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us Cholecystitis Case Study Sample

Description

Calculous Cholecystitis A Case Study Presented to the Faculty,

Ateneo de Davao Universi ty College of Nursing

Submitted to: Daphny Grace Peneza,

Clinical Instructor – Panelist for the Case Study Submitted by: Gino Gregor Palaca Marvin Rey Andrew Pepino Rio Remonde Kevin Melvin Roa Krystle Rustia BSN-3H-4a

May 25,

TABLE OF CONTENTS

Introduction

Objectives (General & Specific)

Patient’s Data

Family Background and Health History

Definition of Complete Diagnosis

Developmental Data

Physical Assessment

26 VIII

Anatomy and Physiology

Etiology and Symptomatology

Pathophysiology

Doctor’s Order

Diagnostic Exam

62 XIII

Drug Study

Procedural Report

Nursing Theories

Nursing Care Plan

100 XVII

Discharge Plan (M

123 XVIII

Recommendation

130 XIX

References

ACKNOWLEDGMENT

The Group 4-1 of section 3H,

would like to acknowledge the contributions of the following groups and individuals to the development of this case presentation

To the Almighty God for blessing them with wisdom,

competence and genuine passion and giving them the strength to finish this presentation

The group dedicates to Him the fruits of their hard-earned achievement

To the staff of the Davao Medical School Foundation Hospital-3C for being accommodating to the students and for giving them additional teachings during their exposure in the said hospital

They have also been very willing to allow the students to obtain records necessary for this presentation

To their respected clinical instructor for this rotation,

Daphny Grace Peneza,

for her support and guidance to the group

She has imparted knowledge that would furthermore enhance the student’s understanding of their patient’s case,

thus making them ready to present this case presentation

To their client,

disclose personal information that would be helpful for this study

The group would also like to thank them for their patience throughout the duration of the study and for giving the group the opportunity to care for Selecta and apply what they have learned

To the proponents’ respective family and friends for their prayers as well as their financial support

They have also been a source of inspiration of the students

To the members of this group for working hard and giving their efforts,

time and resources in conducting the study and for the completion of the written output

INTRODUCTION One of the body organs that we can live without is the gallbladder

However,

does this mean it is of no use to the body

? The gallbladder is a pearshaped organ situated underneath the liver

Its function is to store bile and release it as needed for digestion

Bile emulsifies the fats in food,

breaking them to small fragments so they can be further digested and absorbed in the small intestine

If the gallbladder is not working as it should,

the digestion of fats can be seriously impaired

One of the common gallbladder diseases is calculous cholecystitis

Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading to poor drainage of bile

Trapped bile can irritate and inflame the walls of the bladder,

Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman,

Friedman & Brandt,

It affects women more often than men and is more likely to occur at the age of 20-50 or over 60

Asians are also more prone to develop pigment stones

Moreover,

people who are obese and those who had had low fat diet are at an increased risk for developing cholelithiasis

In the United States,

Maurer,

In the Philippines,

an extrapolated prevalence of 5,

Gallstones that do not cause symptoms do not require treatment

However,

surgical removal of the gallbladder is recommended

Recently,

the Group 3H-4a had a patient who was diagnosed with symptomatic

The group chose this case for they see it fit for their perioperative concept

Rarely do they interact with patients who had minimally invasive surgery

The proponents are hoping that through this case study,

they will be more knowledgeable and aware about such gallbladder disorder and the surgical procedure done for the said disease

They are also interested to know Page | 1

the proper and necessary nursing management that will be given to a patient affected by the disease

Moreover,

they would also like to impart their learning to their families and their community regarding the prevention and care if ever such condition will arise in the scenario

As nursing students,

they are hoping that this study will help them become more efficient and better nurses in the future

The student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well

Page | 2

OBJECTIVES General objective: Within 2 weeks exposure to various clinical areas,

the group should have been able to present a comprehensive case study which explains the pathology,

the treatment and the appropriate medical and nursing management regarding the condition of their chosen client

The group also aims to perform the necessary nursing interventions to help alleviate the patient’s condition and improve her health

Specific Objectives: The proponents also created certain aims that will help them in achieving their general objectives

Within 2 weeks of exposure,

the proponents aim to: Cognitive:  Gather pertinent data regarding the past and present health history of the patient through interview and assessment

 Draw the family genogram of the patient

 Define the complete diagnosis of the patient by directly citing it from three different sources

 Ascertain the patient’s developmental status using the theories of Robert Havighurst,

Erik Erikson and Lawrence Kohlberg

 Conduct a thorough cephalocaudal assessment obtained from the client

 Review the anatomy and physiology of the organs affected in the patient’s disease

 Present the etiology and symptomatology of the disease

 Trace the pathophysiology of the patient’s disease

 Obtain the doctor’s orders and make rationales for each order

Page | 3

analyze and interpret laboratory and diagnostic procedures done on the patient and include the normal and abnormal values and findings for comparison,

and the specific nursing responsibilities associated with each diagnostic procedure

