CHAPTER I INTRODUCTION

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East .Gallstones are crystalline structures formed by concretion (hardening) or accretion(adherence of particles, accumulation) of normal or abnormal bile constituents .According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation. Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation, Diet-Very low calorie diets, prolonged fasting, and lowfiber /high-cholesterol/high-starch diets all may contribute to gallstone formation. Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment. The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bileducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.

CHAPTER II ASSESSMENT A. Nursing Health History Personal Data Name: Age: Gender: Status: Address: Date of Birth: Place of Birth: Religion: Date of Admission: Time of Admission: Chief Compliants: Final diagnosis: Opreation: Mrs. Dina Natuto 70 years old Female Married Pob. San Manuel, Tarlac Nov. 23, 1943 Nueve Ecija Roman Catholic Nov. 30, 2013 3:10pm chills and abdominal plain Hydrops of gallbladder secondary to cholecystolithiasis multiple E RUQ exploration,adhesiolysis, cholecystectomy with IOC( Intraoperative Cholangiogram), Common Bile Duct - exploration, T- tube choledochostomy.

Past Medical History

Present Medical History 3 days prior to admission (+) fever on and off. 1 day prior to admission (+) abdominal pain at the hypogastric area to epigastric area associated with chills.

Family Health History

B. Physical Assessments Physical Assessment done by the attending physician reveals that patient is; Febrile pale anicteric sclera pinkish palpebral conjunctiva symmetrical chest expression fair pulse (-) cyanosis (+) NABS non tender abdomen

Vital Signs upon admission (Nov. 30, 2013) o o o o BP- 130/80 mmHg RR-20 cpm PR-89 bpm Temp-38 C

Physical Assessment done by the student reveals that patient is; Febrile Warm to touch pale and weak looking (+) dry lips (+) dry skin decreased skin turgor

Vital Signs taken and recorded as of (Nov. 30, 2013) are as follows; o o o o BP- 130/80 mmHg RR-20 cpm PR-89 bpm Temp-38 C

C. Laboratory Exams 1. Complete Blood Count (CBC) This is to determine blood components and the response to inflammatory process and streptococcal infection.

Date Ordered: Nov. 30, 201 Date Result In: Nov. 30, 2013 Results: WBC - 14.5 g/l RBC - 3.73 g/l Lymphocytes - 0.15 g/l Monocytes - 0.08 g/l Granulocytes - 0.77 g/l Hemoglobin 126 g/l Hematocrit - 0.34 g/l Platelet count 357 g/l

Repeat CBC Date Ordered: Dec. 1, 2013 Date Result In: Dec. 1, 2013 Results: WBC - 18 g/l RBC - 3.71 g/l Lymphocytes - 0.04 g/l Monocytes - 0.06 g/l Granulocytes - 0.90 g/l Hemoglobin 106 g/l Hematocrit - 0.29 g/l Conclusion: WBC is slightly elevated based on the normal value of 5.0-10 g/l which confirms the presence of infection.

2. Serum Electrolytes Date Ordered: Nov.30, 2013 Date Result in: Nov.30,2013 Results: Serum Sodium - 135.7 mmol/L Potassium - 3.25 mmol/L Chloride - 98.1 mmol/L

Repeat Serum Electrolytes Date Ordered: Dec.1 ,2013 Date Result In: Dec. 1, 2013 Results: Potassium - 3.24 mmol/L

Date Ordered: Dec. 6, 2013 Date Result in: Dec. 6, 2013 Results: Serum Sodium 138.1 mmol/L Potassium 2.83 mmol/L Conclusion: The potassium level is below the normal value of 3.40-5.60 mmol/L. While the sodium level is within nomal range based on the normal value of 134.0-148.0 mmol/L.

3. Creatinine This is the indicator of the renal function. Date Ordered: Dec. 4, 2013

Result In: Dec. 4, 2013 Results: 0.8mg/dl Conclusions: The result is within normal range based on the normal value of 0.5 - 1.7mg/dl.

4. BUN This is an indicator of renal function and perfusion, dietary intake of CHON and the level of protein metabolism. Date Ordered: Dec. 4, 2013 Date Result In: Dec. 4, 2013 Results: 5.3 mg/dl Conclusions: The result is within normal range based on the normal value of mg/dl.

