I.

Acknowledgement
I would like to extend my heartfelt and sincerest gratitude to the following people who

have made this endeavor possible: First and foremost, we glorify our Lord and creator for providing us with the physical strength and mental capability to accomplish the work of this case study. For the determination and perseverance to push through despite very hectic schedules. For the courage and strength to fulfill this task.

To the groups clinical instructor, Mr. Rey D. Pinalba, R.N. for providing us with the much needed guidance in our clinical and for inculcating us of his knowledge beyond our shortcomings. For his patience, forbearance and kindness in making us nurses of the future.

To the staff of Northern Mindanao Medical Center- Surgical \Ward, who have been very kind and generous in assisting us to obtain the needed information for the completion of this case study.

To our practicing clinical instructor, Ms. Normie Ann Tan for her unending support and guidance.

To my dear families, friends and group mates for their never ending support and understanding; for always being there to guide us and care for us after the long days of duties.

[Type text]

Page 1

II. Introduction
Gallstones are small or large rocks that can be formed in the gallbladder, when the balance of bile composition differs from the norm. Gallstones are frequent, but the state gives first symptoms when the stone blocks drained from the gallbladder or is stuck in the deep bile times on the way to the gut. Bile is fluid and formation in the liver of, among other things, cholesterol and wastes, including billirubin (colored product from dead red blood cells) and assembled in the gallbladder, which sits in close relation to the liver. When you eat, headed bile through the deep bile times to gut, where bile is necessary for digestion of essential fats and neutralizing stomach acid. While waste is then excreted in faeces, which is why its dark color. When the balance between the substances in the bile pushed too much towards high cholesterol can be deposited in cholesterol crystals, which are the most common basis for gallstones. Blocks grows when bile ingredients bind to the solid crystals and is composed of cholesterol, bile pigment and lime (calcium). There may be many small stones or some large, which may be larger than a hen. Large stones do not need to give serious symptoms. Disorders of the gallbladder and ducts are extremely common. The two most common conditions are gallstones and associated cholecystitis (inflammation of the gallbladder). ` Cholelithiasis is gallstone formation in the gallbladder. Gallstones are composed

primarily of cholesterol, biles, salts, calcium, bilirubin and proteins. The specific factors contributing to the formation of gallstones can be categorized into metabolic factors and factors that cause stasis or inflammation. About 75% of gallstones in Western cultures are cholesterol stones. The remaining 25% consist of bilirubin pigment stones. (Bare &Smeltzer, 2004). Cholecystolithiasis is the presence of one or more gallstones in the gallbladder. The incidence increases with age, and the frequency of gallstones in the common duct in the older population may be as high as 25%. Frequently, inflammation or bacteria are present, and cholangitis may develop. (Black&Halwks, 2009).In the context of Cholelithiasis, Choledocholithiasis has rank 3 out of 6021 'Disease' concepts (top 0.05%) in BioGraph's knowledge base. In the United States,

[Type text]

Page 2

about 20 million people (10-20% of adults) have gallstones. Every year 1-3% of people develop gallstones and about 1-3% of people become symptomatic. Although gallstone surgery is relatively safe, cholecystectomy is a very common procedure, and its rare complications result in several hundred deaths each year. Choledocholithiasis complicates 10-15% of cholelithiasis cases.

III.

SIGNIFICANCE OF THE STUDY

I chose this case because it encompasses medical-surgical nursing concepts in which we

are able to relate to. More clinical skills will be developed by experiencing the clinical management of this disease-condition and it will enhance ones knowledge in implementing proper nursing intervention to the patient towards recovery. And also, the disease condition of the selected patient requires intensive research and study, thereby stimulating and enhancing the researchers analytic skills and resourcefulness. Nursing Education This case study gives us so much ideas and concepts beyond our imagination. It

surpasses basic and interesting information. With this, we acquired and gained knowledge that we can apply to my nursing practice through experience. We learned some basic concepts such as etiology, risk factors, disease process, possible complications, and nursing interventions as well. Above all, we found out some actions for the prevention, treatment, and rehabilitation of this condition. Experience cant be satisfied without knowledge, so education is very important. Furthermore, nurses should also possess great intelligence and good teaching strategies as part of patients education. a. Nursing Practice In the future this case study can be very useful even though we werent able to care for this patient. As we go along our nursing practice, the information and concepts presented may be applied in the health care setting. We might be able to encounter other patients with this

[Type text]

Page 3

condition and other emergency cases. Through this case study, we can give quality nursing care and immediate interventions appropriate to the manifestations and condition. b. Nursing Attitude Patience is the best virtue. As we assess our patient. We learned to be very patient as much as possible. Now, we can anticipate what should be the best approach in terms of attitude in dealing with patients suffering from stroke and other emergency. So, for the time that we can handle this kind of patient, we can cope up easily upon caring my clients not just with jaundice patient but also other urgent cases. c. Nursing Research Being resourceful is what a good nurse should seize. Through this case study, we were able to explore beyond the limits. We learned to be very curious and seek other pertinent data that can be helpful in this case study. It includes the incidence, some supporting data in the pathophysiology and the current trends about prevention, treatment, and rehabilitation.