 Make drug studies on each drug given to the client,

correlate them with the disease process,

explain why such drugs were ordered,

and present important interventions in administering the drug

 Identify three nursing theories that can be applied to the patient’s condition

and time-bounded nursing care plans for the patient

 Correlate the different nursing theories with the nursing care plans that are presented in this case study

 Make a discharge plan for the patient with the use of M

 Validate patient’s prognosis according to the following categories: onset of illness,

willingness to take medications and treatment,

environmental factors and family support

 Broaden our scope of knowledge about the disease and the appropriate Nursing Care for the patient with the disease

Psychomotor:  Find a patient who will be the subject of their case presentation

 Render health teachings to the patient and her significant others to promote health

 Provide care based on the various nursing care plans formulated by the researchers and the patient herself

Page | 4

 Share information about calculous cholecystitis and the factors that cause the development of such disease and its complications

 Share how the disease affects those affected by it and the systems involved in its occurrence

Affective:  Establish rapport with the patient and significant others

 Show genuine concern and willingness in serving the client

 Be aware of the client’s progress on the succeeding interactions

 Appropriately state the bibliography of all resources used in order to prevent plagiarism and promote honesty

Page | 5

PATIENT’S DATA Client’s Code Name:

Gender:

Birth date:

November 6,

Address:

Upper Sirib,

Calinan Davao City

Nationality:

Filipino

Religion (Denomination):

Christian (Roman Catholic)

Civil Status:

Married

Spouse:

Educational Attainment:

Occupation:

House keeper

Height:

Weight:

Health Insurance:

Phil Care

Hospital:

Davao Medical School Foundation (DMSF)

Vital Signs on Admission:

BP: 130/80 mmHg PR: 79 bpm RR: 19 cpm T: 37 ºC

3C- 324-5

Chief Complaint:

Pain at right upper quadrant

Admitting Physician:

Walter Batucan

Admitting Diagnosis:

Acute Cholelithiasis

Final diagnosis

Calculous Cholecystitis

Surgical procedure

Laparoscopic cholecystectomy

Page | 6

FAMILY BACKGROUND AND HEALTH HISTORY A

Family Background Meg is the second child among Mamang and Papang’s four children

All children of Mamang were born through Normal Spontaneous Vaginal Delivery without any complications

She delivered all her children at their house with the help of ―mananabang‖

The family has been residing in Sirib,

Calinan Davao City since the marriage of Papang and Mamang

Their home is near their farm

The client,

Meg has 3 siblings namely: Kenny (Male,

Luigi (Male,

Meg graduated high school and didn’t to proceed to college because she helped her family tend their farm

According to the patient,

her father and mother are still alive and they suffer from hypertension and diabetes

She said that the family lineage of her mother also suffers from heart problems as well as kidney problems

Two of her uncles on father’s side underwent surgery,

and had the same condition as Meg

Her older brother died due to motorcycle accident

Luigi was diagnosed with hypertension and Dora had a history of UTI

There was no one else in her immediate family that suffered cholecystitis aside from Meg herself

Meg got married to Bobong in the 1998

They were blessed with 3 children

Her 3 children were delivered through Normal Spontaneous Vaginal Delivery,

all were born in the Maternity clinic in Calinan

Her eldest child is now studying in 4th grade

So far,

none of her children suffer a serious illness

In terms of their expenses,

Bobong is the one that provides money for their daily expenses

Bobong is a Supervisor at DABCO and has a wage of approximately 10,000 a month

Meg said that they budget the Page | 7

money well for them to have food and to provide the necessary daily needs and expenses

By helping tend to the 2 hectare farm of the patient’s parents,

They plant coconut trees,

Lifestyle The patient has sedentary lifestyle

When Meg stopped going to school,

she helped her mother with household chores

Right now,

she is busy taking care of Bobong and their 3 children

She is the one who cooks,

and does the laundry of the whole family

Sometimes,

she does gardening in their backyard

According to her,

she experiences fatigue from doing household chores especially since she is the only one who does the laundry

She reported that she doesn’t smoke,

he smokes almost one pack a day

Meg said that she drinks liquor very seldom

she only consumes a half of glass or a glass of liquor occasionally

The family has good relationship

At night,

they watch television together and this serves as their bonding time

Occasionally,

they gather together with her relatives when there are fiestas,

birthday celebrations and other special occasions

She is not so active in terms of social organizations such as GKK (Gagmay’ng Kristohanong Katilingban),

but she sometimes joins in the events in their community like the fiesta

She sometimes goes to church on Sundays together with her children

Page | 8

Meg sleeps around 9:00 o’clock at night and wakes up around 5:00 o’clock in the morning to prepare things needed of her husband

She is the one who cooks the ―baon‖ of her husband for work

Meg said that she eats at least two times a day in small meals

She said “naga-diet diet man ko kay tabaan nako sa akoang lawas,

nagsugod ko katong 36 years old pako,

pero karong tuiga giundangan na nako ang pagdiet-diet”

