GENERAL OBJECTIVES: The study intends to improve the knowledge of the students regarding Choledocholithiasis.

It gives the student the chance to be trained regarding the case of the patient that can be use in the future. It expands the knowledge of the student related to the body system involved. The study also intends to apply the different skills that students learned from the related learning experiences regarding on physical assessment and also on those different nursing intervention that may be apply according to patients case. Other than improvement of knowledge and skills, this study intends to improve the attitude of the students. The proper approach towards the patient is vital to develop a good way of communication and rapport. This leads them to have a professional relation and pleasant trust with the patient that may use to garner precise information and accomplish a positive health outcome.

SPECIFIC OBJECTIVES: 1. To identify the basic information of the client and know how to relate it to the study. 2. To perform a thorough physical examination with the use of therapeutic communication. 3. To gather laboratory exams and correlate to the study. 4. To know the affected part of the body of this case. 5. To understand how Choledocolythiasis happens. 6. To distinguish the drugs that is being used for the treatment. 7. To formulate an accurate nursing care plan that is suitable for the client. 8. To be aware of proper attitude that an ideal nurse should posses.

I. i.

INTRODUCTION Background of the Study Incidence, race, gender, age , ratio, and proportion A UTIs are a very common type of infection particularly in women. It is estimated in

thePhilippines that one woman in three will have a UTI before the age of 24, and that half of all womenwill have at least one UTI during their lifetime. This is less common in men. It is estimated that everyyear in the Philippines, in otherwise healthy men, only one in every 2,000 will develop a UTI.

ii.

Rationale for choosing the case I decided to choose the case of Urinary Tract Infection to a specific patient

because as nursing student, I have to relate our learning acquired in Medical Surgical Nursing subject regarding renal disorder especially as I handle our patients from childrens Ward. This case may leave a more interesting study that will bring up knowledge to us. iii. Significance of the studies The significance of the study is to gain and enhance knowledge, to develop

skills and apply the attitudes that must be render to the client whatever the case may be. This study will also contribute in the widening of the ideas of the student about the topic of the case.

iv.

Scope of limitation of the study The study would only focus on the information gathered from the patient,

relatives of the patient, from her records and laboratory results. This will be covering about the case of Urinary Tract Infection, all about its anatomy and physiology and

how did all of the records may it be the medications, doctors order and nurses notes correlates to each other.

v.

Conceptual/ Theoretical Theory

DOROTHEA ELIZABETH OREM (SELF-CARE DEFICIT NURSING THEORY)

Since that Orems theory, defines self-care as the practice of activities that individuals initiate and perform independently on their behalf in maintaining life, health, and well-being. (Udan, 2011)

According to Orem, you can say that a person is having a self-deficit when he is unable to carry out his own self-care. (Udan, 2011)

In the case of our patient, she lacks to take care of herself by simply having the discipline to take foods that is high in sodium and influenced by her friends in engaging in drinking alcoholic beverages, also carbonated drinks.

Orem also stated about the self-Care agency, wherein it is a human ability for engaging in self care activities and Self-care demands wherein it is the totality of self care actions to be performed for some duration in order to meet self care requisites (Udan, 2011),

For our client, Orem stated 5 methods of helping her to conquer self-care deficit. First, is acting for and doing for others, as her student nurse, we should help her in things she cant do while shes confined. Doing dependent activities wherein we can help her. Also guiding her and supporting her on what to do better with those things that she ought to do. Also by providing an environment to promote patients ability and teaching her the proper things to do for her situation.

vi.

