UNIVERSITY OF ILOILO

Phinma Education Network

Rizal St., Iloilo City

COLLEGE OF NURSING

WEST VISAYAS STATE UNIVERSITY-MEDICAL CENTER

(SAN LORENZO RUIZ WARD)

ACUTE CALCULOUS CHOLECYSTITIS

A Case Study

Presented to

Mr. Llue Dex Gabuelo, RN

Clinical Instructor

Presented by

BSN 3-C

Gatuteo, Joan
Genodia, Maria
Guelos, Cindy
Gonzaga, Honeylee
Hilisan, Harlyn
Indico, Rodelyn
Iwag, Erick Laine
Laguerder, Tresza Shane
Laquian, Raymun Edward
Laurino, Sandra

August 26, 2010

NURSING ASSESSMENT

I. BIOGRAPHIC DATA

NAME: Ms. N. S.

ADDRESS: San Pedro, Jaro Iloilo City

AGE: 70 Years Old

BIRHT DATE: April 21, 1940

GENDER: Female

RELIGION: Roman Catholic

RACE: Filipino

STATUS: Single

OCCUPATION: Health Worker

SOURCE OF HEALTH FINANCING: Herself

DATE AND TIME OF ADMISSION: August 12, 2010 (7:50 PM)

CHIEF COMPLAINT: “Gasige-sige sakit tiyan ko, mga 2 na ka bulan” as verbalized by

the patient.

ADMITTING DIAGNOSIS: Choledocholithiasis Beginning Cholangitis

FINAL DIAGNOSIS: Acute Calculus Cholecystitis

II. CLINICAL ASSESSMENT

A. NURSING HISTORY

1. HISTORY OF PRESENT ILLNES

According to her since she got an illness, there is a great change in her lifestyle. She
couldn’t do all her usual tasks. She experienced the symptoms 2 months ago in the middle of
July. It was sudden and often since then. She pointed out that the exact location of the pain was in
the epigastric area radiating to her lower back. Over fatigue was her primary reason of how the
problem occurred. She experienced the symptoms such as nausea, vomiting, and body malaise.
The problem aggravates during her eating time and alleviates when she takes a nap. She denies
any family members having related disease as hers.

2. PAST HISTORY OF ILLNESS

 According to her, she wasn’t able to complete the different immunizations offered
at her time. She already had Chicken pox; she had allergies to dust, and drugs such as
afloxacin. She had Diabetes Mellitus when she was 59 and been prescribed with
Dimetron and soon discontinued. She only managed it by having a proper diet.

Whenever she perspires, she often experience flushed skin and diminishes when
wiping it. She had suffered from minor trauma brought by a vehicular accident when she
was a child but immediately coped up.

3. FAMILY HISTORY OF ILLNESS

Her father has hypertension as well as her 2 siblings: her Mother died with
unknown cause; the uncle in her mother side also has Diabetes Mellitus. And there is no
family history of Osteoarthritis, Malignant Neoplasia and Cholecystisis.

GENOGRAM

89 ♀ 87♥ ᴥ ᴥ
N
/A

89 ♥ 88 ♀ 86♀ 84ᴥ 82ᴥ 79 ᴥ

37
85 ♥
85♥ 72♥ 70 ♥,DM 67 ☺ 63☺
Calculous Cholecystitis

Legend: --Male --Deceased ♥--Hypertension ᴥ -- Unknown

--Female --Deceased ☺ --Alive and well ♀--Old Age

4. PATIENT’S EXPECTATIONS

She expects to get well during her stay at the hospital; she wanted also to be
educated regarding the Do’s and Don’ts of her disease as well as the right foods and
proper management. She said that the nursing care nowadays is better than before and her
needs are always attended.

5. PATTERNS OF FUNCTIONING

a. Breathing Pattern:
Respiratory Problems: Shortness of breath caused by her operation alleviated
when put in semi- Fowler’s position.
b. Circulation: Her usual blood pressure before was 110/70 mmHg but now it
increased to 140/90 mmHg. She experienced palpitations whenever she was
surprised and she suffers mild hypertension.
c. Sleeping Pattern:
Usual Bedtime: 10:00 PM- 4:00 AM
No. of Pillows: Only one under head
Bedtime Rituals: Doing rosary or watching television at times
Problems regarding sleep: None
d. Drinking Pattern
Type of Fluid No. of Bottles/Glasses per Day Pattern of drinking

1. Water 8 glasses Everyday

2. Juice 2 glasses Weekends

3. Coffee 2 cup Morning, afternoon

4. Soft drinks 1 Bottle Weekends

e. Eating Pattern

Meal Type and Amount of Food Time

Breakfast Oatmeal (1 bowl) 6-7 am

Morning Snacks Skyflakes(2 pieces) 9-10am

Lunch Rice (1/2 cup)

Vegetable (1 serve preparation) 11-12nn

Fish (1 serve preparation)

Afternoon Snacks Skyflakes (2 pieces) 3-4 pm

 Dinner Rice (1/2 cup) 4-5pm

Grilled fish (1 piece)

Midnight Snacks Skyflakes (1 whole pack) 10-11pm

Food Likes: Ice Cream, cake, chocolates

Food Dislikes: None

f. Elimination Pattern

1. Bowel Movement

Frequency: Once a day

Problems or Difficulties: None
Usual Remedy: N/A
2. Urination
Frequency: 5-7x/ day
Problems or Difficulties: None
Usual Remedy: N/A
g. Exercise-walking, jogging and aerobics
h. Personal Hygiene

1. BATH

Type: Full Bath

Frequency: 2x a day
Time of Day: 8-9am and 8-9pm
2. ORAL CARE

Frequency: 3x a day
Care of Dentures: Tooth Brushing
3. SHAVING: N/A
4. USE OF COSMETICS: Make-up occasionally, Pedicure

i. Recreation- Seldom attends to party. Usually present on health seminars in their barangay
health clinic.

j. Health Supervision- Seek consultation whenever there is a change in physiologic

function.

