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TABLE OF CONTENTS
I.
v.
vi.
II.
Biographic/Demographic Data
History of Present Illness
Past Health History
Childhood Illnesses
Immunizations
Hospitalizations
Current Medications
Family History of Illness
Lifestyle/Activities of Daily Living
4
4
4
5
5
PHYSICAL ASSESSMENT
III.
IV.
V.
VI.
VII.
VIII.
IX.
11
13
15
16
DISCHARGE PLAN
22
i.
ii.
iii.
iv.
v.
vi.
vii.
I.
Introduction
Medications
Exercise
Treatment
Health Teaching
Out Patient (Follow-up Consultation)
Diet
Spiritual
Lifestyle together with heredity, sex, race and age are just some factors that leave a room
for gallbladder complications to occur. In the case of our patient, his diet along with his sedentary
lifestyle would be the precipitating factors that lead him to have Cholelithiasis, presence of stones
to gallbladder. He was first diagnosed to have Cholelithiasis two years ago but due to his
negligence it leads to another complication of Cholecystitis, inflammation of the gallbladder.
Last May 28, he underwent a procedure called Cholecystectomy. The patient was placed
under General Anesthesia and then a surgical incision is made at the right upper quadrant of the
abdomen to surgically remove the gallbladder.
General Objectives:
This case study will help and serve us to enhance our knowledge and to understand more
information about Cholelithiasis and Cholecystitis, thus to give us an idea of how we could give
proper nursing care for our clients with this condition, and so that we could apply them on our future
exposures as nurses.
Specific Objectives:
This case study aims to determine How the patient acquired the illness and the process by which
the body responds to the situation. This also specifically attempts to answer the following questions:
Prevalence
An estimated 10-20% of Americans have gallstones, and as many as one third of these people
develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is
the most common major surgical procedure performed by general surgeons, resulting in
approximately 500,000 operations annually. Cholelithiasis, the major risk factor for cholecystitis, has
an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic
populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and
Asia.
In Palawan Adventist Hospital alone, there are 11,300 case rates of patients who had Calculous
of gallbladder with other cholecystitis, chronic cholecystitis and cholecystitis with cholelithiasis.
ii.
BIOGRAPHIC/DEMOGRAPHIC DATA
Name: EEM
Address: Honda Bay
Age: 37 years old
Birthdate: July 17, 1976
Gender: Male
Religious Affiliation: Roman Catholic
Marital Status: Single
Occupation: Event Host (Freelancer)
Room Number: 320 bed 1
Chief Complaint: Severe abdominal pain
Provisional Diagnosis: Cholelithiasis
Post-operative Diagnosis: Chronic Calculous Cholecystitis
Attending Physician: Dr. Sabando
3 | Page
iii.
iv.
v.
vi.
ADL
Nutrition
Elimination
Exercise
Before Hospitalization
The patient is fond of
eating fatty foods, he only
take small amount of
vegetables and fruits. He
said that his favorite dish is
liempo and sinigang na
baboy. He drinks 8-10
glasses of water a day.
The client did not have any
problems with his urination
and bowel movement. He
urinates approximately six
times a day and defecates
once a day.
The client did not engage
in formal exercise. Parang
sedentary lifestyle kasi
During Hospitalization
Two days after his
operation, he was given a
soft diet. Mostly soups
and eggs are served to
him.
4 | Page
ako.
Hygiene
Substance use
II.
PHYSICAL ASSESSMENT
Norms
General Appearance
1. Posture/Gait
Actual Findings
Relaxed, lying on
bed
Healthy Appearance
Slightly yellowish
3. Personal Hygiene/
Grooming
Clean, neat
Clean, fresh-looking
Normal
5. Age Appropriateness
Appropriate to Age
Appropriate to Age
Normal
6. Verbal Behavior
Exhibits thoughts of
Association
Answers questions
properly
Normal
Measurements
Pre-operative:
1. Temperature
2. Pulse Rate
3. Respiratory Rate
4. Blood Pressure
36.5 C-37.5 C
80 (60-100) bpm
16 (12-20) cpm
120/80 mmHg
36.6 C
96 bpm
20 cpm
120/90 mmHg
Normal
Normal
Normal
Normal for age group
Post-operative:
1. Temperature
2. Pulse Rate
36.5 C-37.5 C
80 (60-100) bpm
37.3 C
105 bpm
3. Respiratory Rate
4. Blood Pressure
16 (12-20) cpm
120/80 mmHg
22 cpm
130/90 mmHg
Normal
Increased; patients who are in pain
usually have increased vital signs.
