Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino Delas Alas Campus
Indang, Cavite


College of Nursing



A Case Study on

CHOLECYSTECTOMY
Presented by:

Baro, Jenelyn L.
Bon, Kelieraine U.
Braga, Rhodeva Joy T.
Cedron, Ariane Rose S.
Cubillo, Irish Jane B.
Espineli, Leanna Mae S.
Lacson, Leonise Joie R.


Presented to:

Evelyn M. Del Mundo, RN, MAN, PhD.
Clinical Instructor, Level IV



August 1, 2014

In Partial Fulfillment of the Requirement in NURS 75 for the Degree Bachelor of Science
in Nursing

VISION
A premier university in historic
Cavite recognized for
excellence in the development
of morally upright and globally
competitive individuals.
MISSION
Cavite State University shall provide
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through quality
instruction and relevant research and
development activities. It shall provide
professional, skilled and morally upright
individuals for global competitiveness.
Page 1

TABLE OF CONTENTS

Table of Contents...............................................................................................................1
Abstract...............................................................................................................................2
Introduction........................................................................................................................3
Anatomy and Physiology...................................................................................................4
Diagnostic Procedures.......................................................................................................7
Medical-Surgical Management.........................................................................................9
Pathophysiology...............................................................................................................10
Post Operative Nursing Intervention.............................................................................12
Drug Study........................................................................................................................14
Problem List.....................................................................................................................22
Nursing Care Plan............................................................................................................23
Discharge Plan..................................................................................................................30
Bibliography.....................................................................................................................33












Page 2

ABSTRACT
The researcher had chosen Cholecystectomy as one of the clinical areas for
detailed study because it involves increase number of cases in the hospital, large
differences in reported costs between hospitals, and differences in reported lengths of
stay. She also wanted to gain more knowledge and acquire more skills of excellence for
the benefit of their future clients in succeeding years of her studies. In addition, is to
enhance the knowledge they learned in Medical Surgical Nursing in relation to its
application in actual setting.

The case is about a client undergone Cholecystectomy. This study aims to
identify the different manifestations of signs and symptoms of the disorder, define the
illness state, trace the pathophysiology, and apply nursing care during the course of
exposure.












Page 3

INTRODUCTION
A cholecystectomy is the surgical removal of the gallbladder. The two basictypes
of this procedure are open cholecystectomy and the laparoscopicapproach. It is estimated
that the laparoscopic procedure is currently used forapproximately 80% of cases.
Cholelithiasis involves the presence of gallstones, which are concretions that form in the
biliary tract, usually in the gallbladder.
More than 80% of gallstones in the United States contain cholesterol as their
major component. In the United States, 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. Each year, in the United States, approximately 500,000 people
develop symptoms or complications of gallstones requiring cholecystectomy.
Gallstone disease is responsible for about 10,000 deaths per year in the United
States. About 7000 deaths are attributable to acute gallstone complications, such as acute
pancreatitis. About 2000-3000 deaths are caused by gallbladder cancers (80% of which
occur in the setting of gallstone disease with chronic cholecystitis). Although gallstone
surgery is relatively safe, cholecystectomy is a very common procedure, and its rare
complications result in several hundred deaths each year. The prevalence of cholesterol
cholelithiasis in other Western cultures is similar to that in the United States, but it
appears to be somewhat lower in Asia and Africa. In an Italian study, 20% of women had
stones, and 14% of men had stones. In a Danish study, gallstone prevalence in persons
aged 30 years was 1.8% for men and 4.8% for women; gallstone prevalence in persons
aged 60 years was 12.9% for men and 22.4% for women.








Page 4

ANATOMY AND PHYSIOLOGY














The human digestive system is a complex series of organs and glands that processes food.
In order to use the food we eat, our body has to break the food down into smaller
molecules that it can process; it also has to excrete waste. Most of the digestive organs
(like the stomach and intestines) are tube-like and contain the food as it makes its way
through the body. The digestive system is essentially a long, twisting tube that runs from
the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce
or store digestive chemicals.