For breakfast she usually eats,

Every morning,

In a day,

she can consume at least 3 cups of coffee

Her lunch and supper are sometimes vegetables that are found in their backyard such as ―kamunggay‖,

―talong‖ and ―tinangkong‖

She is not fond of eating pork and beef

She said that before,

she limits herself from eating fatty foods since she aimed to lose weight because she was afraid of becoming obese

she is so fond of drinking soft drinks

In a day she can consume 4 glasses of coke

But she also drinks approximately 5-6 glasses of water

She also loves to eat salty foods,

According to her,

she has no allergy from any form of food

Past Health History Meg and her husband preferred to have artificial family planning than natural family planning

She started using birth control pills since she was 36 years old

She said that she is not sure if she completed her immunizations

Her mother forgot already and the records were lost

They only avail of the services of the health center very seldom

She said that their house was far from the health center so they weren’t able to avail of all of the services

She also experienced common illnesses such as cough,

They only treated it at home,

since her mother knows how to make use of different herbal medicines such as Page | 9

they sometimes bought over-the-counter drugs such as paracetamol,

Neozep,

With regards to how long she experienced those usual illnesses,

she said “dili man jud ko maabtan ug simana sa akoang kalintura ug bisan ubo”

She experienced measles when she was a 1-year old and had chickenpox when she was 10-year old

Meg had her menarche when she was 11 years old

Meg reported that she got pregnant with her 1 st child at the age of 28

she had miscarriage on the 1st week of pregnancy

She was hospitalized at Robillo Hospital,

Calinan Davao City

Completion curettage was performed to her

she had a miscarriage and was hospitalized on the maternity clinic and underwent completion curettage

She reported that in almost all her pregnancies,

she experienced an increased blood pressure,

After delivering her third child at the age of 36,

Bobong and Meg decided to make use of family planning

Meg started to take birth control pills until now to prevent unexpected pregnancy

History of Present Illness On the second week of December 2009,

Meg felt mild pain at the right upper quadrant of her abdomen

She neglected it thinking that it’s nothing serious and might be just an episode of indigestion

After three days,

But after two weeks,

pain recurred at a higher scale (5/10)

Because of this,

she was forced to seek medical advice

She went to Isaac T

Robillo Memorial Hospital Calinan,

Davao City and was asked to have ultrasound of the whole abdomen

After 2 days,

the result was released and they found out that there were stones in her gallbladder

She was advised by the doctor to undergo surgery,

However,

Page | 10

the patient resisted the doctor’s advice due to fear of surgery

She was given medications as an alternative (the patient already forgot the name of medications prescribed)

She was instructed by the doctor to increase water intake and have a low fat diet,

she wasn’t able to follow the doctor’s order and still continued with her usual lifestyle

Meg said that she still felt the pain after the check-up but she could still tolerate it

She just took medications that were prescribed by the doctors to alleviate the pain she felt

Last May 5 this year,

three days prior to admission,

the patient again experienced right upper quadrant pain which lasted until the present condition

This was characterized to be progressive pain with a pain scale of 8 out of 10

There was no radiation noted and no associated symptoms

Two days prior to admission,

pain recurred with a pain scale of 10 out of 10

This prompted Meg to seek consultation,

On May 8,

the patient was admitted at Davao Medical School Foundation at Surgical Ward,

room 324 bed 5 under the service of Dr

Batucan,

with admitting diagnosis of Acute Cholelithiasis

Effects/Expectations of Illness to Self/Family

Biological: When Meg knew about her condition that she needs to undergo surgery,

She was very worried about herself because she has fear of not waking up after surgery

She feared having complications of not having a gall bladder anymore

Page | 11

Psychosocial: Also,

she is worried about her 3 children,

who still need care and guidance from their mother

This made her decide not to go through with the surgery before

Meg wants to overcome her illness so that she can still spend time with her family and friends

Furthermore,

she said that she wants to be in good condition as much as possible so that she can do her daily task in everyday life for her family

The client is worried about her condition because she has many plans in life together with her family

Spiritual: Still,

Meg is still hopeful to overcome her challenges in life

The client still has faith in the Creator,

and she continues to pray to Him

She believes that everything will be alright with the help of the creator

her children were worried about their mother,

who’s suffering from such condition

Her husband,

Bobong is trying his best to support his wife

Bobong was worried about Meg because for him,

it makes him suffer seeing his wife suffering

In addition,

their relatives are also extending their care and prayers for Meg because they are worried and concerned for her

The client is also very thankful because her family,

relatives and friends are still there giving support to her for her fast recovery

They are always there and look after her in the hospital and to aid her physically,