Increased
Increased
Body Part
Skin
1. Inspect skin color.
2. Inspect uniformity of
skin color.
Norms
Actual Findings
Interpretation and
Analysis
Slightly yellowish
Cholestatic jaundice
develops as a consequence
of bile flow obstruction.
Uniform
Normal
5 | Page
Normal
Transparent; capillaries
sometimes evident; sclera
appears white
Transparent; yellowish
sclera
Pale
Normal
Bronchovesicular and
vesicular breath sounds
Normal
No pulsations
No pulsations
Normal
No abnormalities
Normal
Anterior Thorax
1. Auscultate the anterior
chest.
Heart and central Vessels
1. Simultaneously inspect
and palpate precordium
for the presence of
abnormal pulsations, lifts,
or heaves.
2. Auscultate the heart in
all four anatomic sites
(aortic, pulmonic,
tricuspid and apical.
Normal
Symmetric pulse
volumes.
Normal
No edema.
No edema.
Full pulsations.
Full pulsations.
Normal
Normal
6 | Page
sufficiently to cause
blanching.
Upper Abdomen
1. Inspect for symmetry,
redness and swelling.
Palpate upper abdomen
for presence of
tenderness.
Lower Abdomen
1. Inspect for symmetry,
redness and swelling.
Palpate lower abdomen
for presence of
tenderness.
Musculoskeletal System
1. Inspect the muscles for
size. Compare the
muscles on one side of the
body to the same muscle
on the other side.
2. Test muscle strength
and compare the right side
from the left side.
Neurologic System
1. Compare the lighttouch sensation of
symmetric areas of the
body.
III.
Symmetrical; No
tenderness
Symmetrical; No
tenderness
Symmetrical; No
tenderness
Normal
Normal
Normal
Normal
Significance
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Slightly Elevated
Elevated
Normal
Normal
Normal
825.1 U/L
0.0-41.0 U/L
Elevated
3.4
12.00
11.50
0.50
562
3.5-5.3
0.1-1.0 mg/dl
0.00-0.3
0.15-0.70
35-104
Normal
Elevated
Elevated
Normal
Elevated
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Urinalysis
Color
pH
Transparency
Specific Gravity
Protein
Glucose
Pus Cells
Red Blood Cells
Dark Straw
Acidic
Hazy
1.025
Trace
Negative
8-12
0.3
IV.
V.
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Structure
The gallbladder and bile ducts are also called the biliary system or biliary tract. It is about 7.510
cm (34 inches) long and about a 2.5 cm (1 inch) wide.
The gallbladder is made up of layers of tissue:
Mucosa: the inner layer of epithelial cells (epithelium) and lamina propria (loose connective
tissue)
a muscular layer: a layer of smooth muscle
perimuscular layer: connective tissue that covers the muscular layer
serosa: the outer covering of the gallbladder
10 | P a g e
Function
The principal function of the gallbladder is the storage and concentration of bile, a yellowishgreen fluid made by the liver. It is capable of holding about 40-70ml of bile. The gallbladder absorbs
water from the bile, making it more concentrated. When bile is needed for digestion after a meal, the
gallbladder contracts and releases it into the cystic duct. The bile then flows into the common bile duct
and is emptied into the small intestine, where it breaks down fats. Bile helps the body digest fats. It is
mainly made up of:
bile salts
bile pigments (such as bilirubin)
cholesterol
water
VI.
emptying), along with decreased reservoir function. The lack of bile flow causes an accumulation of bile
and an increased predisposition for stone formation. Ineffective filling and a higher proportion of hepatic
bile diverted from the gallbladder to the small bile duct can occur as a result of hypomotility.
