ACALCULOUS CHOLECYSTITIS

I. INTRODUCTION A. BACKGROUND OF THE STUDY Cholecystitis is an acute inflammation of the gallbladder which causes pain, tenderness and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting, and the usual signs of an acute inflammation. There are two types of Cholecystitis, one of these is the CALCULOUS CHOLECYSTITIS, in this type, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of Escherichia coli (60%), Kleibsiella species (22%) or streptococcus (18%) is identified with cultures obtained during surgery in a small percentage of surgical treated patients.

Another type is ACALCULUOS CHOLECYSTITIS, which describes gallbladder inflammation in the absence of obstruction of gallstones. Acalculous Cholecystitis occurs after major surgical procedures, severe trauma, or burns. Other factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial infections of the gallbladder and multiple blood transfusions. It is speculated that acalculous cholecystitis is caused by alterations in fluids and electrolytes and alterations in regional blood flow in the visceral circulation. Bile stasis (lack of gallbladder contraction) and increased viscosity of the bile are also thought to play a role. The occurrence of acalculous cholecystitis with major surgical procedures or trauma makes its diagnosis difficult. There are a total of 16 cases, (11 from males and 5 incidences from females) of cholecystitis starting from January to April 2008 according to the Abra Provincial Hospital statistics records. Our client is Mr. B. R. who was diagnosed to have Acalculous cholecystitis with his recent hospitalization (April 12-21, 2008) based on the results of ultrasound of his Hepatobiliary tree and pancreas.

B. RATIONALE FOR CHOOSING THE CASE We have chosen Acalculous Cholecystitis as our case, because it would be very helpful for us to know this disease and for us to have a broader knowledge regarding the etiology, the risk factors, the nursing interventions, and treatment we can provide our patient. As a member of the Healthcare team, we should have a wide range of knowledge about such diseases and impart what we know to our patient and significant others and to general public, for them also to have or gain knowledge which will develop their intellectual predictions so that they will do ways and means to prevent any disease.

C. SIGNIFICANCE OF THE STUDY

This study is of great importance to the patient for he will be provided with necessary health teachings and given effective nursing care. This will also give her an overview of the appropriate care he might receive during the course of hospitalization For the family or significant others, they will be given enough information regarding the illness of their relatives that they will be able to cooperate in the recovery of the patient. In nursing education, this study may also serve as a basis for further studies. This also serves as a reference in meeting the same case. To broaden our knowledge that we may be able to apply certain appropriate nursing care and the important health teaching to people to lessen the possibilities on having Acalculous Cholecystitis.

D. SCOPE AND DELIMITATIONS OF THE STUDY

This study focuses on the clinical summary of the patient, diagnostic exams, medical, nursing and surgical managements done to the patient. It also includes the physical exams, course in the ward, drug study, nursing care plans and discharge planning. Information about our patient is also included from the general data to present and past medical history, familial medical history, social and environmental histories. The data we made were mainly gathered through interviews with the patient and based on the patients chart.

E. THEORETICAL FRAMEWORK
Faye Glenn Abdelah Nursing is broadly grouped into 21 problem areas to guide, care and promote the use of nursing judgment Nursing is comprehensive service that is based on the art and sciences. It aims to kelp people, sick or well, copes with their health needs.

Key Concepts of 21 Nursing problems:

To maintain good hygiene To promote optimal activity exercise, rest and sleep To promote safety To maintain body mechanics To facilitate the maintenance of a supply of oxygen To facilitate the maintenance of nutrition To facilitate the maintenance of elimination To facilitate the maintenance of fluid and electrolyte balance To recognize the physiologic response of the body to disease conditions To facilitate the maintenance of regulatory mechanics and functions To identify and accepts positive and negative expressions, feelings and reactions To facilitate the maintenance of sensory functions To identify and accept the interrelatedness of emotions and illnesses To facilitate the maintenance of effective verbal and non-verbal communications To promote the development of productive interpersonal relationship To facilitate progress toward achievement of personal and spiritual goals To create and maintain a therapeutic environment To facilitate awareness of self as an individual with varying needs. To accept the optimum possible goals To use community resources as an aid in resolving problems arising from illness To understand the role of social problems as influencing factors

APPLICATION Personal hygiene and dietary management are key factors in maintaining a healthy body. Thus, to help patient to get away completely with his disease, the importance of these two key factors was emphasized. It was made clear that pleasant personal hygiene can be achieved through taking a bath everyday, brushing teeth regularly, thorough hand washing. The patient was also recommended of different ways to develop a healthy diet helpful to his condition. He was also encouraged to follow the health care providers treatment recommendations.

II. PERSONAL DATA Name: Address: Age: Gender: Civil Status: Religion: Citizenship: Birth Date: Birthplace: Name of Hospital: Hospital No.: Admitting Physician: Date of Admission: Time of Admission: Attending Physician: Ward: Bed No.: Chief Complaint: Date of Surgery: Operation Performed: Surgeon: Assistant Surgeon: Anesthesiologist: Admitting Diagnosis: Final Diagnosis: Date of Discharge:

Mr. B.R. Sulvec, Pidigan, Abra 51 y/o Male Married Roman Catholic Filipino December 6, 1956 Pidigan, Abra Abra Provincial Hospital #809141 Dr. Antonio Valera April 12, 2008 10:45 am Dr. Antonio Valera Surgery bed no. 13 Right Upper Quadrant pain April 17, 2008 Cholecystectomy Dr. Antonio Valera Apolinar Turqueza Dr. Lorna Deauna Calculous Cholecystitis Acalculous Cholecystitis April 21, 2008

III. MEDICAL HISTORY Present Medical History Two days prior to hospitalization, patient felt right upper quadrant flank pain with a scale of 7 / 10 ( wherein 0 denotes absence of pain, and 10 denotes severe) and took Mefenamic Acid (500mg) 1 tablet through mouth in answer to this, but since it is not getting any better, he decided to consult a physician for prompt medical attention.

B. Past Medical History According to Mr. B. R., it was his first hospitalization. He was fully immunized. According to him, he never experienced any, serious illness before, he only had minor ones like headache, muscle pain, cough, and colds and fever. He had taken OTC (over the counter) drugs like Para (500 mg) tablet and Alaxan FR (500 mg) tablet to treat his minor sickness. He did not suffer from any injuries and has no allergies to any foods and drugs.

C.

Family Medical History Mr. B. R. has three sons and a daughter. According to him, they were fully immunized and that they only suffered from fever, cough and colds. According to him also, his father died seven years ago because of Liver cancer. But with mother side, nobody had history of Hypertension, Diabetes Mellitus or any of the cardiovascular diseases

D. Socio-Economic Background Mr. B.R. is a farmer and so his wife, they have four children, two of them are already employed, one is a high school graduate and the youngest helps in the farm. He was formerly consuming 1 pack of cigarette per day and a chronic alcohol drinker consuming 300ml per day. He spends his leisure time watching TV and listening to radio. He and his family usually consults traditional healers in cases of illness due to financial constraints.

E. Environmental History The family of Mr. B. R. resides in a semi concrete house. They have only four neighboring houses and about 5 meters away and their house is situated beside vast farmlands. Their house has three rooms a small living room and a kitchen. Their toilet is located inside their house 8 steps adjacent to their kitchen, they get water work system or individual house connections which is utilized for drinking, cooking, washing and cleansing.

IV. PATTERNS OF FUNCTIONING (April 17, 2008) ( PRE OPERATIVE )

Patterns Of functioning 1. Nutritional Pattern Before Hospitalization Has regular eating pattern usually eats three times a day (300g/meal). Drinks 6-8 glasses of water and ( app. 150 ml/glass) Voids 6-7 times a day (100 ml- 150 ml/void) with teacolored urine. Defecates once a day with semi solid, clay-colored stool. During Hospitalization Eats three times a day with minimal amount(100g/meal) Drinks 3-4 glasses/day (approx. 150ml/ glass). Significance

Related to loss of appetite secondary to pain brought about by the disease process (Acalculous Cholecystitis).

2. Elimination pattern

Voids 3-4 times a day (100ml-150ml/void). Defecates every two-three days with clay-colored stool. .

Decreased urinary and stool output related to decreased intake of fluids and food.

3. Activity and recreational pattern

Works as a farmer He takes a bath in the morning as well as in the evening.

Limited level of activities. He just wipe his whole body with towel soaked with tap water every morning.

Related to fatigue and body malaise secondary to disease process.

4. Sleep and rest Pattern

Sleeps about 5-6 hours a day. Usually sleeps at 11:00 at night and wakes up 4:00-5:00 in the morning. Doesnt nap at day time.

Sleeps 7-8 hours a day. Usually sleeps 10:00pm and wakes up 5:00am. Does nap at day time (1hour).

Increased total sleeping time related to limited physical activity enticing to fall asleep and as method to reduce pain. Normal.

V. PATTERNS OF FUNCTIONING (April 18-21, 2008) ( POST OPERATIVE )

Patterns Offunctio ning 1.Nutritio nal Pattern Before Hospitalization During Hospitalization Significance Post Operative (at the ward) Significance

> Has regular eating pattern usually eats three times a day (300g/meal). > Drinks 6-8 glasses of water and (approx. 150 ml/glass)

> Eats three times a day with minimal amount (100g/meal) > Drinks 3-4 glasses/day (approx. 150ml/ glass).

