A Case Study

TABLE OF CONTENTS I. Introduction

3

II. Objectives

4

III. Nursing Assessment 1. Personal History 1.1. Patient’s profile

5

1.2. Family and individual information

5

1.3. Level of growth and development 1.3.1. Normal development at particular stage

5-7

1.3.2. The ill person at particular stage of patient

8

2. Diagnostic Results

8-9

3. Present profile of Functional Health Patterns

9-11

4. Pathophysiology and Rationale 4.1. Normal anatomy and physiology

12

4.2. Schematic diagram

13

4.3. Disease process and its effect on different organ/system14-15 4.4. Comparative chart

15-16

IV. Nursing Intervention 1. Care guide of patient

16-18

2. Actual patient care: 2.1. Nursing care plans

19-22

2.2. Brunswick lens model

23

2.3. SOAPIE charting

24-25

2.4. Drug therapeutic record

26-30

2.5. Health teaching plan

31-32

V. Evaluation and recommendation

33

VI. Evaluation and implication of this case study to:

33

1. Nursing practice 2. Nursing education

2 3. Nursing research VII. Bibliography

34

I. INTRODUCTION They say that along with old age comes a different perspective of health. As many of us know the older we get the more prone we are to certain health problems and diseases. Such is the case of Ms. Lagura, Lourdes. In Open Cholecystectomy, the patient is placed under general anesthesia and then a surgical incision is made at the right upper quadrant of the abdomen. The gallbladder is then surgically removed and assessment of other organs are also done. The specimen may then be taken for biopsy. The post – operative period lasts usually a week but can sometimes take months depending on the patients’ health condition and if any other complications occurred. During this time nursing interventions are centered not only on reestablishment of physiologic balance and pain relief but also on preventing complications and promoting independence by teaching the patient self-care. Open Cholecystectomy is definitely not a rare procedure. In line with this, the student decided to take the opportunity to make a case study on the said topic not only to gain further knowledge on the said surgical procedure but also to learn more about the post-operative care given to such patients. The hopes are that this paper would also be able to guide other students on the care rendered should they encounter a postopen cholecystectomy client.

3

II. OBJECTIVES GENERAL OBJECTIVE: After 3 days of holistic nursing care, the patient will be able to attain maximum level of functioning and manifest positive response to medical and nursing interventions. SPECIFIC OBJECTIVES: A. Student-Nurse Centered: After 8 hours of holistic nursing care, the student nurse will be able to: 1. establish rapport and a good working relationship with the client 2. update the client's profile based on Gordon’s Functional Health Pattern 3. present informative data including client’s family and health history 4. discuss pathophysiology of the disease 5. formulate a comprehensive nursing care plan for the client 6. impart health teaching to client and significant others to promote independence B. Client Centered: After 1 week of holistic nursing care, the patient will be able to 1. establish rapport and a good relationship with the student nurse 2. gain knowledge regarding the condition and the operative procedure undergone 3. show positive response to medications 4. function normally and perform activities of daily living

4

1. PERSONAL HISTORY 1.1 Patient’s Profile Ms. Lagura, Lourdes a 68yr. old, single woman was admitted to Cebu Doctors’ University on February 19, 2008 and was scheduled surgical operation of her Cholecystolithiasis last February 20, 2008. Patient was under the care of Dr. Rosello. 1.2 Family and individual information, social and health history Ms. Lagura, a 68yr. old, single woman, a Roman Catholic and Filipino. She is a retired teacher. She was experiencing discomforts at her right upper quadrant of her abdomen which turn out to be gall stones. This discovery prompted the patient’s admission and surgical operation, Open Cholecystectomy. 1.3. Level of Growth and Development Physical changes Most elderly experience declines in hearing, vision, taste, and smell. They also experience some declines in their ability to detect pain and notice temperature changes. These declines are typically gradual and become more pronounced in late old age (70 +). Other health related issues include rising blood pressure, declining lung capacity, and neural loss. It is important to note that declines in all these areas can be greatly influenced by one's lifestyle. Some may also experience changes in their sexuality. Psychosocial development Late Adulthood: 55 or 65 to Death Ego Development Outcome: Integrity vs. Despair Basic Strengths: Wisdom Erikson felt that much of life is preparing for the middle adulthood stage and the last stage is recovering from it. Perhaps that is because as older adults we can often look back on our lives with happiness and are content, feeling fulfilled with a deep sense that life has meaning and we've made a contribution to life, a feeling Erikson calls integrity. Our strength h comes from a wisdom