B. PSYCHOSOCIAL ASSESSMENT
NAME: N. S. AGE: 70 YEARS OLD HOSPITAL: WEST VISAYAS STATE MEDICAL
CENTER DATE: 08-19-10

ERICK ERICKSON theory SIGMUND JEAN PIAGET LAWRENCE

THEORY of psychosocial development FREUD theory of theory of KOHLBERG
psychosexual cognitive theory of moral
development development development
theory
OLD AGE / LATE ADULT

STAGE PSYCHOLOGICAL CRISIS: GENITAL FORMAL POST

INTEGRITY VS. STAGE OPERATIONS CONVENTION
DESPAIR,DISGUST
 AL
DEFINITION As the aging process creates True maturity The person at An individual
physical and social looses the requires the this stage can reaches this stage
adult also suffered loss status timing of think acts out universal
and function such as through aggressive and abstractive. principals based
retirement or illness this sexual urges, upon equality
external struggles met also allowing them to and worth of all.
with internal struggles, such release.
as search for meaning in life.
Meeting this challenge
creates the potential for
growth and wisdom. Many
elders review their lives with
the sense of satisfaction even
with the inevitable mistakes.
Others see them selves as
failures with marked
contempt and disgust.

C. CLINICAL INSPECTION
Date and Time Taken: Aug. 20, 2010 (6:00 am)

Vital Signs

T- 36.8⁰C RR: 17 cpm

PR- 82 bpm BP: 140/90 mm Hg

1. Height: 4’11’’

2. Weight: 50 kg

3. Physical Assessment

A. Integumentary System

Brown complexion, uniformly warm to touch, and moist with skin turgor of
approximately 1second. No lesions noted.

B. Neurologic System

Alert, conscious and coherent. Oriented to person, place and able to recall previously
done activities.

CN I (Olfactory): intact as able to identify aroma of coffee.

CN II (Optic): intact as evidenced by ability to see and recognize nurses and folks and
able to read magazine.

CN III (Oculomotor); IV (Trochlear), VI ( Abducens): intact as evidenced by the ability

of eyes to move in a smooth, coordinated motion of six ocular movements, P E R R L A.

CN V (Trigeminal): intact as evidenced by ability to differentiate sharp and blunt points

of pencil, ability to clench teeth. Eyelids blink bilaterally.

CN VII (Facial): intact as evidenced by ability to smile, frown, wrinkles forehead, raise
eyebrows, close eyes, purses lip and puff cheeks symmetrically in symmetrical manner.
 CN VIII (Auditory): intact as evidenced by the ability to hear the ticks of a wrist watch 5
inches away from the ears.

CN IX (Glossopharyngeal): intact as evidenced by the ability to move tongue from side

by side, uvula and soft palate rise bilaterally and symmetrically on phonation.

CN X (Vagus): intact as evidenced by ability to swallow foods and fluids. Gag reflex
intact.

CN XI (Spinal Accessory): intact as evidenced by ability to move head from side by side.

CN XII (Hypoglossal Nerve): intact as evidenced by ability to protrude tongue at the

midline and move from side by side in apparent strength.

C. Respiratory System

Nose at midline, both nares are patent as evidenced by ability to identify the aroma of
coffee. RR- 17cpm, regular in rate and rhythm, shallow inhalation, deep expiration. Clear
lung sounds upon auscultation of all lung fields.

D. Cardiovascular/ Circulatory System

PR- 82bpm, BP- 140/90 mmHg, capillary refill of approximately 2 seconds in upper and
lower extremities.

E. Gastrointestinal System

Lips dark red, moist; pink moist tongue; grade 1⁺ tonsils; gag reflex present, able to
swallow foods and fluids, abdomen not tender upon palpation.

F. Hepatobiliary System

Liver not palpable.

G. Genitourinary System
With Foley catheter attached to urobag, drained at approximately 50cc/hr of light yellow
urine. Bladder not distended.
H. Reproductive System

Symmetrical breast. No lumps upon palpation and unnecessary discharge noted.

I. Musculoskeletal System

Full ROM in upper and lower extremities, muscle strength of 5/5 in both extremities.

J. Lymphatic System

Lymph nodes are not palpable.

K. Hematopoetic System

Hematology result as of 8/18/10

Hgb= 117g/L

Hct=

RBC=

D. LABORATORY FINDINGS
 A. Clinical Chemistry

NAME OF DEFINITION PURPOSE DATE RESULTS NORMAL SIGNIFCANCE

EXAMINATION VALUES OF
ABNORMAL
RESULTS

SODIUM This is the To assess for 8/12/10 142.3 135-148

predominant level of mmol/L mmol/L
cation in the sodium in
extracellular relation to loss Normal
fluid, including of water.
plasma.