> Related to loss of appetite secondary to pain brought about by the disease process (Acalculous Cholecystitis

> Didnt take any food for the first day postoperative due to NPO maintenance. Following day, he eats three times a day with minimal amount (50-60 mg/ml) of general liquid diet. Following day, he eat three times a day with minimal feedings of solid foods (75mg/ml). > Didnt drink on the first day postoperative due to NPO maintenance. For the following days, he drinks 23 glasses/day ( approx. 150ml/day) > first day postoperative he is with IFC with total volume of 400cc. For the following days, voids 2-3 times/day (approx. 50100ml/void) > first day postoperative he didnt defecate. For the following days, he only defecates once.

>Decreased input related to NPO order and loss of appetite secondary to post-op condition.

>Decreased input related to NPO order and loss of appetite secondary to post-op condition.

2.Elimina tion pattern

> Voids 6-7 times a day (100 ml- 150 ml/void) with tea-colored urine. > Defecates once a day with semi solid, claycolored stool.

> Voids 3-4 times a day (100ml150ml/void). > Defecates every two-three days with clay-colored stool.

>Decreased urinary and stool output related to decreased intake of fluids and food.

>Decreased output related to decreased intake of food and fluids secondary to NPO order and loss of appetite due to post-op condition..

( POST OPERATIVE )

3.

Act ivit y an d rec reat ion al pat ter n

4.

> Works as a farmer > He takes a bath in the morning as well as in the evening.

> Limited level of activities. > He just wipe his whole body with towel soaked with tap water every morning

> Related to fatigue and body malaise secondary to disease process.

> limited range of motion. >with few bed exercises and repositioning, socializes with watcher and other patients.

>related to perceived pain and weakness secondary to postoperative condition.

Sle ep an > Usually sleeps d at 11:00 at rest night and Pat wakes up ter 4:00-5:00 in n the morning. > Doesnt nap at day time.

> Sleeps about 56 hours a day.

>Sleeps 7-8 hours a day. > Usually sleeps 10:00pm and wakes up 5:00am. > Does nap at day time (1hour).

>Increased total >sleeps most of the sleeping time (9-10 hours time related a day). to limited >Usually sleeps physical 9:00pm to activity 6:00am. enticing to >Does nap at fall asleep daytime (1-2 and as hours). method to reduce pain. > Normal.

>Increased total sleeping time related to perceived pain and weakness secondary to postoperative condition.

VI. SYSTEMS REVIEW ( April 17, 2008 ) CONTITUTIONAL: __irritability __Weakness __ Wt. loss (from 67 kg-63 kg) _X _insomnia __anorexi _X_profuse sweating whole day

INTEGUMENT: __ Rashes CNS: _X_ Headache HEENT:_X_ vertigo CVS: _X_ chest pain RESP: _X_ Difficulty of breathing _X_ Colds GIT: _X_nausea GUT: __ dysuria NMS: __muscle pain __ non-healing lesion __ Loss of Consciousness __ Consistency _X_joint pain

__ itching __ loss of vision __ tinnitus _X_ palpitation _X_fast breathing _X_ Cough _X_vomiting __ polyuria

__ diarrhea __ nocturia

__ seizure _X_ nape pain _ abdominal pain __ swelling

VII. PHYSICAL EXAMINATION (April 17, 2008) ( PRE OPERATIVE )

Body Parts Assessed

Head

Technique used
Inspection Palpation

Normal findings

Actual findings

Analysis
Normal Normal

Proportional to the Rounded size of the body normochephalic Round with symmetrical in all prominences in the planes, with frontal and frontal and occipital prominence occipital area, symmetrical in all planes gently curved White, clear, free from lumps, no scars, nits, dandruff and lesions Black, evenly distributed and covers the whole scalp, thick, shiny, free from split ends Smooth, no masses, scars, lesions, dandruff noted

Scalp

Inspection

Normal

Hair

Inspection

Black, evenly distributed, thick and shiny.

Normal

Face

Inspection

Oblong or oval or square or heart shaped, facial expressions that is dependent on the true mood or true feelings, smooth and free from wrinkles no involuntary muscle movement

Oval-shaped, with symmetrical, no involuntary muscle movement

Normal

Eyes

Inspection

Parallel and evenly placed, symmetrically, non protruding with scant amount of secretions, both eyes black and clear

Parallel symmetrical, no discoloration and both are black Yellowish sclera.

Normal Related to the obstruction of the cystic duct secondary to disease process (Acalculous Cholecystitis).
Normal

Eyebrows

Inspection

Black, symmetrical, and thick and can raise and lower eyebrows at the same time without difficulty, evenly distributed and parallel

Black, symmetrical, parallel, evenly distributed and can raise and lower simultaneously without difficulty

Eyelashe s Ears

Inspection

Black evenly distributed and turned outward Parallel, symmetrical proportional to size of the head, bean shaped, color is the same as the surrounding area, clear Midline, symmetrical patent, no discharge/flashing

Black evenly distributed and turned outward Parallel symmetrical, color same as facial, clear Midline symmetrical, no lesion, no nasal discharge.

Normal

Inspection

Normal

Nose

Inspection

Normal

Mouth/L ips

Inspection Palpation (light)

Inspection

Pinkish, symmetrical, lip margin well defined, smooth and moist

Pinkish, smooth, moist, no swelling, no retraction 32 permanent teeth, well aligned, free from carries or filling to halitosis

Pinkish symmetrical, smooth

Pinkish, moist, no swelling, no retraction 25 permanent teeth left well aligned.

Normal

Gums

Normal

Teeth

Inspection

related to poor oral hygiene

Tongue

Inspection

Large or medium, red or pink. Moist freely movable Proportional to the body size symmetrical and straight

Medium size, pink, moist and freely movable Proportional to the body size, symmetrical and straight

Normal

Neck

Inspection

Normal

Palpation

No palpable No lumps, mass lumps, masses or and not tender areas of tenderness

Normal

Range motion chin to chest ear to shoulder

Freely movable without difficulty

Performed with a little difficulty

Related to Fatigue secondary to disease process.

Normal Normal

Chest

Inspection Palpation

Normal bilateral expansion. No deformities and hematoma

Bilateral expansion. No deformities and hematoma.

Lung

Auscultati on

No adventitious breath sounds

No adventitious breath sounds

Normal

Abdomen

Inspection Auscultati on Percussion And palpation.

Skin is unblemished, Skin is no scar, color is unblemished, no uniform, flat, scar, color is symmetrical uniform, flat, movement symmetrical there are gurgling movement, sounds, tympany there are gurgling predominates sounds, tympany because of presence predominates of air in the stomach because of and intestines, presence of air in Soft abdomen, No the stomach and tenderness, no intestines, masses, no lumps. tenderness
Palms: pinkish, warm, males: thick, female: softer, elastic Yellowish discoloration noted, thick. With slight swelling at the dorsal surface of the left hand

Normal Normal Related to inflammation of gallbladder secondary to disease process.

Palms and dorsal surfaces

Inspection

Related to cystic duct obstruction secondary to disease process. swelling of the dorsal surfaces is related to IV catheter infiltration.

Fingers

Inspection

Freely movable 5 fingers in each hands Nails are transparent, smooth and convex with pink nail beds, white tips

Freely movable 5 fingers in each hands Transparent, smooth, convex with pink nail beds, white tips

Normal

Fingernail

Inspection

Normal

Elbows

Range of motion bend straight

Inspection

Performs with relative case

Can perform with relative ease.

Normal

Lower extremi ties Legs

Skin color varies Skin yellowish (pinkish, tan, dark discoloration brown) skin is smooth, noted, hair evenly fine hair, evenly distributed. distributed, muscle 5 fingers in each foot, 5 finger in each sole and dorsal surface foot, sole and is smooth, transparent dorsal surface are nails with pink nail smooth with pink beds and white tips nails beds and white tips

Jaundice-Related to cystic duct obstruction secondary to disease process. Normal

Toes and Toenail s

Inspection

VIII. PHYSICAL EXAMINATION (April 18, 2008) ( POST OPERATIVE ) Body Parts Assesse d Head Technique used Inspection Palpation Normal findings Actual findings Analysis

Proportional to the size of the body Round with prominences in the frontal and occipital area, symmetrical in all planes gently curved White, clear, free from lumps, no scars, nits, dandruff and lesions Black, evenly distributed and covers the whole scalp, thick, shiny, free from split ends Oblong or oval or square or heart shaped, facial expressions that is dependent on the true mood or true feelings, smooth and free from wrinkles no involuntary muscle movement

Rounded normochephalic symmetrical in all planes, with frontal and occipital prominence

Normal

Scalp

Inspection

Smooth, no masses, scars, lesions, dandruff noted

Normal

Hair

Inspection

Black, evenly distributed, thick and shiny.

