CHRONIC CALCULOUS CholeCYSTITIS

Group III Case Presentation

Janfil Roy L. Gealon

Lisa Mar G. Elgario
Abegail F. Fiedacan
Joyce Ann B. Quicho
Valeen Eleanore C. Pacaldo

TABLE OF CONTENTS

I.

NURSING HEALTH HISTORY

i.
ii.
iii.
iv.

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.

LABORATORY/DIAGNOSTIC EXAMINATION RESULTS

IV.

MEDICATIONS AND TREATMENTS GIVEN

V.
VI.
VII.
VIII.
IX.

ANATOMY AND PHYSIOLOGY

11

PATHOPHYSIOLOGY OF THE DISEASE

13

PRIORITIZED LIST OF NURSING PROBLEMS

15

NURSING CARE PLAN

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

NURSING HEALTH HISTORY

i.
INTRODUCTION
Gallbladder plays a major role in the digestive process. Despite its importance in the
digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the
gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of
the majority. The gallbladder tends to be taken for granted ignored of the proper care and
conditioning, such in the case of our chosen patient for our case presentation.
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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:

What are Cholelithiasis and Cholecystitis?

What system, organs or parts of the body are affected by the disease process?
Where and how the illness was obtained, how it progressed and affected the body?
What were the predisposing factors that lead the patient to acquire the disease?
What interventions are needed to manage such condition?
Were the interventions effective in helping the patient recover?

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
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iii.

HISTORY OF PRESENT ILLNESS

Last December 2011, the patient was on a Christmas party drinking alcohol with friends when
he felt severe abdominal pain. So his friends took him to a hospital in Pasig, he underwent
ultrasound and was diagnosed to have gallstones. He was advised to have an operation but he
refused. The patient only requested a medicine for his severe pain so he was given Tramadol.
Umiinom lang ako ng Tramadol pag sobrang sakit na ng abdomen ko, siguro I took that for 2
consecutive years then I stopped. the patient claimed. After taking Tramadol for 2 years, the pain
suddenly stopped so he did not take any pain medications.
One month prior to confinement, the patient again experienced right upper quadrant tenderness,
intermittent, colicky pain. So he took Tramadol but felt only temporary relief. Sobrang sakit na
talaga ng tiyan ko noon, nawalan na din ako ng appetite. Kapag kakain ako sinusuka ko lang. the
patient said. Three days prior to confinement, the patient and his friends noticed the yellowing of
his sclera and skin, so he decided to consult a doctor.

iv.

PAST HEALTH HISTORY

1. Childhood illnesses
The patient usually experienced common colds and cough during his childhood and was
never been confined in a hospital.
2. Immunizations
Mr. EEM verbalized that he was unsure if he had and completed his immunizations. He
was unable to confirm that information due to family problems.
3. Hospitalizations
According to Mr. EEM he was hospitalized on December 2011 when he felt severe
abdominal pain. He was diagnosed to have gallstones. He only stayed there for two days after
he refused to undergo an operation to remove the stones.
4. Current Medications
Prior to hospitalization the patient has been taking Tramadol to relieve the abdominal
pain that he was experiencing. No other medications other than that, according to the patient.
Not even vitamins.

v.

FAMILY HISTORY OF ILLNESS

The patient said that both sides of his parents have a history of hypertension. They also have a
history of leukemia on his fathers side and tumor on his mothers side. There is no family history
of Diabetes Mellitus on both sides of his parents.

vi.

LIFESTYLE/ACTIVITIES OF DAILY LIVING

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.

Interpretation & Analysis

Since he is a post-operative patient,
soft diet will help him to have
loose stools so he wont need to
strain himself when defecating.
Protein rich diet will also help for
faster wound healing.

The patient said that hes

having a problem when
defecating because he is
anxious about his postoperative site.
After his operation, he
was only confined to bed,
having a hard time in

Anxiety is usually expected to

patients who underwent operation.
They are afraid to move and strain
themselves. But since he is on a
soft diet, his stool is probably
loose.
Obviously, the patient cannot have
enough activity because of his
condition. However, he is

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ako.
Hygiene

Sleep and rest

Substance use

II.

The patient takes a bath a

minimum of twice a day
and does other hygienic
activity.