5. Urinalysis Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract, and systematic disorders that alter urine composition. Urinalysis data include color, specific gravity, pH, and the presence of protein, RBCs, WBCs, bacteria, Leukocyte, esterase, bilirubin, glucose, ketones, casts and crystals. Date Ordered: February 10, 2006 Date Result In: February 10, 2006 Results: Color- yellow Specific Gravity- 0.010

Sugar/ Albumin- negative Pus cells- 0.1 hpf Conclusions: The results are normal but there is a presence of pus cells in the urine which means that there is also the presence of infection.

D. Anatomy and Physiology

Gallbladder, muscular organ that serves as a reservoir for bile, present in most vertebrates.

In humans, it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in)long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous membrane coat (tunica mucosa).The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.

E. Pathophysiology

Risk factor Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60 Bile must become supersaturated with cholesterol and calcium The solute precipitate from solution as solid crystals Crystals must come together and fuse to form stones Gallstones Obstruction of the cystic duct and common bile duct Sharp pain in the right part of abdomen Jaundice Distention of the gall bladder Venous and lymphatic drainage is impaired Proliferation of bacteria Localized cellular irritation or infiltration or both take place Areas of ischemia may occur Inflammation of gall bladder CHOLECYSTITIS CHAPTER III PLANNING A. List of Prioritized Nursing Diagnosis Pre-operative nursing diagnosis: Acute pain Knowledge Deficit Disturbed sleeping pattern Intra-operative nursing diagnosis Post-operative nursing diagnosis: Deficient Fluid Volume Risk for infection Ineffective Coping

B. Nursing Care Plan 1. Acute Pain Cues S- ang sakit ng tyan ko as claimed by the patient. O-(+) guarding behavior , pain scale of Nursing Diagnosis Acute pain related to inflammati on and distortion of the gallbladder as evidenced by verbal reports of pain. Scientific Explanation Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute Objective After 4 hours of nursing intervent ion the patient will report relieve of pain. Nursing Intervention 1. Observe and document location, severity (0 10scale), and character of pain (e.g., steady, intermittent, colicky). 2. Promote bed rest, allowing patient to Rationale - Assists in differentiating cause of pain, and provides information about disease progression/r esolution, development of complications, and effectiveness Evaluation Is there a change on the patients; a. Pain scale b. RR c. BP d. Reports of pain. e. Facial expressions.

7/10, difficulty in moving as manifest ed by facial grimaces -(+) pallor, V/S as follows: BP 130/80 mmHg, PR- 89 bpm, RR20cpm, T- 38C

pain on the right part of the abdomen.

assume position of comfort. 3. Control environmental temperature. 4. Encourage use of relaxation techniques, e.g., guided imagery, visualization, deepbreathing exercises. Provide diversional activities. 5. Make time to listen to and maintain frequent contact with patient. 6. Administer analgesics as indicated.

of interventions. - Bed rest in low-Fowlers position reduces intraabdominal pressure; however, patient will naturally assume least painful position. Cool surroundings aid in minimizing dermal discomfort.Promotes rest, redirects attention, may enhance coping.Helpful in alleviating anxiety and refocusing attention, which can relieve pain.Relief of pain facilitates cooperation with other therapeutic interventions.

2. Fluid Volume Deficit Cues S Nursing Diagnosis - Deficient Scientific Objective Nursing Rationale Evaluation Explanation Intervention There is this After an 1. Provide - Information -Does the patient

pwede bang maulit ang sakit ko as verbaliz ed by the patient OFrequen tly asking question about his conditio n, treatme nt and diet -With worried gaze dry mouth

knowledge related to condition, prognosis, treatment, self - care, and discharge needs

presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed.

hour of nursepatient interacti on the patient will verbalize understa nding of disease process, prognosi s, and potential complica tions

explanations of reasons for test procedures and preparation needed. 2. Review disease process/ prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern. 3. Review drug regimen, possible side effects 4. Instruct patient to avoid food/fluids high in fats (e.g., whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants(e.g., spicy foods, caffeine, citrus). 5. Suggest patient limit

can decrease anxiety, thereby reducing sympathetic stimulation. Provides knowledge base from which patient can make informed choices. - ----Effective communicati on and support at this time can diminish anxiety and promote healing. - Gallstones often recur, necessitating long-term therapy. - Prevents/ limits recurrence of gallbladder attacks. Promotes gas formation, which can increase gastric distension/ discomfort.