Normal

Face

Inspection

Oval-shaped, with symmetrical, no involuntary muscle movement

Normal

Eyes

Inspection

Parallel and evenly placed, symmetrically, non protruding with scant amount of secretions, both eyes black and clear

Parallel symmetrical, no discoloration and both are black. With minimal yellowish discoloraion on sclerae.

Normal Related to remnance of bile in the circulatio n.

Eyebrows

Inspection

Black, symmetrical, and thick and can raise and lower eyebrows at the same time without difficulty, evenly distributed and parallel

Black, symmetrical, Normal parallel, evenly distributed and can raise and lower simultaneously without difficulty

Eyelashes

Inspection

Black evenly Black evenly distributed distributed and turned and turned outward outward

Normal

Ears

Inspection

Parallel, symmetrical proportional to size of the head, bean shaped, color is the same as the surrounding area, clear

Parallel symmetrical, color same as facial, clear

Normal

Nose

Inspection

Midline, symmetrical patent, no discharge/flashing Pinkish, symmetrical, lip margin well defined, smooth and moist

Midline symmetrical, no lesion, no nasal discharge. Pinkish symmetrical, smooth Dry and chapped

Normal

Mouth/L ips

Inspection Palpation (light)

Normal Related to poor rehydration secondary to NPO order by Dr. Valera. Normal

Gums

Inspection

Pinkish, smooth, moist, no swelling, no retraction

Pinkish, moist, no swelling, no retraction

Teeth

Inspection

32 permanent teeth, 25 permanent teeth left well aligned, free from well aligned. carries or filling to halitosis Large or medium, red or pink. Moist freely movable Medium size, pink, moist and freely movable

related to poor oral hygiene

Tongue

Inspection

Normal

Neck

Inspection

Proportional to the body size symmetrical and straight No palpable lumps, masses or areas of tenderness

Proportional to the body size, symmetrical and straight No lumps, mass and not tender Performed with a little difficulty

Normal

Palpation

Normal

Range motion Freely movable chin to chest without difficulty ear to shoulder

Related to Fatigue secondary to disease process. Normal Normal

Chest

Inspection Palpation

Normal bilateral expansion. No deformities and hematoma

Bilateral expansion. No deformities and hematoma.

Lung

Auscultation

No adventitious breath sounds

No adventitious breath sounds

Normal

Abdomen

Inspectio n Ausculta tion

Skin is unblemished, Presence of surgical no scar, color is wound, redness uniform, flat, there are gurgling symmetrical movement sounds, tympany there are gurgling predominates because sounds, tympany of presence of air in predominates because the stomach and of presence of air in the intestines, stomach and intestines, Palms: pinkish, warm, males: thick, female: softer, elastic

Related to postoperative condition Normal

Palms and dorsal surfaces

Inspectio n

Yellowish Related to discoloration noted, remnance of thick. With slight bile in the swelling at the dorsal circulation; surface of the left hand swelling of the dorsal surfaces is related to IV catheter infiltration.

Fingers
Fingernail

Inspectio n
Inspectio n

Freely movable 5 fingers in each hands

Nails are transparent, smooth and convex with pink nail beds, white tips

Freely movable 5 fingers in each hands

Transparent, smooth, convex with pink nail beds, white tips

Normal
Normal

Elbows

Range of motion bend straight

Performs with relative case

Can perform with relative ease.

Normal

Lower Inspection Skin color extremiti varies (pinkish, es tan, dark brown) Legs skin is smooth, fine hair, evenly distributed, muscle Toes and Toenails Inspection 5 fingers in each foot, sole and dorsal surface is smooth, transparent nails with pink nail beds and white tips

Skin yellowish discoloration noted, hair evenly distributed.

Related to remnance of bile in the circulation.

5 finger in each foot, sole and dorsal surface are smooth with pink nails beds and white tips

Normal

IX. LABORATORY AND DIAGNOSTIC EXAMINATIONS LABORATORY: Hematology DATE: April 12, 2008 REQUESTING PHYSICIAN: Dr. Antonio Valera

HEMATOLO GY HEMOGLOBI N Hematocrit

NORMAL VALUES >14-16 g/dl > 37-47%

RESULT >16.3 g/dl > 48%

INDICATIO N >Indicates anemia >Indicates anemia

WBC
Neutrophils Lymphocytes

5,000-10000 cumm
> 55-70% > 20-40%

>9,400 cumm
>70% > 30%

> Normal
> Normal > Normal

DATE: April 16, 2008 REQUESTING PHYSICIAN: Dr. Antonio Valera HBsAg Determination non - reactive Cross matching result 0+ ULTRASOUND REPORTS DATE: April 9, 2008 REQUESTING PHYSICIAN: Dr. Antonio Valera The liver is normal in size extending to the costal margin. The common bile duct is not dilated. Homogeneous pattern: The gallbladder can not be visualized. The pancreas is normal in size measuring 21mm at its widest diameter. No mass demonstrable. Impression: Liver, pancreas-negative. DATE: April 10, 2008 REQUESTING PHYSICIAN: Dr. Antonio Valera Gallbladder is normal in size measuring 52mm x 13mm with thickened wall. No stone demonstrable. Impressions: Normal sized gallbladder with thickened wall: consider: cholecystitis.

X. ANATOMY AND PHYSIOLOGY OF SYSTEM / ORGAN INVOLVED THE DIGESTIVE SYSTEM The digestive system is made up of the alimentary canal (also called the digestive tract) and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal is the long tube of organs including the esophagus, stomach, and intestines that runs from the mouth to the anus. An adult's digestive tract is about 30 feet (about 9 meters) long. Digestion begins in the mouth, well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty meal, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal. As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase, which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth. Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx, a passageway for food and air, is about 5 inches (12.7 centimeters) long. A flexible flap of tissue called the epiglottis reflexively closes over the windpipe when we swallow to prevent choking.

From the throat, food travels down a muscular tube in the chest called the esophagus. Waves of muscle contractions called peristalsis force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract. At the end of the esophagus, a muscular ring or valve called a sphincter allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts (2.8 liters) of these digestive juices each day. Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an adult's stomach has a volume of one fifth of a cup (1.6 fluid ounces), but it can expand to hold more than 8 cups (64 fluid ounces) of food after a large meal.

By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme. A walnut-sized muscular valve at the outlet of the stomach called the pylorus keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream.
The small intestine is made up of three parts: the duodenum, the C-shaped first part the jejunum, the coiled midsection the ileum, the final section that leads into the large intestine The inner wall of the small intestine is covered with millions of microscopic, finger-like projections called villi. The villi are the vehicles through which nutrients can be absorbed into the body. The liver (located under the rib cage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are essential to digestion.

The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food. The liver also plays a major role in the handling and processing of nutrients, which are carried to the liver in the blood from the small intestine.
From the small intestine, undigested food (and some water) travels to the large intestine through a muscular ring or valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished

THE ANATOMY OF STOMACH AND GALLBLADDER

XI. PATHOPHYSIOLOGY AND SCHEMATIC DIAGRAM OF THE DISEASE Non-Modifiable Factors: >Male >51 years old Damage to the liver Decreases functional level of the liver May send excessive alcohol fats to the gallbladder which pass to the cystic duct. Cystic duct obstruction: Modifiable Factors: >drinks approx. 350 ml of alcohol per day for 20 years now.

Biliary stasisincreased viscosity of the bile

Infection and or inflammation on the entire wall of the gallbladder (Cholecystitis). Gallbladder becomes edematous and hyperemic. Bile flow is compromisedleakage into the circulation causing jaundice. S/S felt by the patient: Right Upper Quadrant Pain; yellowish discoloration of the skin and sclera. This may lead to further complications like: >Stone formation and >cystic duct scarring.

XII. COURSE IN THE WARD

PRE - OPERATIVE April 12, 2008 7:00-3:00 pm 10:45 am Into ward from ER via wheel chair with no contraptions. Placed on bed comfortably. On DAT instructed. Vital signs monitored and recorded. Afebrile: 36.7 C, with a complaint of severe pain at the right upper quadrant of his abdomen. For CBC typing and CP clearance. With oral medications of Ciprofloxacin 500mg BID, Cefalexin 500mg 1 capsule TID, Multivitamins plus Minerals 1 capsule TID.
April 13, 2008 7:00-3:00pm Received lying on bed with no contraptions. Vital signs were checked and recorded: BP- 110/80 mmHg, Temperature-36.5C. On DAT instructed and maintained. Seen and examined by Dr. Valera with order of cholecystectomy on Tuesday. CP evaluation: non hypertensive, non diabetic, non asthmatic, no allergies to foods and drugs; denies any familial diseases and previous confinement, previous cigarette smoker and beverage drinker.

April 14, 2008 7:00-3:00pm Received lying on bed with no contraptions. Vital signs checked and recorded: BP- 120/90 mmHg and temp.- 36.5C.On DAT maintained. Seen and examined by Dr. Valera with orders of Cefuroxime 70mg 1 hour prior to operation. April 15, 2008 7:00-3:00pm Received lying on bed with no contraptions. Vital signs checked and recorded: BP- 110/90 mmHg and temp.- 36.0C.On DAT maintained. Seen and examined by Dr. Valera with orders to continue medications: Ciprofloxacin 500mg BID, Cefalexin 500mg 1 capsule TID, Multivitamins plus Minerals 1 capsule TID. Operation was rescheduled on April 16, 2008.