IV. Objectives of the study

Nurse Centered: a. General: To enhance skills, comprehension and approach in the practice of nursing and be able to establish knowledge on the risk factors, prognosis nursing management, current trends and incidence of the disease condition that was chosen. To come up with a comprehensive presentation of the disease condition by means of correct presentation of the data gathered through the use of nursing process. b. Specific: 1. To present the current trends about the disease condition; the reason for choosing such case for presentation; and the importance of the case study.

[Type text]

Page 4

2. Describe and explain the disease together with the risk factors contributing to the occurrence of the condition. 3. Review the anatomy and physiology of the organs involved. 4. Analyze the clients disease process along with its signs and symptoms, laboratory results and its complications, 5. Interpret the results in the laboratory and diagnostic procedures done with the patient. 6. Enumerate the different medications administered for the condition, their indications and specific nursing responsibilities. 7. Formulate significant nursing diagnoses, with their significantly related nursing care plans as well as the discharge plan. Patient Centered: General: To be able for the client to fully understand and recognize the disease condition, emphasize the importance of making appropriate action and to guide the patient towards recovery. Specific: 1. To impart knowledge about the importance of healthy lifestyle. 2. To render proper nursing management and medical regimen needed by the patient. 3. To identify predisposing factors that aggregate the present condition of the patient Scope and Limitation Due to limited time, all data contained are taken only from the day of admission until 2 days of duty. Researchers had only assessed the patient after 3 days of admission and found out some remarkable findings. Data such as laboratory results and findings taken beyond this date have no account in this study. Therefore, the scope and purpose of the Nursing Care Plans (NCPs), Drug Studies, Significance of Doctors Orders and Discharge Plan are primarily intended to patients condition within the time being.

[Type text]

Page 5

V.

PATIENTS PROFILE
Demographic Data Patient X is a 71-year-old Male, Filipino, a Seventh Day Adventist and currently residing Butuan City. He is happily married and has 3 children. Patient X was admitted at Northern Mindanao Medical Center last July 24, 2013 due to abdominal pain at the right upper quadrant. Upon admission, he was diagnosed to have cholecystolithiasis. Upon admission, his vital signs were as follows: Temperature=36.90C; pulse rate= 73bpm; respiratory rate=20cpm; BP=120/80mmHg. He stands 171 cm tall and weighs 40 kg.

HEALTH PATTERNS ASSESSMENT 1. Health Perception and Management Chief complaint: The patient had abdominal pain at the right upper quadrant History of Present Illness: 1 day PTA patient X had abdominal pain at the right upper quadrant in the epigastric region and was admitted at Butuan Hospital but he was transferred to Northern Mindanao Medical Center due to incomplete equipments. Past Medical History: According to patient X he was admitted at Butuan Hospital for 3 weeks when he had a severe abdominal. Then he was referred and admitted here at Northern Mindanao Medical Center due to cholecystolithiasis. Patients General Appearance: Upon assessment, the patient appears well nourished and he appears weak, calm, oriented and responsive to questions being asked. The patient undergone surgery last July 30, 2013.

[Type text]

Page 6

Habits The patient is a smoker and used to smoke 15 sticks per day and drinks alcoholic beverages (1 junior tanduay) occasionally. He has no known allergies to medications or foods. He has no maintenance medications. 2. Nutrition and Metabolic Pattern Prior to hospitalization, patient X had a good appetite and he can consume his whole share of meals which usually consists of 2 cups of rice and 2 servings of viand (more on vegetables, pork, and dried seafood). He also drinks approximately 1.5 L of water a day. He is not taking any supplements. The following are IV fluids received by the patient during from July 25- 27,2013: DATE July 25, 2013 July 26, 2013 July 27, 2013 IV SOLUTION None PNSS PNSS 30 gtts/min DROP RATE

3. Elimination Pattern Bowel Before admission, patient X usually defecates twice a day with pale-colored or yellowish colored stool, with soft consistency. He does not feel any discomforts when defecating and there are no problems with hemorrhoids or incontinence. According to him the last time he defecates is on July 27, 2013

[Type text]