understands and could recall all the teachings given? -Is there a significant changes that occur on the patients knowledge regarding; a.disease condition b.diet c.treatment d.medication e.self-care needs

gum chewing, sucking on straw/hard candy, or smoking

C. Drug Study Name of Drug Route/ Action Indication Dosage and Frequency 750 mg IV Perioperative Q8hrs Anti-infectives prevention ANST(-) -Secondgeneration cephalosphorin that inhibits cellwall synthesis, promoting osmotic instability; usually bactericidal Adverse Reaction Nursing Consideration

GN:Cefuroxime BN: Zinacef

Phlebitis, nausea, anorexia,vomiti ng, maculopapular and erythematous rashes, urticarial, pain, induration

1.Check the doctors order. 2. Inform the patient about the adverse reaction. 3. Before giving drug, ask patient if he is allergic to penicillins or cephalosphorin s. 4. Intsruct patient to notify prescriber about rash, loose stools, diarrhea, or evidence of superinfection. 5. Advise patient discomfort receiving drug IV to report discomfort at IV insertion

GN: Cefoxitin 1gm IV Sodium Q8hrs Anti-infectives BN: Mefoxitin ANST(-) -Secondgeneration cephalosphorin that inhibits cellwall synthesis, promoting osmotic instability; usually bactericidal

Serious infection of the respiratory and GU tracts; skin; soft-tissue, bone, or joint infection; blood-stream or intraabdominal infection caused by susceptible organisms( such as E. coli and other coliform bacteria.

Fever, phlebitis, diarrhea, nausea, vomiting, anemia, acute renal failure, pain, induration.

GN: Metronidazole BN: Flagyl

500 mg IV Q8hrs ANST(-)

Bacterial Infectio ns caused by anaerob ic microor ganisms. To prevent postope rative infectio n in

Direct- acting trichomonocid e and amoebicide that works inside and outside the intestines. Its thought to enter the cells of microorganism s that contain nitroreductase, forming

Headache, seizures, fever, constipation, nausea, pain, edema, peripheral neuropathy

site. 1. Before givig ng drug, ask patient if he is allergic to penicillins or other cephalosphorin s. 2. After reconstitution, drug may be stored for 24hrs at room temperature or 1 week under refrigeration. 3. Intsruct patient to notify prescriber about rash, loose stools, diarrhea, or evidence of superinfection. 4. Advise patient discomfort receiving drug IV to report discomfort at IV insertion site. 1. Monitor liver function test results carefully in elderly patients. 2. Use cautiously in patients who take hepatotoxic drug or have hepatic disease or alcoholism. 3. Use cautiously in

contami nate or potencia lly contami nate colorect al surgery.

unstable compounds that bind to DNA and inhibit synthesis, causing cell death.

GN: Ketorolac 15 mg/ml Short-term Tromethamine IV Q6hrs management of BN: Toradol PRN moderately severe, acute pain for multiple dose treatment.

May inhibit prostaglandin synthesis, to produce antiinflammatory, analgesics, and antipyretic effects.

patients with history of blood dyscrasia, CNS disorder, or retinal or visual retinal changes. 4. Record number and character of stool when drug is used to treat amoebiasis. 5. Observe patient for edema, especially if hes receiving corticosteroids; Flagyl IV RTU may cause sodium retention. Headache, 1. Correct dizziness, hypovolemia drowsiness, before giving. hypertension, 2. Carefully palpitation, observe sedation, peptic patients with ulceration, coagulopathies prolonged and those bleeding time taking anticoagulants. 3. Teach patient signs and symptoms of GI bleeding, including blood in vomit; and black tarry stool. Tell patient to notify prescriber immediately if any of these

occurs. 4. Serious GI toxicity, including peptic ulcers and bleeding, can occur in patient taking NSAIDs, despite lack of symptoms.

CHAPTER IV - IMPLEMENTATION

Medical/ Surgical Management 1. Chest X-ray- this is used to rule out respiratory causes of referred pain. 2. Intake and Output- I&O measurement provide an other means of assessing fluid balance. This data provide insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. These measurement are not that accurate as body weight, however, because of relative risk of errors in recording. 3. Electrocardiogram - The 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. 4. O2 Inhalation - Oxygen therapies are used to provide more oxygen to the body into order to promote healing and health. 5. Intravenous Rehydration - when the fluid loss is severe or life - threatening, intravenous (IV) fluids are used for replacement. 6. Ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs. Ultrasounds are used to view internal organs of the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels. 7. Hepatobiliary scintigraphy - an imaging technique of the liver, bile ducts, gallbladder, and upper part of the small intestine. 8. Cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast).