April 16, 2008 7:00-3:00pm Received lying on bed with no contraptions. Vital signs were checked and recorded: BP- 120/80 mmHg, Temperature36.7C. On NPO post midnight instructed and maintained. Seen and examined by Dr. Valera with order to check vital signs prior to OR and record; insert IVF of D5LRS 1 liter at the left hand at 6 am; Vitamin K 10 g IM; Cefuroxime 70mg IV 1 hour prior to OR. April 17, 2008 7:00 3:00pm Received lying on bed with an ongoing IVF of D5LRS 1 liter at 800 cc level regulated at 30gtts/min; infusing well. Vital signs were checked and recorded: BP 110/80 mmHg, Temperature-36.4C. On NPO maintained. One hour prior to operation physical preparations were done: shaved hairs over the site, removed jewelries, dressed client in gown and cap, checked vital signs and recorded.

INTRAOPERATIVE April 17, 2008 7:00 3:00pm At 2:22 in the afternoon, patient B.R. scheduled for an emergency cholecystectomy was transported to the operating room from the surgery ward via wheelchair and accompanied by a student nurse. He had an ongoing intravenous fluid of D5LRS 1 liter regulated at 30 gtts/min and at approximately 100cc level inserted at the left metacarpal vein. The patient was observed with jaundice on his sclerae. IVF was changed with same solution and fast dripped as ordered by Dr. Deauna at 2:30 p.m. After few minutes, the patient was placed on the operating table located on the center of the operating room at supine position.

Patients initial blood pressure was checked after placing him on the OR table and it was 120/90 mmHg. The induction prep was done at about 3:41 p.m. and the patient was positioned left lateral decubitus position with his back facing Dr. Deauna, the anesthesiologist, at the edge of the bed. In this position, the patient is encouraged to curl up his shoulders and legs while arching his back "like a cat". This position will maximize the distance between the spinous processes while pulling the spinal cord superiorly. At 3:45 p.m., 10cc of Bupivacaine Hydrochloride which is a local anesthetic diluted with 12cc of CSF was inducted at the interspace of L3-L4 using the posterior superior iliac crest line. The size of the needle used was 0.65 x 88mm/ 23 G x 3.5 inches. After induction, the patient was placed back to supine position. After the induction of anesthesia, stage of excitement occurred wherein the patient experienced numbness on the extremities then surgical stage happened next, wherein the patient encountered total numbness and paralysis, this then allows medical procedures to be performed with little or no sensation to the person undergoing the procedure, and provides a still patient or area for the surgeon to work on.

At 3:55 pm, his blood pressure was again checked and it was 140/100 mmHg. Abdominal prep was done at 4:00 pm. Lap sheets were placed at 4:09 pm. after lap sheets were already placed, the surgeon started to open the patients abdomen using right upper transverse incision. As the operation continues, several drugs were infused by the anesthesiologist. At 4:26 p.m., Dr. Deauna infused intravenously 1cc of Ephedrine Sulfate 50mg/ml. Atrophine Sulfate was inducted which is an anticholinergic drug via IV with an amount of 0.5cc at about 4:27p.m. At 4:31 p.m., 0.1 cc of metoclopramide, 0.1cc of Promethazine, and 0.1 cc of Nalbuphine were inducted simultaneously. 1 ampule of Diclofenac Na was inducted via intramuscular at left deltoid at about 4:36 p.m.

The deceased gall bladder was removed out from the patients body at 4:40 p.m. The surgeon closed and ended suturing at exactly 5:00 p.m. Dr. Turqueza, the assistant surgeon, ordered Phytomenadione 1 ampule every 8 hours and was started at 4:57 p.m. The urine volume was measured after the operation and it was approximately 900cc. also, patients blood pressure was checked and recorded, it was 110/80 mmHg.
Patient was transferred to the recovery room at about 5:12 p.m. He was observed chilling and unconscious but regained consciousness after few minutes. He complained of pain at the incision site. His vital signs were monitored every 15 minutes for the first hour, every 30 minutes for the second hour and every hour after the second hour. The student nurses provided warmth through putting blanket on him. He was transferred to the surgery ward at about 9:00 in the evening.

POST - OPERATIVE April 18, 2008 7:0-3:00pm Received lying on bed with an ongoing IVF of D5LRS 1 liter + Vitamin B Complex at 600cc level regulated at 30gtts/min; infusing well. Vital signs were checked and recorded: BP- 120/80 mmHg, Temperature-36.7C. On NPO maintained. Seen and examined by Dr. Valera with order of Vit.K 1ampule IV every 8 hours; Cefuroxime 75mg IV every 8 hours; Tramadol 50mg IV every 8 hours PRN, remove IFC and monitor v/s and record. April 19, 2008 7:00-3:00pm Received lying on bed with an ongoing IVF of D5LRS 1 liter at full level regulated at 20gtts/min; infusing well. Vital signs were checked and recorded: BP- 120/90 mmHg, Temperature-36.5C. On General Liquid Diet instructed and maintained. Seen and examined by Dr. Valera with order of continue medications ( Vit.K 1ampule IV every 8 hours; Cefuroxime 75mg IV every 8 hours; Tramadol 50mg IV every 8 hours PRN), and Ambroxol 30 mg 1 tab TID.

April 20,2008 7:00-3:00pm Received lying on bed with an ongoing IVF of D5LRS 1 liter at 400cc level regulated at 20gtts/min; infusing well. Vital signs were checked and recorded: BP- 120/80 mmHg, Temperature36.6C. On DAT instructed and maintained. Seen and examined by Dr. Valera with order of discontinue Vit. K;continue meds (Cefuroxime 75mg IV every 8 hours; Tramadol 50mg IV every 8 hours PRN). April 21, 2008 7:00-3:00pm Received lying on bed with an ongoing IVF of D5LRS 1 liter at 700 cc level; regulated at 30 gtts per minute; infusing well. Vital signs checked and recorded as follows: BP-110/90 mmHg; Temp-36.8. Seen and examined by Dr. Valera with orders of: May go home. Take home medications were: Ciprofloxacin 500 mg 1 tab BID, Mefenamic Acid 500 mg 1 tab TID, Multivitamins 1 tab OD.

XIII. DRUG STUDY ( PRE OPERATIVE)

GENERIC NAME / BRAND NAME CLASSIFIC ATION MECHANISM OF ACTION CONTRAIND ICATIO N SIDE EFFECTS / ADVERSE REACTIO N GI: nausea, vomiting,di arrhea,cram ps Muskuloskeletal : tendon rupture CNS: headache, vertigo, malaise Skin: rash, pain, pruritus NURSING IMPLICA TION EVALUA TIO N

Ciprofloxaci n/ Ciprome t

Quinolone Antibioti c

Inhibits DNAgyrase, an enzyme necessary for bacterial DNA replication and some aspects of transcription, repair, recombination , and transportation THERAPEUTIC EFFECT

Hypersensitivit y to ciprofloxa cin or other quinolone s

DOSAGE

INDICATIO N

PRECAUTIO N

500 mg 1 tablet BID 6pm

Infections or imminent risk for infection

Effective against many grampositive and gram-negative organisms

Severe and persistent diarrhea during or after treatment

assess patient for signs and symptoms of fever befor and after treatment assess for allergic reaction and anaphylaxi s monitor I & O ratio and patterns

Absence of signs and symp toms of infec tion

GENERIC NAME / BRAND NAME

CLASSIFICA MECHANISM OF TION ACTION

CONTRAIND ICATIO N

SIDE EFFECTS / ADVERSE REACTIO N

NURSING IMPLICA TION

EVALUA TIO N

Cefalexin / Cefanex

Antibiotic

Inhibits third and final stage of bacterial wall synthesis thus killing the bacterium THERAPEUTIC EFFECT It is active against many gram positive aerobic cocci and much less active against gramnegative bacteria

Hypersensitivit y to cephalosp orins

DOSAGE 500 1 capsule TID 12pm,6p m

INDICATIO N > Infections or imminent risk for infection

PRECAUTIO N History of hypersensi tivity to penicillin or other drug allergy

Body as a whole: anaphylaxis GI: diarrhea, nausea, vomiting, anorexia, abdominal pain CNS: dizziness, headache, fatigue Skin: rash, urticaria

monitor for manifestati ons of hypersensit ivity ( urticaria, pruritus, edema, redness,ana phylaxis) instruct patient to take medication for the full course of medication

Absence of signs and symp toms of infect ion

GENERIC NAME / BRAND NAME Cefuroxime / Kefurox

CLASSIFICA MECHANISM TION OF ACTION

CONTRAINDI CATION

SIDE EFFECTS / ADVERSE REACTIO N Body as a whole: pain, thrombophle bitis (IV site) GI: diarrhea, nausea Skin: pruritus, urticaria, rash Urogenital: Increased serum creatinine and BUN