5 that the world is very large and we now have a detached concern for the whole of life, accepting death as the completion of life. On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They may fear death as they struggle to find a purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may feel they have all the answers (not unlike going back to adolescence) and end with a strong dogmatism that only their view has been correct. The significant relationship is with all of mankind—"my-kind." Psychosexual development 

The Genital Stage (Sigmund Freud Stages of Psychosexual Development)

During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. Where in earlier stages the focus was solely on individual needs and, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm, and caring. The goal of this stage is to establish a balance between the various life areas. Cognitive development: The mental processes of the late adult become slower, this involves the working memory of the person, and there is forgetfulness, confusion, deficits in concentration. Older people also tend to be more reflective and introspection, they develop a heightened aesthetic, creative, philosophical and spiritual sensitivity. Moral development: The post-conventional level, also known as the principled level, consists of stages five and six of moral development. Realization that individuals are separate entities from society now becomes salient. One's own perspective

6 should be viewed before the society. It is due to this 'nature of self before others' that the post-conventional level, especially stage six, is sometimes mistaken for pre-conventional behaviors. In Stage five (social contract driven), individuals are viewed as holding different opinions and values. Along a similar vein, laws are regarded as social contracts rather than rigid dictums. Those that do not promote the general welfare should be changed when necessary to meet the greatest good for the greatest number of people.[8] This is attained through majority decision, and inevitably compromise. In this way democratic government is ostensibly based on stage five reasoning. Spiritual development 

Individual-Reflective Period

Individual focuses on reality, constructing ones own explicit system; high degree of self-consciousness. Young adults who need to answer the religious questions of their own children may find that the teaching of their own early childhood is more acceptable to them now than during adolescence.

Developmental tasks:



Later Adulthood (60 to 75)



Promoting intellectual vigor



Redirecting energy to new roles and activities adopting ones life



developing a point of view about death

7

1.3.2 THE ILL PERSON AT THE PARTICULAR STAGE The client at present particular stage is manifesting the normal physical, emotional and cognitive deterioration that is associated with the aging process. Due to client’s ill status, the client is having difficulty in coping with her aging process, the slow degenerative manifestations particularly her physical attributes. The additional trauma received from her surgical operation also hinders her activities of daily living, altering her diet and additional discomfort from the pain. 2. DIAGNOSTIC RESULTS

Diagnostic Tests

Normal Values

Patient’s Results Significance

CBC as of February 26, 2007 Decreased with anemia or

Hemoglobin

14.0-17.5 d/dL

11.2 g/dL

Hematocrit

41.5-50.4%

33.3%

Normal

WBC count

4,400-11,000

18.2 cu/mm

Normal

cu/mm 40-70%

60%

Normal

0-5%

3%

Normal

20-40%

33%

Normal

Monocytes

0-8%

4%

Normal

RBC

4.5-5.9 10^g/uL

4.45 10^g/uL

80-96 fL

86.6 fL

Neutrophil Eosinophil

after blood loss

Lymphocytes

Mean Corpuscular

Decreased with anemia or after blood loss Normal

8 Mean Corpuscular HgB

27.5-33.2 pg

29 pg

Normal

33.5 pg

Normal

314 10^g/L

Normal

(MCH) Mean Corpuscular HgB 33.4-35.5% Concentration (MCHC) Platelets

150-450 10^g/L

Source: Medical-Surgical Nursing, 10th Edition, by Smeltzer and Bare, Vol. 2, pg. 2214 – 2233