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THE DIGESTIVE PROCESS

The start of the process - the mouth:
The digestive process begins in the mouth. Food is partly broken down by the process of
chewing and by the chemical action of salivary enzymes (these enzymes are produced by
the salivary glands and break down starches into smaller molecules).
On the way to the stomach: the esophagus
After being chewed and swallowed, the food enters the esophagus. The esophagus is a
long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle
movements (called peristalsis) to force food from the throat into the stomach. This
muscle movement gives us the ability to eat or drink even when we're upside-down.
In the stomach
The stomach is a large, sack-like organ that churns the food and bathes it in a very strong
acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach
acids is called chyme.
In the small intestine
After being in the stomach, food enters the duodenum, the first part of the small intestine.
It then enters the jejunum and then the ileum (the final part of the small intestine). In the
small intestine, bile (produced in the liver and stored in the gall bladder),pancreatic
enzymes, and other digestive enzymes produced by the inner wall of the small intestine
help in the breakdown of food.
In the large intestine
After passing through the small intestine, food passes into the large intestine. In the large
intestine, some of the water and electrolytes (chemicals like sodium) are removed from
the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus,
Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The
first part of the large intestine is called the cecum (the appendix is connected to the
cecum). Food then travels upward in the ascending colon. The food travels across the
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abdomen in the transverse colon, goes back down the other side of the body in the
descending colon, and then through the sigmoid colon.
The end of the process
Solid waste is then stored in the rectum until it is excreted via the anus.










The so-called hepatobiliary system consists of the gallbladder, the left and right hepatic
ducts, which come together to form the common hepatic duct, the cystic duct, which
extends to the gallbladder, and the common bile duct, which is formed by the union of the
common hepatic duct and the cystic duct. The common bile duct descends posterior to
the first part of the duodenum, where it comes in contact with the main pancreatic duct.
These ducts unite to form the hepatopancreatic ampulla (ampulla of Vater). The circular
muscle around the distal end of the bile duct is thickened to form the sphincter of the bile
duct.
The gallbladder is a distensible, pear-shaped, muscular sac located on the ventral surface
of the liver. It has an outer serous peritoneal layer, a middle smooth muscle layer, and an
inner mucosal layer that is continuous with the linings of the bile duct. The function of
the gallbladder is to store and concentrate bile. Bile contains bile salts, cholesterol,
bilirubin, in the plasma. The cholesterol found in bile has no known function; it is
assumed to be a by-product of bile salt formation,and its presence is linked to the
excretory function of bile. Normally insoluble in water, cholesterol is rendered soluble by
the action of bile salts and lecithin, which combine with it to form micelles. In the
gallbladder, water and electrolytes are absorbed from the liver bile, causing the bile to
become more concentrated. Because neither lecithin nor bile salts are absorbed in the
Page 7

gallbladder, their concentration increases along with that of cholesterol; in this way, the
solubility of cholesterol is maintained.
Entrance of food into the intestine causes the gallbladder to contract and the sphincter of
the bile duct to relax, such that bile stored in the gallbladder moves into the duodenum.
The stimulus for gallbladder contraction is primarily hormonal. Products of food
digestion, particularly lipids, stimulate the release of a gastrointestinal hormone called
cholecystokinin from the mucosa of the duodenum. Cholecystokinin provides a strong
stimulus for gallbladder contraction. The role of other gastrointestinal hormones in bile
release is less clearly understood.
DIAGNOSTIC PROCEDURES
Diagnostic Examination Clinical Significance
1. Abdominal radiograph An abdominal x-ray is an imaging test to look
at organs and structures in the belly area.
Organs include the spleen, stomach, and
intestines. When the test is done to look at the
bladder and kidney structures, it is called a
KUB (kidneys, ureters, and bladder) x-ray.
2. Ultrasonography or cholecystography Cholecystography is a procedure that helps to
diagnose gallstones. In the test, a special dye,
called a contrast medium, is either injected into
your body or is taken as special pills (oral
cholecystography). This contrast medium
shows up the structure of the gallbladder and
bile duct on X-ray.
3. Radionuclide Imaging Nuclear Medicine Imaging is a test that
produces pictures (scans) of internal body parts
using small amounts of radioactive material.
This test is used to provide images of organs
and areas of the body that cannot be seen well
with standard X-rays. Many abnormal tissue
growths, such as tumors are particularly visible
using nuclear medicine imaging.
4. Cholescintigraphy Cholescintigraphy is a test done by nuclear
medicine physicians to diagnose obstruction of
the bile ducts (for example, by a gallstone or
a tumor), disease of the gallbladder, and bile
leaks. It sometimes is referred to as a HIDA
scan or a gallbladder scan.
5. Endoscopic retrograde
cholangiopancreatography (ERCP)
Endoscopic retrograde
cholangiopancreatography is a procedure that
Page 8