Page 7

Bladder Prior to admission, he usually urinates 4-5 times a day to a yellowish colored urine with approximately 1-1 1/2 glass (210-230cc) of urine per voiding. There are no discomforts reported. During the duration of care, patient X usually urinates 2-3 times to a dark colored urine for about 120-240 ml per 8 hours shift. He reported no discomforts or any problem in control. 4. Activity-Exercise Pattern Prior to hospitalization, patient does walking on his way to work daily and served it as his regular exercise. But upon admission, patients only means of exercise is active range of motion. With patients activities of daily living, he is assisted with person. PATIENTS ACTIVITIES OF DAILY LIVING FUNCTIONA L ABILITIES Feeding Assisted person Bathing Assisted person Toileting Assisted person Bed Mobility Impaired ability to move from supine to sitting Impaired ability to move from sitting to supine Impaired ability to move from supine to prone Assisted Impaired ability to move from prone to supine person Impaired ability to move from supine to long sitting Impaired ability to move from scoot or reposition with 2 with 2 with 2 with 2 SCORE

[Type text]

Page 8

self in bed Impaired ability to move from side to side.

Dressing Assisted person Grooming Assisted person General Mobility Unable to ambulate on his own and needs assistance Assisted from his significant others. ROM Active Range of Motion Total 0 independence person with 2 with 2 with 2

5. Cognitive-Perceptual Pattern Upon assessment, he is conscious, and in a calm state. He is oriented to time, person, and place. His primary language is vernakular; no speech deficits noted but he speaks at slow pace. He is an elementary graduate. There are no learning difficulties reported. 6. Sleep-Rest Pattern He usually sleeps 4-5 hours at night prior to admission. Although, upon his admission his sleeping pattern is quite disturbed considering the pain at right upper quadrant with pain scale of 7/10. He also takes a 1-2 hours nap in the afternoon. He is not insomniac.

[Type text]

Page 9

7. Self-Perception and Self-Concept Pattern The patient stated that hes quite worried about his current condition. During assessment, patient X has been responsive and cooperative to our questions being asked. 8. Role-Relationship Pattern He is married, with 3 children. He currently lives with his family. His family and nearest relatives are worried about his condition and he is also eager to go home. He supports himself and his family through his work as a farmer. They have no known familial history of any serious illnesses. 9. Sexuality-Reproductive Pattern Patient has no reported prostate problems and does not practice monthly selftesticular examination. No discharges were observed and no presence of nodules or lesions noted. 10. Coping-Stress Tolerance pattern During the duration of care, patient X did not experience any stressful event in his life. His form of relaxation is napping especially in the afternoon and sometimes slight conversation to his wife. 11. Value-Belief Pattern He is a Seventh Day Adevntist by faith and he believes that God is the source of everything. Their religious practice is going to church every Sunday.

[Type text]

Page 10

PHYSICAL ASSESSMENT Tabulation of Vital Signs

Vital signs Temperature Pulse Rate Respiratory Rate BP Pain Scale

Initial Assessment (July 25, 2013) 36.90C 71bpm 20cpm 110/70 mmHg 7/10

First day of Care (July 26, 2013)

Second day of Care (July 27, 2013)

Vital signs

4:00

8:00

4:00

8:00

Temperature Pulse Rate Respiratory Rate BP Pain Scale

36.80C 71bpm 20cpm 120/80 mmHg 5/10

36.60C 71bpm 20cpm 120/80mmHg

36.90C 61bpm 19cpm 110/70mmHg 3/10

36.80C 63bpm 20cpm 120/80mmHg

[Type text]

Page 11

PHYSICAL ASSESSMENT (Cephalocaudal Approach) *data in merged cells represent same findings in three different assessment dates. Day 1 (July 25, 2013) Day 2 ((July 26, 2013) Day 3 (July 27, 2013)

He is normocephalic, with symmetrical facial movements. Fontanels are closed. Head His hair is fine and evenly distributed. His scalp is clean. He has symmetrical lids, no edema in the lids and periorbital region. The Eyes conjunctivae are jaundice, with icteric sclera. The pupils are of equal size (2mm) with brisk reaction to light and uniform constriction and convergence. He has a normoset and symmetrical external pinnae. He reported no abnormality Ears or difficulty in hearing. The septum is midline; both patents; sinuses are not tender; with pallor nasal Nose mucosa. Lips, mucosa and gums are pallor. The tongue is midline; with missing teeth Mouth (right upper molar and right lower molar) and with dental caries. Pharynx The uvula is located midline; with pallor mucosa. The tonsils are not inflamed. The trachea is midline; thyroids are non-palpable. Neck has normal range of Neck motion. Cardiovascular: no Cardiovascular: still no Cardiovascular: still no

reported chest pain; the complaints of chest pain; complaints of chest pain; precordial area is flat. the apical rate range from the apical rate range from The point of maximal 65-70bpm with regular 63.-68bpm with regular Chest impulse is at the left 5th rhythm. intercostal midclavicular No other rhythm. No other

space, significant changes. line.

significant changes.