3. PRESENT PROFILE OF FUNCTIONAL HEALTH PATTERNS 1. Health perception The client has undergone open cholycystectomy and is still in mild discomfort from the surgical trauma. She is worried about her wound and how long it would heal considering she has been diagnosed with diabetes mellitus which could slow down her healing process. However the patient thinks that if she could maintain her blood sugar level to normal she would heal in a shorter span of time. She does not remember if she is fully immunized but she takes care of her health following doctor’s orders and modified her diet to maintain her blood pressure and glucose level. 2. Perceptual pattern The patient wears glasses for reading and writing. She sometimes complains about her hearing but she does not wear hearing aids. She expresses that she has less sensitivity to pain or sometimes touch but she easily gets cold but has no sensitivity to heat. Most of the time she feels dizzy and light headed when she moves suddenly or stands up after sitting or lying down in prolonged periods of time. 3. Self – concept

9 Ms. Lagura jokes that she is old and that she is sickly. She says that she does her best to keep herself fit and keep her diagnosed problems in check to avoid any complications. She says she knows how to take care of herself and know how to modify her lifestyle accordingly. 4. Sleep and rest Ms. Lagura usually sleeps at around 9 – 10pm in the evening and wakes up as early as 5:00 in the morning she also takes naps in the afternoon. However, during her hospital stay she says she frequently wakes up in the evening as there are medications and vital signs to be taken. But she is not very disturbed as she manages to sleep again. 5. Nutritional and metabolic pattern The patient’s usual intake is vegetables, fish and not so much on pork. She has also been avoiding too salty and too sweet foods as she is a hypertensive diabetic. Though she admits to have eaten food that should be avoided she says she is compliant of her maintenance medications. She drinks 8 glasses or more of water and states that she has maintained her weight to keep herself as healthy as she could be. 6. Elimination pattern The patient is on foley bag catheter. She usually defecates early morning everyday. But since her operation she has not defecated for 4 days. Her skin is warm, but a little bit yellow, non-pruritic and there is slight edema.

7. Activity and Exercise pattern Ms. Lagura said that she tries some exercises while sitting down whenever she can. However she complains that she easily gets tired and becomes dyspneic sometimes after much exertion. After surgery she guards her movements as it is still a bit painful to move around and she says she is scared the stitches might come off. 8. role and relationship pattern

10 Ms, Lagura lives with her sister. She has no children and is retired and is living off on her pension and some money given by friends and relatives. Decision making is mainly made by her and her sister depending on the situation or matter to be discussed. 9. Sexuality and sexual functioning Patient had her menarche at the age of 15 yrs then she had menopause at 50yrs old. She is in her genital stage. She is not sexually active. 10. values – belief system The patient is a Roman catholic. She prays the rosary everyday and goes to mass every Sunday with her family. She is not very active in church activities as she says she is old and easily gets tired so she opts to pray every night and go to mass as often as she can.

11

4.PATHOPHYSIOLOGY AND RATIONALE 4.1 NORMAL ANATOMY AND PHYSIOLOGY OF ORGAN AFFECTED:

The gallbladder is a small pear-shaped organ that stores and concentrates bile. The gallbladder is connected to the liver by the hepatic duct. It is approximately 3 to 4 inches (7.6 to 10.2 cm) long and about 1 inch (2.5 cm) wide.

The function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine).

12

4.2 SCHEMATIC DIAGRAM OF THE PATHOLOGY OF THE DISEASE Factors:  More in women than in men.  Above 40 years of age.  Obesity  High cholesterol levels

    

High calorie diet Cirrhosis Bile stasis Diabetes Cystic Fibrosis

Pathophysiology: Decrease bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stones. The cholesterol – saturated bile predisposes to the formation of gall stones and acts as an irritant, producing inflammatory changes in the gall bladder.

Signs and Symptoms:  Epigastric distress such as fullness  Abdominal distention  Biliary colic  Jaundice  Changes in urine and stool color  Vitamin deficiency

Surgical Management:  Open cholecystectomy  Laparoscopic cholecystectomy  Lithotripsy Medical Management:  Medications: - Antibiotics - Analgesics

Nursing Management:  Encourage ambulation  Encourage deep breathing exercises and use of incentive spirometry  Monitor intake and output  Monitor vital signs  Give patient health teaching for home care

13

4.3 DISEASE PROCESS AND IT’S EFFECTS ON THE ORGAN OR SYSTEM: Cholelithiasis Also known as gallstones, these hard masses are formed in the gallbladder or passages, and can cause severe upper right abdominal pain radiating to the right shoulder, as a result of blocked bile flow.