POTASSIUM This is the To determine 8/12/10 4.06 3.5- 5.3

predominant changes in mmol/L mmol/L
cation in the serum
cellular fluid. concentration Normal
of potassium
that could
produce
profound
effects on the
nerve
excitation,
muscle
contraction,
and
myocardial
potential

CREATININE 8/12/10 96.3 53.0- Normal

mmol/L 115.0
umol/L

CHOLESTEROL 8/13/10 5.86 1.3- 5.2

mmol/L mmol/L

LDL- 8/13/10 4.3 0.0- 3.9

CHOLESTEROL mmol/L mol/L

REV. 8/13/10 1.27 0.17-1.7 Normal

TRIGLYCRIDE mmol/L mmol/L

HDL- 8/13/10 1.02 0.9- 1.55 Normal

CHOLESTEROL mmol/L mmol/L

GLUCOSE This is the To assess level 8/13/10 7.32 3.9- 6.1

principal sugar of glucose in mmol.L mml/L
of the body; the blood
permits all body resulting from
water. either failure
to synthesize
or ingestion of
superfluous
quantities.
 B. Hematology

Definition:

It is a basic screening test and one of the most frequently ordered blood test. It
includes hemoglobin and hematocrit measurements, RBC count, WBC count, RBC
indices, and a differential white cell count.

Purpose:
• To serve as baseline data.
• To detect any abnormalities or disease process in the body.
NAME OF EXAMINATION RESULTS NORMAL Significance
VALUES

8/12/10 8/17/10 8/18/10

HEMOGLOBIN 131g/L 87g/L 117g/L 120- Decreased in RBC

160g/dL may indicate anemia
and it may result
ERYTHROCYTE 0.34L/L 0.26L/L 0.34L/L 0.37-
from decreased
0.47L/L
production of RBC in
ERYTHROCYTE NO. 3.81×1012L 2.71×1012L 3.63×1012L 4.2- spleen and kidney
CONCENTRATION 5.4×1012L because of
inflammatory
response.

LEUKOCYTE NO. 8.5×1012L 10.7×1012L 12.6×1012L 4.5- Increase in no.

CONCENTRATION 11.0×10L concentration of
leukocytes indicates
inflammation.

NEUTROPHIL No. Fraction Increased in response

(SEGMENTER) to breakdown of
0.76 0.86 0.76 0.50-0.70 RBCs marginated
polymorphonuclear
neutrophils mobilize
and the sphlenic
reserve of PMNs is
exhausted.

LYMPHOCYTE NUMBER Normal

FRACTION
0.24 0.12 0.22 0.20-0.40

EOSINOPHIL NUMBER Normal

FRACTION
0.01 0.02 0.01-0.04

C. Radiological Exams

RESULTS:
Follow up study done as compared with previous study taken 5/7/10 shows normal- sized
 liver with hyperechogenic parenchyma. No focal masses seen. The intrahepatic ducts are not
dilated.
The common bile duct measures 0.5 cm in its widest visualized diameter.
The gallbladder measures 7.4 x 3.8 x 3.7 cm (L x W x AP) with thickened wall measuring 0.9
cm. Multiple high intensity echoes with posterior sonic shadowing are still seen intraluminally,
the largest measuring 1.3 cm.
The pancreatic head is normal in size and parenchymal echopattern. The pancreatic body and
tail are obscured. The pancreatic duct is not dilated.
The spleen is normal in size and parenchymal echoppattern. No focal masses seen.
There is no disparity in the size of the kidneys. The right kidney measures 9.7 x 4.8 x 4.2 cm
(L x W x AP) with cortical thickness of 0.9 cm, while the left kidney measures 10.2 x 4.1 x 3.9
cm (L x W x AP) with cortical thickness of 1.0 cm. The central echo complexes are intact. The
cortico- medullary demarcations are well defined. No lithiasis seen.
The urinary bladder is well distended. Its wall is not thickened. Intraluminal echoes noted.
The uterus is atrophic measuring 3.4 x 2.9 x 2.6 cm (L x W x AP) with an endometrial stripe
thickness of 0.4 cm (previously 4.0 x 2.4 x 1.0 cm). No focal masses noted. No adnexal masses
ascites demonstrated.
Impression:
FATTY LIVER
CALCULOUS CHOLECYSTITIS
ATROPHIC UTERUS
NORMAL PANCREATIC HEAD, SPLEEN, KIDNEYS AND URINARY BLADDER
ULTRASONOGRAPHICALLY
D. Other Special Exams

a. Chest X-ray

RESULT:

Poor inspiratory film shows crowding of the pulmonary vascular markings.

The trache is deviated to the right due to positional obliquity
The heart appears enlarged with CT-ratio of 0.56.
The aorta is atherosclerotic.
The costophrenic sulci are intact
The hemidiaphragms are elevated
The rest of the findings are unremarkable

IMPRESSION:
CARDIOMEGALY.
ATHEROSCLEROTIC AORTA.
FOLLOW-UP WITH BETTER INSPIRATORY EFFORT
SUGGESTED FOR FURTHER EVALUATION.

b. Urinalysis

PHYSICAL PROPERTIES: MICROSCOPIC FINDINGS:

Color: Straw Pus Cells: 2-4/hpf
Transparency: hazy Red blood cells: 14-16/hpf

Reaction: Acidic (6.5) Cast:

Specific Gravity: 1.010 Hyaline:
Fine granular:
Coarse granula:/lpf
CHEMICALS TESTS Crystals
Amorphous: Many urates
Sugar:
Albumin: Negative Squamous Epithelial Cells: few
 Ketone: Round Epithelial Cells: few
Others: Mucus Threads:

c. ECG

Interpretation: Sinus Bradycardia

III. DRUG STUDY
University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Patient’s Name: Ms. N.S. Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis
Age: 70y.o. Chief Complaints: persistent epigastric pain Attending Physician: Dr. T

