Cp On Calculous Cholelithiasis

Ateneo de Davao University College of Nursing Bachelor of Science in Nursing

In Partial Fulfilment for the Requirements in Nursing Care Management [Related Learning Experience] - - -

Calculous Cholelithiasis Submitted to:

Theresa Kintanar, R.N. Ella Mae Navarro, R.N. Clinical Instructors Submitted by: Lim, Stephanie Marie Madrazo, Benedict Edmund Mangitngit, Jeferson Margaja, Dominique Dawn Maulion, John Charls Mendoza, Kathreen Glaiza Nalzaro, Sheena Ann Olalo, Angeli Omandac, Alyssa BSN 3E; Group 3; College of Nursing

February 26, 2009

TABLE OF CONTENTS I.

INTRODUCTION...............................................................................................

II.

OBJECTIVES......................................................................................................

III.

PATIENT’S DATA ............................................................................................

IV.

FAMILY BACKGROUND/ HEALTH HISTORY ............................................

V.

DEVELOPMENTAL DATA ..............................................................................

VI.

DEFINITION OF COMPLETE DIAGNOSIS ...................................................

VII.

PHYSICAL ASSESSMENT ..............................................................................

VIII.

ANATOMY AND PHYSIOLOGY ....................................................................

IX.

ETIOLOGY AND SYMPTOMATOLOGY .......................................................

X.

PATHOPHYSIOLOGY ......................................................................................

XI.

DOCTOR’S ORDER ..........................................................................................

XII.

DIAGNOSTIC EXAM .......................................................................................

XIII.

DRUG STUDY ...................................................................................................

XIV.

NURSING THEORIES ......................................................................................

XV.

NURSING CARE PLAN ....................................................................................

XVI.

PROGNOSIS.......................................................................................................

XVII.

DISCHARGE PLAN ..........................................................................................

XVIII. RECOMMENDATION ......................................................................................

I

NTRODUCTION

Cholelithiasis refers to the presence of gallstones in the gallbladder which occurs more often in women than men. Gallstones are formed within the gallbladder and can range in size from as small as a particle to golf-ball size, depending on how long they have been building. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East. Gallstones are rock-like accumulations of material that take shape inside the gallbladder. There are different types of gallstones, but cholesterol stones are the most common. The gallbladder stores bile in the liver. The bile is composed of bile salts, bile pigments, cholesterol, phospholipids and electrolytes. When bile contains excess cholesterol, gallstones begin to form. Cholesterol stones can be green, white or yellow in color and are made primarily of cholesterol while pigment stones are somewhat dark and made of bilirubin and calcium salts in bile. Much has been learned about how gallstones are formed and experts believe that gallstones may be caused by a number of factors such as inherited genetic chemistry, gallbladder movement and diet.

When bile builds up too much cholesterol, gallstones form. Furthermore, not emptying the gallbladder enough may allow the bile to become compacted and form stones. Increased levels of estrogen could raise cholesterol levels in bile, promoting the formation of gallstones. Persons with high cholesterol levels are more prone to develop Cholelithiasis. Diets high in fats contribute to the formation of gall stones and over time the stones can grow to considerable size, causing serious pain and discomfort. Our patient, given the code name: Mr. R, is a hardworking supervisor for a certain mining industry. He was admitted in DMSFH to undergo a surgery that will remove his gall bladder. The operation he underwent was a Laparoscopic Cholecystectomy. We were able to choose Mr. R as our case, with the help of our clinical instructor. Mr. R’s disease is in line with our concept which is Nephrology and he was able to give us his approval when we asked for his cooperation. Throughout this Case Presentation, numerous data about Mr. R’s disease will be presented for the deepened understanding of his disease, Calculous Cholelithiasis.

A

CKNOWLEDGEMENT

Many people have been kind and helpful to us in finishing this case study. We would like to extend our gratitude to the following:

First, we would like to thank the Almighty God for giving us guidance, strength and enlightenment upon doing this case study. Second, we would like to thank each and everyone’s parents for their support financially, physically and emotionally. Third, we would like to thank our dearest clinical instructor, Ms. Theresa Kintanar, for guiding us in choosing the appropriate family for our case study and for giving us some guidelines that could help us in acquiring necessary information. Fourth, we would like to thank our group mates for their cooperation and determination to finish and learn something from this case presentation. Fifth, we would like to thank all the personnel and staff members of St. Joseph ward, Davao Medical School Foundation Hospital for their accommodation and assistance during our duty. Lastly, we would like to extend our heartfelt gratitude to Mr. R. and his family for their willingness to involve themselves openly in this case study.

O

BJECTIVES

General Objectives: To conduct a thorough and comprehensive study about Mr. R’s disease according to the data that was gathered by conducting a series of interviews and extensive research.

Specific Objectives: •

To organize our patient’s data for the establishment of good background information

•

To analyze the family health history as well as the history of past and present illness for the knowledge of what could be the predisposing factors that might contribute to the patient’s illness

•

To create a Genogram containing different informations that will help out in tracing hereditary risk factors

•

To evaluate our patient’s development through the use of different developmental theories

•

To differentiate the definitions of our patient’s complete diagnosis for better understanding

•

To describe the current condition of our patient through the Physical assessment

•

To explain the anatomy and physiology of different organs involved and affected during cholelithiasis

•

To list several factors, signs and symptoms of cholelithiasis that are present or absent in our patient

•

To compose a flow chart showing the pathophysiology of cholelithiasis for a clear visualization of how cholelithiasis affects a person

•

To list the different orders of the physicians assigned to our patient together with their rationale for a general knowledge of what consists of the medical management for cholelithiasis

•

To interpret the different results of our patient’s diagnostic exams together with comparisons of normal values for the understanding of what changes during the disease

•

To classify the different drugs used by our patient so that we can identify its functions and purposes

•

To analyze the different nursing theories that can be applied to our patient

•

To create Nursing Care Plans applicable to our patient

•

To construct a discharge plan following the METHOD format

•

To validate a prognosis according to a specific criteria.

•

To compose an over-all Conclusion and recommendations about the case study

•

To gather all the references used upon making this case study

P Patient's code name: Mr. R Age: 53 yrs. Old Address: San Mateo Laverna Buhangin, Davao City Date of Birth: March 3, 1955 Nationality: Filipino Civil Status: Married (living separately) Occupation: Mining Engineer (DENR) Sex: Male Religion: Roman Catholic Ward: St. Joseph 3-C Bed no.: 325/4 Date of Admission: February 18, 2009 Time: 2:00 pm Vital signs upon admission: BP: 120/70 mmHg

RR: 19 cpm

Temp.: 37.1 °C

PR: 66 bpm

Admitting Diagnosis: Calculous Cholelithiasis Attending Physician: Dr. Enojo Type of Admission: Ambulatory

ATIENT’S

D

ATA

F

AMILY

H

B

EALTH

ACKGROUND

H

ISTORY

Mr. R, a 53 year-old male, was born in Bohol on March 3, 1955. He is currently residing at B-12 L12 P1 San Mateo Laverna Buhangin, Davao City. They are 7 in the family including his parents. He is the third child among the five children. Our patient has completely received immunization since he was a child. Upon interview, Mr. R said that they had a family history of the same type of disease, which is the Diabetes Mellitus. He mentioned that within the family, they had 2 cases from his mother’s side and on his father side of the family. His aunt from his father’s side was also diagnosed with cholelithiasis. LIFESTYLE: ACTIVITIES Mr. R described how his workplace is similar to his home in terms of stress. He verbalized that there are times when he is stressed and there are others when he the situations can let him relax. When asked about how he usually spends his days, Mr. R was able to formulate a schedule that would describe his activities of daily living. He would wake up at 6:00am. The first thing he would do is take a bath. Right after taking a bath, he takes his breakfast. After brushing his teeth, he rides his transportation service to his office. By 8:00am, he arrives in his office. Here, he usually does paper work, participates in interviews and meetings, records data in his office computer and, on some occasions, perform field work as a supervisor. After work, he has the option to either go home directly (7:00pm arrival)

or have a night out with his friends from work. There are times that he chooses to go out and drink; the most would be two times in a week. For every time that he goes out to drink, he would consume an average of 2 bottles. If he chooses to go out and spend the night outside the house, he’d get home by around 12:00 midnight and onwards. LIFESTYLE: DIET Since his grade school years, Mr. R was fond of eating all kinds of “lechon.” He is also fond of drinking carbonated beverages and he drinks alcoholic beverages occasionally. After he was diagnosed with Diabetes, he started eating less lechon and more vegetables, whole grains and fish. During the interview, Mr. R was asked if he knows any more changes in his diet. He only shrugged and said he was still unsure of how his diet will change now that he is missing a gall bladder. HISTORY OF PATIENT’S PAST ILLNESS Mr. R was diagnosed of having Diabetes Mellitus type II last 1997. He was advised by his doctor to be more particular on his diet (to eat more vegetables and fruits and not to eat too much fatty foods) and do some exercise so that his diabetes will not get complications. He was also diagnosed of having gallstone last 2003 at a community hospital, which is located at Magallanes, through ultrasound on the hepato-biliary tree. He recalls being instructed to take buscopan and co-amoxiclav after being diagnosed. Mr. R had also mentioned that he has a history of hypertension. This wasn’t evident during the group’s assessment on Mr. R. However, Mr. R remembers that he had gone to several hospitals and doesn’t remember where he was diagnosed with hypertension. Mr. R does remember this happened in the year 1995. Since then, he had been taking anti-hypertensives like Pritor and Lipitor.