NURSING IMPLICA TION

EVALUA TIO N

Antibiotic

Second cephalospori ns that inhibits cell wall synthesis, promoting sosmotic instability, usually bactericidal THERAPEUTI C EFFECT

Hypersensitivity to cephalospori ns

DOSAGE

INDICATIO N

PRECAUTION

75 mg IV q 8

Perioperative prophylax is

It is effective for the treatment of penicillinase -producing Neisseria gonorrhea

History of allergy, particularly to drugs; penicillin sensitivity

Inspect IV injection site for signs of phlebitis Report onset of diarrhea Monitor for manifestati ons of hypersensit ivity Monitor I & O rates and ratio

Absence of signs and symp toms of infect ion

GENERIC NAME / BRAND NAME Vitamin K / Mephyto n

CLASSIFICA MECHANISM OF TION ACTION

CONTRAI NDICA TION

SIDE EFFECTS / ADVERSE REACTIO N Body as a whole: facial flushing, chills, fever, diaphoresis, weakness, dizziness CNS: headache, brain damage GI: gastric upset Hematologic: severe hemolytic anemia Respiratory: bronchospas m, dyspnea Skin: pain

NURSING IMPLICA TION

EVALUA TIO N

Hormones ans synthetic substitute s, Antidote

Essential for hepatic biosynthesis of blood clloting

Sever liver disease

DOSAGE

INDICATIO N Drug of choice as antidote for overdosa ge of coumarin indandion e oral anticoagu lants

THERAPEUTIC EFFECT Promotes liver synthesis of clotting factors by unknown mechanism

PRECAUTI ON Pregnancy;la ctation

1 ampule IM

Instruct patient to report symptoms of bleeding Caution patient not to use OTC medication s or take other supplement s unless directed by physician

Patient does not devel op any injur y relate d to drug induc ed adver se reacti on

DRUG STUDY ( INTRAOPERATIVE)

GENERIC NAME / BRAND NAME CLASSIFICATIO N MECHANISM OF ACTION CONTRAIND ICATIO N SIDE EFFECTS / ADVERSE REACTION NURSING IMPLICATI ON EVALUATI ON

Bupivacaine Hydrochlo ride / Marcaine

Local Anesthetic ( Amide type )

Anesthetic of the amide type. Decreases sodium flux into nerve cell, inhibiting initial depolarization, and prevents propagation and conduction of nerve impulse THERAPEUTIC EFFECT Primary depressant effect is in medulla and higher center affecting patients reaction to pain, temperature and pain

Known sensitivit y to bupivacai ne

Body as a whole: urticaria, sneezing, syncope CNS: nervousness, dizziness GI: nausea, vomiting

DOSAGE 10 cc with 12 cc of CSF

INDICATION for local anaesthesia including infiltration, nerve block, epidural, and intrathecal anaesthesia

PRECAUTIO N Known drug allergies and sensitiviti es

>Assess patients condition before therapy and re-assess regularly, thereafter to monitor drugs effectiveness. >Monitor blood pressure, check for rebound hypertension after 1-2 hours. >Monitor for possible adverse reactions.

Reduced sensatio n while maintain ing normal thought process through out therapy.

GENERIC NAME / BRAND NAME Ephedrine Sulfate / Vatronol

CLASSIFICATI ON

MECHANISM OF ACTION

CONTRAINDIC ATION

SIDE EFFECTS / ADVERSE REACTION

NURSING IMPLICATI ON

EVALUA TIO N

Alpha- and BetaAdrenergic antagonist (Sympatho mimetic)

Thought to act indirectly by releasing tissue stores of norepinephrine and directly by stimulation of alpha-, beta1-, beta2-adrenergic receptors THERAPEUTIC EFFECT Like epinephrine, contracts dilated arterioles of nasal mucousa, thus reducing engorgement and edeme and fecilitating ventilation and drainage.

History of hypersensiti vity to ephedrine

DOSAGE 1 cc IV

INDICATION Hypotension including orthostatic hypotension .

PRECAUTION Asthma; hypertensio n

CNS: headache, insomnia, anxiety CV: palpitation, tachycardia, cardiac arrythmias GU: difficult or painful urination Body as a whole: sweating, thirst Skin: dryness of nasal mucosa, sneezing, rebound congestion

>monitor possible drug induced adverse reaction: dizziness, headache, palpitation, nausea, vomiting >monitor respiratory function: lung sounds and rhythm >monitor for and report evidence of allergic reaction >monitor vital signs >assess for coldness of extremities.

Patient exhi bits impr ove ment in unde rlyin g cond ition .

GENERIC NAME / BRAND NAME

CLASSIFICA TION

MECHANISM OF ACTION

CONTRAI NDICA TION

SIDE EFFECTS / ADVERSE REACTION

NURSIN G IMPL ICAT ION >monitor vital signs >monitor I &O >monitor CNS status >monitor respir atory status: rate rhyth m >monitor for bowel move ment: check for consti pation

EVALUA TIO N

Atrophine Sulfate / Atropair

Anticholinergi c

Acts by selectively blocking all muscarinic responses to acethylcholine, wheter excitatory or inhibitory THERAPEUTIC EFFECT Atropine is a potent bronchodilator when bronchoconstrcti on has been induced by parasymphapom imetics.

Hypersensiti vity to bellado nna alkaloid s

DOSAGE 0.5 cc IV

INDICATIO N Administratio n prior to anesthesi a to reduce or prevent secretions of respirator y tract.

PRECAUTI ON Myocardial infarcti on, hyperte nsion, hypoten sion and coronar y artery disease.

CNS: headache, ataxia, dizziness, excitement, irritability, drowsiness, fatigue, weakness CV: hypertension or hypotension, ventricular tachycardia, palpitation GI: dry mouth with thirst, dysphagia, nausea, vomiting, constipation, delayed gastric emptying Urognital:dysuria, impotence Skin: flushed, dry skin, urticaria, contact dermatitis

Reduction of respir atory secret ions.

GENERIC NAME / BRAND NAME Metocloprami de / Clopra

CLASSIFICA TION

MECHANISM OF ACTION

CONTRAINDIC ATION

SIDE EFFE CTS

NURSING IMPLICAT ION

EVALUA TIO N

Direct Acting Cholinerg ic ( parasymp athomime tic )

Potent central dopamine receptor antagonist. Structurally related to procainamide but has little antiarrythmic or anesthetic activity.

Sensitivity or intolerance to metoclopram ide

CNS: mild sedati on

DOSAGE 0.1cc IV

INDICATIO N Nausea and vomiting of central and peripheral origin associate d with surgery

THERAPEUTIC EFFECT Increases resting tone of esophageal sphincter and tone and amplitude of upper G contractons

PRECAUTION CHF; kidney dysfunction

assess patients GI complaints:n ausea, vomiting frequently monitor blood pressure assess ,mental status during treatment:de ppressin, anxiety and irritability

Nausea and vomit ing were nt obser ved.

GENERIC NAME / BRAN D NAME Promethazi ne / Phenad oz DOSAGE 0.1cc IV

CLASSIFI CATIO N

MECHANISM OF ACTION

CONTRAIN DICATI ON

SIDE EFFECTS / ADVERSE REACTIO N CNS: sedation, confussion, sleepiness, dizziness CV: hypotension, hypertension EENT: blurred vision GI: nausea, vomiting Respiratory: respiratory depression, apnea Skin: rash

NURSIN G IMP LICA TIO N

EVALU ATI ON

Antihistamin At high doses, es drug also has local anesthetic effects INDICATI ON Preoperative sedation THERAPEUTIC EFFECT

Hypersensitiv ity to phenothia zines PRECAUTI ON

Reduces sensation. Asthma or pulmonar y disease

monit Reduced or sens patien ation t for . neuro leptic malig nant syndr ome

GENERI C NAM E/ BRA ND NAM E Nalbuphin e/ Nubai n

CLASSIFICATI ON

MECHANISM OF ACTION

CONTRAIND ICATIO N

SIDE EFFECTS / ADVERS E REACTI ON CV:

NURSING IMPLIC ATION

EVALUAT ION

Narcotic Agonist Antagonist

Synthetic narcotic analgesic with antagonist and weak antagonist properties THERAPEUTIC EFFECT Analgesic action that relieves moderate to severe pain with apparently low potential for dependence

History of hypersensi tivity to drugs

DOSAGE 0.1cc IV

INDICATION Symptomatic relief of moderate to severe pain. Also preoperative sedation analgesia and as supplement to surgical anesthesia

PRECAUTIO N History of emotional instability or drug abuse

hypertensi on, hypotensio n, bradycardi a, tachycardi a, flushing CNS: sedation, dizziness, depression, restlessnes s, crying, euphoria Respiratory: dyspnea, asthma Skin: pruritus, urticaria, burning sensation

assess respirator y rate before drug administr ation watch for allergic response monitor ambulator y patient: nalbuphin e may produce drowsines s

Relief of pain.