Page | 12

Genogram

Maternal

Mamita,

Paternal Side Lola,

Papito,

Mamang,

Papang,

Bobong,

D- diabetic K- Kidney problem o- old age c- cholelithiasis a- accident

Bebe three,

Bebe two,

Bebe one,

Page | 13

DEFINITION OF COMPLETE DIAGNOSIS Complete Diagnosis: Calculous Cholecystitis

Calculous

Calculi,

usually form in the gallbladder from the solid constituents of bile

Source: Boyer,

Brunner and Suddarth’s Textbook of MedicalSurgical Nursing,

11th ed

Lippincott Williams & Wilkins

Calculus (pl

an abnormal stone formed in body tissues by accumulation of mineral salts

Calculi are usually found in the biliary and urinary tracts

Source: http://medical-dictionary

Retrieved May 15,

Calculi (stones) can be divided into two groups—renal calculi and gallstones

The majority of gallstones are composed principally of cholesterol and other calcium salts

Source: Iyengar,

Elemental Analysis of Biological Systems: Biomedical,

Environmental,

Compositional and Methodological Aspects of Trace Elements,

Cholecystitis

Cholecystitis is the inflammation of the gallbladder

In more than 90% of the cases,

Page | 14

Source: White,

Foundations of Nursing: Caring for the Whole Person,

Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation)

Source: Crowley,

An Introduction to Human Disease: Pathology and Pathophysiology Correlations,

USA: Jones and Bartlett Publishers

Inflammation of the bladder which may be either acute or chronic

the blood flow to the gallbladder may become compromised which in turn will cause problems with the filling and emptying of the gallbladder

A stone may block the cystic duct which will result in bile becoming trapped within the bladder due to inflammation around the stone within the duct

Chronic cholecystitis occurs when there have been recurrent episodes of blockage of cystic duct

Source: Digiulio,

Medical-Surgical Nursing Demystified,

USA: McGraw-Hill

Calculous Cholecystitis

Acute cholecystitis is inflammation of the gallbladder

There are two major types of acute cholecystitis— calculous and acalculous

In calculous cholecystitis,

gallstones obstruct the gallbladder outlet leading to poor drainage of bile

In physical exam,

patients may exhibit Murphy’s sign— right upper quadrant pain elicited by palpation under the right costal margin when the patient inspires

Page | 15

Source: Ginsber,

(2006) The Clinician’s Guide to Pancreaticobiliary Disorders,

121-123

USA: SLACK Incorporated

Page | 16

DEVELOPMENTAL DATA According to Taylor,

Lillis,

LeMone and Lynn (2008),

growth and development are orderly and sequential as well as continuous and complex

All humans experience the same growth patterns and developmental levels,

because these patterns and levels are individualized,

a wide variation in biologic and behavioral changes is considered normal

Within each developmental level,

certain milestones can be identified

the time the infant rolls over,

or says his or her first words

Although growth and development occur in individual ways for different people,

certain generalizations can be made about the nature of human development for everyone

Robert Havighurst’s Developmental Task Theory Robert Havighurst believed that living and growing are based on learning,

and that a person must continuously learn to adjust to changing societal conditions

He described learned behaviors as developmental tasks that occur at certain periods in life

Successful achievement leads to happiness and success in late tasks,

whereas unsuccessful achievement leads to unhappiness,

The developmental tasks arise from maturation,

and values that determine occupational and family choices,

Description

In the middle years,

Age(30-40)

the peak of their influence upon society,

Justification

Page | 17

at the same time the society makes its maximum demands upon them for social and civic responsibility

It is the period of life to which they have looked forward during their adolescence and early adulthood

And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it

The patient married and started a Achieved

She is happy with her

 Learning to live with a partner

husband since she receives care and

She works

together with her husband in taking care of and rearing their children by providing

Page | 18

The patient has no job,

she is the one managing the house,

Achieved

 Getting started in occupation

peacemaker when trouble happens among her children

She is the one

Meg is also responsible for budgeting their money needed to sustain them in their everyday living

She sees to it that her husband’s salary is well budgeted and not put into waste

 Taking on civic responsibility

Achieved

The patient is doing her responsibilities as a Filipino citizen by following laws in our country such as not throwing garbage anywhere,

She is also a registered voter

Page | 19

Patient verbalized that if she were not admitted in the hospital,

she would really vote in the 2010 Presidential elections

(property tax and cedula) as part of her responsibility as a citizen

Erik Erikson’s Psychosocial Development Theory Erikson emphasized developmental change throughout the human life span

In Erikson’s theory,

eight stages of development unfold as we go through the life span

Each stage consists of a crisis that must be faced

According to Erikson,

this crisis is not a catastrophe but a turning point of increased vulnerability and enhanced potential

The more an individual resolves the crises successfully,

the healthier development will be

It is patterned to the Psychosexual Development of Sigmund Freud but more concentrated on what task and conflict should a person be able to manage in a certain age group

That is termed psychosocial development

He described eight stage of development: 1

Infancy

Adolescence

Early childhood

Young adulthood

Late childhood

Adulthood

School age

Maturity Page | 20

Each stage signals a task that must be accomplished

The resolution of the task can be complete,

Description

Justification

Middle Adulthood: 25-65 years

The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable

Ego Development Outcome: Generativity vs

Basic Strengths:

Strength comes through care of others and production of something that contributes to the

Working

As a wife and a mother of three children,

the one who inculcates values in the family

whom she acquired from her parents

makes sure that her children will be raised with good attitude and as good Filipino Citizens

As of now,

her children are dependent and still

she still doesn’t know what her

feelings will be when her children will leave

As the children leave home,

of her children and her husband as those are the responsibilities of a mother and wife

Page | 21

Production

life changes—the mid-life crisis—and struggle with finding new meanings and purposes

If a person doesn't get through this stage successfully,

Significant relationships are within the workplace,

Creativity,

Kozier and Erbs,

Fundamentals of Nursing,

Page | 22

Lawrence Kohlberg’s Levels of Moral Development Lawrence Kohlberg outlined the different planes of moral adequacy,

based on his continued interest in how children would react to varying moral dilemmas

Kohlberg stated that ethical behavior was based on moral reasoning,

which in turn could be broken down into six specific developmental stages

The stages are progressive,

in that it is highly improbable for someone to regress backwards

Once a person acquires the functionalities of higher stages of moral development,

it will be difficult for him to lose these abilities and revert to lower levels of growth

Every stage follows another,

making it difficult for a person to jump forward and virtually skip an entire stage

The levels and stages are as follows: Level 1: Preconventional

Level 2: Conventional

Level 3: Postconventional

Stage1: Punishment/obedience

Stage3: Approval Seeking

Stage5: Social Contract

Stage2: Instrumental/relativist

Stage4: Law and order

Stage6: Universal-ethical

Page | 23

Description

Justification

Postconventional Level

At stage 5 social contract and utilitarian

Achieved

She sees that most of the laws are correct and worth to

She said that she follows the rules of the

country and the city she lives in

She doesn’t want

Laws can be

nuisance in the society because she believes that to be

Contract

able to live in a serene place,

establish respect with themselves and then to others

maintaining respect for self and others

Stage Stage6: Universalethical

equality for all human beings,

Working towards achieving goal

She knows about universal laws,

She is concerning about justice,

“malooy gyud ko sa mga tao nga dili matagaan ug hustisya,

standards regardless of those Page | 24

Justice might be internalized at an even higher level than society

Few adults ever reach this stage of development

Page | 25

PHYSICAL ASSESSMENT Patient’s Name: Meg Age: 38 yrs

old Sex: Female Admitting Diagnosis: Acute Cholelithiasis Final Diagnosis: Calculous Cholecystitis Chief Complaint: right upper quadrant pain Date of Assessment: May 12,

Room 324-5 Vital Signs upon physical assessment: Temperature :

Pulse Rate:

Respiratory Rate:

Blood Pressure:

General Survey The patient was received lying on bed,

She has three 0

Incision site is dry and intact

Each incision is covered with dry and intact dressing

Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale

She is oriented to time (verbalized it was late in the afternoon),

person (identified watcher correctly),

place (verbalized she’s in the hospital) and

Page | 26

reason for admission (stated that she was admitted due to right upper quadrant abdominal pain)

Patient is not in respiratory distress

Patient appears appropriate for her stated age

She stands 5 feet and 2 inches tall and weighs 62 kg

Her body mass index (BMI) is 24

She has an endomorphic body type

Patient is in fair grooming as evidenced by unsoiled t-shirt she is wearing,

well-kept hair and clean linens and pillows

However,

it was noted that patient has halitosis

Nails were long but clean

Through the course of the physical assessment,

it was observed that the patient is cooperative and has an accommodating attitude towards the student

The patient is calm

Patient’s speech was audible,

comprehensible and in moderate pace

Skin Skin is fair in color,

soles and dorsa of the distal phalanges

Skin is dry and slightly warm upon palpation

It returns quickly to its normal state when picked up between two fingers and released

Skin texture is soft and fine while extensor surfaces such as the elbows have coarser skin

The palms and the soles are calloused

No skin breaks present aside from the incision sites on her abdomen

No edema present

Hairs and Nails Upon inspection,

It is thick,

Hair is also evenly distributed as evidenced by absence of bald spots

Dandruff or flaking was not present

Other infestations,

The color of scalp is lighter than the color of skin

Nails on both hands and feet are long but clean

Nail polish was removed

Client has a capillary refill time of 2 seconds

No clubbing of the nailbeds noted

Page | 27

Head Patient’s head is round and normocephalic in configuration with smooth skull contour

There were no palpated masses,

Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds

Facial movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions

Patient can move her head up and down and side to side

No lesions noted on the face

Eyes Hairs of eyebrows are thick and evenly distributed

Eyebrows are symmetrically aligned and there’s equal movement as evidenced by the patient’s ability to elevate and lower the eyebrows

No edema,

puffiness or tenderness noted upon inspection and palpation of the periorbital area

Eyelashes are equally distributed and curled slightly outward with no ectropion or entropion

Eyelids’ surface is intact with no discharges and no discoloration but with noted eye bags on the lower surface