HISTORY OF PATIENT’S PRESENT ILLNESS Mr. R started experiencing a sharp RUQ pain in the year 1994. He suspected a disturbance in the stomach, so he took Kremil-S and Buscopan. As an additional selftreatment for the pain, he frequently ate “lugaw” and he took a lot of rest. Eventually, the pain went away but it came back three years later. In 1997, the year he was diagnosed with Type 2 Diabetes Mellitus, he experienced the same sharp RUQ pain just like the one in 1994. Knowing that his previous self-treatment was effective, he used it again, with an additional advice from his doctor: drinking plenty of apple juice. Again, the pain went away as expected. However, Mr. R did not know that his condition was actually getting worse. Two years after the second incidence, the pain returned. Still not alarmed as he was in the previous years, Mr. R still used his self-treatment for the pain in 1999. Mr. R shared that after 1999, he experienced the pain every year already. He also shared that every time, he used the same self-treatment. By January 26, 2009, he experienced the worst pain of them all. He shared that his self-treatment methods was able to ease the pain, but it surprisingly took longer than it did before. By this time, he decided to have himself checked by a doctor. He was admitted and undergone a surgical procedure which is Laparoscopic Cholecystectomy at Davao Medical School Foundation Hospital after being diagnosed with Calculous Cholelithiasis.

GENOGRAM

D

EVELOPMENTAL

D

ATA

DEVELOPMENTAL DATA Theorist

Theory

Erik Erikson’s Erik Psychosocial Theory

Erikson

theorized

that

of development

Development

Stage

is

Integrity Vs. Despair

Result and Justification The patient has

(45 years old and above)

positively achieved

a A person who can look this

stage

of

lifelong process and back on good times with development.

He

does not end with gladness, on hard times views his life as Source:

the

cessation

Fundamentals of Nursing, 3rd Edition By: Sue C. Delaune Patricia K. Ladner

adolescence. Just as mistakes and regrets with fulfilling. He said physical patterns

of with self – respect, and on meaningful

and

growth forgiveness, will find a that he had coped can

predicted,

be new sense of integrity and well

with

certain a readiness for whatever struggles

psychosocial

tasks life or death may bring.

must be mastered in

the and

problems that came

A person caught up in old his

way.

each developmental sadness, unable to forgive thankful

He

is

because

stage. The greater themselves or others for the struggles made the

task perceived

wrongs,

and him a better person.

achievement,

the dissatisfied with the life, Without doubt, Mr.

healthier

the they’ve led, will easily R did not have any

personality of the drift into depression and regrets in all things person.

However, despair.

he made whether it

failure to achieve a A positive outcome in this be bad or good.

task influences the stage is achieved if the person’s ability to person achieve

the

gains

a

self Mr. R said that

next fulfillment of about life even though he is

task. The resolution and a sense of unity separated with his of the conflicts at within himself and others. wife he still has a each stage enables That way, he can accept very supportive and the

person

to death with a sense of caring

family.

function effectively integrity.

According to him,

in society.

he is very thankful to

have

and

children family

members who are always there to care for

him

support matter

and

to

him

no

what

life

may give them. He is also ready to accept

whatever

life or death may bring him.

Lawrence

Lawrence

Kohlberg’s

Kohlberg’s

Stages of

specifically

Moral

addresses

Development

development

Source:

Level

III: He

theory Postconventional

knows

understands

and the

In this level, the person basic social rules moral lives autonomously and and

laws

that

in defines moral values and should be followed

children and adults. principles that are distinct and

The morality of an Fundamentals of Nursing, individual’s 3rd Edition By: decision was not Sue C. Delaune Patricia K. Kohlberg’s concern; Ladner rather, he focused

from

he seriously

personal abides

with

it.

identification with group According to Mr. values.

R, when coming up

Stages:

with a decision he

Social

Contract considers

on the reasons the Legalistic Orientation:

the

feelings and rights

individual makes a The social rules are not of other people. He decision. His model the states

that

sole

a decisions

person’s ability to because make

basis

for makes sure that no

and

behavior one will be hurt

the

person whenever he makes

moral believes a higher moral certain decisions.

judgments

and principle applies such as Mr.

R

also

behave in a morally equality, justice , or due verbalized that in correct develops

manner process over

period of time.

a Universal

making

decisions,

Ethical it is important to

Principle Orientation:

consider not just

Decisions and behaviors the rules in our

are based on internalized society but one’s rules, on conscience rather feelings

and

than social laws, and on perceptions as well. self chosen ethical and Our

patient

was

abstract principles that are able to achieve the universal, comprehensive consistent

last stage of this ,

and level because when he and his wife made the decision to separate, chose

to

they follow

their feelings rather than

the

norms.

social Even

though it is against the norms in our society to separate, they considered

still to

separate from each other because they believe that doing so would be the

right thing to do.

Robert

Havighurst

Middle Adulthood (30-60 years)

Havighurst’s

theorized that there

Mr. R is currently working

as

a

This stage in a person’s Developmental are

six

government life is concerned with the

Milestones

developmental

employee.

Theory

stages of life, each

achievement

of

He

the works in DENR as

following tasks: with essential tasks Source:

to

be

achieved.

Fundamentals of Nursing, 3rd Edition By: Sue C. Delaune Patricia K. Ladner

Mastery of a task in

the chief mining  Fulfill civic and social

stage is essential for

 Maintain

subsequent A

task

standard

stages.

leads

happiness

and

failure

children

to

individual

tasks.

as an Engineer, he to

responsible, happy adults X Relate to one’s partner

and

difficulty with later

the laws.

Through his work

become

to

unhappiness in the

of

adolescent

to

However, leads

also votes, pays his taxes and abides

 Assist

success with later tasks.

safety division. He

living

successful

achievement of a

an

economic

mastery of tasks in

for

environmental and

responsibilities

one developmental

supervisor



Adjust to physiological

was able to earn enough money to send his children to school. In addition, his salary is also enough to sustain their daily needs.

changes 

Adjusting

Mr. R is a hands on to father. He guides

aging parents

and

supports

his

children up to now. According to him, the way he raised and disciplined his children made them good people.

The patient was not able to achieve the fourth task because he is separated with his wife for 12 years and they do not with

communicate each

other

anymore. However, he does not restrict his

children

to

communicate with their mother.

Our patient accepts the

changes

accompanied aging,

by

especially

with the changes in health. He accepts and complies with his

medications

religiously. Mr. R’s father died of stroke in the age of 62 years old. His mother is still alive and is residing at his sister’s house in Bohol. to

According

him,

even

though his mother is in Bohol he still continues to check on

his

mother’s

condition.

D

EFINITION OF

C

OMPLETE

D

IAGNOSIS

Diagnosis: Calculous Cholelithiasis Definition 1. Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. (reference: Page 1347, Textbook of Medical-Surgical Nursing, Eleventh Edition, Brunner and Suddarth's) 2. a stonelike mass that forms in the gallbladder (reference: Saunders Comprehensive Dictionary, 3 ed. © 2007 Elsevier) 3. a calculus formed in the gallbladder or bile duct. (reference: Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc.) Calculous - describing a substance that has the hardness of stone. - pertaining to calculus (reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied Health, Fourth Edition. ) Calculus



an abnormal stone formed in the body tissues by an accumulation of mineral salts. Calculi are usually found in biliary and urinary tract.

(reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied Health, Fourth Edition.)

Calculus 

A calculus (plural calculi) is a stone (a concretion of material, usually mineral salts) that forms in an organ or duct of the body. Formation of calculi is known as lithiasis. Stones cause a number of medical conditions.

(reference: http://en.wikipedia.org/wiki/Calculus_(medicine)

Cholelithiasis 

the presence of gallstones in the gallbladder.

(reference: Page 256, Mosby's Pocket Dictionary of Medicine, Nursing and Allied Health, Fourth Edition. )

•

the presence of gallstones in the gallbladder

(http://wordnetweb.princeton.edu/perl/webwn?s=cholelithiasis)

P

HYSICAL

Patient’s Name:

Mr. R

Age:

53 years old

Sex:

Male

Ward:

3C - Surgical Ward (St. Joseph Ward)

A

SSESSMENT

GENERAL SURVEY Our patient, Mr. R was assessed on February 21, 2009 @ 6:00 am. He was received lying on bed awake, conscious and coherent. He has an ongoing IVF of D5NSS 1 liter regulated at 140cc/° infusing well at R metacarpal vein at 300cc level. He weighs 72 kilograms with a height of 5’6”. He has an endomorphic body structure. Calculation of his BMI reveals that he is overweight (25.62kg/m2) He was responsive and cooperative when asked. The patient was 1 day post-op.

VITAL SIGNS 6:00 am BP – 120/80 mmHg PR – 62 beats per minute RR – 22 breathes per minute Temp. – 36.9°C

SKIN Our patient has a tan complexion. He has a good skin turgor as skin goes back to its previous state after being pinched and with a capillary refill of 2 seconds. He has dry skin with a rough texture. Nails were properly trimmed and no traces of dirt were noted.

HEAD Our patient’s head is normocephalic. Presence of hair was noted in the head and in the upper and lower extremities. Lesions, bleeding and bruises were not seen upon inspection. His hair is evenly distributed and majority of hair color is grey with several strands of black and white hair. No signs of dandruff and lice noted.

EYES Eyes are symmetrical with each other. The cornea is moist and white in color. The iris appears to be black on both eyes. Pupils are equally round and reactive to light and accommodation with a pupillary size of 2 mm. He needs reading glasses when reads small texts. His eyebrows are thick and eyelashes are evenly distributed along the margin of the eyelids; both eyes move in unison; no signs of scratches on both eyes and no discharges noted.

EARS The shape of the pinnaes is oval and with no discharges noted. Upper margin of the pinnaes is in line with the outer canthus of the eyes. Ears are firm and non-tender. Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was able to repeat a sentence when it was softly said behind his ears, which reveals that he does not have any hearing problems.