The patient said that he

finds difficult to sleep at
night. He usually sleeps at
2am and wakes up at
11am.
The patient claimed that he
is a smoker. He smokes 1
pack per day and is an
alcohol drinker.

moving because of his

post-operative site.
The patient does his
hygiene with the help of
his friends.

The patient still have a

hard time to fall asleep
because of the
environment.
During his
hospitalization, the patient
refrained himself from
smoking cigarette.

recommended to ambulate early for

fast recovery.
Few days after the operation would
be difficult for the patient to move
so he needs the help of his friends
to maintain a good hygiene.
Hygiene is very important for him
because improper hygiene could
bring infection to his surgical
incision.
One factor of good sleeping pattern
is the environment. The patient
doesnt get enough sleep because
he is not comfortable with his
environment.
It is advised to patients who are
admitted to refrain from smoking
inside the hospital facilities. It will
also aid him for faster recovery.

PHYSICAL ASSESSMENT
Norms
General Appearance
1. Posture/Gait

Actual Findings

Interpretation and Analysis

Relaxed/ erect posture;

coordinated movement

Relaxed, lying on
bed

Normal for post-operative patients

but is recommended to ambulate
early.

2. Note obvious signs of

health or illness (skin
color)

Healthy Appearance

Slightly yellowish

Cholestatic jaundice develops as a

consequence of bile flow
obstruction.

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

Varies from light to deep

brown; from ruddy pink
to light pink; from yellow
overtones to olive.

Slightly yellowish

Cholestatic jaundice
develops as a consequence
of bile flow obstruction.

Generally uniform except

in areas exposed to the
sun; areas of lighter

Uniform

Normal

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pigmentation (palms, lips,

nail beds) in dark-skinned
people.
3. Observe and palpate
skin moisture.
External Eye Structure
1. Inspect the bulbar
conjunctiva for color,
texture, and the presence
of lesions.

Moisture in skin folds and

axillae

Moisture in skin folds

and axillae

Normal

Transparent; capillaries
sometimes evident; sclera
appears white

Transparent; yellowish
sclera

Deviation from normal;

Cholestatic jaundice
develops as a consequence
of bile flow obstruction.

2. Inspect the palpebral

conjunctiva.

Shiny, smooth, and pink

or red

Pale

Deviation from normal;

possible cause is anemia

3. Inspect the pupils for

color, shape and
symmetry of size.

Black in color; equal in

size; normally 3-7 mm in
diameter; round smooth
border, iris flat and round

Black in color; equal in

size; round smooth
border, iris flat and round

Normal

Bronchovesicular and
vesicular breath sounds

Normal breath sounds

Normal

No pulsations

No pulsations

Normal

S1: usually heard at all

sites (louder at apical
area)

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.

S2: Usually heard at all

sites (usually louder at the
base of the heart)
S3: in children and young
adults
S4: in many older adults
3. Auscultate the carotid
artery.
Peripheral Vascular
System
1. Palpate the peripheral
pulses on both side of the
client's body individually,
simultaneously and
systematically to
determine the symmetry
of pulse volume.

No sound heard upon

auscultation.

No sound heard upon

auscultation.

Normal

Symmetric pulse volumes.

Symmetric pulse
volumes.

Normal

2. Inspect the skin of the

hands and feet for color,
temperature, edema, and
skin changes.

Skin color pink.

Skin color pink.

Skin temperature not

excessively warm or cold.

Skin temperature not

excessively warm or cold.

No edema.

No edema.

Skin moisture resilient

and moist.

Skin moisture resilient

and moist.

Immediate return of color

Immediate return of color

3. For capillary refill test,

squeeze the clients
fingernail and toenail
between your fingers

Full pulsations.
Full pulsations.

Normal

Normal

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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

Pre-op: Pain upon

palpation; (+) Murphys
sign
Post-op: (+) redness in
post-operative site

Biliary colic occurs when

the bile duct muscle
contracts the mucosa presses
on the stones surface.
Redness is usually normal in
post-operative sites but may
signify presence of infection
on the site.

Symmetrical; No
tenderness

Symmetrical; No
tenderness

Normal

Equal size on both sides

of body.

Equal size on both sides

of body.

Normal

Equal strength on each

body side.

Equal strength on each

body side.