4.3.1 THE SURGICAL OPERATION A cholycystectomy is the surgical removal of the gallbladder. The two basic types of this procedure are open cholycystectomy and the laparoscopic approach. It is estimated that the laparoscopic procedure is currently used for approximately 80% of cases. A cholycystectomy is performed to treat cholelithiasis and cholecystitis. In cholelithiasis, gallstones of varying shapes and sizes form from the solid components of bile. The presence of stones, often referred to as gallbladder disease, may produce symptoms of excruciating right upper abdominal pain radiating to the right shoulder. The gallbladder may become the site of acute infection and inflammation, resulting in symptoms of upper right abdominal pain, nausea and vomiting. This condition is referred to as cholecystitis. The surgical removal of the gallbladder can provide relief of these symptoms.

14 In a conventional or open cholycystectomy, the gallbladder is removed through a surgical incision high in the right abdomen, just beneath the ribs. A drain may be inserted to prevent accumulation of fluid at the surgical site. As with any surgical procedure, the patient will be required to sign a consent form after the procedure is explained thoroughly. Food and fluids will be prohibited after midnight before the procedure. Enemas may be ordered to clean out the bowel. If nausea or vomiting is present, a suction tube to empty the stomach may be used, and for laparoscopic procedures, a urinary drainage catheter will also be used to decrease the risk of accidental puncture of the stomach or bladder with insertion of the trocar (a sharp-pointed instrument). 4.4 COMPARATIVE CHART Classical symptoms POSTOPERATIVE Surgical incision

Clinical symptoms

Rationale

Manifested

-a necessary part of the

-a 10-15cm incision was

surgical procedure

made through the abdomen to remove gallbladder Postoperative pain

Manifested

-due to tissue trauma from

-patient is reluctant to

procedure

breathe deeply due to the pain caused by the proximity of the incision to the muscles used for respiration. The patient was shown how to support the operative site when breathing deeply and coughing, and given pain medication as necessary. Hypotension

Not Manifested

Hemorrhage

-result from blood loss -may occur due trauma of

Not manifested

the surgical procedure

15 Nausea and vomiting

Not Manifested

-side effect of anesthesia

Malignant hyperthermia

Not manifested

-chemically induced by anesthetic agents

Respiratory complication

Not Manifested

-anesthetic agents can cause respiratory depression or aspiration of respiratory tract secretion or vomitus

Constipation

Manifested

-from decrease in mobility

- patient has not been able

and oral intake and due to

to defecate since the

the opioid analgesics used

procedure was done Urinary retention

Not Manifested

-anesthetics and opioids may interfere with the perception of bladder fullness and the urge to void

Anxiety

Not manifested

-may be from pain, new environment, lack of control, fatigue Source: MS by Brunner and Suddarth, 19th ed.

IV. NURSING INTERVENTION 1. Care Guide of Patient who has undergone Open Cholecystectomy Postoperative care begins in the operating room immediately after surgery and continues in the postanesthesia care unit (PACU) as well as during the days after the procedure. Factors affecting the extent of care required are: the original health status of the patient, type of surgery, and whether the surgery was performed in a day-surgery setting or in the hospital. Day-surgery centers operate on an out patient basis and intensive monitoring is done in the few hours postoperatively that the patient remains in the center. Should any complications occur, then the patient is sent to the hospital. Patients admitted in the hospital may require anything between a day to weeks of postoperative care before they are discharged. Postoperative care includes:

16  Preventing respiratory complications - The patient is encouraged to turn frequently and take deep breaths at least every 2 hours to clear secretions and prevent pneumonia. Coughing is also encouraged to dislodge mucus plugs. This is done with a pillow as a splint to lessen pain on incision site & overcome fear of undoing the stitches. Analgesics may also help as oxygen may be given via cannula to prevent or relieve hypoxia.  Encouraging activity - Surgical patients are encouraged to be out of bed as soon as possible. Early ambulation reduces the incidence of postoperative complications, increases ventilation, reduces the stasis of bronchial secretions in the lungs, and reduces postoperative abdominal distention by increasing the muscle tone of the abdominal wall tone and stimulating peristalsis.  Promoting wound healing - Periodic assessment of surgical site is done. The wound edges, integrity of sutures or staples are inspected for infection, redness, warmth, swelling, unusual tenderness or drainage. It should also be inspected for reactions to tape or trauma from tight bandages.  Dressing Changes - The first postoperative dressing is usually changed by a member of the surgical team. Subsequent dressing changes, however, are at times done by the nurse. A dressing is applied to provide a proper environment for wound healing, absorb drainage, splint or immobilize the wound, protect the wound and new epithelial tissue from mechanical injury, protect the wound from bacterial contamination and from soiling, promote homeostasis, and to provide mental and physical comfort to the patient  Maintaining normal body temperature - The patient is at risk for malignant hyperthermia and hypothermia in the postoperative period. The room is maintained at a comfortable temperature, and blankets are provided. Treatment includes oxygen administration, adequate hydration and proper nutrition. The patient is also monitored for cardiac dysrhythmias. The risk for hypothermia is greater in the elderly and in patients who were in the cool operating room for a long time.  Maintaining gastrointestinal function and resuming nutrition The patient may not be allowed to eat post op as the effects of the anesthesia causes reduced bowel movement. So the patient is placed on temporary NPO. The patient may only start liquid diet when she is able to produce gas and on

17 full diet when she is able to remove her bowel contents which is a sign of bowel movement.  Promoting bowel function - Early ambulation, improved dietary intake, and a stool softener promote bowel elimination. Until the patient reports return of normal bowel function, the nurse should assess the abdomen for distention and the presence and frequency of bowel sounds.  Managing voiding - Bladder distention and the urge to void should be assessed on the patient’s arrival on the unit and frequently thereafter. The patient is expected to void within 8 hours after surgery. If the patient has an urge to void but cannot void, catheterization may be done.  Managing a safe environment - Because the patient remains groggy during the immediate postoperative period, the siderails should be up, and the bed should be in the low position to prevent falls. Other immediate postoperative orders involve special positioning, equipment, or intervention. The patient is instructed to ask for assistance with any activity.  Providing emotional support to the patient and family - The nurse helps the patient and the family work through their anxieties by providing reassurance and information and by spending time listening to and addressing their concerns. The family should be pre-oriented to the patient’s postoperative look such as presence of tubes and the size of incisions to prepare them and keep them calm in front of the patient.

18

19

CEBU DOCTORS' UNIVERSITY COLLEGE OF NURSING Name of patient: Lagura, Lourdes

CEBU CITY

Hospital no: 207631 Age: 68 yrs old Impression/diagnosis: Acute Cholelithiasis Gender: female Attending physician: Dr. D. Rosello Chief complaints: pain in the right upper quadrant of abdomen NURSING CARE PLAN Problems Cues/ Needs

Nursing Diagnosis

Scientific Basis

Objective of Care

Nursing Actions

I. Physiologic

Altered

Most patients

After 8 hrs.

Measures to:

A. Overload

comfort:

experience some pain

of SN-

1. alleviate pain

1. Altered comfort: pain

pain,

after a surgical

patient

1.1 encourage adequate rest

- status 1 day post- open

related to

procedure. Many

interaction,

cholecystectomy.

tissue

factors influence the

the patient

1.2 provide comfort measures

- with surgical wound at

trauma

pain experience. The

will be able

(backrub, position change,

midline from lower rib down

seconda-

degree and severity of

to:

environmental control)

past umbilical level

ry to

postoperative pain and

1. verbalize

1.3 encourage deep breathing

- with a surgical wound at the

surgical

the patient’s tolerance

relief of

exercises

right upper quadrant of

operation

for pain depend on the

pain as

1.4 position patient on

abdomen

incision site, the

evidenced

optimum comfort

- reports pain on movement

nature of the surgical

by a pain

1.5 monitor vital signs

that is 7 out of 10 on pain scale

procedure, the extent

scale of 4

1.6 observe non verbal cues

-client describes piercing pain

of surgical trauma, the

out of 10

(i.e. facial grimace)

felt at incision site upon

type of anesthetic

1.7 administer pain

movement of abdomen and

agent, and how the

medication per doctor’s order

anterior chest lasting for 2-5

agent was

prior to exercise or activities

minutes; aggravated by sudden

administered.