9. Percutaneous transhepatic cholangiography (PTC) - a needle is introduced through the skin and into the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray. 10. 10. Endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope. A long flexible, lighted tube. The scope is guided through the patient's mouth and throat, then through the esophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an x-ray. 11. 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. 12. Cholecystectomy- removal of the gallbladder. This procedure may be performed to treat chronic or acute cholecystitis, with or without cholelithiasis, to remove a malignancy or to remove polyps. 13. Cholecystotomy - the establishment of an opening into the gallbladder to allow drainage of the organ and removal of stones. A tube is then placed in the gallbladder to established external drainage. This is performed when the patient cannot tolerate cholecystectomy. 14. Choledochoscopy- the insertion of a choledoscope into the common bileduct in order to directly visualize stones and facilitate their extraction.

CHAPTER V DISCHARGED PLANNING

Instructed the patient and S.O to continue medication at home as ordered. 1) Tergecef ( Cefixime ) 400mg/ cap, 1 capsule once a day for 7 days. (8am) 2) Ciprofloxacin ( Ciprobay ) 1 gm/tab, 1 tablet once a day for 7 days. (8am) 3) Omeprazole 400mg/cap, 1 capsule twice a day (7am-7pm) 4) Vestar MR 35mg/tab, 1 tablet twice a day (8am-8pm) 5) Clopidogrel 75mg/tab, 1 tablet once a day (8am) 6) Erdostiene 300mg/tab, 1 tablet three times a day (8am-1pm-7pm) 7) Levociterizine/Montelukast 10/5, 1 tablet daily at bedtime. (9pm) 8) Kalium Durule tab, 1 tablet three times a day for 6 doses. (8am-1pm-7pm) 9) Celecoxib 200mg/cap, 1 capsule twice a day. (8am-8pm) Instructed patient to do deep breathing exercise, coughing technique while putting pressure/splinting at the operative site, and walking as tolerated. Emphasized the importance of completing the drug regimen, especially the antibiotics.

 Encouraged patient to increase oral fluid intake. Advised patient to eat nutritious foods rich in Vit.C. Advised patient avoid eating salty and fatty foods. Advised to return for the follow-up check-up on Monday, Dec.16,2013.

VI Conclusion Cholecystitis is the inflammation of the gall bladder which is usually accompanied by gallstones or cholelithiasis these gallstones may block the way of toxic substances that really needs to go out, but due to this blockage this toxic substances are not then being expelled and are just being stored in the bladder for a period of time. This then causes inflammation of the gallbladder. The treatment usually done is the cholecystectomy. In order to lower the risk of having this kind of condition each and every one of us must be conscious in our diet. We should try to avoid foods which are rich in salt and fats, especially those foods which contains many seasonings. Though there is a saying that Mas masarap pag bawal which always pertains to the food were eating we should still be conscious on our health especially if we want to live longer and also to avoid those life-threatening diseases which not only shorten our life but causes us some financial problem. Remember also the saying Mahal ang magkasakit. Just like on what our patient had experience she still has to collect money for the operation she had underwent causing them to have debt with different persons. Let us not enjoy ourselves with the delicious food were eating that is rich in salts and fats but we should enjoy living because we have a healthy condition.

VII - BIBLIOGRAPHY

Books Joyce M. Black,PhD, RN, CPSN, CWCN & Jane Hokanson Hawks, DNSc, RN, BC,Medical- Surgical Nursing 7th edition, pg.1302-1314. Nursing 2004 Drug Handbook, 24th Edition Doenges, Moorhouse, & Murr, Nurses pocket guide 9th edition. Online Resources www.facs.orghttp://tjsamson.client.web-health.com/webhealth/topics/GeneralHealth/generalhealthsub/generalhealth/liver&gallbladder/what_gall bladder.htmlhttp://www.emedicine.com/emerg/topic97.htmhttp://www.emedicine.com/radio/topic16 3.htmhttp://www.healthsystem.virginia.edu/uvahealth/adult_liver/chole.cfmhttp://www.emedicine.co m/EMERG/topic98.htmMicrosoft Encarta 2004 Nursing Care Plan Content CD-ROM