Normal

Light tickling or touch

sensation

Light tickling or touch

sensation

Normal

LABORATORY/DIAGNOSTIC EXAM RESULTS

Diagnostic Tests
Hemoglobin
Hematocrit
Red Blood Cell
MVC (Mean Corpus Volume)
MCH
MCHC
RDWSD
RDWCV
White Cells
Neutrophils
Eosinophils
Basophils
Lymphocytes
Monocytes
Alanine Transaminase (ALT)
Serum Glutamic Pyruvate
Transaminase (SGPT)
Potassium
Total Bilibrubin
Direct Bilirubin
Indirect Bilirubin
Phosphatase

Complete Blood Count

Patients Results
Normal Values
140-180
180
0.54
0.400-0.54
5.45
4.6-6
85.9
80-100
28.5
27-34
332
320-360
42.4
35-56
12
11-16
9.32
4.3-10x10
72.5
50-70
3.3
0.5%
0.3
0-1%
20.3
20-40%
3.6
0-7
Clinical Chemistry

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

Ultrasound Whole Abdomen Result

The liver is not enlarged but with slight non-homogenous hyperechogenisity of the parenchyma.
Impression: Non-specific liver parenchyma disease (Fatty infiltration or hepatitis)
Gallbladder Findings:
Adenomyomatosis
More than five stones (sizes 4.3-12.6mm)
Minimal bile sludge
Acute medical renal disease with microlithiasis: Right Kidney

IV.

Microlithiasis: Left Kidney (Acute renal disease is not ruled out)

Boarder line prostate size

MEDICATIONS AND TREATMENTS GIVEN

Ranitidine (Zantac) 50mg IV q 8hours
Classification: Gastro-intestinal agents, Anti-secretory (H2-receptor antagonist)
Mechanism of Action: Ranitidine is a specific, rapidly acting histamine H 2-antagonist. It inhibits
basal and stimulated secretion of gastric acid, reducing both the volume and the acid and
pepsin content of the secretion. Ranitidine has a long duration of action and so a single
75- or 150-mg dose effectively suppresses gastric acid secretion for at least 12 hrs.
Clinical evidence has shown that ranitidine combined with amoxicillin and
metronidazole eradicates Helicobacter pylori in approximately 90% of patients. This
combination therapy has been shown to significantly reduce duodenal ulcer recurrence.
Helicobacter pylori infects about 95% of patients with duodenal ulcer and 80% of
patients with gastric ulcer.
Indication: Duodenal and Gastric Ulcers, GERD, Erosive Esophagitis, Heartburn
Side Effects: (CNS) headache, malaise, dizziness, somnolence, insomnia, vertigo, mental
confusion, agitation, depression, hallucination; (Cardio) Bradycardia; (GI) constipation,
nausea, abdominal pain, vomiting, diarrhea; (Skin) rashes; (Hematologic) reversible
decrease in WBC count, thrombocytopenia
Contraindication: Pregnancy and lactation
Principles of Care: Give with or without food. Administer adjunctive antacid treatment 2 hours
before or after taking the medication.
Treatment: Monitor lab results. Monitor hepatic functioning. Monitor intake and output every
shift. Monitor vital signs every 4 hours.
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Cefuroxime 750mg IV q 8hours