Related literature of the study

Cholelithiasis, cholecystitis and related disorders The leading biliary tract disease, cholelithiasis is the formation of stones or calculi (gallstones) in the gallbladder. The prognosis is usually good with treatment unless infection occurs. In that case, the prognosis depends on the infections severity and its response to antibiotics. The formation of gallstones can give rise to a number of related disorders. In cholecystitis, the gallbladder becomes acutely or chronically inflamed, usually because a gallstone becomes lodged in the cystic duct, causing painful gallbladder distention. The acute form is most common during middle age; the chronic form among elderly persons. The prognosis is good with treatment. In Choledocolythiasis, gallstones pass out of the gallbladder and lodge in the common bile duct, causing partial or complete biliary obstruction. The prognosis is good unless infection occurs. Generally, gallbladder and duct diseases occur during middle age. Between ages 20 and 50, theyre six times more common in women, but the incidence in men and women equalizes after age 50. The incidence rises with each succeeding decade.

CAUSE:

These related disorders all stem from a common cause: formation of calculi. Although the exact cause of gallstones formation is unknown, abnormal metabolism of cholesterol and bile salts clearly plays an important role. A number of risk factors have been identified that predispose a person to calculi formation. These include: A high-calorie, high-cholesterol diet, associated with obesity Elevated estrogen levels from oral contraceptive use, postmenopausal hormonereplacement therapy, or pregnancy The use of clofibrate Diabetes mellitus, ileal disease, hemolytic disorders, hepatic disease, or pancreatitis.

COMPLICATIONS:

Each of these disorders produces its own set of complications. Cholelithiasis may lead to any of the disorders associated with gallstone formation: cholangitis, cholecystitis, choledolithiasis and gallstone ileus. Cholecystitis can progress to gallbladder complications, such as empyema, hydrops or mucocele, or gangrene. Gangrene may lead to perforation, resulting in peritonitis, fistula formation, pancreatitis, and porcelain gallbladder. Other complications include chronic cholecystitis and cholangitis. Choledocholithiasis may lead to cholangitis, obstructive jaundice, pancreatitis, and secondary biliary cirrhosis.

ASSESSMENT:

Although gallbladder disease may produce no symptoms, acute cholelithiasis, acute cholecystitis, and choledocolithiasis produce symptoms of a classic gallbladder attack.

 In a gallbladder attack, the patient typically complains of sudden onset of severe steady or aching pain in the midepigastric region or the right upper abdominal quadrant. She may describe this pain as radiating to his back, between the shoulder blades, over the right shoulder blade, or just to the shoulder area. This type of pain is known as biliary colic and is the most common characteristic symptom of gallbladder disease. Its often severe enough to send him to the emergency department. Often, the patient reports that the attack followed eating a fatty meal or a large meal after fasting for an extended time. The attack may have occurred in the middle of the night, suddenly awakening him. He may also report nausea, vomiting and chills; a low-grade fever may be assessed. The patient may report a history of milder GI that preceded the acute attack. He may have experienced these symptoms for some time before seeking treatment. Such symptoms may include indigestion, vague abdominal discomfort, belching, and flatulence after eating meals or snacks rich in fats. TREATMENT: Surgery, usually elective, remains the most common treatment for gallbladder and duct disease. Surgery is usually recommended if the patient has symptoms frequent enough to interfere with his regular routine; if he has any complications of gallstones; or if he has had a previous attack of cholecystectomy.

II.

CLINICAL SUMMARY A. GENERAL DATA PROFILE Name: Mrs. X

Address: Birthday: Birth Place: Spouse Name: Nationality: Religion: Occupation: Date of Admission: Admitting Diagnosis: Admitting Physician:

Guianangan, Quezon June 16, 1981 Guianangan, Quezon Mr. X Filipino Catholic Vendor July 27, 2013 Abdominal and Back pain Dr. Combalicer

B.

CHIEF COMPLAINT Prior to admission the patient has hypogastric pain distal with dysuria.

C.

NURSING HISTORY History of present Illness a. Childhood Illness - cough, colds, fever Immunization - BCG, measles, OPV, DPT, Hepa B Allergies - when eating rotten foods Accidents - none

b. c. d.

e.

Hospitalizations - deliveries Medication used or currently taking Cefuroxime tramadol

f.

ranitidine essential forte ciprofloxacin omeprazole simvastatin HNBB pantoprazole morphine ketorolac cefotiam meloxicam estrogen pills

E. SOCIAL HISTORY Include theories and growth and development Psychosocial theory according to Erik Erikson Stage Age Central task Indicators of positive resolution Creativity, productivity, concern for others. Indicators of negative resolution Self-indulgence, self-concern, lack of interests &commitments.