NOSE External surface of the nose is smooth and oily. Nasolabial folds are symmetrical. Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs of tenderness were noted. Patient was able to distinguish the smell of rubbing alcohol while eyes were closed.

MOUTH Lips are dry with minimal cracks. Teeth are not complete with dentures noted upon inspection. A total of 3 cavities were also seen upon inspection of the teeth. Gums and buccal mucosa are pinkish in color. Tongue is in the midline of the mouth. Tonsils

are not inflamed. No signs of inflammation and laceration on the uvula. Bleeding, ulceration and swelling were not seen upon inspection. Patient was on soft diet and was able to drink coffee and medications with no dysphagia.

NECK The neck of our patient can move easily without any difficulty, which includes right and left lateral, right and left rotation, flexion and hyperextension. Neck can properly support the head. No signs of enlargement and masses on the thyroid. Carotid pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No deformities noted.

CHEST AND LUNGS Chest muscle expansion during inspiration and relaxation during expiration are symmetrical and painless. There were no presence of scars and lesions. He was not in respiratory distress. Respiratory rate is 18 cycles per minute and rhythm was regular. Breath sounds were clear on both lungs indicating that he is free of cough or colds.

ABDOMEN Patient’s abdomen is globular in shape, soft, and flabby. Bowel sounds are hyperactive with 17 sounds counted within one full minute. Four intact and dry

commercially prepared dressings were seen upon inspection. One dressing was seen on the umbilical area, another dressing was seen just below the xiphoid process, and two other patches were seen in the upper and lower regions of the iliac. A dull pain was felt by the patient in the umbilical area and worsens upon palpation. GENITO-URINARY Patient refused to be assessed on his genital area. However, patient verbalized no pain or difficulty upon urination and defecation. Average urine output of patient was 31 cc/hr. His total output for 8 hours was approximately 250cc.

UPPER EXTREMITIES Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted on the bones of the wrist and fingers. No deformities and swelling noted. He could freely move his shoulders. No structural deviations noted.

LOWER EXTREMITIES Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and bend without any difficulty. No signs of deformities, lesions, lacerations, bruises and bleeding were seen upon inspection. Patient does not have any difficulty ambulating.

A

NATOMY AND

P

HYSIOLOGY

The liver is the largest internal organ in the body, and weighs about 3 pounds in an adult. The liver is located in the right upper quadrant of the abdomen, just below the diaphragm. A thick capsule of connective tissue called Glisson's capsule covers the entire surface of the liver. The liver is divided into a large right lobe and a smaller left lobe. The falciform ligament divides the two lobes of the liver. Each lobe is further divided into lobules that are approximately 2 mm high and 1 mm in circumference. These hepatic lobules are the functioning units of the liver. Each of the approximately 1 million lobules consists of a hexagonal row of hepatic cells called hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a variety of metabolic functions. Between each row of hepatocytes are small cavities called sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove amino acids, nutrients, sugar, old red blood cells, bacteria and debris from the blood that flows through the sinusoids. The main functions of

the sinusoids are to destroy old or defective red blood cells, to remove bacteria and foreign particles from the blood, and to detoxify toxins and other harmful substances. Approximately 1500 ml of blood enters the liver each minute, making it one of the most vascular organs in the body. Seventy-five percent of the blood flowing to the liver comes through the portal vein; the remaining 25% is oxygenated blood that is carried by the hepatic artery. The liver is responsible for important functions, including: 

Bile production and excretion



Excretion of bilirubin, cholesterol, hormones, and drugs



Metabolism of fats, proteins, and carbohydrates



Enzyme activation



Storage of glycogen, vitamins, and minerals



Synthesis of plasma proteins, such as albumin and globulin, and clotting factors



Blood detoxification and purification

Gallbladder: muscular organ that serves as a reservoir for bile, present in

most vertebrates.

In humans, it

is

a pear-shaped

membranous sac on the undersurface of the right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. The gallbladder (or cholecyst, sometimes gall bladder) is a small non-vital organ which aids in the digestive process and concentrates bile produced in the liver. The cystic duct connects the gall bladder to

the common hepatic duct to form the common bile duct. This common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla. The different layers of the gallbladder are as follows: •

The gallbladder has a simple columnar epithelial lining

•

Under the epithelium there is a layer of connective tissue (lamina

propria). •

Beneath the connective tissue is a wall of smooth muscle

(muscularis externa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum. •

There is essentially no submucosa separating the connective

tissue from serosa and adventitia, but there is a thin lining of muscular tissue to prevent infection.

Function

The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin. The gallbladder stores about 50mL (1.7US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat

enters

the

digestive

tract,

stimulating

the

secretion

of

cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum. Cholesterol Metabolism Cholesterol is an extremely important biological molecule that has roles in membrane structure as well as being a precursor for the synthesis of the steroid hormones and bile acids. Both dietary

cholesterol and that synthesized de novo are transported through the circulation in lipoprotein particles. The same is true of cholesteryl esters, the form in which cholesterol is stored in cells. The synthesis and utilization of cholesterol must be tightly regulated in order to prevent over-accumulation and abnormal deposition within the body. Of particular importance clinically is the abnormal deposition of cholesterol and cholesterol-rich lipoproteins in the

coronary

arteries.

Such

deposition,

eventually

leading

to

atherosclerosis, is the leading contributory factor in diseases of the coronary arteries.

E PREDISPOSING FACTORS AGE

PRESENT

TIOLOGY AND

S

ABSENT

/

YMPTOMATOLOGY

JUSTIFICATION Mr. R is 53 years old; At his age, the ability of his body to heal

itself

is

diminished,

making him more prone to developing diseases like gall stones. GENDER

/

Although the disease is not exclusive to one gender only, statistics show that women are more prone to develop gall stones.

HEREDITY

/

Gallstones are very common and

thus

suspected

to

be

hereditary. However, Mr. R’s past

illnesses

Hypertension)

(DM

are

and

found

to

have hereditary causes. These illnesses predispose him to developing gall stones. RACE

/

Statistics

show

that

Caucasians are more prone to develop their

gallstones

race

is

because

exposed

to

resources that provides a high

fat diet for them.

PRECIPITATING FACTORS HIGH CHOLESTEROL DIET

PRESENT

ABSENT

JUSTIFICATION Mr. R verbalized that since his

/

grade school years, he is fond of eating all kinds of lechon.

OVERWEIGHT

/

Mr. R’s BMI was 25.62kg/m2.

HYPERTENSION

/

Mr.

R

was

diagnosed

with

Hypertension in 1995. DIABETES MELLITUS II

/

Mr. R was diagnosed with type 2 DM in the year 1997.

NEGLIGENCE LACK

OF

AND

/

Mr. R verbalized that he only

KNOWLEDGE

took Kremil-S and rest to treat his sharp, intermittent RUQ pain – a primary symptom of cholelithiasis.

TREATMENT

WITH

/

ESTROGEN ILEAL RESECTION ILEAL DISEASE

Mr. R never had the need of estrogen therapy.

OR

/

Mr. R’s ileus does not have a disease had never been in need of surgical manipulation.

SYMPTOMATOLOGY

SYMPTOMS

PRESENT

Pain

/

ABSENT

JUSTIFICATION

Mr. R had intermittent RUQ pain for a span of approximately 14 years.

Biliary Colic

/

Mr. R’s gall stone can only be found within his gallbladder.

Jaundice

/

Mr. R had never experienced jaundice.

Vitamin Deficiency

/

Mr. R’s laboratory results only revealed hypokalemia.

Changes in Urine and Stool Color

/

Mr. R verbalized that he had never experienced changes in the urine and stool color.

P Predisposing Factors -Age -Gender

-Hereditary -Race

ATHOPHYSIOLOGY

Precipitating Factors -Previous Illnesses: DM and Hypertension -Overweight -Lifestyle: Diet -Negligence and lack of knowledge -Estrogen therapy -Ileal resection or ileal disease

DM II - ↓ glucose utilization

cell hunger polyphagia (with high cholesterol food preference) ↑ fatty substances into the hepato biliary system

liver excretes more cholesterol in to the bile

↓ gall bladder contractility and emptying; spasm of the sphincter of Oddi

↓ bile synthesis in the liver

gall bladder stasis

bile stasis

inflammation of the gallbladder formation of a NIDUS for stone growth tissue injury in gallbladder increased reabsorption of bile salts and lecithin

alteration in composition of bile

bile becomes supersaturated with cholesterol

fusion of crystals to form stones DIAGNOSTIC PROCEDURE ultrasound of the hbt

interruption of bile flow

Diagnosis: CALCULOUS CHOLELITHIASIS Medical Management -Anti-inflammatory -Antibiotics -Analgesics

Surgical Management Laparoscopic Cholecystectomy

If treated:

Nursing Management - low salt, low fat Diet - Promote Exercise - Deep breathing

If not treated:

- good compliance of medication - adequate financial support

- poor compliance of medication - poor financial support POOR PROGNOSIS

GOOD PROGNOSIS

DEATH

D

OCTOR’S

O

DATE

DOCTOR'S ORDER

Feb. 18, 2009

Pls. admit under my service

The patient is in need of medical attention so he is admitted in Davao Medical School Foundation Hospital for preparations for the Preoperation.

DONE

TPRq4˚

Vital signs are recorded to obtain patients baseline data and are useful for further management. A temperature higher than normal may indicate the development of infection. Pulse & respiration is taken to watch out for tachycardia - a sign of hemorrhage & dehydration. The patient is maintained on NPO in order to prevent aspiration from vomiting which is one of the side effects of anesthesia. These entire lab tests are performed to screen for alteration and to serve as a baseline data for future comparison.

