I.

Introduction

Gallstone or cholelithiasis are concretion that form in the biliary tract, usually in the gallbladder. Their
development is insidious & they may remain assymptomatic for decades. Migration af gallstones may lead to
occlusion of biliary & pancreatic ducts, causing pain (biliary colic) & producing acute cholecystitis, ascending
cholongitis or acute pancreatitis. Chronic gallstones disease may lead to fibrosis & lose of function of the
gallbladder cancer. Excission of the gallstone disease is among the most frequency performer abdominal surgery.

Pathophysiology:
Gallstone formation occurs because of certain substances ,bile are present in contractions that approach
the limits of solubilità. When bile is concentrated in the gallbladder it can become super saturate with this
substances, which then precipitate from solution as microscopic crytals. The crystals are trapped in gallbladder
mucus, producing macroscopinc stones. Occlusion of the ducts by sludge & stone produces the complication of
gallstone disease.

People at Risk of Gallstone Disease:

Gallstones tend to affect females more than males, women who have experienced multiple pregnancies,
overweight and in their fourties.
Precipitating factors are pregnancy, contraception, obesity, diabetes, and increasing age, pregnant
starvation, total parenteral nutrition, clofibrate use diet/weight loss. Predisposing factors are advanced age,
gender, ileal resection/disease, race, and genetics.

II.PATIENT PROFILE
A. BIOGRAPHIC DATA

Ward: 1211

Date of Admission: April 29, 2010/ 10:30am

Name: R.U

Address: #08 San Andres Cabanatuan ,Isabela

Age: 33 yrs. Old

Gender: Female

Birth date: October 31,1975

Educational Attainment: College Graduate

Religion: Roman Catholic

Nationality: FIilipino

Civil Status: Single

Occupation: Bussiness woman

Health Care Financing : SSS, Philhealth

B. ADMISSION DATA

Chief complaint: abdominal pain

Initial Diagnosis: Chronic Calculuos cholecystitis inacute exacerbation
Final Diagnosis: Chronic calculous cholecystitis;Pregnancy 12 weeks breech
Attending physician: Dr. Leonard Santos

III.Patient History/ Nursing History

A. History of Present Illness

6 mos. Prior to admission, patient experienced crampy epigastric pain aggravates by

food intake, 7-8/10 severity which radiates to the upper quadrant of the abdomen and right flank
area . she was admitted in a private Hospital in Isabela for 3 days. Patient said that she was given
unrecalled antibiotic & omeprazole. She was discharge on the third day with a diagnosis of UTI
& cholelithiasis patient claims that the abdominal pain persisted but tolerable hence, no consult
done and no medication taken.

3mos. Prior to admission, patient had 12 weeks amenorrhea & suspected pregnancy
hence pregnancy test was done at home which revealed positive result, the abdominal pain was
noted to be intermittent only with intake of fatty foods. She was started with multivitamins and
folic acid once daily.

1week prior to admission, patient again experienced severe abdominal pain entering
on the epigastric area 8-9/10 in severity radiating to the right upper quadrant and right flank pain
with associated nausea and vomiting patient claims that the severity is most after food intake.

She was rushed to a private hospital and was admitted for 3 days, abdominal
ultrasound was done with revealed cholelithiasis and normal liver. She was only given
Paracetamol for pain and antacid (kremil-S and maalox) with afforded relief. She was discharged
and the pain was acted to be 4-5/10 in severity. She then decided to seek consult for second
opinion.

1 day prior to admission, she consulted with the attending physician who referred her
to a surgeon. The surgeon advised cholecystectomy which she agreed hence the admission.

B. Past Medical History

The patient had chicken fox when she was a child, she cannot remember what age.
Previously she was hospitalized. The patient had complete Immunization. She doesn’t have any
allergies of whatever food she takes and whenever she had fever she takes Paracetamol.

C. Family Health History

 The patient quoted that Hypertension, Diabetes and Goiter was made her known to
her father side and Heart diseases and Gallstone in her mother side.

D. Genogram
 E.Personal and Social History

The patient is a business woman, non smoker, non alcholic beverage

drinker. Patient denies illicit drug usage.