Adulthood

25-65 y/o

Generativity vs. stagnation

According to this theory, Generativity is the concern in establishing and guiding the next generation. Simply having or wanting children doesnt achieve generativity. Socially valued work and disciples are alsp expressions of generativity.

According to Sigmund Freud Stage Genital Age Puberty Characteristics Energy directed Implication Achievement

onwards

towards full sexual maturity & function &development of skills to cope with the environment.

of independence and decision making.

According to this theory, the genital age correlates to his age because she wants to gain independence and decision making by working and from her age she wants to separate from her parents to start with a family. When it comes in decision making, she is the one who make a decision for her problem as long as she knows that she can solve it with her own, we can say that she is in the stage of independency.

F. ENVIRONMENTAL/ LIVING CONDITION The The environment where she lives and work can be found near main road. She also has her live in partner and child living with her. G. PHYSICAL ASSESSMENT

Parameters General Appearance

Normal findings -clean in appearance & well groomed -cooperative

Pre operative -pale in appearance

Post operative -pale in appearance

Interpretati on -before and after surgery, pt is slightly pale due to pain and the effect of surgery

Skin Hair

-with good skin turgor -evenly

Nails

Skull & face

Eyes

Ears

distributed hair -thick hair -with good capillary refill of 2 seconds -with pinkish nail beds -with clean and short nails -mouth uniform consistency; absence of nodules & masses -rounded smooth skull contour symmetrical facial movement -no eye discharge -with anicteric sclera -eyebrows hair evenly distributed/ skin intact -(+) blink reflex -with pinkish conjunctiva -auricle color same

Mouth

Musculoskeletal (upper & lower extremities)

as facial skin -auricle are mobile firm and not tender -able to hear on both ears -no edema & discharge -pinkish lips -without missing teeth -with pink gums -no foul odor -with symmetrical contour symmetrical -no atrophy -with full range of motion

-dry lips

-dry lips

-PTs lips are dry because she was placed in pre and post NPO status.

-with low range of motion

-pt is in complete bed rest

Abdomen

-no abdominal distention -flat rounded abdomen symmetrical contour -no surgical incision

-with surgical incision at the right lower abdomen

-pt is in low range of motion because of the pain, and complete bed rest due to post operative -because of post cholecystect omy

H. PATTERNS OF FUNCTIONING

Functional Health Pattern

Before Hospitalization

During Hospitalization Pre operative Post operative Follows treatment regimen

Interpretation

Health Management Pattern

Self-medication

Follows treatment regimen

Prior to admission the patient was self medicated due to less severe illness.

Nutritional/M etabolic a. number of meals per day

3 times a day

NPO post midnight

Soft diet, once a day Decrease in appetite 3-4 glasses of water a day

b. appetite

Eats one cup of rice and viand appropriately every meal 5-6 glasses of

----

c. glass of

------

Prior to hospitalization the patient is on NPO post midnight and after surgery but before hospitalization she eats and

water per day

water a day only little change of body built

drinks in normal pattern.

d. body built

Large body built

Large body built

Elimination a.frequency of urination 6 times 6 times per day With Foley catheter

The patient is constipated but has a good bladder

b. amount of urine per day c. frequency of bowel movement d. consistency of the feces

Approx. 300 cc/day

Approx. 300 cc/day

Approx. 200cc/day

functioning before and after surgery

Once a day

No bowel movement ----

No bowel movement -----

Formed

Activity and exercise a. Exercise

Walking as form of exercise

Not active, limited movements

Limited movement s

b. Fatigability

Does not easily get tired

Does not get tired

Does not get tired

c. d. e. ADL f.

Independent Slightly dependent Dependent

While in the hospital, before operation the patient has been slightly dependent in doing her ADL, she is still doing some alternative exercises as instructed by the health provider. After

operation the patient has become dependent in doing her ADL.