DONE

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing,

DONE

Wt – 73 kg Temp 36˚C BP120/80 RR-21 PR-26 HGT-120

NPO post midnight

Labs:CBC, Blood typing, platelet count, Urinalysis, Creatine,FBS,B1 B2, Alk phosphate, Protime, APTT, Chest X-ray PA view. ECG Schedule patient for laparoscopic cholecystectomy.

RATIONALE

RDERS REMARKS

DONE

DONE

Pls. secure consent.

Inform OR & Dr. Camarao Refer to OR and Dr. Camarao

Refer to Dr. Pasia for CP clearance

Start IVF D5LR 1L to run at 120cc/o prior to transport Give cirprobay 200mg IVTT NOW 30 mins prior to OR (ANST) Refer accordingly

Feb. 18, 2009

For Na, K, Creatinine, Mg

2:20pm Inform IM-ROD ( re: cp clearance ) HGT now

improved cosmetic results, and fewer complications such as infection and adhesions. The surgery must be scheduled so that all the necessary things could be prepared and arranged. For legal purposes: to ensure that the patient knows the majority of the operation to be done. To schedule the operation Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. For replacement of fluid electrolytes balance maintenance. Prevents infections by inhibting the growth or action of the microorganism. Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. These entire lab tests are performed to screen for alteration and to serve as a baseline data for future comparison. To aware the IM-ROD about the result for further management. To test the amount of glucose in the blood. An abnormal may signify further management.

DONE

DONE DONE

DONE

DONE DONE

DONE

DONE

DONE DONE

Dr. Joy Enojo 5:00pm

NPO Post midnight

Start venoclysis once NPO: D5LR 1L @ 120cc/o-hold For HGT monitoring q6˚ ( 5-11 11-5)

Continue maintenance meds c/o Rx’s stocks.

Pls. do Hgt q6˚ (5-11 5-11) & relay to Medical ROD

The patient is maintained on NPO in order to prevent aspiration from vomiting which is one of the side effects of anesthesia. For replacement of fluid electrolytes balance maintenance. Blood glucose testing can be used to screen healthy, asymptomatic individuals for diabetes and pre-diabetes because diabetes is a common disease that begins with few symptoms. Screening for glucose may occur during public health fairs or as part of workplace health programs. It may also be ordered when a patient has a routine physical exam. Screening is especially important for people at high risk of developing diabetes, such as those with a family history of diabetes, those who are overweight, and those who are more than 40 to 45 years old. All medications previously ordered by attending physician should be continued to hasten patient's recovery. Blood glucose testing can be used to screen healthy, asymptomatic individuals for diabetes and pre-diabetes because diabetes is a common disease that begins with few symptoms. Screening for glucose may occur during public health

DONE DONE

DONE

DONE

Feb. 18, 2009 @ 5:30pm

Start venoclysis now: PNSS 1L+40meqs KCL to run @ 120cc/o.

Hold surgery temporarily. Feb. 18, 09 11:30 pm

fairs or as part of workplace health programs. It may also be ordered when a patient has a routine physical exam. Screening is especially important for people at high risk of developing diabetes, such as those with a family history of diabetes, those who are overweight, and those who are more than 40 to 45 years old. For replacement of fluid electrolytes balance maintainance.

The patient had low potassium levels which poses as a risk in the patient’s cardiac functions under anesthesia

DONE

DONE

DONE Pls incorporate additional 20 meqs to current IVF (950cc PNSS + 40 meqs KCL) and set rate @ 100 cc/hr. Kalium durule 2 tabs now then 1 tab t.i.d.

February. 18, 09 @ 11:40pm

Repeat serum K+ 6pm tomorrow. Will inform Dr. Malubay

IV potassium is irritating to blood vessels and myocardium. DONE Replaces potassium and maintains potassium level. To determine if potassium levels are normal already Informing the physician of the latest news about the patient will mean better care given to the patient.

Carry out IM orders.

Orders from internal medicine will help prepare the patient

Please inform OR.

To schedule the operation and for the surgical team to

DONE DONE

DONE

Refer

February. 19,2009 @ 12am

make their initial assessment procedures on the patient Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.

Schedule surgery on Friday 8am.

To inform the nurses that a surgical operation is being planned; also, to signal preparation for pre-operative care.

Inform OR

To schedule the operation.

DONE

DONE

DONE Inform Dr. Laminose - aware

May have low fat, diabetic diet

refer

@11pm

D/C Hgt monitoring.

Informing the physicians of the latest news about the patient will mean better care given to the patient. To prevent the patient from eating foods that may aggravate his illness which may lead to complications during the upcoming operation Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. To signal the cessation of the monitoring of the patient’s blood glucose

DONE

DONE

DONE

Februar y.19,200 9@ 6:30 am

May go ahead of surgery if K+ is > or = to 3.5

Patients with low potassium levels are prone to bradycardia and will worsen when administered with anesthetics during surgery. A normal level of potassium is vital for operations

@ 7am

Please carry out IM suggestions.

Suggestions from internal medicine will help prepare the patient for his upcoming operation

@ 2am

IVF TF: PNSS 1L and 60 meqs Kcl @ 100 cc/hr.

Daily maintenance of body fluids when less Na+ and Clare required.

DONE

DONE

DONE

Pre-op orders: Februar y. 19, 2009 @ 7:35pm

NPO post midnight

The patient is maintained on NPO in order to prevent aspiration from vomiting which is one of the side effects of anesthesia. Vital signs are recorded to obtain patients baseline data and be useful for further management.

DONE

General / oral hygiene PTOR

General and Oral Hygiene is performed frequently to promote comfort and prevent infections. [PTOR – Prior To Operation]

DONE

IVF: D5NSS 1L @ 120 cc/hr.

D5NSS restores sodium chloride deficit and extra cellular fluid volume.

V/S on call to OR

DONE

DONE

Meds: 1. Diazepam 10mg at 6 am with sips of water. 2. Ranitidine 150mg 3. Nalbuphine 5mg IVTT prior to transport

Diazepam- to treat anxiety, nervous tension, muscle spasm, and as an anticonvulsant. Ranitidine- to treat gastroesophageal reflux disease and gastric hypersecretory condition; to decrease gastric acid secretion in which preventing the stomach from scarring of the lining. Nalbuphine- to treat moderate to severe pain Blood glucose levels can vary within a short period of time. HGT prior to OR determines the blood glucose levels right before the operation is made. This will ensure that other complications will be dealt with according to the test results Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.

DONE

To indicate the specific diet appropriate for the patient at a specific time. Soft diet is ordered because the GI tract may still be under trace effects from the anesthesia

DONE

To PACU; then to ward once stable

For close monitoring of the patient. To watch out for any signs of unusualities.

DONE

VS q 15 mins. until stable; then q hourly.

Vital signs is taken to provide baseline data and to watch for any unusualities. To prevent hypoglycemia and dehydration.

DONE

Hgt prior to OR

Refer

May have soft diet 8 hours post-op

DONE

DONE

Post-op orders Februar y.20,200 9@ 9:35 am

IVF rate; D5NSS to run in 160 cc/hr.

DONE

IVF TF: D5NSS 1L @ 140 cc/hr. Meds: 1. Ciprofloxacin 200g IVTT q 8 x/ more doses then shift to ciprofloxacin 400g p.o. B.I.D. 2. Ketorolac 30g IVTT q 8 hours x 2 more doses. 3. Etoricoxib 120g p.o. B.I.D. to start at 6am tomorrow x 4 doses then decrease to OD thereafter. 4. Tramadol retard 100 g to start at 6pm tonight T.I.D. 5. Ranitidine 50g IVTT q 8 hours x 3 doses. O2 inhalation at 2 cpm Keep patient warm and well thermoregulated. Deep breathing exercise for 15 minutes, 3x a day. Moderate high back rest. May turn to sides once able. Please do Hgt monitoring q 6 hours; may give 4 “u” HR SQ for Hgt > 240. Watch out for any unusualities; refer accordingly.

@ 11pm

IVF TF: D5NSS 1L @ 140 cc/hr.

To follow-up IVF and maintain replacement of fluid and electrolyte balance.

DONE DONE

Ciprofloxacin - to fight bacteria in the body; to prevent or slow anthrax after exposure. Ketorolac - to reduce pain, fever & inflammation. Etoricoxib - to provide analgesic effect. Tramadol – to alleviate moderate to severe pain. Ranitidine - promoting healing of stomach and duodenal ulcers, and in reducing ulcer pain. Oxygen therapy is provided to prevent patient from hypoxia. Warmth makes the patient comfortable and alleviate anxiety that may be helpful for his recovery. To expand the lung fully and prevent atelectasis.

DONE

To promote breathing and chest expansion. To prevent pulmonary complications as well as other complications. To monitor the blood sugar levels of the patient

DONE

To ensure that immediate nursing interventions can be administered to avoid complications; Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition. For replacement of fluid electrolytes balance

DONE

DONE

DONE

DONE DONE

DONE

maintenance.

D

IAGNOSTIC

E

XAM

Urinalysis Name: Mr. R Age/gender: 53/M

Feb. 18, 2009 325-4

PE

CE

Color: yellow

Glucose: (-)

Transparency: clear

Albumin: (-) Rxn: 6.0 Specific Gravity: 1.005

Microscopic Examination Pus cells: 0.1/hpf

Uric Acid -------

RBC: 1.3/hpf

calcium Oxalate ------

Epithelial cells (+)

Triple phosphate -------

Mucous threads (-)

Amorphous Urates

Yeast cells -------

Phosphate -------

Hyaline Cast ------

Others ------

Fine granular cast ------Coarse granular cast -------

Oscar P. Grageda MD, FPSP, APCP

Pathologist

Date: 2/18/09 X-Ray Report The lung fields are clear The heart is not enlarged Great vessels are not unusual Diaphragm and costophrenic sulci are intact. No other remarkable findings.

