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Patients Profile
Name: Patient D.F.V
Sex: Female
Age: 26 y/o
Birthdate: May 19, 1987
Address: Elias St. Sta. Cruz Manila
Religion: Roman Catholic
Nationality: Filipino
Chief Complaint: Right Upper Quadrant Pain
Diagnosis: Acute Calculous Cholecystitis
Family/Personal history:
The patient is a non-smoker and consumes moderate alcohol. She eats little
amount of vegetables and fruits and mostly consumes meat on her meal.
She does little exercise but spends most of the time doing household chores.
She is a plain housewife and lives with her common law husband and her 2
children. The diseases that her family has is diabetes mellitus and gallstones
on the maternal side and has no history on the paternal side.
Physical Assessment
Name: Patient D.F.V
Age: 26 years old
Sex: Female
Department: ER-Surgery
Diagnosis: Acute Calculous Cholecystitis
Chief Complaint: Right Upper Quadrant pain
General Survey
The patient is awake and responsive, not in any respiratory distress, ambulatory but with fair
activity.
II
Vital Signs
Techniques: Inspection, Palpation, Auscultation
Patient has temperature of 37.3C, axillary with cardiac rate of 110 beats per minute, regular
respiratory rate of 23 breaths per minute, and blood pressure of 130/80 mmHg.
PART
Skin
Head
TECHNIQ
UE
Inspection
and
Palpation
Inspection
and
Palpation
NORMAL FINDINGS
ACTUAL FINDINGS
INTERPRETATION
No edema
No edema noted
Normal
Skin temperature is
uniform within
normal range
Skin temperature is
uniform with axillary
temperature of 37.C
Normal
Configuration is
normocephalic
No lesions or
tenderness
Head is
normocephalic in
shape
Absence of lesions
and no signs of
tenderness
Normal
Normal
Normal
Normal
Normal
Anterior and
posterior fontanels
are flat and closed
Hair
Inspection
Evenly distributed,
thick hair, silky,
resilient, no
infestation
Eyes:
Sclera
Inspection
Appears white
Appears white
Normal
Cornea
Inspection
Transparent, shiny,
smooth with corneal
details visible
Pupils
Inspection
Black/brown in color;
constricts when
illuminated and
when looking at near
objects; dilates when
looking at far objects
Symmetrically
aligned
Eye Balls
Inspection
Palpebral
and
Bulbar
Conjuctiv
a
Ears
Eyeballs are
symmetrical in size
Not protruding
Inspection
Inspecton
and
Palpation
Transparent, shiny,
smooth; details
apparent
Aligned
Normal
Normal
Normal
Normal
color, symmetrical in
shape, flexible with
no tenderness
There is no discharge
from the ear canal
Normal
Eyeballs are
symmetrical in shape
and size
There is no protrusion
Smooth, pink or red
Normal
Normal
Nose
Inspection
and
Palpation
Mouth
Inspection
and
Palpation
external canal
Patient responds to
sound
Nares are patent
Septum on the
midline
Mucosa is pinkish in
color
Lips are moist and
pinkish in color
Oral mucosa is
pinkish with no
ulcerations
Normal
Normal
Normal
Oral mucosa is
pinkish with no
ulcerations e
No ulcerations in oral
mucosa
Normal
Normal
Neck is symmetrical
Thyroid glands are
not tender and
enlarged
Normal
Normal
Normal
Normal
Normal
Neck
Inspection
and
Palpation
Neck is symmetrical
Thyroid glands are
not tender and
enlarged
Chest
Inspection
,
Palpation,
Auscultati
on
Abdominal breathing
is present (pediatric)
and posture of
thorax is
symmetrical upon
respiration
Heart
Auscultati
on
S1 usually heard at
all sites but louder at
apical area
S2 usually heard at
all sites but louder at
base of the heart
Symmetrical in size
and shape
Areola is round or
oval and color is light
pink to dark brown
Nipples are round,
and equal in size
Breast
Inspection
Finger
and Toe
Nails
Inspection
and
Palpation
with thoracic
movement
symmetrical
Normal
Normal
Normal
Normal
almost in size
Normal
No presence of harsh
breath sounds;
patient was crying
and irritable during
assessment
S1 and S2 are heard
audibly on apical and
base areas of the
heart
No murmur or gallops
(S3 and S4)
Symmetrical in size
and shape
Areola is small and
brown in color
Normal
Normal
Normal
Abdomen
Inspection
,
Auscultati
on,
Palpation
seconds
Unblemished skin,
uniform in color
No tenderness upon
palpation
no evidence of liver
enlargement
Audible bowel
sounds
Presence of Scar at
right lower quadrant
Tenderness noted
upon palpation at the
right upper to
epigastric portion of
the abdomen
Muscles
Inspection
, Palpation
no evidence of liver
enlargement
Audible bowel sounds
at 12 per minute;
abdomen produces a
growling sound
Normal
Symmetrical in size
on both sides of the
body
Normal
Normal
Laboratory Procedures
Serum Creatinine, Total, Sodium, Potassium
Test
Result
Unit
Normal
Value
Creatinine
47.30
Mmol/L
45-104
Na+
136.90
Mmol/L
135-143
K+
4.49
Mmo/L
3.4-4.82
Normal
Value
123-153
Analysis and
interpretation
The result is
within the normal
range.