combines upper gastrointestinal (GI)
endoscopy and x rays to treat problems of the
bile and pancreatic ducts. ERCP is also used to
diagnose problems, but the availability of non-
invasive tests such as magnetic resonance
cholangiography has allowed ERCP to be used
primarily for cases in which it is expected that
treatment will be delivered during the
procedure.
6. Percutaneous transhepatic
cholangiography (PTC)
PTC is used to take pictures of the bile ducts
that drain the liver. Unlike the ERCP that uses
an endoscope to obtain clear images, the PTC
uses the insertion of a small needle into the
liver to reach the bile ducts. Once in the bile
duct, a radio-opaque dye is injected into the
biliary system and pictures are taken.
7. Computed tomography scan (CT or
CAT scan)
A diagnostic imaging procedure using a
combination of x-rays and computer
technology to produce cross-sectional images
(often called slices), both horizontally and
vertically, of the body. A CT scan shows
detailed images of any part of the body,
including the bones, muscles, fat, and organs.
CT scans are more detailed than general x-rays.
8. Hepatobiliary scintigraphy An imaging technique of the liver, bile ducts,
gallbladder, and upper part of the small
intestine.
9. Electrocardiogram ECG is an essential tool in evaluating cardiac
rhythm. Electrocardiography detects and
amplifies the very small electrical potential
changes between different points on the surface
of the body as a myocardial cell depolarize and
repolarize, causing the heart to contract.
10. Choledochoscopy The insertion of a choledoscope into the
common bile duct in order to directly visualize
stones and facilitate their extraction.





Page 9

MEDICAL-SURGICAL MANAGEMENT
Major objectives of medical therapy are to reduce the incidence of acute episodes of
gallbladder pain and cholecystitis by supportive and dietary management and if possible,
to remove the cause by pharmacotherapy, endoscopic procedures or surgical intervention.

Infusion of a solvent into the gallbladder to dissolve gallstones
Stone removal using an instrument with a basket or by ERCP endoscope
Extracorporeal shock-wave lithotripsy (repeated shock waves directed at the
gallstones located in the gallbladder or common bile duct to fragment the
stones)
Intracorporeal shock-wave lithotripsy (stones fragmented by ultrasound,
pulsed laser, or hydraulic lithotripsy applied through an endoscope directly to
the stones)

Goal of surgery is to relieve persistent symptoms, remove the cause of colic and treat
acute cholecystitis.
Laparoscopic cholecystectomy: performed through a small incision or
puncture made through the abdominal wall in the umbilicus
Cholecystectomy: gallbladder removed after ligation of the cystic duct and
artery
Mini-cholecystectomy: gallbladder removed through a 3~4cm incision
Cholecystectomy (surgical or percutaneous): gallbladder is opened and the
stones, bile or purulent drainage are remove





Page 10

PATHOPHYSIOLOGY
CHOLECYSTITIS AND CHOLELITIASIS








Genetic & Demography Change in Bile Decreased contractility Increased
Composition of bile flow intraluminal
Pressure
Bile Stasis


Contraction of substances present in bile Stimulates smooth Increase
muscle contraction tension to
Precipitation of bile substances duodenum