IV.Gordons Functional Health Pattern

Level of Before During Analysis/Inference

Functioning Hospitalization Hospitalization

Health Perception/ “akala ko malusog “hindi ako The health belief model
health a ko”. Maging malusog sa estado (rosenstock, 1974) is concerned in
Management checkup o ng aking what people perceive, or belief, to
Objective: emplies consultation ay di kundisyon sa be true about themselves in
insufficient ko ginagawa, at ngayon “ relation to health.
knowledge wala naman akong as verbalized by ( FUNDAMENTALS OF
regarding healthy allergy sa kahit the patient NURSING BY: TAYLOR, PAGE
diets anong kainin ko” 64)

As verbalized by
the patient

Nutritional & “Mahilig sa “Sa ngayon na ka An individual’s heath status greatly

Metabolic Pattern. matataba at malaat dextrose ako yung affects eating habits and nutritional
na pagkain” as sa pagkain ayos status [Fundamentals of Nursing by
Objectives: Patient
verbalized by the lng, kaya lang … kozier p.1117]
R.U. is currently
patient. walang lasa”
taking oral “Nutrition is essential and
medication and As verbalized by physiologic needs of individual”
parenteral fluids the patient (Maslow’s Hierarchy of needs)
for food
supplement
&medication
Ellimination “maaayos naman Patient R.U “Elimination is normal functioning
Pattern ang pag dumi at defecates ones, and Clients with bowel elimination
pag ihi ko” every other day and voiding problems manifest
and void 3x a day common problem.” (Maslow’s
As verbalized by
Objectives: Stool Hierarchy of needs)
the patient ones
is soft in minimal
every other day and
amount and it is
day
brown in color.

Urine is yellowish
in color and no
pain when
voiding.

Activity Exercise Patient R.U Patient R.U’s Bandura’s social learning theory
Pattern reported no routine activities in the suggest individuals who see
exercise only work hospital are deep themselves as capable of achieving
Objectives: due to
and mall shopping breathing, a particular out come, well expend
her confinement
with her friends. personal hygiene more effort to achieve that out
and suture, daily
such as taking a come (www.medscape.com)
activities has
bath and toileting.
limitation.

Sleep Rest Pattern “Ayos lang naman “Hindi gaanong “Illness that causes pain or physical
ang tulog ko pag maganda ang distress can result in sleep
Objectives: Patient
wala akong tulog ko dahil sa problems. People who are ill
R. U’s sleeping
maramdamang tahi ko sa tiyan at require more sleep than normal
pattern is greatly
sakit”. iba pa rin ang rhythm and wakefullness is often
affected by the
matulog sa disturbed”. (Fundamentals of
suture of her As verbalize by the
bahay” Nursing 7th Edition by KOZIER
abdomen which is patient.
pg. 1117)
contributed to
sudden feeling of
pain.

Cognitive- Patient R.U is a Patient R.U is Piaget Cognitive development

Perceptual Pattern college graduate attentive and have Theory integrates others view point
 from Isabela thus full cooperation into own understanding of truth.
she can easily regarding
(Fundamentals of Nursing by
perceived by others physician’s
TAYLOR Pg. 377)
and also has advice, opinion
adequate thus, tolerating
comprehension that specialized
regarding physician on
medication doing certain
instructions from procedure for her
any healthcare sake.
provider.

Self Perception Patient R.U is kind She considered “Events or situation may change
and Self Concept and friendly, she her status as the level of self concept over time.
Pattern loves to socialize something Illness and trauma can also affect
with her friends. lacking not fully the self concept”. (Fundamentals of
She considered complete but yet Nursing by KOZIER pgs. 959-967)
Objective: Due to herself as hollistic she prospected of
her condition a being, although she being cure from
change to the level have’nt grown with her present illness
of self perception her mother. She sooner.
is slightly affected. wants to have good
health and live life
to the fullest.
Role Relationship “lumaki lang ako Patient, R.U’s Love and belongingness needs
Pattern na kasama ang relatives is behind include the understanding and
kamag-anak ng her acceptance of others in both giving
tatay ko minsan hospitalization and receiving love,and the feeling
nakikita ko ang days giving her of belonging to
mga kapatid ng stength and full families,peers,friends,a
nanay ko pero ang support. neighborhood, and a community.
nanay ko di ko
(Fundamental of Nursing)
nakikita kasi nasa
ibang bansa na CAROL TAYLOR
sya”As verbalize
page 27
by the patient

Sexuality Patient started her Patient R.U is Sex is considered by maslow

Reproductive Menarche when she single but (1970) to be basic Physiological
Pattern was 11 years old. presently she’s 12 need that generally takes priority
Patient is Single weeks breech over higher level need.(Patter &
but has a boyfriend pregnant. Perry’s Foundation in nursing
they engaged in Theory www.
sexual activity books.goolge.com.ph)
matter with the
used of
contraceptives

Coping Stress “stress sa trabaho “manood ng tv “Coping is the cognitive and

Tolerance lang naman ang makipagkwentuha behavioral effort to manage
dahilan kung bakit n sa kamag anak. specific external & internal
sumasakit ang ulo demands that are appraised as
para lang di ko
Objective: ko, kaya taking or excluding the resources of
gaanong
watching nagpapahinga ako the person”. Fudamental of nursing
maramdaman ang
television, talking at umiinom ng by kozier pg. 1020).
kirot ng tiyan to”
with someone is gamot”
significant factor As verbalized by
As vebalized by the
in diverting the patient
patient.
 patient’s feelings.