No lid lag noted

Blink reflex is present

Palpebral fissure is equal in both eyes

Bulbar conjunctiva is pale pink

Cornea is transparent and without cloudiness

Sclera is anicteric

Eyeballs are symmetrical with no bulging observed

Pupils were black in color,

Pupils quickly constrict when a penlight is shone towards the pupil from a lateral position

Iris is dark brown in color

Client has central and peripheral vision

She can see things on the side of her eye,

even when looking straight ahead

Moreover,

pupils constrict when looking at near objects and dilate when looking at far objects

During ocular motility testing,

patient was asked to follow the examiner’s Page | 28

finger in the six cardinal fields of gaze

There was smooth,

parallel movement of eyes in all direction

Both eyes move in unison

No nystagmus noted

To test her visual acuity,

the students asked her to read their nameplates placed about 1 ½ feet away from her

She was able to correctly read the names without any difficulty

Patient verbalized she doesn’t use any corrective aids

She also did not report any vision difficulty or eye pain

Ears The color of the patient’s ears is the same as her facial skin

The skin behind the ear in the crevice is smooth and without breaks

The left and right pinna are symmetrical and aligned with the inner canthus of the eye

Pinna recoils after it is folded

Auricle is nontender upon palpation

Mastoid process is smooth and hard and no tenderness or swelling noted

External canals have minimal cerumen

No sanguinous discharges noted on the meatus

Patient was able to hear a soft whisper equally in both ears

She can also hear normal voice tones as evidenced by prompt responses to questions asked

Nose It was noted that the nostrils were symmetrical and the nasal septum is midline

There were no observed discharges draining from the client’s nose

Hair is noted on the nares

Nares are patent since patient is able to breathe normally on both nostrils without difficulty when one nose is closed with digital compression and patient inhaled with mouth closed

No lesions on the external nose structure were seen

There was no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges

Client’s gross smell was functional as she could identify the scent of alcohol

Page | 29

Mouth Mouth is proportional and symmetrical

Lips are cracked,

color and with no masses or congenital defect

Buccal mucosa was uniform pale pink in color and moist

The patient’s gum was,

No gum retraction or bleeding was noted

Teeth are of complete set

There are no spaces in between teeth

Dental carries are evident in lower right and left molar

Teeth are yellow in color

Patient has no dentures

Tongue is pink,

slightly rough and has thin whitish color on the surface

It is also in central position and moves freely

The base of tongue is smooth with prominent veins

No tenderness,

lesions or any unusualness noted

Soft palate is light pink in color

On the other hand,

hard palate is much lighter and more irregular in texture

Uvula is positioned in midline of soft palate and rises when the patient says ―ah‖

Tonsils are not inflamed

No ulcerations and exudates present

Patient has no difficulty of masticating and swallowing

Halitosis was noted

Patient has no speech disorders

Neck Neck is symmetrical with no masses or unusual swelling upon

No jugular vein distention noted

Pulsation at carotid arteries is strong and regular in rhythm

Range of motion is normal and no pain elicited upon flexion,

Thyroid is not enlarged upon palpation with no nodules,

masses or irregularities upon palpation

Thyroid also rises when patient was asked to swallow

Trachea is symmetrical and in midline without deviation

No lymph adenopathies appreciated

No torticollis present

Page | 30

Breast Breast is conical,

symmetrical and skin color is lighter than exposed areas

No lesions,

No dimpling or retraction

Nipples are in midline and everted pointing in the same direction

Areola and nipples are dark brown in color and has no discharges,

Chest/Lungs Chest skin integrity is good and intact

Patient has symmetrical chest wall movement

Point of maximal impulse is at 5th intercostal space left midclavicular line

Apical pulse is 84bpm

Patient has distinct heart sounds,

There were no noted deformities in the client’s thoracic area

There are no bulges or retraction of the intercostal spaces

Client’s respiratory rate is 18 cycles per minute

Patient did not complain of chest pain or chest tightness

Guarding of the chest noted upon respiration due to the proximity of the incision site to the diaphragm

Patient is not in respiratory distress

Coughing episodes were also not observed

Vesicular breath sounds are soft and low pitched

Her breathing is deep,

regular and slow with a long inspiratory phase and a short expiratory phase

With no adventitious sounds,

lungs are clear to auscultation and no crackles,

It was observed that vocal fremitus is present both at the back and front of the chest when the patient says ―ninety-nine‖

Abdomen Abdomen is round

Color of skin in abdomen is slightly lighter than the rest of the body

Another two 0

A 1-cm incision is also present just below her umbilicus

All four incisions are covered with dry and intact dressing

Patient complains of pain on the surgical site and verbalized,

Page | 31

―Nagangulngol tong gioperhan

Pwede makahingi ug tambal para sa sakit

?” Patient reported a pain scale of 6 out of 10

Aortic pulsations are not visible

Umbilicus is midline and inverted

Symmetrical movement of abdomen upon respiration was noted

Upon auscultation of the abdomen,

it was noted that patient has normal bowel sounds—high-pitched and occurred 16 times per minute