Bile substance will increase in size

Stones migrate to gall bladder RUQ abdominal Pain

Non modifiable factors
-Age (40 years old and above)
-Gender/sex (female)
-Genetic predisposition
-Estrogen levels
-Ethnicity (Native American & Hispanics)
Modifiable factors
-Obesity
-Rapid weight loss and diet
-Lack of physical activity
-Long-term total parenteral nutrition
-Oral contraceptives
-Pregnancy


Page 11

Obstruction of the flow in bile Radiating pain to lower back




Impaired Hepatic uptake Collection of soluble No bile reaches the GIT
of bilirubin bilirubin in the urine



Cholesterol salts Escape of bilirubin to GUT No bile in small Decrease bile
In the skin intestine for fat in the duodenum
Digestion
Jaundice Sterobilin
Emulsification of fats
Clay-colored stool
Presence of Nausea and Vomiting
Bile in the urine

Dark yellow urine

Obstructed cystic duct
Bile duct obstructed already
Gall bladder becomes distended (Cholelitiasis)
RUQ pain

Page 12

Interpretation:
Bile is a complex solution of cholesterol, bile-pigments, bile salts, calcium and
water. Under certain situations the lining of the gallbladder becomes diseased and the
solution becomes unstable leading to crystal formation. Eventually crystals provide a
nidus for nucleation and stones form.

POSTOPERATIVE NURSING INTERVENTION
Place patient in low Fowlers position
Provide intravenous fluids and nasogastric suction
Provide water and other fluids and soft diet, after bowel sounds return

Relieving pain
Instruct patient to use a pillow to splint incision
Administer analgesic agents as ordered

Improving Respiratory Status
Remind patient to expand lungs fully to prevent atelectasis; promote early ambulation
Monitor elderly and obese patients most closely for respiratory problems

Improving Nutritional Status
Advise patient at time of discharge to maintain a nutritious diet and avoid excessive fats;
fat restriction is usually lifted in 4~6 weeks

Promoting Skin Care and Biliary Drainage
Connect tubes to drainage receptacle and secure tubing to avoid kinking (elevate
above abdomen)
Place drainage bag in patients pocket when ambulating
Observe for indications of injection, leakage of bile, or obstruction of bile drainage
Observe for jaundice (check the sclera)
Note and report right upper quadrant pain, nausea and vomiting
Page 13

Change dressing frequently, using ointment to protect skin from irritation
Keep careful record of intake and output
Measure bile collected every 24 hours; document amount, color and character of
drainage

Monitor and managing complications
Bleeding: assess periodically for increased tenderness and rigidity of abdomen and
report; instruct patient and family to report change in color of stools. Monitor vital
signs closely. Inspect incision for bleeding
Gastrointestinal symptoms: assess loss of appetite, vomiting, pain, distention of
abdomen and temperature elevation; instruct patient and family to report promptly;
provide written reinforcement of verbal instructions














Page 14

DRUG STUDY
DRUG
MECHANISM
OF ACTION
INDICATION
CONTRAINDICAT
ION
SIDE/ ADVERSE
EFFECTS
NURSING
RESPONSIBILITIES
Generic Name:
Mefenamic Acid

Brand Name:
Ponstan

Classification:

Analgesic

Dosage:
500 mg

Route:
Oral

Frequency:
PRN

Form:
Capsule

Color:
Red and Yellow


Inhibits CNS
prostaglandin
synthesis with
minimal effects
on peripheral
prostaglandin
synthesis


1. Control of pain
due to headache,
earache,
dysmenorrhea,
arthralgia,
myalgia,
musculoskeletal
pain, arthritis,
immunizations,
teething,
tonsillectomy

2. As a substitute
for aspirin in
upper GI
disease, bleeding
disorders clients
in anticoagulant
therapy and
gouty arthritis

Previous
hypersensitivity
Products
containing
alcohol,
aspartame,
saccharin, sugar,
tartrazine should
be avoided by
patients who
have
hypersensitivity
or intolerance to
these compounds