Value belief Patient R.U is She follow Madeleine Leinenger’s

Pattern Roman Catholic therapeutic Transcultural Care theory &
she usually go to regimen and Ethnonursing
Objectives: patient
Church every strong faith to
is always seeking Focus on the fact that different
Sunday, god for her
for medical cultures have different caring
comunicating with illness.
assistance, behaviors and different health and
God.
religous support illness values, beliefs and patterns
and practice of behaviors.

(www.wikipedia.com)

V. ANATOMY AND PHYSIOLOGY

Anatomy of the Biliary system:

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:

1. 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.

2. These ducts ultimately drain into the common hepatic duct.

3. 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).

4. 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.

5. 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:

• to drain waste products from the liver into the duodenum

• to help in digestion with the controlled release of bile

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the
liver cells to perform two primary functions, including the following:

• to carry away waste

• to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body
in the form of feces, is what gives its dark brown color.

Physiology

The gallbladder stores about 50ml (1.7 oz. to 1.8 oz.) of bile, which is released when food containing fat
enters the digestive tract, stimulating the secretion of CCK. The bile, produced in the liver, emulsifies fats in
partly digestive food.

Being stored in the gallbladder, bile becomes more potent and intensifies its effect on fats.

Abnormal Conditions

Gallstones may develop in the gallbladder as well as else where in the biliary tract. If gallstones in the
gallbladder are symptomatic and cannot be dissolved by medication or broken into smaller pieces by ultrasonic
waves, surgical removal of the gallbladder known as cholecystectomy, may be indicated.
VI.PATHOPHYSIOLOGY

 Diagram Format

Description:

 Size

A gallstone's size varies and may be as small as a sand grain or as large as a golf ball. The gallbladder may
develop a single, often large stone or many smaller ones. They may occur in any part of the biliary system.

 Content

Gallstones have different appearance, depending on their contents. On the basis of their contents, gallstones can
be subdivided into three following types:

• Cholesterol stones are usually green, but are sometimes white or yellow in color. They are made primarily
of cholesterol and account for 80 percent of gallstones.
 • Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They
account for 20 percent of gallstones.

• Mixed stones account for the majority of stones. Most of these are a mixture of cholesterol and calcium
salts. Because of their calcium content, they can often be visualized radiographically.

 Causes

Gallstones may be caused by a combination of factors, including inherited body chemistry, body weight,
gallbladder motility (movement), and perhaps diet. Additionally, people with erythropoietic protoporphyria (EPP)
are at increased risk to develop gallstones.

Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts. Besides a high
concentration of cholesterol, two other factors seem to be important in causing gallstones. The first is how often
and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile
to become over concentrated and contribute to gallstone formation. The second factor is the presence of proteins
in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones.

In addition, increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the use of
combined (estrogen-containing) forms of hormonal contraception, may increase cholesterol levels in bile and also
decrease gallbladder movement, resulting in gallstone formation.

No clear relationship has been proven between diet and gallstone formation. However, low-fiber, high-cholesterol
diets, and diets high in starchy foods have been suggested as contributing to gallstone formation. Other nutritional
factors that may increase risk of gallstones include rapid weight loss, constipation, eating fewer meals per day,
eating less fish, and low intakes of the nutrients folate, magnesium, calcium, and vitamin C. 0n the other hand,
wine and whole grain bread may decrease the risk of gallstones.

The common mnemonic for gallstone risk factors refer to the "fifth's": fat (overweight), forty (age above 40),
female, and fertile (pre-menopausal); a fifth F, fair is sometimes added to indicate that the condition is more
prevalent in Caucasians. The absence of these risk factors does not, however, preclude the formation of
gallstones.