Apical rate is 82bpm, with regular rhythm. The

[Type text]

Page 12

peripheral

pulses

are

symmetrical and regular. Capillary refill time is less than 2 seconds. Respiratory: the shape Respiratory: of chest patients is He is Respiratory: He is

2:1; the breathing regularly with breathing regularly with breathing respirations of 20 cycles respirations of 20 cycles

pattern is irregular with per minute. No other per minute. No other respiration of 24cpm. His significant lung expansion is noted. changes significant changes noted

symmetrical. No other abnormalities and observed. Presence of wound on the right upper quadrant with dressing dry and intact. He has a globular configuration. With normoactive bowel sounds with 5-15 Abdomen clicks/minute in all quadrants. Upon percussion, abdomen sounds tympanic and there were no tenderness reported upon palpation. Genitourin ary (external genitalia) The external genitalia were not assessed but the patient reported no abnormalities or any problems. reported

Back

and He has full range of motion. Spine is midline. Muscle strength has equally strong. And he was able to ambulate with coordination on his own.

Extremities

His skin turgor is firm; the texture is rough; temperature is warm. There was no Skin presence of petechiae, ecchymoses or any lesions.

[Type text]

Page 13

VI. DEVELOPMENTAL DATA

3Cs by Linda E. Hall The student nurses are instruments by which certain nursing problems which are faced by the client and the client's family are addressed and met. Quality professional nursing care requires the nurses to identify and solve overt and covert nursing problems. This theory emphasizes a client-centered approach because it is the primary role of the nurse to alleviate the patient from whatever suffering he/she is in and help her/him meet the needs. Her framework is efficient enough to address and meet the different requirements of the three aspects of her "pendulum model" which consists of client-oriented, nursing-centered and disease-centered approach.

Nursing is participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team.

The core is the person or patient to whom nursing care is directed and needed. The core has goals set by himself and not by any other person. The core behaved according to his feelings, and value system.

The cure, on the other hand is the attention given to patients by the medical professionals. The model explains that the cure circle is shared by the nurse with other health professionals. These are the interventions or actions geared on treating or curing the patient from whatever illness or disease he may be suffering from.

The care explains the role of nurses, and focused on performing that noble task of nurturing the patients, meaning the component of this model is the motherly care provided by nurses, which may include imited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed.

[Type text]

Page 14

VII.

ANATOMY AND PHYSIOLOGY

Anatomy of the biliary system: The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile. The transportation of bile follows this sequence: 1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. 2. These ducts ultimately drain into the common hepatic duct. 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). 4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver. 5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.

[Type text]

Page 15

Functions of the biliary system: The biliary system's main function includes the following:

to drain waste products from the liver into the duodenum to help in digestion with the controlled release of bile

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following:

to carry away waste to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, is what gives feces its dark brown color. Reference: http://medicalcenter.osu.edu/patientcare/healthcare_services/liver_biliary_pancreatic_disease/b iliary_system_anatomy/pages/index.aspx

The gallbladder, a pear-shaped organ, lies on the inferior surface of the liver. The biliary system consists of the gallbladder and its associated ductal system. The ductal system provides a pathway for the biles that is formed in the liver to be transported to the gallbladder or to the intestine and also functions to regulate bile flow. The liver produces up to 1L of bile per day. As it is formed, bile is excreted into hepatic duct, where it passes to the cystic ducts to be stored in the gallbladder. The capacity of the gallbladder is usually 50mL but can increase under normal conditions. In the gallbladder, bile is concentrated to a solution that is 5-10 times as concentrated as that produced in the liver. Bile contains cholesterol, phospholipids, bile salts, bilirubin, and a very small amount of protein and electrolytes: 97% o0f bile is water. Some toxins, drug metabolites, and hormones are excreted in bile. Because bile can be released directly into the duodenum through the common bile duct, the removal of the gallbladder has no long term consequences.

[Type text]

Page 16

Neural and hormonal mechanisms control the secretion of bile from the gallbladder. Food, particularly lipids in the duodenum, causes the release of cholecystokinin (CCK), also sometimes still called cholecystokinin-pancreozymin, from the mucosa of the duodenum. CCK is released into the blood and travels to the gallbladder. One of its activities is to stimulate the gallbladder musculator to contract. At the same time, it causes the muscle of the sphincter of oddi (at the end of the common bile duct) top relaxed and permit entry of bile into the duodenum. Gastrin, another gastrointestinal hormone, and vagal stimulation can also cause the gallbladder to contract. Bile acids are predominantly composed of a cholesterol derivative, and they function in the intestinal metabolism of fats and other substances as follows: 1. Facilitate fat digestion by emulsifying fats for action by intestinal lipases 2. Facilitates absorption of fats, fat-soluble vitamins, iron and calcium. 3. Activates the release of pancreatic and intestinal enzymes. Most of the bile salts secreted into the duodenum are reabsorbed into the intero-hepatic circulation from terminal ileum or other parts of the intestines. These bile salts are recirculated 23 times per meal. The reabsorption from the intestinal tract is so efficient that only 15-25% of the bile salts need to be replaced per day. Reference: Cassmeyer V.L., Process Phipps W.J., Approach Long B.C.,1993. Medical-Surgical Nursing: A Nursing 4th ed. Mosby:AllisonMeye