Roles/ relationship a. as a daughter

With good relationship to her parents and she provides financial aid to the family

b. as a sister

With good relationship to her sisters

c. as a wife d.

e. co-worker

With good relationship to her husband

With good relationship to her parents and she provides financial aid to the family With good relationship to her sisters With good relationship to her husband With good relationship with her co workers Have a high self worth/imp ortance

With good relationshi p to his parents

She has still good relationships with his family, husband, coworkers

With good relationshi p to her sisters With good relationshi p to her husband

With good relationship with her co workers

With good relationshi p with her co workers Have a high self worth/imp ortance She has still has a high self worth in spite being in the

Self perception/ Self Concept

Have a high self worth/importanc e

hospital and undergoing operation. Coping/Stress Talks to friends and family,when she have problems Talks to friends and family members Sleeping Talks to friends and family She has a good coping technique and is considered to be like other peoples way to cope when they are stressed

I.

COURSE IN THE WARD DAY 1 JULY 27, 2013 (SATURDAY) A 31 years old female was admitted at 11:10pm. Accompanied by her mother-in-law,

with a chief complaint of abdominal pain. The resident on duty examined her and following orders were given. Please admit to the female surgical ward, secure consent, temperature, pulse rate and respiratory rate must be recorded every shift, for complete blood count blood typing and for chem, for urinalysis, random blood sugar, urea, for electrocardiogram, for chest x-ray posterior-anterior. It was done at the same day. The physician ordered a 5% Dextrose in Lactated Ringers 1 liter to run for eight hours. Cefuroxime 750mg IV every 8 hours after negative skin test. Tramadol 50mg IV every 8 hours after negative skin test. Hyoscine-N-butylbromide 10mg IV every 8 hours after negative skin test. Ranitidine 50mg IV every 8 hours. For cholecystectomy with common bile duct exploration once cardiopulmonary clearance. Refer to medicine resident on duty for continue management. DAY 2 JULY 28, 2013 (SUNDAY)

The physicians ordered to continue medications and follow up diagnostic chem. Examined decrease abdominal tenderness. Essential forte 1 cap three times a day.

DAY 3 JULY 29, 2013 (MONDAY)The physicians ordered during rounds general liquid diet and follow up cardiopulmonary clearance results.

DAY 4 JULY 30, 2013 (TUESDAY) The physicians ordered soft diet, IVF and IV medications to consume. Ciprofloxacin 500mg 1cap BID. Omeprazole 20mg 1tab BID. Simvastatin 20mg 1tab OD. For pre operation on Thursday.

DAY 5 JULY 31, 2013 (WEDNESDAY) The patient was seen and examined by Dr. Mallare and made ordered for pre operation on Thursday. For cholecystectomy with common bile duct exploration tomorrow. Notify OR/AOD. Secure consent. NPO post midnight. HNBB 10mg IV now. Pantoprazole 4g IV OD.

DAY 6 AUGUST 1, 2013 (THURSDAY)

The patient was seen and examined by Dr. Mallare and made ordered for cholecystectomy tomorrow. NPO post midnight. IVF to follow 5% Dextrose in Lactated Ringer 1 liter to run for eight hours, 5% Dextrose in Normosol-M 1liter to run for eight hours, 5% Dextrose in Lactated Ringer 1 liter to run for eight hours. Cefuroxime 750mg IV on call OR. Ranitidine 50mg IV on call OR. Please inform Dr. Morales.

DAY 7 AUGUST 2, 2013 (FRIDAY) The physicians post operative ordered vital signs every 15minutes for 2 hours. IVF same rate 30 drops per minute. IVF to follow to follow 5% Dextrose in Lactated Ringer 1 liter to run for eight hours, 5% Dextrose in Normosol-M 1liter to run for eight hours, 5% Dextrose in Lactated Ringer 1 liter to run for eight hours. Cefotiam 1gm IV every 12 hours. Ranitidine 500g IV every 8 hours. Morphine Sulfate 10ml every 12 hours for 4 doses. Ketorolac 30mg IV every 8 hours. Encourage deep breathing. Oxygen inhalation. Refer accordingly.