CLASSIFICATION/ SIDE EFFECTS/ ADVERSE SPECIAL PRECAUTION/ NURSING

CONTRAINDICATION
DRUGS MECHANISM OF ACTION INDICATION REACTION RESPONSIBILITY

Classification: Post surgery antacid to Hypersensitivity to Side Effects: headache, rash, 1. Assess patient for contraindication.
prevent ulcer formation ranitidine, lactation. dizziness, vertigo, constipation, 2. Assess for baseline data.
Generic: Histamine 2 antagonist diarrhea, nausea, vomiting, abdominal 3. Tell patient that he may experience
discomforts, local burning or itching side effects brought about by the drug.
Ranitidine Competitively inhibits the at IV site 4. Instruct patient to take his meal if
action of histamine at the H2 nausea or vomiting occurs.
Brand: receptors of the parietal cells f 5. Oral care if vomiting occurs.
the stomach, inhibiting basal
Zantac gastric Adverse Effects: malaise, insomnia, 6. Adjust lighting and temperature and
Dosage: 50 somnolence, urticaria, tachycardia, avoid noise if he experiences headache
acid secretion and gastric acid and instruct him to report if it is
mg secretion that is stimulated by bradycardia, intolerable so that medication may be
Route: food, given.
leukopenia,
IVTT insulin, histamine, cholinergic
pancytopenia, 7. Instruct him to report intolerable side
Frequency: agonist, gastrin, and effects so as prompt
q 8H pentagastrin.
thrombocytopenia,
intervention could be done.
Timing: 10 gynecomastia, impotence, hepatitis
AM 6 PM 8. Instruct him to report adverse effects
2AM that he may experience.

Patient’s Name: Ms. N. S.
Age: 70 y.o. Chief Complaints: persistent epigastric pain
CLASSIFICATION/
MECHANISM OF
DRUGS
ACTION
Classification: HMG-
CoA reductase inhibitor,
Generic: antihyperlipemic
Simvastatin (synvinolin) Inhibits HMG-CoA
reductase. This enzymeis
Brand: early (and rate limiting)
Lipex, Zoc step in synthetic pathway
of cholesterol. Lowers
Dosage: 20 mg 1 tab LDL and total cholesterol
level.
Route: PO
Frequency: OD @ HS
Timing: 6 PM
University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis
CONTRAINDICATION
INDICATION
To reduce total Hypersensitivity to
cholesterol and LDL in simvastatin and in those
patients with homozygous with active liver disease or
familial conditions that have
hypercholesterolemia. unexplained persistent
elevations of transaminase
levels.
University of Iloilo
Phinma Education Network
Attending Physician: Dr. T.
SIDE EFFECTS/ ADVERSE
REACTION
CNS: Headache
Asthenia
GI: Abdominal pain,
constipation, diarrhea,
dyspepsia, flatulence, nausea.
Respiratory: Upper Respiratory
Tract infection.
SPECIAL PRECAUTION/
NURSING RESPONSIBILITY
1. Assess patient’s history of
LDL and total cholesterol
levels.
2. Monitor patient for myalgia
and for elevated CK level
during treatment.
Rhabdomyolysiswith and
without acute renal
sufficiency has been reported.
3. Assess patient’s dietary fat
intake
4. Give drug with evening meal
for enhanced effectiveness,
5. Teach patient dietary
management of
lipids(restricting total fat and
cholesterol intake) and
measures to control other
cardiac disease risk factors.
 COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis
Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician:Dr. T.

CLASSIFICATION/ SIDE EFFECTS/ SPECIAL PRECAUTION/ NURSING

CONTRAINDICATION
DRUGS MECHANISM OF ACTION INDICATION ADVERSE REACTION RESPONSIBILITY

Generic:

Omeprazole Classification: Proton Pump Gastric Ulcer. Hypersensitivity to CNS: Headache, 1. Assess contraindication.
Inhibitor omeprazole. dizziness 2. Lower doses that aren’t needed for patients
Brand: with renal or hepatic impairment.
Inhibits acid (proton) Pump 3. Advise OTC drug isn’t intended for
Losec, and binds to hydrogen- immediate relief of heartburn or to treat
Prilosec, Risek potassium adenosine GI: diarrhea, abdominal infrequent heartburn
triphosphate on secretory pain, nausea, vomiting, 4. Warn patient not to crush or chew tablets
Dosage: 40 mg surface of gastric parietal cells constipation, flatulence.
1cap or capsules.
to block formation of gastric 5. Inform patients wthat the OTC drug may
Route: PO acid. Relives symptoms require 1-4 days for full effect, although
caused by excessive gastric MUSKULOSKELETAL: some patients may get complete reliefof
Frequency: OD acid. backpain symptoms within 24 hours.

Timing: 6 AM RESPIRATORY: cough

SKIN rash
 University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Cholecystitis
.
Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician:Dr. T.