Occasionally, gallstones are composed of bilirubin, a chemical that is produced as a result of the
standard breakdown of RBCs. Infection of the biliary tract and increased enterohepatic cycling of
bilirubin are the suggested causes of bilirubin stone formation. Bilirubin stones, often referred to
as pigment stones, are seen primarily in patients with infections of the biliary tract or chronic hemolytic
diseases (or damaged RBCs). Pigment stones are more frequent in Asia and Africa.
The pathogenesis of cholecystitis most commonly involves the impaction of gallstones in the
bladder neck, Hartmann's pouch, or the cystic duct; gallstones are not always present in cholecystitis,
however. Pressure on the gallbladder increases, the organ becomes enlarged, the walls thicken, the blood
supply decreases, and an exudate may form. Cholecystitis can be either acute or chronic, with repeated
episodes of acute inflammation potentially leading to chronic cholecystitis. The gallbladder can become
infected by various microorganisms, including those that are gas forming. An inflamed gallbladder can
undergo necrosis and gangrene and, if left untreated, may progress to symptomatic sepsis. Failure to
properly treat cholecystitis may result in perforation of the gallbladder, a rare but life-threatening
phenomenon. Cholecystitis also can lead to gallstone pancreatitis if stones dislodge down to the sphincter
of Oddi and are not cleared, thus blocking the pancreatic duct.
Gallstones are generally asymptomatic. In the uncommon event that a patient develops
symptomatic cholelithiasis, presentation can range from mild nausea or abdominal discomfort to biliary
colic and jaundice. Biliary colic, usually sharp in nature, is postprandial epigastric or right-quadrant pain
that lasts for several minutes to several hours. The pain often radiates to the back or the right shoulder,
and in more intense cases it may be accompanied by nausea and vomiting. Upper-right-quadrant
tenderness and palpable infiltrate in the region of the gallbladder are revealed upon physical examination.
Cholecystitis presents in the same manner; however, the obstruction of the cystic duct is persistent (rather
than transient), and fever is common.
A patient with cholecystitis also may exhibit Murphy's sign (discomfort so severe that the patient
stops inspiring during palpation of the gallbladder) or jaundice. Jaundice, a yellow discoloration of the
skin and the sclera of the eyes, occurs when the common bile duct is obstructed because of an impacted
stone in Hartmann's pouch (Mirizzi's syndrome). Other nonspecific symptoms, such as indigestion,
intolerance to fatty or fried foods, belching, and flatulence, may also be present.
12 | P a g e
13 | P a g e
VII.
Cues
Subjective Cues:
Makirot pa rin ung sugat ng inoperahan sa akin, pain scale
of 7, 10 as worst.
Objective Cues:
Vital signs:
BP= 130/90 mmHg
PR=105 bpm
RR= 22 cpm
(+) Facial Grimaces
Appears irritable, restlessness noted
Guarded or protective behavior in the surgical wound
(RUQ of the abdomen)
Slightly diaphoretic
Subjective Cues:
Nahihirapan pa ako kumilos pagkatapos ko maoperahan.
Objective Cues:
Difficulty from side to side
Muscle weakness
Limited range of motion
Needs assistance when moving
Subjective Cues:
Mahilig akong kumain ng karne at taba araw-araw at bihira
akong kumain ng prutas at gulay.
Objective Cues:
SP cholecystectomy because chronic calculous
cholecystitis
Justification
HIGHEST PRIORITY
2nd day Post-operative pain with a pain scale of 7 is considered as
severe therefore it needs to be highly prioritized. Immediate
interventions should be done to reduce the pain sensation.
The existing problem makes the patient in an uncomfortable state
and reduces his ability to perform his activities of daily living.
2ND PRIORITY
Post-op patients usually have limited strength due to the stress from
the past operation. This problem disables them to perform ADLs at
ease and needs the assistance of others.
This was secondly prioritized because in order to intervene with this
problem, the pain sensation should be reduced first since it is an
immediate problem. Presence of pain adds to the burden of the
patients intolerance of his activities.
3RD PRIORITY
The patients lifestyle including the pattern of his usual diet, and
activity was one of the greatest factors that lead to his condition and
prompted his surgery.