[Type text]

Page 17

VIII. PATHOPHYSIOLOGY
Modifiable factors

Non-modifiable factor AGE: 32 years old within the range 0f middle age 20-50 which are commonly affected with this condition

Smoker: For 17 years, he can consume 15 sticks a day). There is no specific reason why smoking precipitates gallstones but recent studies shown that smoking decreases gallbladder emptying and delays contraction upon digestion. Alcoholic: For 14 years, he occasionally drinks alcoholic beverages. High fat diet: He eats meat products before admission such as, pork and dried seafood, thus consuming high cholesterol and saturated fats.

Delays gallbladder emptying

Bile is supersaturated with cholesterol

The solute precipitates from the solution as solid crystals in the gallbladder

Crystals come together and fuse to form stones in the gallbladder

Biliary spasm

Epigastric pain/Biliary colic

The stones move into the biliary tree through the cystic duct Activation of Sympathetic NS Obstruction of common bile duct

Diaphoresis
Surgical Management: Laparoscopic

Cholecystectomy, [Type text] Page 18

Medical Management:

Ketorolac, IVTT, 30 mg, q 8 hrs Tramadol, IVTT,100 mg, PRN

Acute Pain related to actual tissue damage as manifested by pain scale of 7/10.

Medical Management:

Impaired tissue integrity related to surgical incision.

Cefuroxime , 750 mg,IVTT, q 8 Ranitidine, 50 mg, IVTT, q 8 hrs

Risk for Infection

Impaired bilirubin transport: Bile cant flow normally into the intestine but it is backed up into the liver substance

It is then reabsorbed into the blood resulting in Hyperbilirubinemia

ALP= 423.0 IU/L

Clay colored stool

Bile pigments are filtered into the renal LEGEND: system

Bile pigments are distributed into tissues in the body

JAUNDICE and ICTERIC SCLERA

If left untreated: Cholangitis

MANIFESTATIONS

LABORATORY RESULTS PREDISPOSING FACTOR

Orange colored/Tea colored urine

Septicemia/ Bactericemia
PRECIPITATING FACTOR DISEASE PROCESS MEDICAL MANAGEMENT

Death

NURSING DIAGNOSIS

[Type text]

Page 19

IX.

DIAGNOSTIC TEST

URINALYSIS TEST RESULT NORMAL VALUE Color Transparency Reaction Sp Gravity Sugar Protein 1.020 NEGATIVE +1 NEGATIVE NEGATIVE Amber Hazy Yellow Clear NORMAL NORMAL NORMAL NORMAL NORMAL MAY INDICATE INTERPRETATION

PROTEINURIA PUS cells RBC Bacteria Epithelial cells Coarsely Granular 0-2 0-1 Moderate Rare 1-2 NORMAL NORMAL

CLINICAL CHEMISTRY

TEST

RESULT

REFERENCE VALUE

INTERPRETATION

Creatinine BUN GLUC

1.0 15.71 147

0.62 1.28 mg/dl 135 148 mg/dl 60-110 mg/dl

NORMAL NORMAL MAY INDICATE

DIABETES

LIVER PROFILE

[Type text]

Page 20

TEST

RESULT

REFERENCE VALUE

INTERPRETATION

GOT

58.6

0.0-37.0 U/l

MAY

INDICATE

LIVER PROBLEM GPT ALP 35.8 662.0 0.0-42.0 U/l 80.0-306.0 U/l NORMAL MAY INDICATE

LIVER DAMAGE Interpretation: The alkaline phosphatase test (ALP) is often used to detect blocked bile ducts because ALP is especially high in the edges of cells that join to form bile ducts. If one or more of them are obstructed due to stones, then blood levels of ALP will often be high. EXAMINATION RESULT PROTHROMBIN TIME PROTIME: 14.2 seconds CONTROL: 11.8 seconds I.N.R. = 1.20 N.R. 10.2-15.2 seconds INTERPRETATION NORMAL

APTT PARTIAL

(AVTIVATED N.R.