SIDE EFFECTS/
CLASSIFICATION/ SPECIAL PRECAUTION/ NURSING
DRUGS INDICATION CONTRAINDICATION ADVERSE
MECHANISM OF ACTION RESPONSIBILITY
REACTION

Generic: Classification: Antidiabetic
agents
Metformin hydrochloride
Exact mechanism is not
Brand: Glucophage understood; possibly increases
peripheral utilization of
Dosage: 500 mg/tab glucose, increase production
of insulin, decreases hepatic
Route: PO
glucose production and alters
Frequency: bid PC intestinal absorption of
glucose.
Timing: 8 AM 6PM
Adjunct to diet to Allergy to metformin; CHF; ENDOCRINE: Monitor urine or serum glucose levels
lower blood diabetes complicated with hypoglycemia, frequently to determine effectiveness of drug
glucose with non- fever,severe infections, severe lactate acidosis and dosage
insulin dependent trauma, major surgery, ketosis,
diabetes mellitus acidosis, coma (use insulin); type 1 GI: anorexia, Arrange for transfer to insulin therapy during
(type 2) in patient or juvenile diabetes, serious hepatic nausea, vomiting, period of high stress
epigastric
less than or equal:; impairement, serious renal
extended released impairement, uremia, thyroid or discomfort, Use IV glucose if severe hypoglycemia as a
result of overdose
in patient less than endocrine impairement, glycosuria, heartburn, diarrhea
17 years old. hyperglycemia associated with
Hypersensitivity: Report fever, sore throat, unusual bleeding or
primary rernal disease; labor and bruising, rash, dark urine, light colored stools, or
delivery- if metformin is used allergic skin
reactions hyperglycemia or hypoglycemia reactions
during pregnancy, discontinue drug
atleast 1month before delivery;
lactation, safety not established.

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
 DRUG STUDY
Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Age: 70 y.o.
Chief Complaints: persistent epigastric pain Attending Physician:Dr. T. Cholecystitis

SIDE EFFECTS/
CLASSIFICATION/ MECHANISM SPECIAL PRECAUTION/
DRUGS INDICATION CONTRAINDICATION ADVERSE
OF ACTION NURSING RESPONSIBILITY
REACTION

Gneric: losartan Classification: Treatment of Contraindicated with CNS: dizziness, Alert surgeon and marks patient
potassium hypertension, alone or in hypersensitivity with to headache, syncope chart with notice that losartan is
Selectively blocks the binding of combination with other losartan, pregnancy, lactation being taken. The blockage of the
Brand: Cozaar angiotensin II to specific tissue anti hypertensive agent use . GI: diarrhea, renin-angiotensin system
receptors, found in the vascular abdominal pain, following surgery can produce
Dosage: 50 mg smooth muscle and adrenal glands; Treatment of diabetic Cautiously with lepatic or nausea problems. Hypotension maybe
/tab this action blocks the neuropathy with an renal dysfunction, reversed with volume expansion.
vasoconstriction effect of the rennin- elevated serum createnine hypovolemia RESP: URI
Route: PO angiotensin system as well as the and proteinuria in patient symptoms, cough, Monitor patient closely in any
Frequency: OD release of aldosterone leaading to with type 2 diabetes and a situation that may lead to a
decreased BP history of hypertension. decrease in BP secondary to
Timing: 6 AM reduction in fluid volume-
excessive respiration,
dehydration, vomiting, diarrhea-
excessive hypotension can occur.

University of Iloilo
aPhinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
 DRUG STUDY
Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Cholecystitis
DRUGS CLASSIFICATION/ MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS/ SPECIAL
ACTION ADVERSE REACTION PRECAUTION/
NURSING
RESPONSIBILITY

Generic: NSAIDs, analgesic (non narcotic), specific Acute and long-term Contraindicated with allergies to CNS: headache, dizziness, Administer drug with food
celecoxib COX-2 enzyme blocker treatment of signs sulfonamides, celecoxib, somnolence, insomnia, or after meals if GI upset
and symptoms of NSAIDs or aspirin; significant occur.
Analgesic and anti-inflammatory activities rheumatoid arthritis renal impairement; pregnancy, DERMATOLOGIC:rush,
related to inhibition of the COX-2 enzyme, and orteoarthritis. lactation. pruritus, sweating Provide further comfort
Brand: which is activated in inflammation to cause measure to reduce pain,
Celebrex the signs and symptoms associated with Management of Use cautiously with impaired GI: dyspepsia, abdominal and to reduce
inflammation; does not affect the COX-1 acute pain. hearing, hepatic and cardio pain, flatulence. inflammation.
Dosage: enzyme, which protect the lining of the GI vascular condition.
200mg /tab tract and has blood clotting and renal OTHER: anaphylactoid Report sore throat, fever,
function. reactions to anaphylactic rush, itching, weight gain,
Route: PO shock swelling in ankles and
Frequency: fingers: changes in vision.
t.i.d

Timing:

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Cholecystitis
Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician:Dr. T.