Impression: Normal Chest findings

Ultrasound Report The liver is normal in size with mild diffuse increase in tissue attenuation. No focal solid or cystic lesions demonstrated. The intra-hepatic ducts are not dilated. The widest antero-posterior diameter of the common duct is about 2.4mm. The gall bladder is adequately distended with slightly thickened walls measuring up to 5.0mm. There is a 1.7cm intra-luminal echo exhibiting posterior sonic shadowing but no dependent mobility in the gall bladder fundus.

Impression: 

Mild Fatty liver



Calculous Cholecystitis

Hematology

Result Hemoglobin

133

Unit

Reference:

g/dl

M: 140 - 170

Erythrocytes

4.29

10^12/L

F: 120 - 150 4.0 - 6.0

Leukocyte

6.9

10^9/L

5.0 - 10.0

Segmenters

0.53

%

0.45 - 0.65

Lymphocyte (P)

0.39

%

0.20 - 0.35

Monocyte (P)

0.06

%

0.02 - 0.06

Eosinophils

0.02

%

0.02 - 0.04

0.41

--

F: 0.38 - 0.4

10^9/L

M: 0.40 - 0.60 150.0 - 450.0

Hematocrit thrombocyte

Blood typing

177

“B” Rht

Coagulation Result Form

Result

Reference Range:

Protime Patient

13.8 sec

11.5 - 14.5 sec

INR

0.99

Normal: 1.0 - 1.2

PTPA

96.4

Therapeutic: 2.0 - 3.0

Control APTT

13.9 sec

Patient

35.6 sec

Control APTT MIXING 1°

24 - 36 sec

30.2 sec

INCUBATION Patient Control CORRECTED APTT

-- sec -- sec

Patient

-- sec

Index: less than 12-

Control

-- sec

corrected Index: less than 16-not corrected

Date: 2/18/09 Blood Chemistry

Test Name

Result

Normal Value

Unit

Creatinine

99.6 H

53.0 - 97.6

Mmol/l

Bilirubin T

7.6

0.0 - 18.8

Mmol/l

Bilirubin O

1.2

0.0 - 4.3

Mmol/l

Alkaline Phosphate

142

64 - 306

U/l

Magnesium

0.94

0.80 - 1.00

Mmol/l

Calcium Chloride

---

1.13 - 1.32 95 - 108

Mmol/l Mmol/l

Potassium

2.73

3.5 - 5.3

Mmol/l

Sodium

140.1

135 - 148

Mmol/l

Magnesium

--

0.8 - 1.0

Mmol/l

Others:

Normal Value LDL:

0 - 4.73 mmol/l

Normal Value Globulin

28 -31 g/l

Normal Value A/G Ratio

1.5 - 2.4 ratio

Date: 2/19/09 Blood Chemistry Test Name Glucose

Result 5.17

Normal Value 4.10 - 6.40

Unit Mmol/l

Others: Calcium Chloride

--

1.13 - 1.32

Mmol/l

--

95 - 108

Mmol/l

Potassium

3.91

3.5 - 5.3

Mmol/l

Sodium

--

135 - 148

Mmol/l

Magnesium

--

0.8 - 1.0

Mmol/l

Normal Value LDL:

0 - 4.73 mmol/l

Normal Value Globulin

28 -31 g/l

Normal Value A/G Ratio

1.5 - 2.4 ratio

Clinical History

Present Complaint: RVQ pain FyHy: (+) DM- maternal (+) HPN – maternal Past Hy: (+) DM – 10yrs. (+) HPN – unrecalled # of years. (-) BA

(-)FDA

Maintenance Meds: 1. Lipitor 2. Plitor

Present Illness:

18 years PTA, Patient noted abdominal pain located @ RUQ area. No consultation done. Took antacids which offered temporary relief. 6 years PTA, (+) recurrence of RUQ pain x 5 days UTZ done revealed gallstones. Took Herbal meds. Patient did not consent for surgery. Patient tolerated the condition, until PTA, (+) RUQ pain, sought consultation to admission.

PE General Appearance: awake, afebrile, NIRD, not in jaundice EENT: pinkish conjunctivae, anicteric sclera, PERLA C/L: regular rate and rhythm, (-) murmur Abdomen: soft, NABs, nontender, (-) murphy’s sign. Extremities: No limitation of movement. Neurologic exam: no neurologic deficit. Impression: Calculus Cholecystitis

Examiner: Dr. Enigo

D

RUG

S

TUD

Generic Name:

Ranitidine hydrochloride

Brand Name:

Zantac

Classifications Antiulcer

Suggested Dose -50 mg q 8 hours IVTT x 3 doses

Mode of Action Competitivel y inhibits action of histamine on the h2 at receptor sites of parietal cells, decreasing gastric acid secretion.

Indications

- Duodenal and gastric ulcer (short-term treatment); pathologic hypersecretory conditions, such as Zollinger-Ellison syndrome - Maintenance therpy for duodenal or gastric ulcer. -Gastroesophageal reflux disease Erosive Heartburn esopaghitis

Contraindications

- Contraindicated in patients hypersensitive to drug and those with acute porphyria.

Drug Interactions Drug-drug. Antacids: May interfere with ranitidine absorption. Stagger doses, if possible. Diazepam: May decrease absorption of diazepam. Monitor patient closely. Glipizide: May increase hypoglycaemi c effect. Adjust glipizide dosage, as directed. Procainamide: May decrease renal clearance of procainamide. Monitor patient closely for toxicity. Warfarin: May interfere with warfarin clearance. Monitor patient closely.

Side Effects/ Adverse Reactions CNS: vertigo, malaise, headache EENT: blurred vision Hepatic: jaundice

Other: burning and itching at injection site, anaphylaxis , angioedema

Nursing Responsibilities 1. Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate. 2. Instruct patient on proper use of the drug 3. Instruct patient to take the drug without regard to meals because absorption isn’t affected by food. 4. Urge patient to avoid cigarette smoking because this may increase gastric acid secretion and worsen disease 5. Inform patient to take drug once daily prescription at bedtime for best results.

Alert: Don’t confuse ranitidine with rimantadine: don’t confuse Zantac with Xanac or Zyrtec.

Generic Name:

KETOROLAC

Brand Name:

Acular, Toradol

Classifications - Non-steroidal antiinflammatory agents - Non-opioid Analgesics - Analgesic, antiinflammatory, antipyretic effects

Suggested Dose 30 mg q 8 hours IVTT x 2 more doses

Mode of Action

Indications

Contraindications

- Inhibits prostaglandin synthesis by decreasing an enzyme needed for biosynthesis

Short-term management of pain (not to exceed 5 days total for all routes combined)

Hypersensitivity; cross-sensitivity with other NSAIDs may exist; labor, delivery or lactation; pre- or perioperative use; known alcohol intolerance

Drug Interactions DRUG-DRUG - concurrent use with aspirin may decrease effectiveness - additive adverse GI effects with aspirin, other NSAIDs, potassium supplements, corticosteroids or alcohol - chronic use with acetaminophen may increase the risk of adverse renal reactions - may decrease the effectiveness of diuretics or hypertensive - may increase serum lithium levels and increase the risk of toxicity. - increased risk if bleeding with cefamandole, cefoten cefoperazone, valproic acid,

Side Effects/ Adverse Reactions - CV: hypertension, flushing, syncope, pallor, edema, vasodilation - CNS: dizziness, drowsiness, tremors - EENT: tinnitus, blurred vision. Hearing loss - GI: nausea, anorexia, vomiting, diarrhea, constipation, flatulence, cramps - GU: Nephrotoxicity: dysuria, hematuria, oliguria, azotemia - HEMA: blood dyscrasias, prolonged bleeding INTEG: pupura, rash, pruritus, sweating

Nursing Responsibilities 1. Obtain patient’s vital signs to note for signs of hypertension. 2. Assess for patient’s hypersensitivity reactions especially those who have asthma, aspirin-induced allergy, and nasal polyps. 3. For patient’s experiencing pain, note the type, location and intensity of pain prior to 1-2 hr following administration. 4. Instruct patient to make medication exactly as directed. If dose is missed, it should be taken as soon as remembered if not almost time for next dose. 5. Advice patient to call for assistance when ambulating and to avoid driving or any activities requiring alertness until response to the medication is known.

Generic Name:

Etoricoxib

Brand Name:

Arcoxia

Suggested

Mode of

Classifications

Non

Indications

Contraindications

Drug

Dose

Action

Interactions

Steroidal - 120 mg

synthesis of

- For the

- Etoricoxib is

Oral

Anti-

P.O. BID x

prostanoid

treatment of

contraindicated to

anticoagulants,

inflammatory

4 doses

mediators of

rheumatoid

patients with known

diuretics and

Drugs

pain,

arthritis,

hypersensitivity to

ACE inhibitors,

(NSAIDs)

inflammation

osteoarthritis Etoricoxib,

Acetylsalicylic

and fever.

, ankylosing

acid,

Selective

spondylitis,

clinical dose range. COX-2 has been shown to be primarily responsible for the active, highly selective cyclooxygenas e-2 (COX-2) inhibitor within and above the

chronic low back pain, acute pain and gout.

patients with active peptic ulceration or

Cyclosporin and

gastro-intestinal (GI) Tacrolimus, bleeding, patients who have developed signs of asthma, acute rhinitis, nasal

Lithium, Methotrexate, oral contraceptives,

polyps,

Prednisone/Pred

angioneurotic

nisolone,

oedema or urticaria following the administration of

Digoxin, drugs metabolized by sulfotransferases

acetylsalicylic acid

(Ethinyl

or other

Estradiol), drugs metabolized by CYP

- exhibits anti-

isoenzymes,

inflammatory,

Ketoconazole,

analgesic and antipyretic activities. It is a potent, orally

Rifampicin, and Antacids have interaction with Etoricoxib.