INTERPRETATION

THROMBOPLASTIN TIME) APTT: 38.4 seconds Control: 28.6 seconds 23.4-38.5 seconds NORMAL

[Type text]

Page 21

PROTHROMBIN TIME PROTIME: 22.7 seconds

N.R. 10.2-15.2 seconds

INTERPRETATION MAY INDICATE

LIVER FAILURE CONTROL: 14.8 seconds I.N.R. = 1.9

APTT PARTIAL

(AVTIVATED N.R.

INTERPRETATION

THROMBOPLASTIN TIME) APTT: 52.2 seconds Control: 30.3 seconds 23.4-38.5 seconds

IMMUNOLOGY HbsAg COMPLETE BLOOD COUNT TEST RESULT REFERENCE VALUE Hgb Hct WBC count DIFFERENTIAL COUNT: Segmenters 16.4 48.0 11.4 13.7 16.7 g/L 40.5 49.7 gm% 5.0-10.0 10^3/uL NORMAL NORMAL INFECTION INTERPRETATION Non- Reactive

[Type text]

Page 22

Lymphocyte Monocyte Eosonophil Platelet count RBC MCV MCH MCHC

42.4 5.5 3.4 332 5.38 95.7 30.5 34.2

17.4-48.2% 4.5-10.5% 1.0-3.0% 150-400 10^3/uL 4.2-5.4 10^3/uL 82.0-98.0 fL 27.0-31.0 pg 31.5-35.5 g/dL

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

COMPLETE BLOOD COUNT TEST RESULT REFERENCE VALUE Hgb Hct WBC count DIFFERENTIAL COUNT: Segmenters 16.4 48.0 11.4 13.7 16.7 g/L 40.5 49.7 gm% 5.0-10.0 10^3/uL NORMAL NORMAL INFECTION INTERPRETATION

Lymphocyte Monocyte Eosonophil Platelet count RBC MCV MCH MCHC

42.4 5.5 3.4 373 5.38 89.2 30.5 34.2

17.4-48.2% 4.5-10.5% 1.0-3.0% 150-400 10^3/uL 4.2-5.4 10^3/uL 82.0-98.0 fL 27.0-31.0 pg 31.5-35.5 g/dL

NORMAL NORMAL

NORMAL NORMAL NORMAL NORMAL NORMAL

[Type text]

Page 23

ULTRASOUND REPORT The liver is normal in size with increased echogenicity. There is no mass or lesion seen. The intra and extrahepaticduts are markedly dilated. The common bile duct measures about .59cm. there are no echoes with largest measuring about 1.09 cm. seen in the distal portion. The gallbladder is distended measuring about 9.57 x 4.53 cm. Wall is thickened measuring about 4.1 mms. Tiny echoes are seen within the lumen. The pancreas, spleen and abdominal aorta are unremarkable. RK: 10.0 x 4.91 x 4.22 cm. with cortical thickness of 1.78 cm. LK: 10.9 x 4.93 x 4.66 cm. with cortical thickness of 1.80 cm. There is no disparity in the size of the kidneys. The central echo complexes are intact. No mass or lithiasis seen. The urinary bladder is unremarkable. The prostate gland is normal in size and echopattern measuring about3.10 x 3.54 x .96 cm. No focal mass lesion is seen.

IMPRESSION: FATTY LIVER CALCULOUS CHOLECYSTITIS INTRA AND EXTRAHEPATIC BILIARY ECTASIA MARKED, LIKELY DUE TO CHOLEDOCHOLITHIASIS, CT SCAN CORRELATION IS SUGGESTED. NORMAL PANCREAS, SPLEEN, ABDOMINAL AORTA, KIDNEYS, URINARY BLADDER AND PROSTATE GLAND

[Type text]

Page 24

X.

Medical and Surgical Management

a. DRUG STUDY Generic Name: Trade Name: Pharmacologic Class: Therapeutic Class : Minimum Dose: Routes of administration: Frequency: Mechanism of Action: wall synthesis. Indications: Treatment for susceptible infection due to gram(-) and cefuroxime Zinacef Cephalosporin (second generation) Antibiotic 750 mg Intravenous through tubing Every 8 hours A third generation cephalosporin that binds to bacterial cell

some gram (+) like biliary tract infections. Contraindications: Contraindicated to patient with history of anaphylactic reaction to penicillin or hypersensitivity to cephalosporins Carnitine deficiency ADVERSE EFFECTS: CNS: Dermatologic: GI: GU: Headache, hyperactivity, hypertonia, seizures, fatigue, malaise, dizziness pruritus, angioedema; bronchospasm and anaphylaxis nausea, vomiting, diarrhea, abdominal pain Nephrotoxicity

[Type text]

Page 25

Hypersensitivity:

Anaphylaxis,

NURSING RESPONSIBILITIES: Assess for history of allergies especially cephalosporins and penicillins Monitor bowel activity and stool consistency Monitor renal function reports for nephrotoxicity Be alert for superinfection; severe genital or anal pruritus, abdominal pain, severe mouth soreness, moderate to severe diarrhea Instruct patient and family to continue antibiotic therapy for full length of treatment.

