdominal
infections due to
E.coli, K.
penumoniae, B.
fragilis, Clostridium
species (most
strain of C. difficle
are resistant) and
Peptostreptococcus
species.

Date Ordered:
November 19,
2013
Date
Performed:
November 19,
2013
Date
Changed:
N/A
Discontinue:
N/A

53 | P a g e

with actu
side effec

No side
effects we
manifested
by the clie

Name

Brand Name:
Usosan
Generic
Name:
Ursodiol
Classification:
Gallstone
solubilizing
drug

Dosage,
Route
and
Frequen
cy
Dosage
>200mg
(1
capsule)
Route
>Oral
Frequen
cy
>Bid

General Action

>Naturally occurring
bile acid that inhibits
the hepatic
synthesis and
secretion of
cholesterol; it also
inhibits intestinal
absorption of
cholesterol. Acts to
solubilize cholesterol
in micelles and to
cause dispersion of
cholesterol as liquid
crystals in aqueous
media. About 90% is
absorbed in the
small intestine after
PO administration.
Undergoes a
significant first-pass
effect where it is
conjugated with
either glycine or
taurine and then
secreted into hepatic
bile ducts.

Indication /
Purpose

>Dissolution of
gallstones in clients
with radiolucent,
non-calcified
gallstones in whom
elective surgery
would be risky or in
those who refuse
surgery.

Date ordered,
Date
performed,
changed or
D/C
Date Ordered:
November 19,
2013
Date
Performed:
November 19,
2013
Date Changed:
N/A
Discontinue:
N/A

54 | P a g e

Clients
Response t
the
medication
with actua
side effect
GI:
Nausea and
vomiting,
abdominal
pain,
cholecystitis
CNS:
Headache,
fatigue.

Name

Dosage,
Route
and
Frequen
cy

Brand Name:
Cephulac,
Chronulac,
Constilac,
Constulose

Dosage
>30 cc

Generic
Name:
Lactulose

Frequen
cy
>once a
day at
bed
time.

Classification:
Cephalosporin

Route
>Oral

General Action

>In the colon,

Lactulose is broken
down primarily to
lactic acid.
Metabolized in the
colon by bacteria.

Indication /
Purpose

>Treatment of
constipation;
prevention and
treatment of portalsystemic
encephalopathy,
including stages of
hepatic precoma
and coma.

Date ordered,
Date
performed,
changed or
D/C
Date Ordered:
November 19,
2013
Date
Performed:
November 19,
2013
Date Changed:
N/A
Discontinue:
N/A

55 | P a g e

Clients
Response t
the
medicatio
with actua
side effect
GI: Abdomin
discomfort
and crampin
Nausea,
Vomiting.

VII. CONCLUSION
Our gallbladder is one of the important organs in our body. However, majority of
us tend to forget its function and importance. Cholecystitis or the inflammation of
the gallbladder because of an obstruction is a disease that requires a medical
attention. It adds on the morbidity and mortality rate of gall stone diseases. Thus, it
is one of the common diseases in our country since one contrubuting factor is the
food that we eat. This obstruction needs immediate attention because it may cause
many complications. The harm that gallstones could give is that they may leave the
gallbladder and enter the small intestine which causes the patient to experience
abdominal pain.
Through this study, everyone will become aware of his/her health and daily
lifestyles. Therefore, we conclude that in order to lower the risk of having this kind
of condition, each and every one of us must be conscious on our diet especially
when it comes to our food preferences. Though there is a saying that, Mas
masarap pag bawal, we should still be cautious of the foods served in our dining
table especially if its high in sodium and fat. As Dr. Harry Johnson stated that the
secret to good health lies in every decision that human beings make.

56 | P a g e

VIII.

RECOMMENDATIONS

To the Philippine Government, they may be aware of increasing incident of the

disease condition in our country and that they may help those who are less
fortunate by making the health care services more affordable and acceptable;
For the students who will study Cholecystitis as their case, that they may know
the different causes of the said condition and understand the pathology of the
disease and how the signs and symptoms manifest. That they may also keep in
mind the importance of the patients information which could be obtained on the
chart.
For student nurses who will be handling patients with this condition, health
education must always be done during nurse-patient interaction. Teaching patients
proper ways in maintaining healthy lifestyle and importance of proper nutrition.
For patients with risk factors in developing any of the conditions that lead to
biliary obstruction, awareness of the signs and symptoms can improve chances for
early diagnosis and improved outcome.

57 | P a g e