GENERI C NAM E/ BRA ND NAM E Vitamin K / Meph ytone

CLASSIFICAT ION

MECHANISM OF ACTION

CONTRAIND ICATIO N

SIDE EFFECTS / ADVERSE REACTIO N

NURSING IMPLIC ATION

EVALUA TIO N

Hormones ans synthetic substitutes, Antidote

Essential for hepatic biosynthesis of blood clloting

Severe liver disease

DOSAGE 1 ampule q 8

INDICATION Drug of choice as antidote for overdosage of coumarin indandione oral anticoagula nts

THERAPEUTIC EFFECT Promotes liver synthesis of clotting factors by unknown mechanism

PRECAUTIO N Pregnancy; lactation

Body as a whole: facial flushing, chills, fever, diaphoresis, weakness, dizziness CNS: headache, brain damage GI: gastric upset Hematologic: severe hemolytic anemia Respiratory: bronchospas m, dyspnea Skin: pain

Instruct patient to report symptoms of bleeding Caution patient not to use OTC medicatio ns or take other suppleme nts unless directed by physician

Patient achie ves norm al PT levels with drug thera py.

GENERIC NAME / BRAND NAME Diclofenac Sodium / Voltaren

CLASSIFI CATI ON antiinflamm atory

MECHANISM OF ACTION

CONTRAIND ICATIO N Hypersensitivit y to diclofenac

SIDE EFFECTS

NURSING IMPLI CATIO N observe and report for signs of bleedin g monitor BP for hyperte nsion monitor for signs and sympto ms of GI irritatio n and ulcerati on

EVALUA TIO N Absence of infla mmat ion

Although its exact mechanism of action has not been fully elucidated, it appears to be a prostaglandin inhibitor of cyclooxygenase, thereby decreasing the synthesis of prostaglandins THERAPEUTIC EFFECT Nonsteroidal antiinflammatory drug with analgesic and antipyretic activity

DOSAGE 1 ampule IM

INDICATI ON Relief of inflam mation in various conditi on

PRECAUTIO N Patients receiving anticoagul ant therapy

CNS: Dizziness, head ache, drowsiness Skin: rash, pruritus GI: dyspepsia, nausea, vomiting, abdominal pain, constipation, diarrhea CV: fluid retention, hypertension Respiratory: asthma Body as a whole: back, leg or joint pain Endocrine: hyperglycemia Hematologic: prolonged bleeding time, inhibits platelet aggregation

DRUG STUDY ( POST - OPERATIVE)

GENERIC NAME / BRAN D NAME Cefuroxime / Kefuro x CLASSIFI CATI ON MECHANISM OF ACTION CONTRAIN DICATI ON SIDE EFFECT S/ ADVERS E REACTI ON NURSING IMPLIC ATION EVALU ATI ON

Antibiotic

DOSAGE

75 mg IV q 8

Body as a whole: pain, thrombop hlebitis (IV site) GI: diarrhea, nausea INDICATI THERAPEUTIC PRECAUTI Skin: pruritus, urticaria, ON EFFECT ON rash Urogenital: For It is effective for History of Increased periope the treatment allergy, serum rative of particularl creatinine prophyl penicillinasey to and BUN axis producing drugs; Neisseria penicillin gonorrhea sensitivity

Semisynthetic Hypersensitiv second ity to generation cephalosp cephalosporin orins antibiotic with structure similar to that of penicillin

Inspect IV injection site for signs of phlebitis Report onset of diarrhea Monitor for manifesta tions of hypersens itivity Monitor I & O rates and ratio

Absence of signs and sym ptom s of infec tion.

GENERIC NAME / BRAND NAME

CLASSIFICA TION

MECHANISM OF ACTION

CONTRAIN DICATI ON

SIDE EFFECTS / ADVERSE REACTIO N CNS: drowsiness, dizziness vertigo, fatigue, headache CV: palpitation, vasodilation GI: nausea, constipation , vomiting, diarrhea

NURSING IMPLICA TION

EVALUA TIO N

Tramadol / Ultram

Opiate Antagoni st, Narcotic Analgesic

Centrally acting opiate receptor antagonist that inhibits the uptake of norepinephrine and serotinine, suggesting opioid and nonopioid mechanism pain relief THERAPEUTIC EFFECT

Hypersensitiv ity to tramadol and other opioid analgesic

DOSAGE

INDICATIO N

PRECAUTI ON

50 mg IV q 8

Management of moderate to moderatel y severe pain

Effective agent for control of moderate to moderately severe pain

Debilitated patients: chronic respirator y disease

Assess for level of pain relief Monitor vital signs and assess for orthostatic hypotensio n Discontinu e drug and notify physician if signs and symptoms occur.

Relief of pain.

GENERIC NAME / BRAN D NAME Cefuroxime / Kefuro x

CLASSIFI CATI ON

MECHANISM OF ACTION

CONTRAIN DICATI ON

SIDE EFFEC TS / ADVER SE REACT ION

NURSING IMPLICA TION

EVALU ATI ON

Antibiotic

DOSAGE

75 mg IV q 6

Body as a whole: pain, thrombo phlebitis (IV site) GI: diarrhea, nausea Skin: pruritus, INDICATI THERAPEUTIC PRECAUTI urticaria, ON EFFECT ON rash Urogenital: For It is effective for History of Increase periope the treatment allergy, d serum rative of particularl creatinin prophyl penicillinasey to e and axis producing drugs; BUN Neisseria penicillin gonorrhea sensitivity

Semisynthetic Hypersensitiv second ity to generation cephalosp cephalosporin orins antibiotic with structure similar to that of penicillin

Inspect IV Absence injection of site for signs signs of and phlebitis sym Report ptom onset of s. diarrhea Monitor for manifestati ons of hypersensit ivity Monitor I & O rates and ratio

XIV. LIST OF NURSING DIAGNOSES (NANDA) ( PRE OPERATIVE ) PROBLEM LIST CUES NURSING DIAGNOSIS S > nasakit toy rusok ko as verbalized O > facial mask of pain >restlessness >diaphoresis >irritability >weak and pale in appearance >pain rate of 7/10 out of 0/10 >narrowed focus (withdrawal from social contact) S> Anya ngata dagiti aramiden da kanyak nu madama iti operasyon?", As verbalized by the patient O>inappropriate or exaggerated behaviors noted >agitated Acute pain related to disease process (Acalculous Cholecystitis) as evidenced by facial mask of pain, diaphoresis, weak and pale in appearance, pain rate of 7/10 out of 0/10 and narrowed focus (withdrawal from social contact)

JUSTIFICATION > Assessing pain characteristics: quality, location, duration, and intensity (1-10 scale) to provide a direction for the pain treatment plan. > Providing comfort measures such as changing position every two hours to prevent bed sore

Knowledge deficit of preoperative procedures and protocols and postoperative expectations related to unfamiliarity with information resources as evidence by inappropriate or exaggerated behaviors; agitated

Providing a quiet atmosphere without interruption. >Allowing patient to identify what is the most important concern to him. >providing information through clear discussion with the patient.

S > Agbutengak nga maoperaan nakkong as verbalized. O >dilated pupil noted >RR:27 >PR:96 >difficulty of breathing noted >increased perspiration noted

Fear related to perceived threat of the surgical procedures as evidence by dilated pupil noted, difficulty of breathing noted, increased perspiration

>Assist the patient to identify coping strategies that he had previously. >Provide information with simple sentences use >Encourage to use diversional activities (socialization with the watcher)

XV. NURSING CARE PLAN/ SOAPIE (April 15, 2008) ( PRE OPERATIVE )
CUES NURSING DIAGNOSIS >Acute pain (moderate) related to disease process(Acalc ulous Cholecystitis) as evidenced by facial mask of pain, restlessness, diaphoresis, irritability, weak and pale in appearance, pain rate of 7/10 out of 0/10 SCIENTIFIC BACKGROUND A state in which an individual experiences and reports the presence of severe discomfort or an uncomfortabl e sensation. EXPECTED OUTCOME After 8 hrs. of rendering effective nursing interventio ns and administeri ng pain medication, patient will able to report relief of pain with a pain rate of 7/10 down to 2/10 INTERVENTIONS RATIONALE

S> nasakit toy rusok ko as verbalized O> facial mask of pain >restlessness >diaphoresis >irritability >weak and pale in appearance >pain rate of 7/10 of 0/10 >narrowed focus (withdrawal from social contact)

>Monitor vital signs >Assess rate intensity duration, location of pain using 0-10 scale >Encourage verbalization of feelings regarding pain >Changing position every 2 hours >Encourage use of diversional activities (socialization with others) >Instruct to use soap containing a detergent-germicide to cleanse the area for several days before the surgery >Advise to have adequate rest periods. >Administer pain medication as ordered

>Serves as baseline data >Allows for care plan modification as needed >To determine and alleviate pain >For comfortable position and prevent bedsore >Helps patients focus on non pain related matters >To reduce the number of skin organisms >To prevent fatigue >to provide a pharmacological relief of pain