Generic Name: Trade Name: Pharmacologic Class:

tramadol Tramadol Opioid Analgesic

Therapeutic Class: Analgesics Minimum Dose: 100 mg

Routes of administration: Intravenous through tubing Frequency: Mechanism of Action: Indications: Contraindications: Hypersensitivity to drug, its components or opioids Acute intoxication with alcohol, sedativehypnotics, centrally acting analgesics, opioids analgesics or psychotropic agents Physical opioids dependence PRN Inhibits reuptake of serotonin norepinephrine in CNS Moderate to moderately severe pain

[Type text]

Page 26

ADVERSE EFFECTS: CNS: Headache, vertigo, drowsiness, dizziness, anxiety, stimulation, confusion,

nervousness and sleep disorder CV: EENT: Dermatologic: GI: flatulence GU: Respiratory: Urinary retention and frequency, proteinuria Respiratory depression vasodilation Visual disturbances pruritus, sweating nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia,

NURSING RESPONSIBILITIES: Monitor respiratory status Monitor for physical and psychological drug dependence Tell patient drug works best when taken before pain becomes severe Monitor pulse and blood pressure. Assist with ambulation if dizziness and vertigo occurs. Monitor pattern of daily bowel activity and stool consistency Record onset of relief of pain

XI.

Nursing Care Management

a. Nursing Care Plan

Priority # 1 Subjective: Sakit kayo akong tahi, as verbalized by the client.
[Type text] Page 27

Objective; C pain scale of 7/10 C Facial grimace noted Guarding behavior noted Irritability Nursing Diagnosis: Acute Pain related to actual tissue damage secondary to post surgical incision Goals and Objectives: After 30 minutes of nursing intervention patients will be minimize.

Nursing Interventions; Independent 1.) Placed in semi-fowlers position. Rationale; This is done so that the patient feels comfortable and is able to recover faster. 2.) Instructed on the use of splinting techniques Rationale; To minimize pressure and to control pain during coughing. 3.) Encouraged to perform deep breathing and coughing exercises. Rationale; Hyperventilate the alveoli and prevent their collapse. Improve lung expansion and volume. Help expel anesthetic gases and mucus. Facilitate oxygenation of tissues. Facilitates the removal of retained mucus from the respiratory tract.

[Type text]

Page 28

 Dependent; 1.) Infused tramadol 50mg IV every 6 hours Rationale; Relief of moderate to moderately severe pain. Evaluation: Goals met: After 30 minutes of nursing intervention goal is met, patients pain was reduced from 7/10 to3/10 Priority # 2

PRIORITY PROBLEM #2: Impaired Skin Integrity related to Presence of a Post-operative Incision secondary to Mechanical Interruption of Skin Tissue

ASSESSMENT

Objective Cues:

Post-operative Incision 2.54 cm horizontally with suture and dressing Disruption of Skin Surface in the Right Umbilical Area Destruction of Skin Layers from surgical incision

GOALS AND OBJECTIVE:

Short-term Goal: Within 8 hours of nursing interventions, the patient will be able to: Achieve optimal nutrition and well-being to improve skin integrity
Page 29

[Type text]

Receive appropriate preventive measures to avoid complications of wound with the help of mother

Long-term Goal:

At the end of 3 weeks of nursing intervention, the patient will be able to: Display timely healing of wound without complication

INDEPENDENT: 1. Provide wound care using aseptic technique. R: To avoid infection.

2. Keep the wound clean and dry. R: To prevent the spread of microorganism. 3. Provide comfort and safety R: To provide optimal health and care to the patient.

EVALUATION GOALS MET as supported by the following manifestations: - Achieved proper healing of wound without complications; Suture and dressing have been removed with no evidence of infection - No more swelling and redness of the wound; skin has closed and timely wound healing is achieved.

Priority # 3 Objective: Wound is wet with drainage. Redness

[Type text]

Page 30

Nursing Diagnosis: Risk for Infection related to wound secondary to post-operative incision.

Goals and Objectives: After 8 hours of nursing intervention there will be decrease factors that predisposes the client for risk for infection Nursing interventions: Independent 1.) Daily wound dressing Rationale; To asses for localized signs of infection. 2). Stress proper hygiene to patient like hand washing when performing procedure. To avoid contamination of microorganism. 2.) Encouraged to eat high-protein and vitamin-C rich foods Rationale: To promote healing Evaluation: Goals met After 5 hours of nursing care, the client has been able to report moist free wound and has identified intervention to prevent or reduce risk of infection

[Type text]

Page 31

XII.