Minimal GI upset.
Methemoglobinemia
Hemolytic Anemia
Neutropenia
Thrombocytopenia
Pancytopenia
Leukopenia
Urticaria
CNS stimulation
Hypoglycemic coma
Jaundice
Glissitis
Drowsiness
Liver Damage

Assessment:
Assess overall
health status and
alcohol usage
before
administering
aceraminophen.
Patients who are
malnourished or
chronically abuse
alcohol are at
higher risk of
developing
hepatotoxicity
with chronic use
of usual doses of
this drug.
Assess amount,
frequency and
type of drugs
taken in patients,
self-medicating,
espciall with
OTC drugs.
Prolonged use of
acetaminophen
increases the risk
of adverse renal
effects. For short
term use,
combined doses
of acetaminophen
Page 15

and salicylates
should not
exceed the
recommended
dose of either
drug given alone.

Patient/ Family Teaching
Advise patient to
take medication
exactly as
directed and not
to take more than
recommended
amount. Chronic
excessive use of
>4 g/day may
lead to
hepatotoxicity,
rena or cardiac
damage. Adults
should not take
acetaminophen
longer than 10
days and children
not alonger than
5 days unless
directed by health
care professional.
Short term doses
of acetaminophen
with salicylates
or NSAIDs
should not
exceed the
recommended
Page 16

daily dose of
either drug alone.
Advise patient to
avoid alcohol 93
or more glasses
per day increase
the risk of liver
damage) if taking
more than an
occasional 1-2
doses and to
avoid taking
concurrently with
salicylates or
NSAIDs for more
than a few days,
unless directed
by heath care
professionals.
Inform patients
with diabetes that
acetaminophen
may alter results
o f blood glucose
monitoring.
Advise patient to
notify health care
professional if
changes are
noted.
Caution patient to
check labels on
all OTC
products. Advise
patients to avoid
taking more than
Page 17

one product
containing
acetaminophen at
a time to prevent
toxicity.
Advise patients
to consult health
care
professionals of
discomfort or
fever is not
relieved by
routine doses of
this drug or if
fever is greater
than 39.5 C or
lasts longer than
3 days..










Page 18

DRUG
MECHANISM
OF ACTION
INDICATION
CONTRAINDICAT
ION
SIDE/ ADVERSE
EFFECTS
NURSING
RESPONSIBILITIES
Generic Name:
Cefuroxime

Brand Name:
Ceftin

Classification:
Anti-infectives
Cephalosporin
(2
nd
generation)

Dosage:
500 mg

Route:
Oral

Frequency:
3x a day

Form:
Capsule

Color:
White or Blue

Bactericidal:
inhibits synthesis
of bacterial cell
wall, causing cell
death.
Treatment of the
following infections
caused by susceptible
organisms:
respiratory tract
infections , skin and
skin structure
infections, bone and
joint infections,
urinary tract
infections, intra
abdominal and
gynecologic
infections,
meningitis, lyme
disease, otitis media,
septicemia and
perioperative
prophylaxis
Hypersentivity to
cephalosporins
Serious
hypersensitivity
to penicillins

Diarrhea
Cramps
Nausea and vomiting
Rashes
Urticaria
Bleeding
Seizures

Assessment:
Assess for
infection (V/S,
appearance of
wound, sputum
urine and stool;
WBC) at
beginning and
during therapy.
Before initiating
therapy, obtain a
history to
determine
previous use of
and reactions to
penicillin or
cephalosprins.
Persons with a
negative history
of penicillin
sensitivity may
still have an
allergic response.
Obtain specimens
for culture and
sensitivity before
initiating therapy.
First dose may be
given before
receiving
response.
Observe patient
for signs and
symptoms of
Page 19

anaphylaxis
(rash, pruritus,
laryngeal edema,
wheezing).
Discontinue the
drug immediately
of these
symptoms occur.
Keep
epinephrine, an
antihistamine,
and resuscitation
equipment close
by in the event of
anaphylactic
reactions.
Monitor bowel
function.
Diarrhea,
abdominal
cramping, fever,
and bloody stools
should be
reported to health
care
professionals
promptly as a
sign of
pseudomembrane
s colitis. May
begin up to
several weeks
following
cessation of
therapy.