Interestingly, a lack of melatonin could significantly contribute to gallbladder stones, as melatonin both inhibit
cholesterol secretion from the gallbladder, enhances the conversion of cholesterol to bile, and is an antioxidant,
capable of reducing oxidative stress to the gallbladder.
VII. Diagnostic/ Laboratory (chronological)

Date Laboratory / Actual Normal Value Analysis/Inference

Diagnostic test result
04/29/10 Hgb 120g/dl 120-170g/dl Decrease protein
production causing
10:30am jaundice

Decreases because of bile

Hematocrit 0.18 0.37 to 0.34
infection
RBC 1.96 4.0-6 x 10g/L Decrease oxygen
production due to billiary
tract infection that causes
anemia

WBC 33.2 4.5 to 10x10g/L

Due to presence of
infection

Neutrophils 0.70 0-38-0-68

slightly increase because
of WBC elevation

increase due to acute

ALP 97u/L 36-92u/L biliary obstruction

Surgical procedure

Date Laboratoy/ Diagnostic test Outcome

4/29/10 Cholecystectomy and Choledochostomy done f-14 t-tube inserted

choledochostomy with vicryl 4-5 closure by layer dressing
patient tolerated procedure well

VIII. Course in the Ward

Patient was admitted due to abdominal pain. Upon admission vital signs were stable,
good fetal movement and fetal heart tone with no uterine contractions. Noted complete blood count
and alkaline phosphate were obtained undergo cholecystectomy with t-tube choledochostomy which
she related post operation. Vital signs, fetal heart tone, fetal movement and uterine contractions were
 monitored on first operative day; Patient had BP elevation, secondary severe pain on the surgical site
which was relieved by pain reliever. The diet was regulated from NPO to full diet IVF was
consumed. Patient remained stable, all throughout for hospital stay.

Patient was prescribed to take Cefuroxime 500mg/cap BID, Paracetamol 500mg/tab. q6h,
isoxsuprine HCL 10mg/tablet TID PRN.

Patients was scheduled for cholecystectomy, choledochostomy procedure is well done.

Histopathopathology:

Description of OP technique (to include incision, drainage, sutures findings) immediate

post op conditions.

Patient supine asepsis antiseptic sterile drainage, kocher incision gallbladder dissected
cystic artery duct clamped, cut and ligated.

Choledochostomy done F 14 t-tube inserted; coledochostomy with vicryl 4-5 closure by

layer dressing patient tolerated procedure well.

IX. Nursing Care Plan

CUES Health Inference Planning Nursing Content/

Problem/Nursi Intervention
ng Diagnosis Rationale
Subjective Pain discomfort Etiology: Goal: 1.Monitor the -To obtain
relating to V/S of the Baseline
cues: Post cholecystectomy After 8 Patient data.
surgical
‘Sumasakit incission due to refers to a group of sign hours of
ang tahi ko“ and symptoms that occur Nursing 2.Encourage
cholecystectom verbalization -Serve as a
y surgery. after cholecystectomy Interventio
verbalized by feeling about guide in pain
the patient procedure.It is often n the pain pain management.
performed to treat the will lessen
Objectives formation of stones in the to pain 3.Established
Cues:
gallbladder. The sign and scale, 5/10 non -To lower
*expressive symptom of post to 2/10 Pharmacologica down the
behavior cholecystectomy is l Therapy: patient pain
pain,such as sharp pain in sensation.
*facial Such as
grimace the lower belly or a dull Watching
pain.Inflammation of the T.V ,Listening
*guarding stomach lining can also Music ,Reading
behavior
occur. Possible signs of books and
Pain scale of post clolecystectomy magazines
8-9/10 include fever,gas,bloating,
4.Administer
V/S and diarrhea.
Analgesic if
(www.medfriendly.com) pain is
Temp.: 36.5 prolonging -To relieve
°C
pain
Pulse: 78bpm 5.Instruct
patient about
RR: 20 cpm deep breathing
exercise and -To minimize
BP: guided imagery and provide
110/70mmHg relaxation
Health and comfort.
Implication:
pain may
caused much
discomfort to
patient and
may suggest or
indicate
underlying
health
problems.