of daily living

mov’ts & coughing; relieved by analgesics and shallow

Source: Fundamentals

breathing

of Nursing by Potter &

- guarded movements and

Perry p. 446

20

facial grimace noted B. Deficit 1. Risk for infection

Risk for

Transmission of

2. identify

2. prevent infection

- status 1 day post-Ex. Lap.

infection:

infective agent from a

interven-

2.1 use aseptic technique

- with surgical wound at

presence

source by a

tions to

when changing dressing

midline from lower rib down

of opera-

susceptible host occurs

prevent

2.2 inspect the incision site

past umbilical level & stab

tive

with the environment.

infection &

for inflammation

wound at left anterior chest

wound,

Organisms live and

reduce risk

2.3 keep area clean and dry

without foul odor or discharges

related to

multiply in reservoir

for acqui-

- reports intermittent tingling at

inade-

which can be a person,

ring it.

itchiness at incision site

quate

animal, or plant or

2.4 note and record

- seen manipulating incision

primary

combination of

characteristics of drainage on

site with unwashed hands

defenses

substances. Wound

dressing

“Katol ang ako tahi

seconda-

sepsis is common

2.5 apply heat and cold

usahay, normal ra

ry to

occurrence after

2.6 clean the wound regularly

na?”

surgical

surgery. It is usually

2.7 administer antibiotics as

incision

heralded by increased

prescribed

site

pain and fluctuating

-

temperature. The wound should be inspected daily for swelling and local tenderness. Source: MS by Black, 6th ed.

2. Impaired physical mobility

Impaired

In the first few days

3.verbalize

3.increase physical mobility

- reports piercing pain upon

physical

after surgery, energy

& demon-

3.1 position patient to

movement that is rated 7 out of

mobility:

reserve is limited and

strate

optimum comfort

10 on pain scale, aggravated by

limited

transitory. When

willingness

3.2 promote medical

sudden movements, relieved

move-

patient is also

to partici-

management for pain

by analgesics

ments,

grieving, lack of

pate in

3.3 provide safety measures

- guarded movements and

related to

energy reserve is even

activities

as indicated

pain

more apparent. During

3.4 implement ROM

21

facial grimace with movements

seconda-

this days of fatigue,

exercises

noted

ry to

more ambulation is

3.5 encourage participation

- unable to transfer and

surgical

required and

of self-care activities

ambulate painlessly

operation

increasing exercise

3.6 promote progressive

- decreased muscle strength

expected.

mobilization to maximum

- needs help with activities

Source: MS by Phipps

within limits of patient’s

- complains of fatigue & pain

and Long

tolerance to pain

- reports inability to move

3.7 encourage repositioning

bowel for 2 days/

while in bed

- ”Di nalang gani ko mulihok kai kutasan ko nya sakit man.”

22 2.3 SOAPIE CHARTING SOAPIE 1 ( February 27, 2008 ) S- “Sakit – sakit pa jud tawn ilihok day” as verbalized by the patient O- Seen patient lying down, awake, conscious, communicative, coherent, with IV 5 D5LR 1 liter infusing well at left forearm; status 1 day post-open cholecystectectomy with surgical wound at right upper quadrant of abdomen, no discharges on dressing, no foul odor; pain upon movement is rated 7 out of 10 on pain scale, piercing pain felt at incision site upon movement of abdomen and anterior chest lasting for 2-5 minutes, aggravated by sudden movements and coughing, relieved by analgesics and shallow breathing, guarded movements and facial grimace noted; with vital signs of BP: 130/60 mmHg, T: 36.8 oC, P: 68 bpm, R: 24 bpm A- Altered comfort: pain, related to tissue trauma secondary to operative procedure P- To reduce pain to a scale of 4 out of 10 I- monitored vital signs, encouraged adequate rest, provided comfort measures, encouraged deep breathing and incentive spirometry exercises, positioned patient for optimum comfort, observed non verbal cues, administered analgesics as prescribed E- “the pain seems to lessen after I took the medication” SOAPIE 2 (February 28,2008) S- “Katol ang ako tahi usahay, normal ra na?” as verbalized by the patient O- Seen patient lying down, awake, conscious, communicative, coherent; with IV 5 D5LR 1 liter infusing well at left forearm; status 3 days post-exploratory laparotomy with surgical wound at right upper quadrant of the abdomen, no discharges on dressing, no foul odor yet patient is noted to regularly manipulate site with unwashedhands; with vital signs of BP: 130/70 mmHg, T: 37.2 oC, P: 84 bpm, R: 19 bpm A- Risk for infection: presence of postoperative wound, related to inadequate primary defenses secondary to surgical operation P- To promote timely wound healing and reduce risk for infection I- vital signs monitored, used aseptic technique in dressing wound, inspected site for inflammation, kept site clean and dry, stressed importance of proper