DAY 8 AUGUST 3, 2013 ( SATURDAY) The physician ordered NPO. IVF 5% Dextrose in Lactated Ringer 1 liter for 12 hours. Discontinue Cefuroxime 750mg IV every 8 hours and Ceftriazone 1gm IV every 12 hours. Add Pharmin BID. DAY 9 AUGUST 4, 2013 (SUNDAY)

The physician ordered remove Foley catheter, change of dressing, general liquid diet. Refer anesthesiologist for epidural catheter.

DAY 10 AUGUST 5, 2013 (MONDAY) Soft diet to diet as tolerated, change of dressing. IV medications to oral medications, Ciprofloxacin 500mg BID, Meloxicam 7.5mg TID, Pantoprazole 400mg OD. May go home. For T-tube cholangiogram on August 16, 2013.

J. LABARATORY DIAGNOSTICS EXAM HEMATOLOGY: Date time report released Name of Test Hemoglobin Hematocrit RBC Count MCV MCH MCHC WBC Count DIFFERENTIAL COUNT 7/27/13 Reference Range 12.0-16.0 0.37-0.43 4.0-5.4 78-102 39.0-54.0 451-574 4.0-10.0 Significance of the result Normal Normal Normal Normal Normal Normal INCREASED WHITE BLOOD CELL: Indicates an increased production of white blood

Result 12.70 g/dl 0.39 4.17 93.70 30.40 325.00 23.30

0.89

0.55-0.65

- Neutrophil - Lymphocyte - Monocyte -Eosinophil -Basophil OTHERS Platelet Count ABO RH Typing ESR

0.19

0.25-0.35 0.03-0.06 0.02-0.04 0.00-0.01 170-400

cells to fight an infection, a disease of bone marrow, causing abnormally high production of white blood cell. INCREASED IN NEUTROPHILS: Indicates acute infections, trauma or surgery.leukemia,malignant disease,necrosis

O Positive 0.10mm/hr

CHEST X-RAY:

Clear lung fields Normal heart shadow Diaphragm, casocus structures and soft tissues are intact IMPRESSION: Essentially normal chest findings

URINALYSIS: Test Color Transparency Specific gravity Rbc Wbc Actual finding Dark yellow Slightly turbid 1.010 2-3 6-10 Norml values Yellow to amber Clear 1.01-1.030 0-1hdp Interpretation Normal Deviation from normal Normal Deviation form normal ( Wbc is present because infections is present)

Epiheleal cells Bacteria Sugar Albumin A.phosph

Moderate Few Negative Negative many

15-20 squamous epithelial cells/hpf none 0-15mg/dl 3.5 - 5 g/dL 2.5-4.5

normal Presence of infection normal normal Indicates that there is kidney problem.

BLOOD CHEMISTRY Test Name Glucose BUN kinetic UV Creatinine Uric Acid AST(SGOT) ALT(SGPT) Cholesterol Triglycerides HDL Cholesterol LDL Cholesterol Result Normal Values Normal: 70.0-115.0 Normal:7.0-1.4 Normal: 0.3-1.3 Normal:2.60-7.20 Normal:0-40 Normal:0-41 Normal:<= 200.0 Normal:0.0- 150.0 Normal:>35.0 Normal:130-150.0 Interpretation

0.60 mg/dl

Serum creatinine (a blood measurement) is an important indicator of renal health because it is an easily-measured by-product of muscle metabolism that is excreted unchanged by the kidneys.