Side Effects/ Adverse Reactions myalgia weight changes, chest pain, fatigue, paraesthesia, influenza-like syndrome &

Nursing Responsibilities 1. Check renal and hepatic function periodically in patients on long term therapy. Stop drug if abnormalities

- Dry mouth, taste

occur and notify

disturbance,

prescriber.

mouth ulcers, flatulence, constipation, appetite and

2. because of their antipyretic and antiinflammatory actions, NSAIDs may mask signs and symptoms of infection 3. Blurred or diminished vision and changes in color vision may occur 4. serious G.I. toxicity, including peptic ulcer and

Generic Name: Brand Name:

Ciprofloxacin

Ciloxan, Cipro, Cipro HC Otic, Cipro I.V., Cipro XR, Proquin XR

Classification s

Suggested Dose

Fluroquinolone 400mg P.O. Antibacterial B.I.D.

Mode of Action it's action depends upon blocking bacterial DNA replication by binding itself to an enzyme called DNA gyrase, thereby inhibiting the unwinding of bacterial chromosomal DNA during and after the replication.

Indications

Contraindications

complicated intraabdominal infection severe or complicated bone or joint infection,

avoid taking ciprofloxacin with antacids which contain aluminium, magnesium or calcium. Sucralfate, which has a high aluminium content, also reduces the bioavailability of ciprofloxacin to approximately 4%. Ciprofloxacin should not be taken with dairy products or calcium-fortified juices alone, but may be taken with a meal that contains these products.

Drug Interactions GI – nausea and vomiting, abdominal pain, constipation

Side Effects/ Adverse Reactions

CNS; seizures, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, headache, insomnia, light-headedness, paresthesia, restlessness, – tremor

Nursing Responsibilities • Arrange for culture and sensitivity tests before beginning therapy

• continue therapy for 2 days after signs CV; chest pain, and symptoms of severe edema, thrombophlebitis infection are respiratory gone GI; tract infection, GU – renal pseudomembranous • be aware failure colitis, diarrhea, nausea, that Proquin XR severe skin abdominal pain or is not structure Skin - rash discomfort, constipation interchangeable infection and dyspepsia, with other forms severe or flatulence, oral complicated • ensure candidiasis, vomiting UTI, that patients GU; crystalluria, swallow ER infectious interstitiial nephritis, tablets whole; do diarrhea, not cut, crush, or hematologic; typhoid fever chew leukopenia, neutropenia, pyelonephritis • ensure nosocomial that patient is pneumonia musculoskeletal; well hydrated chronic aching, neck pain, Heavy exercise is bacterial tendon rupture • give discouraged, as prostatitis antacids at least achilles tendon Skin; rash, acute 2 hrs after dosing rupture has been pruritus uncomplicated reported in • monitor cystitis patients taking clinical response; mild to ciprofloxacin. if no moderate cute Achilles tendon improvement is sinusitis rupture due to seen or a relapse ciprofloxacin occurs, repeat use is typically culture & associated with sensitivity renal failure. • CNS headache, dizziness, fatigue, lethargy

encourage patient to complete full course of therapy

Generic Name: Diazepam Brand Name: Valium

Classificatio ns

Suggested

Mode of

Dose

Actions

Anxiolytics

10 mg PO OD

A benzodiaze pine that probably potentiates the effect of GABA, depresses the CNS, and suppresses the spread of seizure activity.

Contra

Drug

Side Effects/

Nursing

Indications

indications

Interactions

Adverse Reactions

Responsibilities

preoperativ e sedation

contraindicate d in patients hypersensitive to drug or soy protein; in patients experiencing shock, coma, or acute alcohol intoxication

Drug-drug

CNS; drowsiness, slurred speech, tremor, headache, fatigue

Warn patient to avoid activities that require alertness and good coordination until effects of drug are unknown.

before endoscopic procedures muscle spasm acute alcohol withdrawal

use cautiously in patients with liver or renal impairment.

Cimetidine may decrease clearance of diazepam and increase risk of adverse effects CNS depressants may increase CNS depression Digoxin may increase risk of toxicity Diltiazem may CNS depression and prolong

CV; bradycardia, hypotension EENT; diplopia, blurred vision, nystagmus GI;nausea, constipation,

Warn patient not abruptly stop the drug because withdrawal symptoms may occur tell patient to avoid alcohol while taking the drug notify patient that smoking may decrease drug's effectiveness Take this medication

effects of diazepam Drug-Herb Kava may increase sedation Drug-lifestyle Alcohol use may cause additive CNS effect Smoking may decrease effectiveness of drug

diarrhea GU; incontinence , urine retention Hepatic; jaundice Respiratory; apnea Skin; rash

exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label. diazepam interacts with the plastic; therefore, introducing diazepam into a container reduces drug availability.

Generic Name:

Potassium chloride

Brand Name: Kalium Durules

Classifications potassium salt

Suggested Dose 1 tab t.i.d.

Mode of Action

Indications

replaces indicated to potassium prevent and hypokalemia, maintains potassium levels

Contraindications contraindicated in patients with severe renal impairment with oliguria.

Drug Interactions

Side Effects/ Adverse Reactions

Nursing Responsibilities

Drug-drug;

CNS; paresthesia of Teach patient signs and limbs, ;listlesness, symptoms of ACE confusion, hyperkalemia, and tell inhibitors, weakness or patient to notify digoxin, heaviness of limbs, prescriber if they occur potassiumflaccids paralysis. sparing Tell patient that drug is diuretics may CV; postinfusion commonly used orally cause phlebitis, with potassium-wasting hyperkalemia. arrhytmias, heart diuretics to maintain block, cardiac potassium levels. arrest, hypotension, Monitor ECG and ECG changes electrolytes levels GI; nausea, during therapy vomiting, Swallow the tablets whole abdominal pain, with a full (8-ounce) diarrhea. glass of water. Do not metabolic; chew or suck on the hyperkalemia tablet. Respiratory; Do not take more of it, do respiratory paralysis not take it more often, and do not take it for a longer time than your doctor ordered.

Generic Name:

Nalbuphine

Brand Name: Nubain Classifications

analgesics

Suggested

Mode of

Dose

Actions

5mg IVTT

Indications

Unknown. adjunct to Binds with balanced opiate anesthesi receptors a in the moderate to CNS, severe altering pain perception of and emotinal response to pain.

Contra

Drug

Side Effects/

Nursing

indications

Interactions

Adverse Reactions

Responsibilities

CNS; dizziness, headache, sedation, vertigo, confusion, restlessnes s. CV; bradycardi a, hypotensio n, tachycardi a, hypertensi on EENT; blurred vision, dry mouth GI; constipatio

Tell patient drug act as an antagonist and may cause withdrawal syndrome Advise the patient to avoid any activities that requires alertness because this drug can cause dizziness Explain to the patient that the drug can cause constipation.

contraindicate d in patients hypersensitive to drug

Drug-drug. CNS depressants and sedatives may cause respiratory depression, hypertension, profound sedation or coma. Opoid analgesics may decrease analgesic effect Drug-lifestyle. Alcohol use may cause additive effects

Tell the patient to report to the prescriber immediately if there is severe itcheness.

n, nausea, vomiting, dyspepsia, cramps GU; urinary urgency Respiratory; asthma Skin; burning, clammines s, diaphoresi s, pruritus

Generic Name: Brand Name: ultram

Tramadol

Classifications

Sugge sted Dose

Analgesics

100mg P.O. t.i.d.

Mode of Action The mode of action of tramadol has yet to be fully understood, but it is believed to work through modulation of the noradrenergic and serotonergic systems in addition to its mild agonism of the μ-opioid receptor.

Indicati ons

Contraind ications

indicated to treat moderate to moderately severe pain

Hypersensitivi ty to tramadol. In acute intoxication with alcohol, hypnotics, centrally acting analgesics,opi ates, or psychotropic drug.

Drug Interaction s

Side Effects/ Adverse Reactions

drug-drug

Nursing Responsibilitie s

CNS; dizziness, headache, somnolence, Carbamezep vertigo, seizures, ine may anxiety, increase asthenia, CNS tramadol stimulation, metabolism confusion, coordination disturbance, CNS depressants euphoria, may cause malaise, nervousness, additive sleep disorders effects CV; vasodilation Cyclobenza

• Document indications for therapy, location, onset, and characteristics of symptoms. Use a pain rating scale.

prine may EENT; increase risk visual of seizures disturbances

• Monitor VS, I & O, liver and renal function studies; reduce dose with dysfunction and if over 75 yrs. Old.

GI; constipation, Quinidine nausea, may increase the vomiting, level of abdominal pain, anorexia, tramadol diarrhea, dry mouth, dyspepsia, flatulence

• Assess for history of drug addiction, allergy to opiates or codeine, or seizures; drug may increase the risk of convulsions.