23 handwashing, discouraged scratching of wound, noted characteristic of discharges on dressing E- “Ila ra man ni i.change ako dressing miss sa?”

24 2.4 HEALTH TEACHING PLAN OBJECTIVES

CONTENT

METHODOLOG Y

General objectives: After 1 week of holistic care, the patient and significant others will be able to acquire adequate knowledge, positive attitude, and proper skills in providing postoperative care. Specific objectives: After 30 minutes of student nurse-patient or significant others interaction, the patient or significant others will be able to: 1.define deep breathing

Definition

Informal

exercises in their own level

1.1 deep breathing exercises are

Discussion

of understanding

exercises done where a large volume of air is inhaled and exhaled promoting optimum lung expansion

2. enumerate the importance

Importance:

Informal

of deep breathing exercises

2.1 promotes adequate oxygenation

Discussion

2.2 promotes airway clearance 2.3 improves respiratory response 2.4 promotes relaxation and comfort 2.5 promotes lung expansion 3. properly perform deep

Method/Technique used:

Informal

breathing exercises

3.1 place hands below the clavicles

Discussion,

25 exerting moderate pressure

Demonstration,

3.2 ask the client to inhale for 5

and Return

seconds ask him or her to

Demonstration

concentrate on expanding the upper chest forward and upward while inhaling to aerate the apical lobes of the lungs 3.3 ask client to hold breath for 3-4 seconds to promote aeration of the alveoli 3.4 ask client to exhale passively and slowly for 8 seconds through the mouth 3.5 repeat exercises for 15 respirations 4 times per day 4. exhibit positive attitude in

Encourage client to ask questions

carrying out the procedure

and voice out concerns regarding

learned

procedure.

5. verbalize feelings with

Encourage client to ask questions

regards the activity and

and voice out concerns regarding

interaction with the student

procedure.

nurse

Open Sharing

Open Sharing

26

DRUG THERAPEUTIC RECORD Drug/Dose/

Classification/

Frequency/

Mechanism

Indication/ Side-effects/ Contraindication

Principles Of Care

Route 1. Co-

Antimicrobial;

I: upper respiratory infections, sinusitis,



Amoxiclav

Antiinfectives

tonsillitis, bronchitis, bronchopneumonia,

solutions should

cystitis

not be mixed with

(Augmentin) 600 mg IV q 8 Hinders the cell

Augmentin

infusions

hours

wall synthesis

S/E:

containing

12pm-8pm-

of sensitive

Hypersensitivity Reactions: Angioneurotic

glucose, dextran

4am

bactericidal

edema, anaphylaxis, serum sickness-like

or bicarbonate.

against many

syndrome, hypersensitivity vasculitis.



gram (+) (-) bacteria

Skin rash pruritis and urticaria have been reported occasionally. Other reactions including erythema multiforme, StevensJohnson syndrome, toxic epidermal necrolysis and bullous exfoliative dermatitis, and acute generalised exanthematous pustulosis (AGEP) as in the case of other β-lactam antibiotics, have been seen rarely. If any hypersensitivity dermatitis reaction occurs, treatment should be discontinued. Interstitial nephritis can occur rarely. Gastrointestinal Reactions: Effects include

Store at 5°C.