Deficient knowledge about the importance of proper nutrition,
regular exercise and reduction of stress made it possible for him to
VIII.
Objective Cues:
presence of surgical wound on RUQ abdominal region
Insufficient knowledge on how to avoid exposure to
pathogens
Nursi
ng
Diag
nosis
Scien
tific
Expl
anati
on
(Rati
onale
)
Plannin
g
Nursing
Interventi
ons
Rational
e
Evalu
ation
Subje
Alter
Surgi
Short term:
ctive
ed
cal
-After
Cues: 1 hour
comfof incisi
nursing
Maki ort:
on
interventions,
rot pa Acutethe from
patient reported
rin
pain
chole
relief from pain,
ung
relate
pain scale of 5 out cyste
sugat
ctom
of 10. d to
ng
tissue
y
-After
inoper 4 hours
traumof
nursing
ahan
a
interventions,
sakin seconthe Tissu
patient
,
dary
e
demonstrated nonpain
to
traum
pharmacological
scale
measureschole
to relief a
of 7, suchcyste
pain
as
focused
10 as breathing.
ctom
worst. y
Relea
Long-term:
se of
-After 4 days of
Objec
chem
nursing
tive
interventions, the ical
Cues: reported medi
patient
>vital
ators
that
the pain is
controlled.
signs:
such
BP=
as
Vital
signs:
130/9
brady
BP 120/80
0 PR 78bpm
kinin
mmH
RR 18 bpm
g
PR=
Direc
105
t
bpm
irritat
RR=
ion to
22
the
Shortterm
goal:
Independe
nt:
1.Establish
rapport
with the
patient
and the
significa
nt others
-After 1
hour of
nursing
interven
tions,
the
patient 2.Monitor
and
will
record
report
vital
slight
signs
relief
from
pain.
3.Assess the
severity,
-After 4
frequen
hours of
cy, and
nursing
characte
interven
ristic of
tions,
pain
the
patient
will be
able to 4.Encourage
verbaliz
diversio
e nonnal
pharma
activitie
cologic
s and
measure
relaxati
s for
on
pain
techniqu
5. To provide comfort.
bpm
nerve
endin
gs
> (+)
Long-term
goal:
facial
-After
grimac4 days of nursing
interventions,
the Signa
es
patient
will
verbalize
>appea
l will
that the pain is
rs
be
controlled.
irritabl
sent
e,
to the
restless
corte
ness
x and
>guard
thala
ed or
mus
protecti
of the
ve
brain
behavi
our on
the
Pain
surgica
perce
l site
ption
(RUQ
is
of the
produ
abdom
ced
en)
>slightl
y
diaphor
etic
>diffic
ulty in
sleepin
g
relief.
es to
relieve
pain
such as
focused
breathin
g,
listening
to
music,
reading
magazin
es or
watchin
g
movies.
5.Provide
nonpharmac
ologial
interven
tions
such as
touch
and
frequent
changin
g of
position.
6.Encourage
adequat
e rest
periods
and
early
ambulat
ion if
tolerate
d.
Dependent:
1. Administer pain medication as
ordered.
-Diclofenac 75 mg IM single
dose
-Remopain 30 mg IV q 6 for 6
doses
-Dolmal drip 6 amps in D5W
500 cc @ 20 gtts/min
Assessment
Subjective
Short
term:Cues:
-The
patient pa rin
Nahihirapan
verbalized
akong kumilos
understanding
pagtapos ko on
improvement of
operahan.
activity tolerance
within his
Objective Cues:
limitation.
>difficulty turning
Long term:
from one side to
-The patient
side.
participated in
> generalized
measures to
weakness
enhance ability to
>limited ROM
perform activities.
>needs assistance
when moving
>muscle weakness
Nursing Diagnosis
Activity Intolerance
related to generalized
weakness secondary
to cholecystectomy
Scientific
Explanation
(Rationale)
Postcholecystectomy
Presence of surgical
incision
Stimulation of nerve
endings during
movement increases
pain sensation
Generalized
weakness
Activity Intolerance
Planning
Short-term:
-After 1 hour of
nursing intervention,
the patient will
verbalize
understanding on
improvement of
activity tolerance
within his limitation.