DRUGS CLASSIFICATION/ MECHANISM INDICATION CONTRAINDICATION SIDE EFFECTS/ SPECIAL PRECAUTION/

OF ACTION ADVERSE REACTION NURSING
RESPONSIBILITY

Generic: Natural opium alkaloid with agonist of Relief of moderate to Hypersensitiviy to CNS: dizziness, Assess patient’s pain before
by binding with the same receptors as severe acute and chronic Narcotics; diarrhea headache, somnolence, starting therapy
Morphine sulfate endogenous opioid peptides. Narcotic pain. caused by poisoning until nightmares
agonist effects of identified with toxins are eliminated; May mask or worsen
Brand: Estramorp, different locations of receptors: during labor or delivery CV: hypotension, gallbladder pain
Avinza, analgesia at supraspinal level, euphoria, or premature infant; after flushing, bradycardia
respiratory depression and physical billiary tract surgery or cardiac arrest Monitor for respiratory
Classification: depressioncheck RR for 30-
Narcotic agonist dependence; analgesia at spinal level, following surgical
sedation and myosis; and dysphoric, anastomosis; pregnan cy; GI: nausea and vomiting, 60 mins.
analgesic constipation
hallucinogenic labor. Be alert for adverse reactions
Dosage: 0.015%, 10 Hematologic:
cc Thrombocytopenia Instruct not to use alcohol
during therapy
Route: via epidural Respiratory: Respiratoty
catheter depression
Frequency: q 12 H Skin: Pruritus
Timing: 8 8 Physical dependence

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
 DRUG STUDY
Patient’s Name: Ms. N.S. Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis
Age: 70 Chief Complaints: persistent epigastric pain Attending Physician: Dr. T

CLASSIFICATION/
SIDE EFFECTS/ SPECIAL PRECAUTION/
DRUGS MECHANISM OF INDICATION CONTRAINDICATION
ADVERSE REACTION NURSING RESPONSIBILITY
ACTION

Generic: Classification: Relief of moderate to Hypersensitivity to Side Effects: 1. Assess for contraindications.
Analgesic, centrally acting moderately severe pain; post tramadol or opioids or 2. Assess for baseline data.
Tramadol surgery analgesia acute intoxication with Nausea, constipation, 3. Tell patient that he may
HCl Binds to mu-opioid alcohol, opioids, or dizziness, headache, experience side effects brought
receptors and inhibits the psychoactive drugs drowsiness, upon by the drug.
Brand: reuptake of norepinephrine vomiting, somnolence, 4. Instruct him to report side
and serotonin; causes many sedation, headache, dry effects that are intolerable.
Ultram effects similar to opioids – mouth, sweating, 5. Control environment
Dosage: dizziness, somnolence, diarrhea, rash, visual (temperature, lighting) if
50mg q 8h nausea, constipation – but disturbances, vertigo sweating or CNS effects occur.
does not have the 6. Encouraged small frequent
Route: IVTT respiratory effects. meals if vomiting occurs.
Adverse Effects: 7. Oral care for dry mouth and
Frequency: vomiting.
BID Confusion, anxiety,
seizure, tachycardia, 8. Encourage him to increase
bradycardia, pallor, oral fluid intake
Timing: 8`8
anaphylactoid reactions 9. Instruct patient to report
adverse effects that he may
experience.
IV. TEXTBOOK DISCUSSION

1. Definition:

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining.

There are two types of cholecystitis, Calculous and Acalculous Cholecystitis. We are focused
to Acute Calculous Cholecystitis, in which a gallbladder stone obstruct the bile outflow. Bile
remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the
blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene
of the gallbladder may result. Bacteria play a minor role in acute cholecystitis.

Anatomy and Physiology

Gallbladder, a muscular organ that serves as a reservoir for bile, is usually present in
most vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the right
lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and 2.5
cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The
body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left.
The wide end (fundus) points downward and forward, sometimes extending slightly
beyond the edge of the liver. 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.
2. Signs and Symptoms
· Intense and sudden pain in the upper right part of the abdomen
· Recurrent painful attacks for several hours after meals
· Pain (often worse with deep breaths, and extending to the lower part of the right shoulder blade)
· Nausea andvomiting
· Rigid abdominal muscles on right side
· Slight fever
· Jaundice - yellowing of the skin and eyes
· Loose, light-colored bowel movements
· Abdominal bloating.

4. Management

A. Medical Management

1. Intake and Output –

I&O measurement provide another means of assessing fluid balance. This data provide
insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. This
measurement is not that accurate as body weight, however, because of relative risk of errors in
recording.
2. 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.
3. Intravenous Rehydration
When the fluid loss is severe or life threatening, intravenous (IV) fluids are used for
replacement.
4. 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.
5. 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.
6. Choledochoscopy –
the insertion of a choledochoscope into the common bile duct in order to directly
visualize stones and facilitate their extraction.

B. Nursing Management

1. Pain Management

ACTIONS / INTERVENTIONS RATIONALE

1. Observe and document location, severity (0–10 ->assists in differentiating cause of pain and
scale), and character of pain (e.g., steady, provides information about disease
intermittent, colicky). progression/resolution, development of
complications, and effectiveness of interventions

2. Note response to medication, and report to ->severe pain not relieved by routine measures
physician if pain is not being relieved. may indicate developing complications/need for
further intervention

3. Promote bed rest, allowing patient to assume ->bed rest in low-Fowler’s position reduces
position of comfort. intraabdominal pressure; however, patient will
naturally assume least painful pos