Page 20

Patient/ Family Teaching
Instruct patient to
take medication
around the clock
at evenly spaced
times and to
finish the
medication
completely, even
if feeling better.
Take missed
doses as soon as
possible unless
almost time for
the next dose, do
not double doses.
Advise patient
that sharing of
this medication
may be
dangerous.
Advise patients
to report signs of
sueprinfection.
Instruct patients
to notify health
care
professionals of
fever and
diarrhea develop,
especially if stool
contains blood,
pus, or mucus.
Advise patient
not to treat
diarrhea without
Page 21

consulting health
care professional.

Page 22


PROBLEM LIST
The following problems are being prioritized according to Maslows Hierarchy of Needs.
Problem Nursing Diagnosis
1 Pain Acute Pain related to Post- Cholestectomy
2 Fear Deficient knowledge related to misconception and belief
3 Infection Risk for Infection





Page 23

NURSING CARE PLAN
Acute Pain Related to Post Cholecystectomy
ASSESSMENT
NURSING
DIAGNOSIS
SCIENTIFIC
RATIONALE
OBJECTIVE
NURSING
INTERVENTION
SCIENTIFIC
RATIONALE
EVALUATION
Subjective:
Kumikirot kirot ang
sugat ko. As stated
by the patient

Objective:
Surgical incision
at abdominal
upper right
quadrant
Pain scale of 3
out of 10 whereas
10 is severe pain
and 0 is no pain.
Reluctant in
performing ROM
Guarding
behavior when
turning on right
side
RR: 22
PR: 80
BP: 120/80
Temp: 36.0 C

Acute pain at
right upper
quadrant related
to post
cholestectomy.
Pain occurs
because of the
trauma on the
surgical incision
done during
cholestectomy.
Skin integrity,
muscle as well as
the affected organ
are traumatized.
After 8 hours of
nursing
interventions, the
patient will report
pain being relieved
or controlled and
appear relaxed as
evidenced by pain
scale of 2 from 3
out of 10.
INDEPENDENT:
1. Assessed pain,
noting location,
intensity (scale
of 0-10)




2. Kept at rest in
low-Fowlers
position.




3. Assisted the
patient in
splinting of the
surgical incision
to relieve pain.


4. Assisted the
patient in
turning to left
side unaffected
area.

5. Promoted deep
breathing

1. Provides
information to
aid in
determining
choice/
effectiveness of
interventions

2. Positioning low-
Fowlers can
promote
relaxation of
abdominal
muscle.

3. Decrease muscle
tension that can
cause pain/
discomfort.

4. Prevent pressure
to the surgical
incision.

5. More oxygen to
the muscle
providing

6. Increased fluid
intake can
After 8 hours of
nursing intervention,
the client reported
reduction of pain from
3 to 2 with a pain scale
of 10 is severe pain and
0 is no pain and
appeared relaxed.

Goal was met.
Page 24

exercise.


6. Increased fluid
intake.


7. Encouraged
early
ambulation.


8. Provided
diversional
activities.





DEPENDENT:
1. Administer
analgesics
as indicated.
promote healing

7. Promotes
normalization of
organ function,
e.g., stimulates
peristalsis and
passing of flatus,
reducing
abdominal
discomfort.

8. Refocuses
attention,
promotes
relaxation, and
may enhance
coping abilities.


1. Relief of
pain
facilitates
cooperation
with other
therapeutic
interventions,
e.g.,
ambulation,
pulmonary
toilet.
Page 26

Knowledge Deficit related to misconception and belief.
ASSESSMENT
NURSING
DIAGNOSIS
SCIENTIFIC
RATIONALE
OBJECTIVE
NURSING
INTERVENTION
SCIENTIFIC
RATIONALE
EVALUATION
Subjective:

Nakakatakot yung tahi
ko baka bumuka. As
stated by the patient

Objective:
Restlessness
Increased
apprehension
RR: 22
PR: 80
BP: 120/80
Temp: 36.0 C
Knowledge
deficit related
to
misconception
and belief.
Inadequate
knowledge
regarding a
particular
condition
increases ones
apprehension.
Single
information that
is not presented
or explained well
might result to
misconception.
After 8 hours of
nursing
interventions the
patient will be able
to respond at least 3
out of 5 questions
as evidenced by
patients
willingness to
cooperate.
1. Assessed
patients
condition.