Interventions
Rationale
Independent
1. Establish rapport. 1.
2.
3.
Monitor vital
signs
Assess the
patients general
condition.
Long-term:
-After 4 hours of
nursing intervention,
the patient will
4. Provide adequate
participate in
rest.
measures to enhance
ability to perform
activities.
5. Assist patient to
lean and
demonstrate
safety measures
To establish nurse
patient
relationship.
2.
To have a baseline
data
3.
To gather baseline
data and compare
it to normal
findings
4.
To prevent fatigue
and conserve
energy.
5.
To prevent injuries
6.
Encourage patient
6.
to maintain a
positive attitude;
suggest use of
relaxation
techniques such
as visualization/
guided imagery as
appropriate.
7.
Teach ways on
7.
To enhance sense
of well-being.
To limit fatigue
Evaluation
how to conserve
energy such as
sitting instead of
standing when
doing activities,
(eg. combing
hair)
Dependent:
1. Administer
medication as
ordered prior to
activity as needed.
-Diclofenac 75 mg
IM single dose
1.
-Remopain 30 mg
IV q 6 for 6 doses
-Dolmal drip 6
amps in D5W 500
cc @ 20 gtts/min
Subjective Cues:
Mahilig akong kumain
ng karne at taba arawaraw.
Nursing Diagnosis
Scientific Explanation
(Rationale)
Deficient knowledge
about the disease process
related to unfamiliarity of
information resources
Planning
Interventions
Short-term:
Independent:
-Verbalize understanding 1. Establish rapport.
of disease process,
surgical procedure
/prognosis, and potential
2. Monitor and record vital
complications
Rationale
Evaluation
1.
2.
To have a baseline
Short-term:
-After 1 hour of nursing
interventions, the patient
verbalized understanding
of the disease process,
Objective Cues:
>S/P cholecystectomy
because of chronic
calculous cholecystitis
signs.
Long-term:
-The patient will initiate 3. Review disease process,
necessary lifestyle
surgical
changes and participate
procedure/prognosis.
in therapeutic regimen
Deficient knowledge
about the disease process
data.
3.
4. Emphasize importance of
4.
maintaining low-fat
diet, eating frequent
small meals, gradual
reintroduction of
foods/fluids containing
fats over a 4- to 6-mo
period
5. Discuss avoiding /limiting
5.
use of alcoholic
beverages.
6. Identify signs/symptoms
requiring notification of 6.
healthcare provider,
e.g., dark urine;
jaundiced color of
eyes/skin; clay-colored
stools, excessive stools;
or recurrent heartburn,
bloating.
Nursing
Diagnosis
Scientific
Explanation
Planning
Interventions
Rationale
Evaluation
Provides knowledge
base on which patient
can make informed
choices.
During initial 6
months after surgery,
low-fat diet limits
need for bile and
reduces discomfort
associated with
inadequate digestion
of fats.
Minimizes risk of
pancreatic
involvement.
Indicators of
obstruction of bile
flow/altered
digestion, requiring
further evaluation and
intervention.
surgical procedure/
prognosis, and potential
complications.
Long-term:
-After 4 hours of nursing
interventions, the patient
initiated necessary
lifestyle changes and
participated in
therapeutic regimen.
(Rationale)
Objective Cues:
>Presence of
surgical wound
on RUQ
abdominal
region
>Insufficient
knowledge on
how to avoid
exposure to
pathogen
Risk for
infection related
to impaired
primary defenses
secondary to
cholecystectomy
PostShort-term:
Independent:
cholecystectomy,-After 1 hour of 1. Establish
nursing
rapport.
intervention, the
patient will
demonstrate
2. Monitor vital
incision and suture
techniques in
made in the abdomen
signs
reducing risk of
having infection.
1. To establish nurse
patient
relationship.
2. To have a baseline
data
6.
Encourage to
increase oral 5. To hasten wound
fluid intake if
healing
not
contraindicat
ed.
6. For mobilization of
respiratory
Encourage
infections, and
early
prevention of
ambulation,
respiratory
deepinfections.
breathing,
coughing and
Short term:
-After 1 hour of
nursing
interventions,
the patient
demonstrated
techniques in
reducing risk of
having infection.