DATE: April 15, 2008 SHIFT:7-7pm 8:00 am> Received lying on bed with no contraption. S > Nasakit toy rusok as verbalized O >facial mask of pain >restless >diaphoresis >irritability >weak and pale in appearance >pain rate of 7/10 out of 0/10 >narrowed focus (withdrawal from social contact) A >Acute pain (moderate) related to disease process (Acalculous Cholecystitis) as evidenced by facial mask of pain, diaphoresis, weak and pale in appearance, pain rate of 7/10 out of 0/10 and narrowed focus (withdrawal from social contact) P >After 8 hours of rendering nursing interventions and administering pain medication, patient will able to verbalize and report relief of pain with a pain rate of 7/10 down to 2/10. I >NPI established >Reinforced on DAT >v/s checked and recorded 9:48>S/E by Dr. Valera during rounds with orders made and carried out >Assessed intensity of pain using a rate of 0/10 >Encouraged verbalization of feelings regarding pain >Encouraged deep breathing exercise to promote relaxation >Encouraged to apply cold compress as ordered to minimize and relieve pain >Instructed to use soap containing a detergent-germicide to cleanse the area for several days before the surgery >Encouraged divertional activities >Thought about good nutrition and the importance of getting adequate >Emphasized the importance of proper hygiene >pain medication given at due time E >Goal met; after series of rendering effective nursing interventions, patient verbalize relief from pain with a rate of 2/10 okey metten a nakkong, hanmet unay nasakit toy rusok kon as verbalized

NURSING CARE PLAN/ SOAPIE (April 16, 2008) ( PRE OPERATIVE )

CUES

NURSING DIAGNOSIS

SCIENTIFI C BACKGRO UND

Absence or deficienc y of cognitive informati on related to specific topic

EXPECTED OUTCOME

INTERVENTIONS

RATIONALE

S> Anya ngata dagiti aramiden da kanyak nu madama iti operasyon ?", As verbalized by the patient O>inappropriat e or exaggerat ed behaviors noted >agitation >repetitive questionin g

Knowledge deficit of preoperative procedures and protocols and postoperative expectations related to unfamiliarity with information resources as evidenced by inappropriate or exaggerated behaviors; agitation, and repetitive questioning.

After 8 hrs. of nursing interventi ons, the patient will increased knowledg e of perioperat ive expectatio ns

>Monitor vital signs >Provide a quiet atmosphere without interruption. >Allow patient to identify what is the most important concern to him. >provide information through clear discussion with the patient.

>Serves a comparative baseline data >This allows the patient to concentrate more completely. >To clarify expectations and helps the nurse match the information to be presented to the individuals needs. >for the patient to understand more about his concerns.

DATE: April 16, 2008 SHIFT: 7-7pm TIME: 8:00am S> Anya ngata dagiti aramiden da kanyak nu madama iti operasyon?", As verbalized by the patient O>inappropriate or exaggerated behaviors noted >agitated >repetitive questioning A>Knowledge deficit of preoperative procedures and protocols and postoperative expectations related to unfamiliarity with information resources as evidence by inappropriate or exaggerated behaviors; agitate P> After 8 hrs. of nursing interventions, the patient will increased knowledge of perioperative expectations I> vital signs checked and recorded. >NPI established >Reinforced on DAT 10:45>S/E by Dr. Valera during rounds with orders made and carried out >Provided a quiet atmosphere without interruption. >Allowed patient to identify what is the most important concern to him. >provided information through clear discussion with the patient. >Emphasized importance of proper hygiene. E> Goal met. After 8 hrs. of rendering effective nursing interventions, the patient had an increased knowledge of perioperative expectations as evidenced by verbalization of understanding of condition and treatment.

NURSING CARE PLAN/ SOAPIE (April 17, 2007) ( PRE OPERATIVE )

CUES S> Agbutengak nga maoperaan nakkong as verbalized. O>dilated pupil noted >RR:27 >PR:96 >difficulty of breathing noted >increased perspiration noted NURSING DIAGNOSIS Fear related to perceived threat of the surgical procedures as evidence by dilated pupil noted, difficulty of breathing noted, increased perspiration SCIENTIFIC BACKGROUND A state in which an individual perceived threat that is consciously recognized as a danger expected outcome. EXPECTED OUTCOME After 8 hrs of nursing interventio ns, the patients will able to verbalize the decrease of fear. INTERVENTIONS >Monitor vital signs >Advise the watcher to stay beside the patient. >Assist the patient to identify coping strategies that he had previously >Reinforce on NPO >Inspect the mouth for dentures or plates > Advise the patient to remove rings, body piercing or any jewelry > Advise the patient to void immediately before the operation >Provide information with simple sentences use >Encourage to use deep breathing exercise >Encourage to use diversional activities (socialization with the watcher) RATIONALE >Serves as a baseline data >Provides the client with desired support from the family >To decrease fear >To prevent aspiration >These items could easily fall to the back of the throat during induction of anesthesia and cause respiratory obstruction >To prevent injury > To promote continence during the surgery >Facilitate better understanding and retention of information >To promote relaxation >To alleviate feeling of fear

DATE: April 17, 2008 SHIFT: 7-7pm 8:00 am> Received lying on bed with an ongoing IVF of D5LRS 1 liter at 800cc level regulated at 30gtts/min; infusing well. S > Agbutengak nga maoperaan nakkong as verbalized. O >dilated pupil noted >RR:27 >PR:96 >difficulty of breathing noted >increased perspiration noted A >Fear related unfamiliarity with environ mental experience as manifested by dilated pupil noted, difficulty of breathing noted, increased perspiration. P >After 8 hrs of nursing interventions, the patient will able to verbalize decrease of fear. I >Vital sign checked and recorded >Bedside care done >On NPO- instructed and maintained 9:00> S/E by Dr. Valera during rounds with orders made and carried out >Advised the watcher to stay beside the patient. >Assisted the patient to identify coping strategies that he had previously >Provided information with simple sentences use >Inspected the mouth for dentures or plates > Advise the patient to remove rings, body piercing or any jewelry > Advise the patient to void immediately before the operation >Encouraged to use deep breathing exercise >Advised to adequate rest periods >Encouraged to use diversional activities E >Goal partially met: patient verbalized decreased fear. Medyo mayat ti rikna kon nakong, hanak unay mabuteng nga maoperaanen.

XVI. LIST OF NURSING DIAGNOSES (NANDA) ( INTRAOPERATIVE )

CUES NURSING DIAGNOSIS JUSTIFICATION

Subjective cues: > malasatak pay lang ngata daytoy nga operasyon? as verbalize Objective cues > facial tension noted > extraneous movement noted > pale in appearance > Irritable > restless > confused

>Anxiety related to threat of death and the outcome of surgery secondary to operation to be perform as evidence by facial tension, extraneous movement, pale in appearance, confused

>encouraging verbalizations of feeling regarding anxiety >providing adequate information about the situation

Subjective cues: >agbibineg ti panagriknak as verbalized by the patient Objective cues: >Verbal reports of numbness or tingling sensation >Limited range of motion

>Risk for injury related to anesthesia and surgery as evidence by verbal reports of numbness or tingling sensation, limited range of motion

>Monitoring Vital signs esp. BP and responses to preoperative sedations/ medications >Staying with the patient. >Placing safety strap strategically > Protecting body from contact with metal parts of the operating table > Checking peripheral pulses and skin color/temp. periodically

XVII. NURSING CARE PLAN/ SOAPIE (April 17, 2008) ( INTRAOPERATIVE )

CUES

NURSING DIAGNO SIS

SCIENTIF IC BACKGR OUND

EXPECTED OUTCOME

INTERVENTIO NS

RATIONALE

Subjective Anxiety related A vague After >monitor vital cues: to threat of uneasy rendering signs > malasatak death and feeling nursing >encourage pay lang the whose interventi verbalization ngata outcome source ons prior s of feeling daytoy nga of surgery is often to regarding operasyon secondary and operation, anxiety ? as to unspeci patient >provides verbalize operation fic and will adequate Ojective cues: to be unknow appear information > facial tension perform as n to relaxed about the noted evidence individu and report situation > extraneous by facial al reduced movement tension, on noted extraneous preoperati > pale in movement ve anxiety appearance ,pale in Irritable appearance > confused , confused

> serves a comparative baseline data > to determine and alleviate feelings of anxiety >helps client to identify what is reality base

NURSING CARE PLAN/ SOAPIE ( INTRAOPERATIVE )

CUES

NURSING DIAGNO SIS

Risk for injury related to sensory/pe rceptual disturbanc es due to anesthesia as evidenced by changes in usual responses to stimuli, limited range of motion, and muscle incoordina tion.