The result is
within the normal
range
The result is
within the normal
range
Result
Unit
Hemoglobin
137
g/L
Hematocrit
0.43
RBC
4.52
10^12/L
4.1-5.1
MCV
94
fL
82-98
MCH
30.35
Pg
28-33
MCHC
32.34
g/L
33-36
WBC
10.9
10^9/L
4.8-10.8
0.359-0.446
Analysis and
interpretation
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
slightly elevated.
A high white
blood cell count,
called leukocytosi
s, may result
from a number of
conditions and
diseases such as
infections and
inflammatory
conditions.
DIFFERENTIAL COUNT
Neutrophils
0.69
0.40-0.70
Lymphocytes
0.22
0.19-0.48
Basophils
0.00
0.00-0.05
Monocytes
0.07
0.00-0.15
Eosinophils
0.02
0.02-0.08
Platelet
Count
490
MPV
7.80
RDW
12.20
10^9/L
150-400
7.80
11.4-14.0
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
A high platelet
count may be
referred to as
thrombocytosis.
This is usually the
result of an
existing condition
such as
inflammatory
conditions.
The result is
within the normal
range
The result is
within the normal
range
Sonographic Report
Gallbladder:
Gallbladder is enlarged, with an approximate measurement of 12.9 x 4.1 cm.
Its wall is slightly thickened, measuring around 0.44 cm. There are 2
intraluminal hyperchoic foci, at the gallbladder neck, with strong posterior
acoustic shadowing approximately measuring 2.3 x 0.6 cm and 0.6 x 0.5 cm.
Impression: Hydrops of the gallbladder with cholecystolithiases and signs of
cholecystitis
PATHOPHYSIOLOGY
Modifiable factors
-Obesity
-Gender/sex (female)
-Genetic predisposition
-Ethnicity
Pigment solute
precipitate as solid
crystals
Crystals clump
together and form
stones
Gallstones
Gallbladder contracts
after intake of fat to
release bile
Upon contraction, a stone is moved
and becomes impacted on the
cystic duct
CHOLELITHIASIS
Lumen is obstructed
by stones
Bile stasis
Inflammation of the
gallbladder
Edema
Increased
intraluminal
pressure and
distention of the
Drug Name
Classification
Indications
Mechanism
of Action
Adverse
Reactions
Metronidaz
ole 500m
IV
antiinfective;
antitrichomon
al;
amebicide;
antibiotic
Amebic liver
abscess
Direct acting
trichomonac
ide and
amebicide
that works
inside and
outside the
intestines.