Test Name

Result

References

Interpretation

Glucose Blood Urea Nitrogen Uric Acid Cholesterol HDL Cholesterol LDL Cholesterol Triglycerides

100 mg/dl 10 mg/dl 2.9 mg/dl 202 mg/dl 16 mg/dl 151.3 mg/dl 71mg/dl

Range 70-110 10-20 mg/dl .60-7.20 <=200.0 50-60mg/dl 130-150.0 0.0-150.0

High level of low density lipoprotein cholesterol is one of the precipitating factors for coronary artery disease Significance of the result Normal Normal Normal

Name of Test Prothrombin time %Pro time activity INR

Result 12.5 105% 0.92

Reference Range 11-16 70-100 .85-1.15

Interpretation: Fatty liver Intra and extrahepatic biliary obstruction due to choledocholithiases Calculous cholecystitis Normal aorta, spleen pancreas, kidneys, ureters, urinary bladder, uterus ad adnexae

DISCHARGE PLAN ( M-E-T-H-O-D ) MEDICATION Adhire to treatment regimen, depending on the duration that the doctor ordered for the total recovery of the patient. Ciprofloxacin 500 mg ( two times a day ) Meloxicam 7.5 mg ( 8am-6pm )

( three times a day ) ( 8am-1pm-6pm) ( 9am) medication.

Pantoprazole 400 mg ( once a day)

Instructed to always check the expiration date before taking the EXERCISE

Consult your doctor before beginning any exercise routine after your gallbladder surgery. Start slowly by walking several times a day with a low pace (This could be around the yard, or even just around your home) Avoid strenuous activity, like moving, carrying or lifting heavy objects for 10 to 14 days, or as directed by your doctor. Encourage bed exercises. Instruct patient to turn frequently when lying every two hours. Teach patient about deep breathing and controlled coughing exercises.

TREATMENT Gallbladder removal, like any surgery, requires recovery time, advice that the typical rest time after major abdominal surgery is six weeks. Advised to avoid eating fatty foods, coffee, cola drinks, and alcohol. Surgical Wound Care

HEALTH TEACHING Teach the patient to avoid submerging the abdomen in the bathtub for the first 48 hours. Take the prescribed antibiotics to provide further assurance against infection. Watch for the incisions site for signs of infection. Instruct the patient on the care of the abdomen wound, keep the dressing clean and dry. May wash the wound with sterile normal saline water, then apply antibacterial ointment or povodine iodine (betadine) ointment,and change the dressing daily. Instruct the patient to report to the physician if any new symptoms occur, such as the appearance of jaundice accompanied by pain, chills and fever, dark urine, or light-colored stools. Instruct patient to comply with the given diet Teach patient about deep breathing and controlled coughing exercise to avoid pressure on the wound.

OUT PATIENT REFFERAL CHECK-UP After discharge, advised the patient to come back for follow-up check up. Schedule: August 12, 2013- Follow-Up Check up. August 16, 2013- For T-Tube Cholangiogram

DIET Low-fat diet to avoid recurrence of gallstones. High intake of fiber has been associated with a lower risk for gallstones. Fruits and vegetables had the lowest risk of developing symptomatic gallstones.

Consumption of vegetable protein (such as soybean products) can help to prevent symptomatic gallstones. Lecithin is a key component of bile. It contains choline and inositol, two compounds that are important for the breakdown of fat and cholesterol. Low levels of lecithin may precipitate the formation of cholesterol gallstones. (Dietary lecithin is available in health food stores and is found in eggs, soybeans, liver, and peanuts.) Ascorbic acid (vitamin C) appears to help break cholesterol down in bile. Vitamin C deficiencies have been associated with a higher risk for gallstones. (Consult first to your physician before taking Vitamins) Avoid consumption of coffee and alcohol.

MANUEL S. ENVERGA UNIVERSITY FOUNDATION COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PREPARED BY:

BANTOC, DIANE GODOY, JENNY LI, MA. KRISTINA MARASIGAN, GEM MERCADO, KAILA MONIQUE

OCTUBRE, ALEXIA CAMILLE PENAFLORIDA, MARIA TANYA VERA SERDON, ISMAEL TAPAR, FAYE ZAMORA, BERNADETH

CLINICAL INSTRUCTOR;
MR. EDWIN Q. YABUT