Classification: Anti-infective agents, Cephalosporin
Mechanism of Action: Inhibits bacterial cell wall synthesis by binding to one or more of the
penicillin-binding proteins (PBPs).
Indication: Treatment of susceptible infections of lower respiratory tract, skin and soft tissue, bone
and joint, and sepsis.
Side Effects: (GI) Diarrhea, abdominal cramps, nausea, vomiting, oral candidiasis
Contraindications: Hypersensitivity to Cefuroxime, any component, or other cephalosporins
Principles of Care: Inject direct IV over 3-5 minutes. Infuse intermittent infusion over 15-30
minutes. Absorption is increased when given with or shortly after food.
Omeprazole 20mg IV OD
Classification: Proton Pump Inhibitor
Mechanism of Action: Decreases the amount of acid produced in the stomach.
Indication: To treat symptoms of Gastroesophageal Reflux Disease and other conditions caused by
excess stomach acid. It is not for immediate relief of heartburn symptoms. Use to
promote healing of erosive esophagitis (damage to esophagus caused by stomach acid).
Side Effects: Fever, cold symptoms such as stuffy nose and sneezing, sore throat, stomach pain,
gas, nausea, vomiting, mild diarrhea, and headache.
Contraindications: Allergy to Omeprazole and to its components.
Principles of Care: Take Omeprazole before meals.
Buscopan 1 ampule IV q 8hours
Classification: Anti-spasmodic
Mechanism of Action: It blocks the muscarinic receptors found on the smooth muscle walls which
means it blocks the action of acethylcholine on the receptors found within the smooth
muscle of the gastrointestinal and urinary tract and thus spasm and contractions. This
relaxes the muscle and thus reduces pain from the cramps and spasms.
Indication: Spasm in the genitourinary tract, gastrointestinal tract, billiary tract and colic
Side Effects: Constipation, decreased sweating, mouth, skin and eye dryness, blurred feeling,
bloating, dysuria, nausea and vomiting, headache, body weakness
Contraindications: Myesthenia gravies, megacolon hypersensitivity to drug contents, narrow angle
glaucoma, prostate hypertrophy with urinary retention.
Principles of Care: Take this drug 30 min. to 1 hour before meals. Buscopan will potentiate the
effect of alcohol and other CNS depressants. Do not take antacids and anti-diarrheal 2-3
hours prior taking this drug. It is necessary to take the medication if you are not in pain.
Avoid driving or operating machinery after parenteral dose.
Diclofenac 75mg IV
Classification: Non-steroidal Anti-inflammatory Drugs
Mechanism of Action: Reduces inflammation and as an analgesic reducing pain in certain
conditions.
Indication: Used to treat mild to moderate postoperative or post-traumatic pain, in particular when
inflammation is also present.
Side Effects: Stomach upset, nausea, heartburn, diarrhea, constipation, gas, headache, drowsiness
and dizziness.
Contraindications: Hypersensitivity against Diclofenac. Active stomach and/or duodenal ulceration
or gastrointestinal bleeding, inflammatory bowels such as Crohns disease or ulcerative
colitis, cautions in patients with severe bleeding such as cerebral hemorrhage.
Principles of Care: Do not drive, use machinery, or do any activity, that requires alertness until you
are sure you can perform such activities safely. This medication may make you more
sensitive to the sun. Avoid prolonged sun exposure, tanning booths or sunlamps. Use a
sunscreen
and
wear
protective
clothing
when
outdoors.

V.

ANATOMY AND PHYSIOLOGY

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The gallbladder is part of the digestive

system. It is a small, pear-shaped hollow sack
resting beneath the right lobe of the liver. Bile,
which is being secreted continuously by the liver,
enters the small bile ducts within the liver. The
small bile ducts join to form two larger ducts
which emerge from the undersurface of the liver
as the right and left hepatic ducts but which
immediately join to form the common hepatic
duct.
The hepatic duct merges with the cystic
duct from the gallbladder, forming the common
bile duct. The common bile duct merges with
the pancreatic bile duct to form the ampulla of Vater (dilated portion in small channel) before opening
into the small intestine. The terminal parts of both ducts and the ampulla are surrounded by circular
muscle fibers, known as the sphincter of Oddi. Hepatic bile may not immediately enter the duodenum;
instead, after passing down the hepatic duct, it may be diverted into the cystic duct and gallbladder.
In the gallbladder, the lymphatics and blood vessels absorb water and inorganic salts, so that
gallbladder bile is about
10 times as concentrated as hepatic bile. At intervals the
gallbladder
contents are emptied into the duodenum by simultaneous
contraction
of the muscular coat and relaxation of the sphincter of Oddi.
The normal
stimulus of gallbladder contraction and emptying is the
entry of
acid chime into the duodenum. The presence of fatty
foods
is the strongest stimulus to contraction.
remove
it
the body

The body can function without the gallbladder. If doctors need to

because of disease, there are no serious long-term effects and
can still digest food.

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

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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.