4. Use soft/cotton linens; calamine lotion, oil ->reduces irritation/dryness of the skin and
(Alpha-Keri) bath; cool/moist compresses as
indicated
5. Control environmental temperature.
6. Encourage use of relaxation techniques,
e.g.,guided imagery, visualization, deep-breathing
exercises. Provide diversional activities.
7. Make time to listen to and maintain frequent
contact with patient.
2. Maintain Adequate Fluid Balance
ACTIONS / INTERVENTIONS
1. Maintain accurate I&O, noting output less than
intake, increased urine specific gravity. Assess
skin/mucous membranes, peripheral pulses, and
capillary refill.
2. Monitor for signs/symptoms of
increased/continued nausea or vomiting,abdominal
cramps, weakness, twitching, seizures, irregular
heart rate, paresthesia, hypoactive or absent bowel
sounds, depressed respirations.
3. Eliminate noxious sights/smells from
environment.
4. Perform frequent oral hygiene with alcohol-free
mouthwash; apply lubricants
5. Assess for unusual bleeding, e.g., oozing from
injection sites, epistaxis, bleeding gums,
ecchymosis, petechiae, and hematemesis/melena.
3. Teaching the Disease Process
ACTIONS / INTERVENTIONS
1. Provide 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. Discuss weight reduction programs if indicate
5. Instruct patient to avoid food/fluids high in fats
(e.g., whole milk, ice cream, butter, fried foods,
itching sensation
->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
RATIONALE
->provides information about fluid
status/circulating volume and replacement
needs
->prolonged vomiting, gastric aspiration, and
restricted oral intake can lead to deficits in
sodium, potassium, and chloride
->reduces stimulation of vomiting cen
->decreases dryness of oral mucous membranes;
reduces risk of oral bleeding
->prothrombin is reduced and coagulation time
prolonged when bile flow is obstructed,
increasing risk of bleeding/hemorrhage
RATIONALE
->information can decrease anxiety, thereby
reducing sympathetic stimulation
->provides knowledge base from which patient can
make informed choices. Effective
communication and support at this time can
diminish anxiety and promote healing
->Gallstones often recur, necessitating long-term
therapy.
->obesity is a risk factor associated with
cholecystitis, and weight loss is beneficial in
medical management of chronic condition
->prevents/limits recurrence of gallbladder
nuts, gravies, pork), gas producers (e.g., cabbage, attacks
beans, onions, carbonated beverages), or gastric
irritants (e.g., spicy foods, caffeine, citrus).
6. Review signs/symptoms requiring medical ->indicative of progression of disease
intervention, e.g., recurrent fever; persistent process/development of complications requiring
nausea/vomiting, or pain; jaundice of skin , itching; further evaluation
dark urine; clay-colored stools; blood in urine,
stools; vomitus; or bleeding from mucous
membranes.

7. Recommend resting in semi-Fowler’s position ->promotes flow of bile and general relaxation
after meals. during initial digestive process.
8. Suggest patient limit gum chewing, sucking on ->promotes gas formation, which can increase
straw/hard candy, or smoking. gastric distension/discomfort

9. Discuss avoidance of aspirin-containing ->reduces risk of bleeding related to changes in

products, coagulation time, mucosal irritation, and trauma
forceful blowing of nose, straining for bowel
movement, contact sports. Recommend use of soft
toothbrush, electric razor.

V. PROBLEM LIST

1. Ineffective breathing pattern related to pain of the operation site as evidenced by respiratory
depth changes, holding breath and reluctance to cough.

2. Acute Pain related to inflammation and distortion of tissues

3. Knowledge deficit regarding condition, treatment, and self-care related to lack of knowledge

4. Risk for fluid volume deficit related to nausea and vomiting.

VI. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS OUTCOME CRITERIA INTERVENTIONS RATIONALE EVALUATION

S:” Nabudlayan ako Ineffective breathing After 3 hours of nursing Independent Goal met:
maginhawa kay kasakit sa pattern related to pain of interventions, patient will
akon nga inoperahan, daw the operation site as be able to establish >Observe respiratory depth/ >Shallow breathing, splinting After 3 hours of nursing
utod bala haw”,as evidenced by respiratory effective breathing pattern. rate. with respirations, holding interventions, patient was
verbalized by patient. depth changes, holding breath may result in able to establish effective
breath and reluctance to hypoventilation/ atelectasis. breathing pattern.
cough. >Areas of decreased or absent
O: RR=10cpm shallow in breath sounds suggest
>Auscultate breath sounds.
inhalation and deep in atelectasis, whereas
exhalation. adventitious sounds reflect
congestion.
>Assist patient to turn,
cough, and deep breathe >Promotes ventilation of all
V/S taken as follows: lung segments and
periodically. Show patient
how to splint incision. mobilization and
T: 36.9ºC
Instruct in effective expectoration of secretions.
PR: 86bpm breathing techniques.
>facilitates lung expansion.
RR: 10cpm >Elevate head of bed; Splinting provides incisional
maintain lo-Fowler’s support/ decrease muscle
BP: 130/70 mmHg position. Support abdomen tension to promote
when coughing and cooperation with therapeutic
ambulating. regimen.

Collaborative: >Facilitates more effective

coughing, deep breathing, and
>Administer analgesics activity.
before breathing treatments/
therapeutic activities.