SCIENTIFIC BACKGROU ND

EXPECTED OUTCOME

INTERVENTION S

RATIONALE

Subjective cues: agbibineg ti panagrik nak as verbalize d by the patient Objective cues: >changes in usual response stimuli >Limited range of motion >Muscle incoordi nation

At risk for After rendering >Monitor Vital injury as a of signs esp. BP result of intraoperat and responses the ive nursing to preoperative environm interventio sedations/ ental ns, the medications conditions patient will >Stay with the found in expected patient. the to remain >Place safety strap perioperat free of strategically ive setting perioperati > Protect body ve from contact positioning with metal injury and parts of the experience operating table no > Check peripheral unexpected pulses and skin threats to color/temp. safety periodically

>Serves as a comparative baseline data > To prevent falls/injury > To secure client for specific procedure > Which could produce burns > To monitor circulation

XVIII. LIST OF NURSING DIAGNOSES (NANDA) ( POST OPERATIVE )

CUES Subjective cues: >Marigatan nak nga umanges as verbalized. Objective cues: >pursed lip breathing >respiratory depth changes >RR: 28 cpm >restless >weak in appearance >difficulty in sleeping >facial grimace NURSING DIAGNOSIS >Ineffective breathing pattern r/t neuromuscular impairment secondary to post-op condition as evidenced by pursed lip breathing, respiratory depth changes, respiratory rate of 28 cpm, restless, weak in appearance, difficulty in sleeping, and facial grimace. JUSTIFICATION >Observing respiratory rate and depth. >Assisting patient to turn, cough, and deep breathe periodically. Instruct in effective breathing techniques. >Elevating head of bed, maintain lowFowlers position. >Providing rest periods between breathing enhancement measures. >Assisting with respiratory treatments. >Providing oxygen as ordered. >Administering analgesics before breathing treatments/therapeutic activities. >Advising to change position every 2 hrs. >Encouraging to eat nutritious food when fully awake and per order. >Advising to have adequate rest and sleep.

Subjective cues: > Agkakapsot nak nakong as verbalized. Objective cues: >Weak and pale in appearance >Limited ROM > restless > irritable > functional level of IV. Subjective cues: Objective cues: > with surgical wound at right upper quadrant. >poor hygiene

>Activity intolerance r/t post operative condition as evidenced by weak and pale in appearance, limited ROM, Restless, irritable, and a functional level of IV.

High risk for infection r/t post operative condition (Cholecystectomy).

> Wash hand before giving care to the patient. > Observe for localized signs of infection at the site of incision. > Note S/S of sepsis (fever, chills, diaphoresis, altered level of conscious) > Clean incision daily and as needed with povidone iodine or other appropriate solution. > Change sterile dressing as needed.

XIX. NURSING CARE PLAN/ SOAPIE ( POST OPERATIVE ) April 18,2008 CUES NURSING DIAGNOSI S Ineffective breathing pattern r/t neuromuscu lar impairment secondary to post-op condition as evidenced by pursed lip breathing, respiratory depth changes, respiratory rate of 28 cpm, restless, weak in appearance, difficulty in sleeping, and facial grimace. SCIENTIFIC BACKGROUN D Changes in rate, depth, or pattern of breathing that alters normal gas exchange. EXPECTED OUTCOME After 30 minutes of rendering effective nursing interventi ons, pt. is expected to verbalize and establish normal and effective respirator y pattern. INTERVENTIONS RATIONALE

Subjective cues: >Marigatan nak nga umanges as verbalized . Objective cues: >pursed lip breathing >respiratory depth changes >RR: 28 cpm >restless >weak in appearanc e >difficulty in sleeping >facial grimace

>Observe respiratory rate and depth. >Assist patient to turn, cough, and deep breathe periodically. Instruct in effective breathing techniques. >Elevate head of bed, maintain lowFowlers position. >Provide rest periods between breathing enhancement measures. >Assist with respiratory treatments. >Provide oxygen as ordered. >Administer analgesics before breathing treatments/therape utic activities.

>Shallow breathing, splinting with respirations, holding breath may result in hypoventilation or atelectasis. >Promotes ventilation of all lung segments. >Facilitate lung expansion. >To avoid fatigue. >Maximizes expansion of lungs to prevent and or resolve atelectasis. >To help relieve respiratory distress. >Facilitates more effective and deep breathing activity.

DATE: April 18, 2008 SHIFT: 7-7pm 8:00 am> Received lying on bed with an ongoing IVF of D5LRS 1 liter + Vitamin B Complex at 600cc level regulated at 30gtts/ min;infusing well. S> Marigatan nak nga umanges as verbalized. O>pursed lip breathing >respiratory depth changes >RR: 28 cpm >restless >weak in appearance >difficulty in sleeping >facial grimace A> Ineffective breathing pattern r/t neuromuscular impairement secondary to post-op condition as evidenced by pursed lip breathing, respiratory depth changes, respiratory rate of 28 cpm, restless, weak in appearance, difficulty in sleeping, and facial grimace. P> After 30 minutes of rendering effective nursing interventions, pt. is expected to verbalize and establish normal and effective respiratory pattern. I>NPI established. > V/S checked and monitored. > NPO-instructed. > Encouraged position of comfort. > Encouraged effective breathing pattern. > Encouraged adequate bed rest. >With oxygen regulated at 2-3 LPM. E> Goal partially met: patient verbalized Medyo simmayat met bassit ti panaganges kon

XIX. NURSING CARE PLAN/ SOAPIE ( POST OPERATIVE ) April 19,2008

CUES

NURSING DIAGNO SIS

SCIENTIFIC EXPECTE BACKGROU D ND OUTCOME

After a series of renderin g effective nsg intervent ions, pt. will able to report measura ble increase of activity toleranc e.

INTERVENTIO NS
>V/S check and record. >Advise to change position every 2 hrs. >Encourage to eat nutritious food when fully awake and per order. >Advise to have adequate rest and sleep.

RATIONALE

Subjective cues: > Agkaka psot nak nakong as verbalize d. Objective cues: >Weak and pale in appearan ce >Limited ROM > restless > irritable > functional level of IV.

Activity A state in intoleranc which an e r/t post individual operative has an condition insufficie as nt evidenced physiolog by weak ic energy and pale in to endure appearanc desired e, limited daily ROM, activities. Restless, irritable, and a functional level of IV.

>Severs as a baseline data. >To prevent pressure sores. >Helps in gaining back energy. >To conserve energy and avoid fatigue.

DATE: April 19, 2008 SHIFT: 7-7 pm TIME: 8:00 am 8:30 am> Received lying on bed with an ongoing IVF of D5LRS 1 liter at full level regulated at 20gtts/min; infusing well. S > Agkakapsot nak as verbalized O > Weak and pale in appearance > Limited ROM > restless > irritable > functional level of IV. A >Activity intolerance r/t post operative condition as evidenced by weak and pale in appearance, limited ROM, restless, irritable, and a functional level of IV. P >After a series of rendering effective nsg interventions, pt. will able to report measurable increase of activity tolerance. I >NPI established. > V/S checked and recorded. > Reinforced on General Liquid Diet. 10:45> S/E by Dr. Valera during rounds with orders made and carried out. >advised to change position every 2 hrs. > Encouraged to eat nutritious food especially those rich in Vit. C. > Advised to have adequate rest periods. > Due IV meds given by NOD. E > Goal partially met. After series of rendering effective nsg. interventions, pt. reported a measurable increase in activity tolerance.

XIX. NURSING CARE PLAN/ SOAPIE ( POST OPERATIVE ) April 20, 2008 CUES NURSING DIAGNOSI S High risk for infection r/t post operative condition (Cholecystect omy) as evidence by surgical wound at SCIENTIFIC BACKGROUN D At high risk for being invaded by pathogenic organism. EXPECTED OUTCOME After 8 hours of rendering nursing interventi ons, the patient will be able to identify interventi ons to prevent risk of infection. INTERVENTIONS RATIONALE

S> O > with surgical wound at right upper quadrant. >poor hygiene.

> Monitor V/S. > Wash hand before giving care to the patient. > Observe for localized signs of infection at the site of incision. > Note S/S of sepsis (fever, chills, diaphoresis, altered level of conscious) > Clean incision daily and as needed with povidone iodine or other appropriate solution. > Change sterile dressing as needed.

> Serves as a baseline data. > Hand washing is the most effective means for preventing microbial transmission. > To assess contributing factor. > To assess contributing factors. > To reduce existing risk factors. > To prevent the entrance of m.o.

DATE: April 20, 2008 SHIFT: 7-7 pm TIME: 7:45 S> O > with surgical wound A > High risk for infection r/t post operative condition (Cholecystectomy) P > After 8 hrs. of rendering nursing interventions, the patient will be able to identify interventions to prevent risk of infection. I > NPI established > Bed side care done > V/S checked and recorded > Observed for S/S of infection on the site of incision. > Wound care done > Advised to have adequate rest and sleep > Deep breathing exercise instructed 9:30> S/E by Dr. Valera during rounds with orders made and carried out. > Due meds given by NOD E > Goal partially met. After 8 hrs of rendering effective nsg interventions, the pt identified some interventions to prevent risk of infection.

XX. DISCHARGE PLANNING MEDICATION >Instructed to take take home meds correctly. >Ciprofloxacin 500 mg 1 tab BID, Mefenamic Acid 500 mg 1 tab TID, Multivitamins 1 tab OD. EXERCISE >Advised to have adequate rest periods. TREATMENT >Advised to increase fluid intake. >Encourage to avoid drinking alcohol. HEALTH TEACHINGS >Advised to avoid consuming fatty foods. OPD FOLLOW-UP >Advised patient to consult or to have follow-up check up if any untoward symptom is felt.

DIET >Advised to eat foods that are rich in protein and fruits rich in Vitamin C.
SPIRITUAL >Advised patient that faith in God should not be lessened when some disagreeable situations happen in life.