Abdomen is soft and there is no point tenderness

Patient was on DAT as ordered

Back and Extremities Peripheral pulse of the patient was symmetrical and regular in rhythm

Patient has normal capillary refill of 2 seconds

The nails were pinkish in color without cyanosis and clubbing

Patient is able to ambulate freely

She was able to sit up on bed and perform range of motion on both upper and lower extremities

However,

it was noted that patient has guarded and slow movement for she feels pain on her abdomen

Client’s grasping ability was moderately strong on both hands

No edema or cyanosis was noted on both upper and lower extremities

There is no swelling,

tenderness or nodules palpated on each joint

The shoulders,

elbows and forearms are free of nodules,

The skin at the back of the patient is uniform in color

Symmetrical chest expansion with respirations noted

No spinal tenderness noted

There are no skin breaks present

The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks

There were no deformities or abnormalities on the bone such as scoliosis,

osteoporosis and alike to be noted

Genito-urinary Pubic hair is present,

No vaginal bleeding or any other unusual discharges noted

Page | 32

Patient voids freely

She has no difficulty urinating and did not report dysuria

She verbalized her urine is amber in color

Neurological Patient was received lying on bed,

Reflexes are normal and symmetrical bilaterally in both extremities

Patient is oriented to person,

She has a Glasgow coma scale of 15: 4 from eye opening,

She is also alert and attentive

Page | 33

ANATOMY AND PHYSIOLOGY

GALLBLADDER The gallbladder is a hollow organ that sits just beneath the liver

In adults,

It is divided into three sections: fundus,

The neck tapers and connects to the biliary tree via the cystic duct,

which then joins the common hepatic duct to become the common bile duct

Its function is to store and release bile,

Page | 34

CYSTIC DUCT The cystic

short duct that joins the gall bladder to the common bile duct

The cystic duct varies from 2 to 3 cm in length and terminates

Throughout its length,

the cystic duct is lined by a spiral mucosal elevation,

called the valvula spiralis (valve of Heister)

a series of crescentic folds of mucous membrane in

Its length is variable and usually ranges from 2 to 4 cm

The cystic duct is usually 2-3 mm wide

It can dilate in the presence of pathology (stones or passed stones)

The duct and spiral folds contain muscle fibers responsive to pharmacologic,

There is,

no convincing evidence of a discrete muscular sphincter within the duct

Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying,

it appears to function as more than a passive conduit

Coordinated,

graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying

The principal function of the internal spiral folds that are found in man may be to preserve patency of this narrow,

tortuous tube rather than to regulate bile flow

BILE The main components of bile include contains water,

Page | 35

is produced by hepatocytes in the liver and and then flows into the common hepatic duct,

which joins with the cystic duct from the gallbladder to form the common bile duct

The common bile duct in turn joins with the pancreatic duct to empty into the duodenum

If the sphincter of Oddi,

a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum,

bile is prevented from draining into the intestine and instead flows into the gallbladder,

where it is stored and concentrated to up to five times its original potency between meals

This concentration occurs through the absorption of water and small electrolytes,

while retaining all the original organic molecules

When food is released by the stomach into the duodenum in the form of chyme,

the duodenum releases cholecystokinin,

which causes the gallbladder to release the concentrated bile to complete digestion

Bile helps to emulsify the fats in the food

Besides its digestive function,

bile serves also as the route of excretion for bilirubin,

a byproduct of red blood cells recycled by the liver

The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum,

the final section of the small intestine

Bile salts also act as bactericides,

destroying many of the microbes that may be present in the food

In the absence of bile,

fats become indigestible and are instead excreted in feces,

a condition called steatorrhea

Page | 36

ETIOLOGY AND SYMPTOMATOLOGY Etiology Predisposing Factors

Present/ Absent

Rationale

PRESENT Women between 20 and 60 years of age are twice as likely to develop

Justification

The patient is female

Estrogen increases cholesterol levels in bile and decrease gallbladder movement,

both of which can lead to gallstones

Sources: Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1822 Lippincott Williams and Wilkins Handbook of Diseases Third Edition,

Diabetes mellitus

People with diabetes generally have

The patient

high levels of fatty acids called

These fatty acids

increase the risk of gallstones

Sources: Harrison’s Principles of Internal Medicine,

Page | 37

Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition,

PRESENT

Many of the body’s systems and

The patient

protective mechanisms become less

Body systems and

Sources: Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition,

Ethnicity (Native American,

Mexican American) (Asian)

PRESENT

Native Americans have a genetic

The patient

predisposition to secrete high levels

In fact,

have the highest rate of gallstones

A majority of

Native American men have

Mexican

American men and women of all ages also have high rates of gallstones

Asians are more genetically predisposed to having pigment stones as compared to those living

Page | 38

in the Western countries Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition,