• Do not perform activities that require mental alertness; drug may cause drowsiness and GU; impair mental or proteinuria, physical urinary performance. frequency, urine Alcohol may retention intensify drug effect. Musculoskeletal; • Report hypertonia lack of response. Review list side Respiratory; effects (nausea, respiratory dizziness, depression constipation,

N

URSING

T

HEORIES

BETTY NEUMAN’S Systems Model Betty Neuman’s systems model focuses on the wellness of the client system in relation to the environmental stressors and reactions to stressors. These stressors include intrapersonal (occur within person, e.g. emotions and feelings), interpersonal (occur between individuals, e.g. role expectations), and extrapersonal stressors (occur outside the individual, e.g. job or finance pressures). The nursing interventions involved in this theory focuses on retaining or maintaining system stability on three preventive levels: [1] Primary prevention (includes health promotion and maintenance of wellness.), [2] Secondary prevention (focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor.), and [3] Tertiary prevention (offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution). Application to patient: Last 2006, the patient was diagnosed of Cholelithiasis and was given medications like pain reliever () and antibiotic (). The pain and discomfort were relieved because of the medications given. After three years, he experienced recurrence of pain and discomfort. This made him decide to consult his physician and agreed to the suggested surgery, which is Laparoscopic Cholecystectomy Our patient belongs to the tertiary prevention since he had already undergone Laparoscopic Cholecystectomy. As a health care provider, we rendered health teachings that would prevent him from developing the same condition. Additional information was also given to the patient that would help hasten the healing process. Examples of health teachings rendered to him are encouraging him to have a strict compliance of his

therapeutic regimen, to have a regular exercise and emphasizing the importance of having a healthy and balance diet. Also, teach the patient and the family about the importance of psychological well being in recovery.

IMOGENE KING’s Goal Attainment Theory Imogene King’s model is a model of three interacting systems: Personal, Interpersonal, and Social. The major elements of the theory are seen in the interpersonal systems in which two people, who are usually strangers, come together in a health care organization to help and be helped to maintain a state of health that permits functioning in roles. She states that client goals are met through the transaction between nurse and client. Application to the patient: As health care providers, we need to learn how to interact and establish rapport to our patients. We must encourage them to verbalize their concerns and feelings in order for us to provide the proper interventions necessary to their condition. During our course of care, we were able to establish a good nurse-patient relationship with Mr. R. Because of this, we were able to obtain information regarding his plans after his discharge. In line with this, involved Mr. R in creating a plan of care and exploring means of achieving this upon his discharge. We must also give him enough information especially on prevention of illnesses so that his role as an individual will not be affected.

LYDIA HALL’S Care, Core, and Cure Model Lydia Hall presented her theory of nursing visually by drawing three interlocking circles, each circle presenting a particular aspect of nursing. The circle represents care, core, and cure. The care circle represents the nurturing component of nursing and is exclusive to nursing. The professional nurse provides bodily care for the patient and helps the patient to complete such basic daily biological functions as eating, bathing, elimination and dressing. When providing this care, the nurse’s goal is the comfort of the patient. The core circle of patient care is based in the social sciences, involves the therapeutic use of self, and is shared with other members of the health team. The professional nurse, by use of the reflective technique helps the patient look at and explore feelings regarding his or her current health status and related potential changes in lifestyle. The cure circle of patient care is based in the pathological and therapeutic sciences and is shared with other members of the health team. The professional nurse helps the patient and family through the medical, surgical, and rehabilitative prescriptions made by the physician. During this aspect of nursing care, the nurse is an active advocate of the patient. Application to the patient: In the care circle, we were able to ensure client safety through raising side rails of bed to prevent patient from falling, assisting patient whenever he ambulates, and imparting health teachings that would help him to have a speedy recovery. In the core circle, we were able to allow the patient to explore his feelings about his condition through letting him express his concerns and worries regarding his

condition. Through this, the patient will be motivated to make appropriate decisions in promoting good health. In the cure circle, we were able to perform a medical procedure that would help the physician to determine the proper treatment that should carried-out to the patient.

N

URSING

C

ARE

P

LANS

DATE/TIME Feb. 21, 2009 @ 5am

CUES

NEEDS

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

S: ‘’medyo sakit2x ang gi operahan diri sa akong tiyan’’ as verbalized by the patient. O: - Presence of patches on the operative sites. - Grimaced face when patch on umbilicu s was palpated - Pain scale of 5moderate

C O G N I T I V E P E R C E P T U A L

Acute pain r/t surgical tissue trauma secondary to laparoscopic cholelithiasis.

Within our span of care, our patient will be able to:

1.Observe and document location, severity (110 pain scale), and character of pain(steady, intermittent, colicky.) R: assists in differentiating cause of pain and provides information about disease progression/resolution, development of complications, and effectiveness of interventions. 2.Promote bedrest , allowing patient to assume position of comfort. R: bedrest in low Fowler’s position reduces intraabdominal pressures; however, patient will naturally assume least painful position. 3.Encourage use of relaxation techniques, e.g., deep breathing exercises. R: promotes rest, redirects attention, may enhance coping. 4.Make time to listen to complaints and maintain frequent contact with the patient. R: helpful in alleviating anxiety and refocusing attention, which can relieve pain. 5.Administer medications as indicated. R: to maintain ‘’acceptable’’ level of pain. Notify physician if regimen is inadequate to meet pain control goal. 6.Observe and document location, severity (110 pain scale), and character of pain(steady, intermittent, colicky.) R: assists in differentiating cause of pain and provides information about disease progression/resolution, development of

P A T T E R N

R: Unpleasant sensory and emotional experience arising from actual or potential tissue damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and duration of less than 6 months. Source: Nurse’s Pocket Guide, Marilynn E.

-

-

Follow interventio ns to relieved pain. Verbalized minimal pain. - utilize comfort measures and techniques effectively to reduce or alleviate pain.

EVALUATION GOAL MET Patient was able to: - minimize manipulation of affected area and utilize relaxation techniques to minimize pain. patient verbalized pain scale of 3

Doenges, Mary Frances, Moorhouse, Alice C. Murr

complications, and effectiveness of interventions. 7.Promote bedrest , allowing patient to assume position of comfort. R: bedrest in low Fowler’s position reduces intraabdominal pressures; however, patient will naturally assume least painful position. 8.Encourage use of relaxation techniques, e.g., deep breathing exercises. R: promotes rest, redirects attention, may enhance coping. 9.Make time to listen to complaints and maintain frequent contact with the patient. R: helpful in alleviating anxiety and refocusing attention, which can relieve pain. 10.Administer medications as indicated. R: to maintain ‘’acceptable’’ level of pain. Notify physician if regimen is inadequate to meet pain control goal.

DATE/TIME Feb. 21, 2009 @ 5am

CUES

NEEDS

NURSING DIAGNOSIS

S:

C

–“Dili ko sure kung unsaon nako ang akoang diet karon na wala na ko’y gall bladder.”

O

Knowledge deficit [Medications] r/t unfamiliarity with information resources.

O: Patient is S/P laparoscop ic cholecyste ctomy

G N I T I V E P E R C E P

OBJECTIVES OF CARE Within our span of care, patient will be able to:

–identify interferences to learning and specific actions to deal with them

EVALUATION

1. Assess client's level of understanding.

GOAL MET

R: Facilitates planning of postoperative teaching program, identifies content needs.

The patient was able to:

2. Identify motivating factors for the individual.

–participate in the learning R: Absenc e or deficiency process of cognitive information related to specific topic.

NURSING INTERVENTIONS

R: Motivating factors will help in the teaching process 3. provide information relevant to the situation. R: for the patient to be informed regarding her present condition. 4. Provide positive reinforcement. R: to encourage continuation of efforts.

5. Identify information that needs to be –exhibit increased remembered. R: The client will know what specific learning of medicines information will help out in remembering what is learned taken. 6. Determine client's method of accessing information and include in teaching plans.

perform necessary interventions correctly verbalize understandi ng of condition/disease process treatment.

and

Identify medications use to treat his condition.

T U A L P A T T E R N

R: to know teaching method to be used and to help facilitate learning. 7 Provide written information and guidelines for client to refer to as necessary. R: Written information will be more reliable for the client whenever information will be forgotten 8. Begin with information that client already knows and move to what the client does not know. R: This will ensure that the client will not have a hard time learning new things 9. Provide information about additional learning resources. R: to assist client with further learnings and promote learning at own pace.

DATE/TIME Feb. 21, 2009 @ 5am

CUES

NEEDS

NURSING DIAGNOSIS

OBJECTIVES OF CARE

O: Disruption of skin layers (epidermis and dermis) due to laparoscopic procedure.

N U T R I T I O N A L

Impaired skin integrity r/t tissue damage secondary to laparoscopic cholecystectomy procedure.

Within our span of care, the client will be able to

M E T A B O L I C P A T T E R

R: Altered epidermis and/ or dermis. Source: Nurse’s Pocket Guide, Marilynn E. Doenges, Mary Frances, Moorhouse, Alice C. Murr

NURSING INTERVENTIONS

1. Identify underlying condition/ pathology trauma. (e.g. surgical incision) R: Identifies impairments and allows for identification of appropriate interventions. - display 2. Note changes in skin color, texture, timely healing and turgor. of skin R: changes in the integument to lesions/ determine skin integrity wounds/ 3. Determine depth of damage to pressure sores integument system (epidermis, dermis, without and underlying tissues.) complication. R: this will help client’s recovery. To note underlying complications for further Maintain management. optimal 4. Note odors emitted from the skin/ area nutrition/ of injury. physical well- R: this will determine occurrence of being. gangrene 5. Note presence of compromised vision, hearing, or speech. R: Skin is a particularly important avenue of communication for these people and, when compromised, may affect responses. 6. Keep the area clean/ dry, carefully dress wounds, support incision, prevent infection, and stimulate circulation to surrounding areas.

EVALUATION Goal Met: Patient was able to: - participate in prevention measures and treatment program. verbalize feelings of increased selfesteem and ability to manage situation.

N

R: to assist body’s natural process of repair. 7. Use appropriate barrier dressings, wound coverings, drainage appliances, and skin-protective agents for open/ draining wounds. R: to protect the wound and/ or surrounding tissues. 8. Provide skin care every 8 hours and prn. Change wet clothing and linens prn R: Helps to promote circulation and reduces potential for skin breakdown. 9. Provide optimum nutrition and increased protein intake. R: to provide a positive nitrogen balance to aid in healing and to maintain general good health. 10. Assist the patient in understanding and following medical regimen and developing program of preventive care and daily maintenance R: Enhances commitment to plan, optimizing outcomes.