Long term:
-After 8 hours of
nursing
interventions,
the patient
achieved timely
wound healing,
had been free of
purulent
drainage and
remained
afebrile.
positioning
changes.
1. To prevent occurrence of
Dependent:
infection
1. Administer
antibiotic as
ordered.
-Cefuroxime 2. To achieve timely wound
750 mg every
healing of the surgical
wound
8 hours
2. Change
wound
dressing as
indicated
using proper
technique for
changing/disp
osing of
contaminated
materials.
IX.
DISCHARGE PLAN
i. MEDICATIONS
Teach the client and the family members about the medications that will be taken after the
hospitalization.
1. Roflexin 500 mg 1 tablet 2x a day for 1 week
2. Celexib 200 mg 1 tablet 2x a day for 3 days
-The more clients understand the medical regimen; the more adept they will be in monitoring for
them.
Educate the patient and family members about the side effects or adverse reaction of the drug.
- Knowledge of the potential side effects will adept in proper monitoring of the condition.
Warn patient never to stop drug abruptly or adjust the dosage without discussing it with the
prescriber.
- To avoid harm or injury to the patient
Instruct family members and patient to double check and compare it to the order of the physician
before administration.
-To know if the drug given is correct
Educate the patient and family to follow strictly the prescribed medication.
- To prevent drug resistance
Instruct the client and his family not to administer drugs that are not prescribed by the physician.
- Non-prescription drugs may have an antagonistic or synergetic effect if taken with other drugs.
Side effects and adverse effects from drug reactions can transpire and cause damage or
complication to the clients body.
ii.EXERCISE
Encourage to do light exercises like walking and avoid intense exercises and strenuous activities.
- Light exercises like ambulation helps hasten recovery.
iii.
Instruct the family to provide the client adequate rest and sleep.
- Sufficient rest and sleep can help for faster healing and recovery. It can also help to prevent
injury and harm.
TREATMENT
Explain to the S.O.s of the client the medical condition involved and provide them with
information regarding the illness.
- This is to have a comprehensive understanding of the clients condition so that they will be able
to give appropriate intervention and optimum care.
Instruct the patient and family/ significant others to follow physicians order until the end of the
course treatment.
- To obtain the desired therapeutic effect and may improve the status of the client.
Instruct the patient and family/ significant others to immediately report any unusualities noted.
- This is important so that appropriate interventions can be done to prevent aggravation of the
problem noted.
Teach patient and family/ significant others about proper wound dressing and drain care daily.
-Prevent occurrence of infection.
iv.
HYGIENE
Instruct the family/ significant others of the client to provide good, clean, and safe environment.
- This will prevent the occurrence of further complications.
Encourage the significant others to do hand washing before and after contact with patient and
preparing food.
- Hand washing reduces risk of infection and cross-contamination.
Advise the patient to do oral care and bath and groom daily and regularly and with the assistance
of the significant others if necessary.
- Proper hygiene and grooming promotes cleanliness, comfort and relaxation.
v.OUTPATIENT (FOLLOW-UP)
Encourage the patient to comply with regular check-ups.
- This will enable the physician to evaluate clients progress after the medical intervention.
vi.
Instruct the family of the client to immediately report any unusualities noted.
- This is to render prompt interventions and treatment regarding patients condition.
DIET
Emphasize importance of maintaining low-fat diet, eating frequent small meals, gradual
reintroduction of foods/fluids containing fats over a 4 to 6 month period.
-During initial 6 months after surgery, low-fat diet limits need for bile and reduces discomfort
associated with inadequate digestion of fats.
Advise the client to eat foods rich in fiber and protein such as vegetables and fruits.
-Protein and fiber rich foods can facilitate tissue healing and will delay the onset of uremic
symptoms.
Encourage the family to give food rich in vitamin C such as oranges, citrus juices, and green leafy
vegetables.
- Food rich in vitamin C can aid in strengthening the bodys immune system to combat infection
and other illnesses.
vii.
SPIRITUAL:
Discuss Gods plan for every individuals life.
Advise the client to pray and trust to God.