27

diarrhea, nausea, vomiting and indigestion. Mucocutaneous candidiasis and antibioticassociated colitis (including pseudomembranous colitis and haemorrhagic colitis) have been reported rarely. Nausea is more often associated with higher oral dosages. If gastrointestinal reactions are evident, they may be reduced by taking Augmentin at the start of a meal. Hepatic Effects: A moderate rise in AST and/or ALT has been noted in patients treated with β-lactam class antibiotics, but the significance of these findings is unknown. Hepatitis and cholestatic jaundice have been reported rarely C/I: hypersensitivity; history of cholestatic jaundice/ hepatic dysfunction. 2. Ranitidine

Gastrointestinal agents;

I:Duodenal and gastric ulcers;



(Zantac) 50

Anti-secretory (H2-receptor

GERD; erosive esophagitis;

without food

mg IVTT q 8

antagonist)

heartburn



hours 6am-6pm

Give with or Administer

adjunctive antacid Ranitidine is a specific,

S/E:

treatment 2 hours

rapidly acting histamine H2-

CNS: headache, malaise,

before or after drug

antagonist. It inhibits basal

dizziness, somnolence, insomnia,

and stimulated secretion of

vertigo, mental confusion,

gastric acid, reducing both

agitation, depression, hallucination

the volume and the acid and

CV: bradycardia

28

pepsin content of the

GI: constipation, nausea,

secretion. Ranitidine has a

abdominal pain, vomiting, diarrhea

long duration of action and

SKIN: rash

so a single 75- or 150-mg

HEMATOLOGIC: reversible

dose effectively suppresses

decrease in WBC count,

gastric acid secretion for at

thrombocytopenia

least 12 hrs. C/I: Clinical evidence has shown Pregnancy and lactation 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.

29

V. EVALUATION AND RECOMMENDATION Prognosis There was an improvement in patient's condition. By 6 days post operative, there was improvement in skin color. More improvement towards optimum health can be expected.

VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO: Nursing Practice This case study is geared towards providing adequate knowledge, developing positive attitude, and proper skills in caring for postoperative patients most specifically those undergoing Open cholecystectomy. Nursing Education This case study aims to help the nursing students become efficient nurses by providing knowledge about the surgical operation, its procedures, the postoperative patient and allows him or her to be able to formulate nursing interventions and a health teaching plan appropriate for the client. Ensuring the student has adequate knowledge also gives him or her a sense of confidence and readiness to care for the postoperative client. Nursing Research This study of may be used as basis for future researchers of this kind of surgical operation. It can also provide information needed by other students so they may understand the procedure and the care needed by postoperative clients.

30 VIII. BIBLIOGRAPHY Beers, Mark. The Merck Manual of Medical Information; 2nd edition: Merck & Co., Inc., 2003. Brunner and Suddarth. Textbook of Medical – Surgical nursing .9th Edition: Lippincott Williams and Wilkins, Inc.: 227 East Washington Square, Philadelphia. PA, 9106, 2000. Doenges, Martlynn E., Moorhouse, Mary Frances, and Geissler-Murr, Alice C. Nursing Care Plans, 6th Edition: F.A. Davis Company, 2002. Doenges and Moorhouse, Nursing Pocket Guide, 8th edition: F.A. Davis Company, 200. George R. Spratto and Adrienne L. Woods. 2003 PDR Nurse’s Drug Handbook: Janssen, 2004 Kozier, Barbara and Erb, Glenora et.al. Fundamentals of Nursing, 5th Edition: Pearson Education: Asia Pte Ltd., 2002 MIMS 101st Edition 2004 Pilliteri, Adele Maternal & Child Health Nursing, 2nd Edition: Philadelphia: J.B. Lippincott Company, 1995 Potter, Patricia A. and Perry, Anne Griffin. Fundamentals of Nursing, 5th Edition: Missouri: Mosby, Inc., 2001. Robbins, Stanley and Ramzi Cotran. Pathologic Basis of Disease, 2nd Edition: Philadelphia: W.B. Saunders Company, 1979 www.wikipedia.org