Its thought
to enter the
cells of
microorgani
sms that
contain
nitroreducta
se, forming
unstable
compounds
that bind to
DNA and
inhibit
synthesis,
causing cell
death
CNS:
Headache,seiz
ures, fever,
vertigo,
syncope,
dizziness,
insomnia
Intestinal
amebiasis
Trichomonia
sis
Refractory
Trichomonia
sis
Bacterial
infections
caused by
anaerobic
microorgani
sms
To prevent
post
operative
infection in
contaminate
d or
potentially
contaminate
d colorectal
surgery
Contraindicat
ns
Contraindicat
d in patients
hypersensitiv
to the drug
and other
nitroimidazole
derivatives
and in patient
CV:
in first
edema,flushing trimester of
thrombophlebit pregnancy
is after IV
infusion
Use cautiousl
in patients
GI: nausea,
with history o
abdominal
blood
cramping or
dyscrasia, CN
pain,
disorder or
stomatitis,
retinal or
epigastric
visual field
distress,
changes
vomiting,
metallic taste
Drug
Name
Classification
Indication
s
Mechanism
of Action
Adverse
Reactions
Contraindi
ons
Ciprofloxa
cin
200mg IV
Inhibition
of topoisomerase(
DNA
gyrase)enzymes,
which inhibits
relaxation of super
coiled DNA
and promotes bre
akage of double
stranded DNA
Complica
ted intra
abdomina
l infection
Inhibit s
bacterial
DNA
synthesis,m
ainly by
blocking
DNA gyrase,
bactericidal
CNS: seizures,
confusion,
depression,
drowsiness,
fatigue,
hallucinations,
headache,
insomnia
Contraindi
ed to patie
hypersens
e to
fluoroquin
nes
CV: edma,
thrombophlebitis
GI:
pseudomembrano
sous colitis,
diarrhea, nausea,
abdominal pain or
discomfort,
constipation
`
Drug
Name
Ketorol
ac 30
mg IV
Classification
non steroidal
anti
inflammatory
drugs
Indication
s
Short term
managem
ent of
moderatel
y severe,
acute pain
for single
dose
treatment
Mechanism
of Action
May inhibit
prostagland
in synthesis
to produce
anti
inflammato
ry ,
analgesic
and anti
pyretic
Short term effects
managem
ent of
moderatel
y severe,
acute pain
for
multiple
dose
treatment
Adverse
Reactions
CNS: dizziness,
drowsiness,
sedation
CV:
arrhythmias,
edema,
hypertension,
palpitations
GI: dyspepsia,
nausea,
constipation,
diarrhea,flatule
nce
Contraindications
Contraindicated in
patients
hypersensitive to
drug and in those
with active peptic
ulcer disease,
recent GI bleeding
or perforation,
advanced renal
impairment
Nursing
Diagnosis
SUBJECTIVE: Acute pain
related to
Masakit
inflammatio
ang
n and
kanang
distortion of
tagiliran
tissues as
ko as
verbalized
by the
patient.
Pain starting
suddenly
and
usually
peaking in
30
minutes.
OBJECTIVE:
Facial mask
of pain
Pain Scale
of 7/10
Muscle
guarding
or rigidly
when right
upper
abdomen
palpated
Narrow
focus
Vital Signs:
- T = 37.3
C
- PR =
110
- RR = 23
BP = 130/80
Inference
Planning
Cholelithiasi
s
I
Further
complicatio
n
I
Inflammatio
n of the
Gallbladder
I
Acute pain
SHORT
TERM
OBJECTIVE:
After an
hour of
nursing
intervention
s, patients
pain will be
relieved or
controlled as
patient
demonstrate
s use of
relaxation
skills and as
indicated for
individual
situation.
Nursing
intervention
INDEPENDEN
T:
Observe and
document
location,
severity (110 scale)
and
character of
pain (steady,
intermittent,
colicky)
(Get a
baseline
data of pain
scale)
Promote bed
rest,
allowing
patient to
assume
position of
comfort.
DEPENDENT:
Administer
medications
per
physicians
order:
*refer to the
Drug study
Rationale
Assist in
differentiating o
pain and provide
information abou
disease
progression/reso
tion, developme
of complications
and effectivenes
of interventions
section for
the
medications
given with
correspondin
g indicatons
Case Study
on Acute
Calculous
Cholecystit
is
PREPARED BY: RYAN JOSEPH M. MAGPAYO, RN
(NURSE I-RNHEALS)