2. Been available
to the patient.
Established
trusting
relationship
with patient/
SO.

3. Provided
information
about the
interventions in
the healing
process. Be
aware of how
much
information
patient wants.


4. Maintained
matter-of-fact
attitude in
doing
procedures/
dealing with
1. This will serve as
a baseline data for
more effective
care to be rendered
to the patient.

2. Demonstrates
concern and
willingness to
help. Encourages
discussion of
sensitive subjects.


3. Helps patient
understand
purpose of what is
being done and
reduces concerns
associated with
unknown,
however, overload
of information is
not helpful and
may increase fear.

4. Communicates
acceptance and
cases patients
embarrassment.


After 8 hours of
nursing intervention,
the patient was able to
answer 4 out of 5
questions regarding her
condition.

Goal was met.
Page 27

patient. Protect
patients
privacy.

5. Encouraged
patient to
verbalize
concerns and
feelings.





6. Reinforced
previous
information
patient has
been given.




5. Defines the
problem,
providing
opportunity to
answer questions,
clarify
misconception and
problem-solve
solutions.

6. Allows patient to
deal with reality
and strengthens
trust in caregivers
and information
presented.

Page 28

Risk for Infection
ASSESSMENT
NURSING
DIAGNOSIS
SCIENTIFIC
RATIONALE
OBJECTIVE
NURSING
INTERVENTION
SCIENTIFIC
RATIONALE
EVALUATION
Risk Factors:
Inadequate
primary defenses
Tissue
destruction;
invasive
procedure
With soaked
wound dressing
Poor hand
washing
With incision on
the right upper
quadrant.

Risk for
Infection on
surgical site
related to post
cholestectomy

Environment,
hygiene and
other external
factors can
contribute to
accumulation of
microorganism
on the affected
site that may
cause
inflammation
and eventually
infection.
After 8 hours of
nursing
interventions, the
patient will be
able to identify
signs and
symptoms of
impending
infection and
verbalize
understanding
about
interventions to
prevent or reduce
risk of infections.
INDEPENDENT:
1. Assessed
patients
condition.



2. Monitored vital
signs. Note onset
of fever, chills,
diaphoresis, and
reports of
increasing
abdominal pain.

3. Inspected
incision and
dressings. Note
characteristics of
drainage from
wound/drains (if
inserted),
presence of
erythema.

4. Encouraged in
good
handwashing and
aseptic wound
care.

5. Changed surgical

1. This will provide
more concise
information about
the patients
condition.

2. Suggestive of
presence of
infection/developi
ng sepsis, abscess,
peritonitis.



3. Provides for early
detection of
developing
infectious process,
and/or monitors
resolution of
preexisting
peritonitis.


4. Reduces risk of
spread of bacteria.




5. Frequent changing
After 8 hours of
nursing intervention,
the client reported
comprehension on his
condition specifically
the signs and symptoms
of impending infection
and demonstrated
interventions to reduce
the risk of infection.

Goal was met.
Page 29

or other wound
dressings as
indicated.




6. Used proper
techniques in
maintaining the
cleanliness of the
wound.




7. Performed proper
disposing of
contaminate
materials.

DEPENDENT:
1. Administered
antibiotics as
appropriate.
of dresses prevents
bacteria to
accumulate on the
incision site.