Precipitating Factors Pregnancy

Present/ Absent

Rationale

Justification

Excess estrogen from pregnancy,

or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement,

both of which can lead to gallstones

The patient is not pregnant

Source: http://www

org/Patients/Modul es/gallstns

Rapid weight loss

As the body metabolizes fat during rapid weight loss,

it causes the liver to secrete extra cholesterol into bile,

No rapid weight loss was noted by the patient

Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition,

org/Patients/Modul es/gallstns

Obesity

The most likely reason is that obesity tends to reduce the amount of bile salts in bile,

Obesity also decreases gallbladder emptying

The patient is not obese

Sources: Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition,

org/Patients/Modul es/gallstns

Fasting

Fasting decreases gallbladder movement,

causing the bile to become overconcentrated with cholesterol,

The patient doesn’t fast

Source: http://www

com/lea rning-center/gallstones

Hormone replacement therapy,

PRESENT

Excess estrogen from pregnancy,

or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement,

both of which can lead to gallstones

The patient has been on birth control pills since she was 36 years old

Page | 40

Source: Lippincott Williams and Wilkins Handbook of Diseases Third Edition,

com/lea rning-center/gallstones

Low Fat Diet

PRESENT

Before dietary fat can be digested,

Bile is used for this purpose

The liver makes bile continuously and stores it in the gall bladder until such time as it is needed

However,

that bile remains in the gall bladder

The patient avoids fatty foods

Gallstones are formed when the gall bladder is not emptied on a regular basis

In people who continually resort to low-fat diets,

bile is stored for long periods in the gall bladder — and it stagnates

In time — and it is really quite a short time — a 'sludge' begins to form

Source: http://www

Page | 41

Symptomatology Signs and Symptoms

Present/ Absent

Right upper

PRESENT

Rationale

patient ducts The into connected to the gallbladder came Obstruction

Justification

inflammation DMSF by increased complaining

intraluminal pressure and of RUQ pain

Sources:

Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1825

Fever (low grade)

patient nonspecific The not response that is mediated was by endogenous pyrogens febrile

released from host cells in response to infectious or non-infections disorders

It may be brought about by prostaglandins

Source: Carol Mattson Page | 42

Porth (2005

Pathophysiology,

Seventh edition page 205)

Murphy's sign (abrupt interruption of deep inspiration)

PRESENT

Classically Murphy's sign is The tested for during was

for it is performed by asking the Murphy’s patient to breathe out and Sign

then gently placing the hand below the costal margin on the right side at the midclavicular line approximate

The patient is then instructed to inspire (breathe

Normally,

the abdominal contents are pushed

the diaphragm moves down (and lungs expand)

If the patient stops breathing in (as

contact with the examiner's fingers) and winces with a 'catch' in breath,

Page | 43

positive test also requires no pain on performing the maneuver on the patient's left hand side

Source: http://www

Nausea and

sometimes occur with biliary didn’t

The inflammation of complain

the gallbladder causes pain nausea

Source: Understanding Surgical

Medical

Nursing

Williams and Hopper page 742

Mildly elevated

Biliary obstruction causes The patient’s suppression of bile flow,

Page | 44

conjugated bilirubin into the bloodstream

Sources: Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1829

Elevated SGPT and SGOT enzymes

PRESENT

SGOT (AST) and (ALT) is The patient’s an enzyme found mostly in lab

the liver but also in the reveal heart,

the pancreas and of SGPT and in red blood cells

High SGOT elevations

Elevations

associated with a variety of conditions

myocardial infarction (heart attack),

Abnormalities enzymes

Page | 45

AST/SGOT and ALT/SGPT are indicative of problems such as Mirrizi syndrome,

or a stone in the bile duct causing

Sources http://my

Page | 46

PATHOPHYSIOLOGY Precipitating Factors: Predisposing Factors:    

Female Age 38 Ethnicity Diabetes Mellitus

Birth control pills Low Fat Diet Pregnancy Rapid weight loss Obesity fasting

Bile stagnates in the gallbladder

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

Page | 47

Chemical reaction inside gallbladder triggers the release of inflammatory enzymes (Prostaglandins)

Fluids leak into gallbladder

Inflammation of the gallbladder

Increased intraluminal pressure and distention of the gallbladder

Constriction of blood vessels

Biliary Colic (RUQ pain)

Murphy’s Sign

ACUTE CHOLECYSTITIS If not treated If treated with:

Surgery,

Continued lack of blood supply to gallbladder

Continued increase in intraluminal pressure of gallbladder

Necrosis Rupture of gallbladder

Good prognosis

Gangrene and empyema

Perforation of gallbladder

Spread of bile indigenous microorganisms peritoneal cavity Page | 48

Page | 49

DOCTOR’S ORDER Date

Rationale

Remarks

Admit under the care

Admitted under the care of

Batucan

Batucan,

Patient was

Secure consent to

Consent is an agreement

between client and health care provider to give proper quality care

It is also to protect the client from harmful procedures and the institution from law suits

Low fat diet

Doctors we

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