EVALUATIONS, RESULTS AND DISCUSSION

Long Range Goal/ Discharge Plan Upon discharge of Patient X, he will be able to achieve optimum wellness and be free from further complications by following the health regimen and taking medication prescribed by the doctor. Significant others will cooperate for the continuous care of patient. Medication Explain to the patient the purpose, dosage, schedule and route of any prescribed drugs as well as the side effects to report to the physician or nurse. Ketorolac, 30mg, 8am and 6pm it is an analgesic drug. Ranitidine hydrochloride, 50mg, 8am and 6pm it is an anti-ulcer drug. Exercise Encourage independence by doing everything he can within the limits of his condition. Treatment Encourage the patient to have an annual check-up to monitor his health condition. Teach patient about the importance of deep breathing exercises. Teach patient about the importance of range of motion exercises.

Health Teachings Out patient After the patient will be discharged, he still needs to have an annual check-up to monitor his health condition.
[Type text]

Instruct patient to have daily wound dressing to avoid infection. Instruct patient to avoid foods rich in fats and cholesterol like meat products Instruct patient to increase fluid intake 2-3 liters per day to promote hydration.

The patient must take his medication as ordered by the physician.

Page 32

Diet Spiritual The patient should strengthen his faith to God. The patient should eat soft diet foods and should avoid those high fat foods.

[Type text]

Page 33

XIII. LEARNING EXPERIENCE

Things were learned and discovered while making this requirement a successful one. And basically, I learned a lot from this duty especially to our clinical instructor. And through that experience, different views and perspectives were raised to have it more comprehensive. This case study and hospital exposure are some proofs that the life of a nursing student is never easy. But our eagerness and passion to have a successful nursing career enable to move on and face the many challenges in the study of nursing. Our second hospital rotation in the first semester has come to an end. At the NMMC hospital, I found our duty as quite difficult because of some adjustments we made due to the long time we havent assigned in the hospital setting. Now, our stay at Surgical ward was worth remembering. Why? Because though we only had a short time at the ward, it feels that the group has a longer time bonding with each other and so with our clinical instructor, Mr. Rey D, Pinalba. Our group does a lot of sharing together with the PCI and enjoyed each others company. But the most memorable thing was to see the faces of our patients the moment we enter the ward. The way they smile at us as if we were their family. Its a happy feeling and it made us feel great and it is a great relief to hear patients commending us, at least our existence in the ward paid off. To the staff nurses of NMMC Hospital who are very accommodating. They gladly entertained us if we have questions without any hesitations. To our patients who were very cooperative and very responsive, we were grateful the way they treated us, the way they respond and laid their trust in our capabilities. They showed gratitude in every nursing service that we rendered to them. To our PCI, Mr Loid Vidad, we are honored working and learning with you. We are very thankful for the things youve taught us which we will never forget as we go on with our profession. We learned a lot of things and we enjoyed your company. To our clinical instructor Sir Rey Pinalba RN, we found him as true to her work, disciplined, and very perfectionist. He understands the struggles we, the student nurses face. He
[Type text] Page 34

recognizes every little mistake we committed and taught us the proper way to do so. He gave us several encouragements especially her knowledge and values that she has imparted on us.

XIV. DEFINITION OF TERMS/KEY WORDS

1. Jaundice-yellowish staining of the skin, sclera and mucous membranes by deposition of bilirubin 2. Choledocholithiasis-presence of a gallstone in the common bile duct. 3. Bilirubin- it is the yellow breakdown product of normal heme catabolism

[Type text]

Page 35

XV.

BIBLIOGRAPHY

Book Sources: Doenges, Marilynn E., et al. Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and rationales. 11thed. The McGraw-Hill Companies, Inc., 2007 Pillitteri, Adele.(2010).Maternal and Child Health Nursing: care of the childbearing and childbearing family (6thed). Philippines. Lippincott Williams &Wilkins Springer-verlag (2002). Vulvar Cancer. Retreived February 09, 2012, from American Committee on Cancer (AJCC), Chicago, Illinois. Joint

Schuiling K, D., &Likis F.E (2006).Womens Gynecological Health Sudbury, M.A Jones and Barllet Publishers Website Sources: http://emedicine.medscape.com/article/26880-treatment http://health.nytimes.com/health/guides/disease/choledocholithiasis/overview.html http://im.unboundmedicine.com/medicine/ub/view/5-Minute-ClinicalConsult/116128/all/Choledocholithiasis http://www.scribd.com/doc/48770974/Pathophysiology-of-Choledocholithiasis http://www.umm.edu/ency/article/000274.htm http://emedicine.medscape.com/article/175667-overview http://www.scribd.com/doc/44647483/The-Grand-Case-Study-choledocholithiasis-group-a4 http://www.netdoctor.co.uk/ate/digestiveandurinary/201869.html

[Type text]

Page 36