6. Maintaining the
cleanliness of the
wound may help
preventing the
spread of
microorganism
that may cause
infection.

7. This will keep and
maintain a clean
environment that
can prevent
infection.

1. Antibiotics
given before
cholecystecto
my are
primarily for
prophylaxis of
wound
infection and
are not
continued
postoperativel
y. Therapeutic
antibiotics are
administered
Page 30

if peritonitis
has developed.
Page 30

Republic of the Philippines
CAVITE STATE UNIVERSITY
Don Severino delas Alas Campus
Indang, Cavite


College of Nursing

DISCHARGE PLAN
A. MEDICATION
Strictly follow the prescribed medication to prevent drug resistance. Alcohol and cigarette
smoking are discouraged to prevent further complications and so that the desired effects of the
drugs will be achieved. It is advised not to administer drugs that are not prescribed by the
physician. Non-prescription drugs may have an antagonistic or synergetic effect if taken with
other drugs. Side effects and adverse effects from drug reactions can transpire and cause
damage or complication to the clients body.

Pail relievers are given to ease the post operative pain. It is only taken when pain is felt. Anti-
biotic medication was also given for 7 days (three times a day- every 8 hours) to prevent
occurrence of infection and further complications.
B. DIET
Skipping of meals and fasting is prohibited. Diets that are high in calories, low in fiber, and
high in refined carbohydrates also increase the incidence of gallstones. Advise the family to
feed the client foods rich in fiber and protein such as vegetables and fruits. Protein and fiber
rich foods can facilitate tissue healing and will delay the onset of uremic symptoms. Foods
rich in vitamin C, such as oranges, citrus juices, and green leafy vegetables are encouraged to
be taken. It can aid in strengthening the bodys immune system to combat infection and other
illnesses.


MISSION
Cavite State University shall provide
excellent, equitable and relevant educational
opportunities in the arts, science and
technology through quality instruction and
relevant research and development activities.
It shall provide professional, skilled and
morally upright individuals for global
competitiveness.
VISION
A premier university in historic
Cavite recognized for
excellence in the development
of morally upright and globally
competitive individuals.
Page 31

C. TREATMENT
Continue to comply with the treatment regimen prescribed by the physician
upon discharge from the hospital. This will promote faster recovery and prevents further
complication.
D. EXERCISE
Daily exercise is recommended to maintain normal body weight. Obesity has a negative
impact by increasing the bodys level of cholesterol. Light exercises like walking and avoid
intense exercises and strenuous activities. Light exercises prevent muscle atrophy and intense
exercises and strenuous activities cause fatigue. Avoid lifting heavy objects and stair
climbing. This is not to strain the abdominal muscles post-operatively. Adequate rest and
sleep is advised. Sufficient rest and sleep can help for faster healing and recovery. It can also
help to prevent injury and harm.
E. ACTIVITY
Patients encourage mobilizing after the surgery for wound healing for bringing back the
system to its normal functioning. Light exercises are also recommended. A good, clean, and
safe environment should be present. This will prevent the occurrence of further complications.
Hand wash before and after contact with patient and preparing food. It is the safest and
cheapest way to prevent the transmission of microorganisms. Bathing and grooming of the
client should be maintained. Proper hygiene and grooming promotes cleanliness, comfort and
relaxation. This protects the clients defense mechanism against diseases. The family
can provide psychological and emotional support. To reduced anxiety and worries.
F. FOLLOW UP CONSULTATION
One week after the surgery, patients are advised to seek for follow up consultation to check
for the patients condition. Regular check-ups should be encouraged to evaluate clients
progress after the medical intervention.

Page 32

G. SIGNS AND SYMPTOMS WHEN TO SEEK IMMEDIATE/ EMERGENCY
CONSULTATION
If black tarry stool was seen and pain in the upper right abdomen was felt immediately seek
for medical assistance. Reporting of any uncommon signs can help in rendering prompt
interventions and treatment regarding patients condition.






















Page 33

BIBLIOGRAPHY

Essentials of Pathophysiology (page 510~512)
Brunner & Suddarths Hand book for Medical-Surgical Nursing 10
th
Ed. (pg. 247~252)
http://www.slideshare.net/sunny_8162/acute-calculous-cholecystitis Updated last June
2008
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