DATE/TIME CUES Feb. 21, 2009 @ 5am

NEEDS NURSING DIAGNOSIS

Objective:

N

>loss of appetite as evidenced by untouched meals and as verbalized by the patient and his significant others.

U

>the patient has undergone laparascopic cholecystectomy.

I

T R I T

O N A L M E T A

Altered nutrition less than body requirements related to impaired fat digestion due to obstruction of bile flow.

OBJECTIVES NURSING INTERVENTIONS OF CARE

EVALUATION

Within our 8 hours span of care, the patient will be able to achieve relief of nausea and vomiting.

eb. 21, 2009 @ 6:00am

1.Monitor vital signs ®serves as a baseline data 2.Monitor IVF ® To maintain the fluid and electrolytes balance in the patient’s body 3. Monitor Intake and output. ®To determine any unusualties for immediate medical management. 4. Assess for abdominal distention, frequent belching, guarding, and reluctance to move. ®Nonverbal signs of discomfort associated with impaired digestion, gas pain. 5. Consult with patient about likes/dislikes, foods that cause distress, and preferred meal schedule. ®Involving patient in planning enables patient to have a sense of control and encourages patient to eat.

Goal met:

The patient was able to demonstrate achievement in relief of nausea and vomiting.

B

O L I

6. Provide a pleasant atmosphere at mealtime; remove noxious stimuli ®useful in promoting appetite/reducing nausea. 7. Keep comments about appetite to a minimum

C

®Focusing on problem creates a negative atmosphere and may interfere with intake.

P

8. Provide oral hygiene before meals.

A

®A clean mouth enhances appetite.

T

9. Offer effervescent drinks with meals, if tolerated.

T E R N

®May lessen nausea and relieve gas. 10. Ambulate and increases activity as tolerated. ®Helpful in expulsion of flatus, reduction of abdominal distention. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility.

DATE/TIME Feb. 21, 2009 @ 5am

CUES

NEEDS

NURSING DIAGNOSIS

OBJECTIVES OF CARE

O:

H

- surgical incision noted on abdomen as possible portal of entry for pathogenic organisms.

E

Risk for infection r/t abdominal incision done secondary to laparoscopic procedure.

Within our span of care, patient will be able to:

A L T H

P E

R: At increased risk for being invaded by pathogenic organisms.

R C E P T I O

Source: Nurse’s Pocket Guide, Marilynn E. Doenges, Mary Frances, Moorhouse, Alice C.

- identify interventions to prevent/ reduce risk of infection.

- achieve timely wound healing.

NURSING INTERVENTIONS

EVALUATION

1. Monitor vital signs and patient for presence of fever and chills.

GOAL MET

R: Fever, tachycardia, and tachypnea may indicate presence of infection.

The patient was able to:

2. Stress proper hand washing techniques between therapies/clients.

-demonstrate technique

R: A first-line defense against nosocomial infections/ cross-contamination. 3. Cleanse incisions or change dressings as needed/indicated. R: Dressings help protect the area to reduce further injury. 4. Administer/ monitor medication regimen and note client’s response. R: to determine effectiveness of therapy/ presence of side effects. 5. Use sterile or strict aseptic technique for all dressing changes. R: .Abdominal incision makes the patient susceptible to infection. 6. Instruct patient/ family regarding signs and

es, lifestyle changes to promote safe environ ment. -stay afebrile. -and achieve timely wound healing.

N H E A L

Murr

symptoms to observe for, such as demarcated area changes, redness, change or presence of drainage, and so forth R: May indicate presence of infection or that tissue necrosis is extending. 7. Instruct patient/family regarding maintaining proper nutrition, with increased protein intake.

T

R: adequate nutrition is required for maximum wound healing.

H

8. Instruct patient on all medications and procedures. R: Promotes knowledge and helps to facilitate compliance with medical regimen.

M A N A G E M E N T

P

ROGNOSIS

Category 1. Duration of Illness

Poor

Fair

Good

(1)

(2)

(3)

It's been 14 years since the



2. Onset of

first sign of pain As soon as the pain got really worse, he immediately sought



Illness

medical treatment, but he could have done this earlier 2 out of 3 predisposing factors

3. Predisposin

are present; his susceptibility



g Factors 4. Precipitatin g

to the disease is unavoidable. His lifestyle could have been adjusted and hid disease could



have been avoided altogether

Factors 5. Willingness to take the medications

Justification

Patient verbalized that this 

experience has taught him valuable lesson in keeping

or

healthy and preventing

compliance

illnesses by taking his

to

medication religiously

treatment regimen

Patient verbalized that his

6. environmen t

home environment and work 

place only give him manageable stress.

During our interview Mr. R's nephew was present; his son 7. family



support

was also expected to visit in the morning; Mr. R was also observed to answer two phone calls from two of his siblings. 3 + 2 + 9 = 14 14/7 = 2

Calculatio

3x1

1x2

3x3 =

ns

=3

=2

9

Ranges: 1.0 – 1.5 = Poor

1.5 – 2.5 Fair 2.5 – 3.0 = Good

Mr. R has a FAIR prognosis. His disease could have been totally avoided just by a change in lifestyle and diet. Mr. R could have paid attention to his weight gain and the rising issues about obesity and what diseases it could bring about. And most of all, Mr. R should have had his RUQ pain checked by a doctor early on. If the gall stones were still during its early stages, they could have been removed by Mr. R taking medications and an invasive procedure could have been avoided. However, the usual prognosis of post laparoscopic cholecystectomy patients is usually very good. Having smaller incisions brings about lower risks for infections. Early ambulation is readily done which then will bring about early recovery. Mr. R has also been educated on the changes in his lifestyle that he could do in order for him to have a good life ahead of him even if he doesn’t have a gall bladder anymore.

D

ISCHARGE

P

LAN

MEDICATION •

Explain each purpose of the medication ® Knowledge about what medications will make the client become aware of what he is taking and for the family to participate more in the client’s treatment.

•

Inculcate to the client to comply all the medications prescribed at the ordered dosage, route and at the ordered time. ® Taking the drugs at the ordered dose, route and time limits the chance for toxicity and ensure its effectiveness.

•

Instruct client not to take over-the-counter drugs without doctor’s knowledge.  Non-prescribed drugs may have an antagonistic effect or synergistic effect in any drug therapy.

•

Explain the side effects or adverse reactions of each medication. Instruct the client and family to watch out for it and to report it immediately as soon as possible to the physician. ® Explaining the side effects will let the client and family identify what harmful effects to expect and for them to distinguish the adverse reaction to medication for them to report it to their physician immediately.

•

Advice client to take medications with food if not contraindicated or to take medicine one hour before meals or one hour after meals.

® Some medications are irritating to the gastric mucosa.

•

Let patient complete the whole course of the drug therapy. This can help the patient alleviate the problem and be able to experience the full therapeutic effect of the medication.

EXERCISE •

Instruct client to avoid strenuous activities for at least a week or a month until fully recovered. Activities that require great muscle strength should be avoided to prevent injury and muscle strain.

•

Encourage early ambulation. Walking is good exercise and could promote circulation, hence, proper healing.

•

Promote exercise to the client especially ROM. ® This will promote good physical health.

•

Advise patient to have adequate rest and sleep. To gain back the lost strength and be able to return to its normal state thus allow ample time for healing.

•

Practice deep breathing exercise. This will help alleviate any pain or discomfort that patient will encounter

TREATMENT •

Explain the need of treatment after discharge and must take it seriously so as to prevent such complications to the patient

 To make the client and family aware that the treatment does not only end at hospital but needs to be continued at home to make the client responsible towards medication.

•

Explain to the family the condition of the patient and give them factual information about the illness. To have better understanding of the patient’s condition and to be able to know what intervention they should give that could not alter the effect of the therapy.

HYGIENE •

Encourage having proper hygiene like taking a bath, meticulous hand washing, and brushing of teeth every after meal.  Hygiene promotes comfort and cleanliness to the patient. It also increases the sense of wellness, which is very much needed in the therapeutic process.

•

Encourage patient to continue hygienic measures practiced at present such as changing clothes everyday and changing of underwear as often as necessary, keeping the nails neatly trimmed, maintaining own supplies/items for personal necessities. Keeping all practiced measures is necessary in consistent maintenance of proper hygiene. Owning personal accessories for hygiene purposes keep client away from contamination and infectious diseases.

•

Provide a calm, clean, and accepting environment.  Calm, clean and non threatening environment may lessen the occurrence of possible infection and would be a good place for healing.

OUTPATIENT ORDER •

Inform the patient that follow-up check-up is important to have continuous monitoring and care even after attainment of the course medical therapy.  Through constant visits as out patient, the physician would still monitor the progress of the therapeutic intervention availed by the patient.

•

Advice the client and the family to carry out follow-up diagnostic examinations ® This is to evaluate the therapeutic response of the patient to the treatment.

•

Instruct the family to report any unusual signs and symptoms experienced by the patient. This will help detect early signs and symptoms of recurrence of the disease.

DIET •

Encourage client to eat a variety of nutritious foods like fruits and vegetables once instructed by the physician. To maintain and promote a healthy body.

•

Instruct client to take vitamins as ordered. To boost the body’s defense mechanism.

•

Encourage patient to increase oral fluid intake. This hydrates the body for normal functioning and maintain acid-base balance.

•

Advise client not to skip meals and have a regular eating pattern/schedule. Regular interval of meals is the basic principle of a good dietary plan.

•

Tell patient not to eat foods contraindicated by the physician. To prevent the occurrence of complications.

•

Instruct patient to avoid drinking liquors and smoking ® To also avoid illness to be triggered.

R

ECOMMENDATION