CUES Health Inference Planning Nursing Content/ Evaluatio

Problem/ Intervention n
Nursing Rationale
Diagnosis
Subjective . condition Etiology: Goal: 1. Review -provide After 8
prognosis, the disease knowledge hours of
cues: Cholecystectomy is the After 8 based on
treatment, process, Nursing
‘Natatakot and surgical procedure to hours of which interventi
ako na baka remark the gallbladder is a Nursing surgical patient can
discharge on the
magkaroon ng pear shape organ that is Intervent procedure make
infection “ needs informed patient
part of the digestive ion the or
maybe choices verba
verbalized by related to system. It lies beneath the patient prognosis. lizes
the patient liver on your right side.It will
lack of understan
exposure; stores bile, which is a verbalize ding of
Objectives
Cues: informatio fluid produced by the liver understa disease
n, to help digest fats. nding of process/
statement of therapeut
deficit misinterpre
(www.med.umich.edu)
2.Demostra -promotes prognosis
knowledge tation, ic te care of independenc and
regarding self unfamilliar regimen e in care and treatment,
care
incision
ity with reduces risk correctly
dressing of
informatio performs
complication
n resources necessary
Pain scale of or infection.
and lack of procedure
8-9/10
recall and
V/S possibly explain
evidenced 3.Stress - 6 months reasons
Temp.: 36.5 importance
by after surgery, for the
°C
questions: of low fat diets actions.
Pulse: 78bpm statement limits need
maintaining Initiate
for bile and
RR: 20 cpm of low fat reduces necessary
misconcept diets, eating discomfort lifestyle
BP: ion, and changes
110/70mmHg frequent
inaccurate associated and
smallmeals,
Health follow with participate
gradual re- inadequate
Implication: through in
introduction digestion of
pain may instruction fats. treatment
s.
of regimens.
caused much
discomfort to foods/fluid
patient and containig
may suggest fats over 4-
or indicate
underlying 6 months
health period.
problems

4.avoid -Minimize
alcoholic risk of
beverages. pancrestic
involment.
 -Intestine
5.Inform requires time
to adjust
patient that
stimulus of
loose stool continuos
1 up to 3 output of
times a day bile.
may occur
for several
months.

-Fats in
6.Advise small
patient to amount are
usually
note and tolerated
avoid foods after period
that seem to of
aggravate adjustment,
patient
diarrhea. usually
doesn’t have
problem with
most foods.

7.Identify -Indicators
sign and of
obstruction
symptom
of bile flow/
requiring altered
notification digestion,
of requiring
further
physician
evaluation
(dark and
urine , intervention.
jaundice
color of
eyes or
skin, day
colored
 stools,
recurrent
heart burns
and -Resumption
bloating. of usual
accomplishe
8.Review d within 4-6
activity weeks.
limitations
dependent
on
individual
situation.

X. Drug Study
 DRUG NAME: ACTION: INDICATION: ADVERSE EFFECT: NURSING
CONSIDERA
Paracetamol TIONS

BRAND NAME: Increase fever Relief of mild-to- Stimulation, drowsiness, ALERT: Many
by inhibiting the moderate pain, nausea, vomiting, OTC and
Biogesic effects of treatment or fever. abdominal pain, prescriptions
pyrogenes in the hepatoxicity, hepatic products contain
GENERIC NAME: hypothalamic seizure, renal failure, acetami-nophen
heat regulating leukopenia, neutropenia, be aware of this
Paracetamol centers and by a hemolytic anemia, when calculating
hypothalamic thrombocytopenia, total daily dose.
DRUG CX; action leading to pancytopenia,
DOSAGE & sweating and rash, urticaria, *Use liquid form
FREQ. vasodilation. hypersensitivity, for children and
cyanosis, anemia, patients who
*Pharmaco-logic
Pharmaco-logic *Relieves pain jaundice, CNS have difficulty
Class: Para amino- by inhibiting stimulation, delirium swallowing.
phenol prostaglandin followed by vascular In children,
•Pregnancy Risk synthesis at the coma and death. don’t exceed 5
Category B CNS but does doses in 24
not have anti- hours.
*Paracetamol inflammatory
500mg.tab/ every action because
6hrs. -(07-02-09) of its minimal
effect on the
prosta-glandin
synthesis.

XI. Discharge planning

M-medication
S- spirituality – Encourage
Encourage the patient to continue
patient the doctors
to communicate in presciption
God regarding home
medication such as taking
– Encourage duvadillan,
patient to cefuroxime(750mg)
communicate with her family and other
E-exercise people
Inform the patient to limit 24 to 48 hours of strenous exercise and advise
light exercise such as deep breathing , physical grooming and hygiene

T-treatment Continue taking medicine, follow doctor’s advice; stick to their health
techniques.

H- health teaching – Limit fatty foods intake

– No strenous activity

– Increase oral fluid intake ( apple juice is advisable)

– Keep on cleaning wound dressing a day

O-outpatient department Do visit the Doctor’s if the patient required to do so or any other signs
and symptoms of complication manifested.

D-diet – Abstain from fatty foods

– Encourage protein intake;such as tofu,mongo beans,and eat

smaller than normal out of food at mealtime.