PATHOPHYSIOLOGY OF THE DISEASE

Gallstones are hard, pebble-like structures that obstruct the cystic duct. The formation of
gallstones is often preceded by the presence of biliary sludge, a viscous mixture of glycoproteins, calcium
deposits, and cholesterol crystals in the gallbladder or biliary ducts. Most gallstones consist largely of
bile supersaturated with cholesterol. This hypersaturation, which results from the cholesterol
concentration being greater than its solubility percentage, is caused primarily by hypersecretion of
cholesterol due to altered hepatic cholesterol metabolism. A distorted balance between pronucleating
(crystallization-promoting) and antinucleating (crystallization-inhibiting) proteins in the bile also can
accelerate crystallization of cholesterol in the bile. Mucin, a glycoprotein mixture secreted by biliary
epithelial cells, has been documented as a pronucleating protein. It is the decreased degradation of mucin
by lysosomal enzymes that is believed to promote the formation of cholesterol crystals.
Loss of gallbladder muscular-wall motility and excessive sphincteric contraction also are
involved in gallstone formation. This hypomotility leads to prolonged bile stasis (delayed gallbladder
11 | P a g e

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.

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VII.

PRIORITIZED LIST OF NURSING PROBLEMS

Nursing Diagnosis
Altered Comfort: Acute Pain related to tissue
trauma secondary to cholecystectomy as manifested
by facial grimace of pain, appears irritable, restless,
guarded or protective behavior and diaphoresis.

Activity Intolerance related to generalized weakness

secondary to cholecystectomy as manifested by
difficulty turning from one side to side, limited
ROM and muscle weakness.

Deficient knowledge about the disease process

related to unfamiliarity of information resources.

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

engage in unhealthy ways.

Risk for infection related to impaired primary

defense secondary to cholecystectomy

VIII.

Objective Cues:
presence of surgical wound on RUQ abdominal region
Insufficient knowledge on how to avoid exposure to
pathogens

NURSING CARE PLAN

Nursing Care Plan #1
Asses
sment

Nursi
ng
Diag
nosis

Scien
tific
Expl
anati
on
(Rati
onale
)

Plannin
g

Nursing
Interventi
ons

Rational
e

Evalu
ation

We had therefore concluded that this problem must also be given

emphasis and proper health education should be rendered to the
client to hasten his recovery and maintain optimum level of health as
possible.
LEAST PRIORITY
This was lastly prioritized since it is a risk problem. The patient did
not manifest any signs of infection post-operatively but proper
interventions must still be rendered to prevent the occurrence of this
problem in the future.

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

1. To enhance nurse-patient interaction.

2. Vital signs are usually altered in acute pain.
3. Pain is a subjective data; therefore it should be assessed to
determine the patients level of pain.
4. To distract attention and reduce tension.

5. To provide comfort.

6. To prevent fatigue. Early ambulation helps hasten recovery.

1. To reduce pain

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

Nursing Care Plan #2

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

and maximize use

of energy.

1.

For pain relief, to

permit maximal
effort and
involvement in
activity.

-Remopain 30 mg
IV q 6 for 6 doses
-Dolmal drip 6
amps in D5W 500
cc @ 20 gtts/min

Nursing Care Plan #3

Assessment

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

Lack of exposure to the

disease process
Lack of knowledge about
the impact of improper

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.

To establish nursepatient interaction.

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

nutrition to his condition

Unfamiliarity of the
information resources

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 Care Plan #4

Assessment

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

3. Stress proper hand washing techniques

Long term:
3. Its the first line of
break in the continuity
-After 8 hours of
defence against
of the first linenursing
nosocomial
defense which is the
intervention, the
infection or
skin
4. Follow strict
patient will
crosscompliance to
contamination.
achieve timely
hospital
wound healing,
4. To establish
control,
be free of
the pathogens will
mechanism to
sterilization,
easily invade thepurulent
prevent
and
aseptic
bodys system drainage and be
occurrence of
policies.
afebrile.
infection.
5.
risk of acquiring
infection

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

Encourage the patient to avoid alcohol and cigarette smoking.

- To prevent further complications and so that the desired effects of the drugs will be achieved

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.

Drink plenty of water every day.

- To help prevent constipation

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.

Encourage to have a regular and balance diet.

-Aids in sustaining energy throughout daily activities

Discuss avoiding/limiting use of alcoholic beverages.

-Minimizes risk of pancreatic involvement.

vii.

SPIRITUAL:
Discuss Gods plan for every individuals life.
Advise the client to pray and trust to God.