fgh
 NURSING SCIENTIFIC OUTCOME INTERVENTIONS RATIONALE EVALUATION
ASSESSMENT
DIAGNOSIS BACKGROUND CRITERIA

Acute Pain related Characterized by After 8 hours of 1. V/s taken and recorded Serve as baseline data Goal met:
S: “Masakit ang to its intensity, rendering proper The patient
tiyan ko,” as location and nursing intervention, 2. Observe and document Assists in differentiating verbalized pain
verbalized by the inflammation duration. It is the client will location, severity cause of pain and provides scale
patient. Pain scale initiated by verbalize pain scale and character of information about rated to 4/10.
and pain. disease progression/ resolution,
rated as 7/10 stimulation of rated from 7/10 to
nociceptors in the 4/10. development of complications
distortion of
O: Grimaced face peripheral nervous and effectiveness of
tissues
system, or by interventions.
With guarding
damage to or
behavior To relieve the pain
malfunction of the 3. Administer analgesic as
peripheral or prescribed Bedrest in Fowler’s position
Restlessness
central reduces intraabdominal pressures;
4. Promote bedrest,
Rigidity of the nervous systems. however, patient will naturally
allowing patient to
abdomen assume least painful position.
assume position of
Splinted
comfort. Promotes rest, redirects
respiration with
short and shallow attention, may enhance coping.
5. Encourage use of
breathing relaxation techniques
such as deep breathing
V/s
exercises.
taken as
follows: Helpful in alleviating
BP: 6. Provide diversional anxiety and
130/90mmHg activities such as watching refocusing
T: 36.7°C television. attention, which
PR: 89bpm can relieve pain.
RR: 32cpm
6
ASSESSMENT NURSING DIAGNOSIS OUTCOME CRITERIA INTERVENTIONS RATIONALE EVALUATION

S: “Ano ni akon sakit Knowledge deficit After 8 hours of nursing Independent Goal met.
man? Ano ang dapat regarding condition, interventions, patient
ko himuon para treatment, and self-care will be able to verbalize >Review disease process. >Provides knowledge base on After 8 hours of
malikawan ang mga related to lack of understanding of the Encourage questions and which patient can make informed nursing
komplikasyon?” as knowledge. disease process, expressions of concern. choice. interventions,
verbalized by the treatment and able to patient was able to
>Review drug regimen, possible >Gallstones often recur, verbalize
patient. initiate necessary side effects necessitating long-term therapy. understanding of the
lifestyle changes and
participate in treatment disease process,
>Instruct patient to avoid foods or >Prevents/limits recurrence of
regimen. treatment and able
O: K,eep on asking, fluids high in fats. gallbladder attacks.
to initiate necessary
>Review signs and symptoms >Indicative of progression of lifestyle changes
Inapparopriate
requiring medical intervention. disease process/ development of and participate in
behavior, statement of
complications requiring further treatment regimen.
misconception
intervention.
>Recommend resting in semi- >Promotes flow of bile and general
V/S taken as follows: Fowler’s position after meals relaxation during initial digestive
process.
T: 36.7ºC >Suggest patient to limit gum
chewing, sucking on straw/ hard >Promotes gas formation, which
PR: 85bpm candy, or smoking. can increase gastric
distention/discomfort.
RR: 16 cpm >Discuss avoidance of aspirin-
containing products, forceful >Reduce risk of bleeding related to
BP: 140/80 mmHg blowing of nose, straining of bowel changes in coagulation time,
movement, contact sports. mucosal irritation and trauma.
Recommend use of soft toothbrush,
electric razor.
ASSESSM NURSING SCIENTIFIC OUTCOME INTERVENTIONS RATIONALE EVALUATIO
ENT DIAGNO BACKGROU CRITERIA N
SIS ND

S:” Risk for Nausea and After 8H of INDEPENDENT After 8H of

Ginasuka fluid vomiting are nursing nursing
ko ang volume not diseases, interventions, -Maintain accurate I and O, -Provides info about interventions,
akun nga deficit but rather are patient will noting output less than intake, fluid status/ patient will
gina ka- related to symptoms of demonstrate increased urine specific circulating volume demonstrate
un,” as nausea and many different adequate fluid gravity. Assess skin/ mucous and replacement adequate fluid
verbalized vomiting. conditions, balance as membranes, peripheral pulses, needs. balance as
by the such as evidenced by and capillary refill. evidenced by
-Prolonged vomiting,
patient. infection, food stable vital stable vital
-Monitor for s/sx of gastric aspiration,
poisoning, signs, moist signs, moist
increased/continued n/d and restricted oral
motion mucous mucous
normal value, abdominal intake can lead to
sickness, membranes, membranes,
O: cramps, weakness, twitching, deficits in sodium,
overeating, good skin good skin
seizures, irregular heart rate, potassium and
240 mL blocked turgor, and turgor, and
paresthesia, hypoactive/absent chloride.
vomitus. intestine, absence of absence of
bowel sounds, depressed
illness, vomiting. vomiting.
respirations.
Pallor, concussion, or
brain injury, -Eliminate noxious -Reduces stimulation
Skin of vomiting center.
appendicitis, sights/smell from
turgor-
and migraines. environment.
greater -Decreases GI
Nausea and
than 3sec., COLLABORATIVE: secretions and
vomiting can
motility.Reduces
Dry skin. sometimes be
-Administer antiemetics, e.g. nausea and prevents
symptoms of
prochloperazine (Compazine.) vomiting.
more serious
diseases such -Review lab studies, e.g. -Aids in evaluating
as heart Hgb/Hct; electrolytes; circulating volume,
attacks, kidney ABGs( pH;) Clotting times. identify deficits, and
or liver influences choice of
disorders, intervention for
central nervous replacement/correctio
system n.
disorders, brain -Administer IV fluids,
tumors, and -Maintains
electrolytes, and vit. K.
some forms of circulating volume
cancer. and corrects
imbalances.

VII. DISCHARGE PLAN

Discharging N. S.,70y/o, female, RC; with working diagnosis of Acute Calculous Cholecystitis;
under the service of Dr. T; with the following discharge criteria:

1. Within normal range.

2. Intravenous solution discontinued and pulled out.

3. Pulled out Epidural Catheter.

4. Signs and symptoms of Acute Calculous Cholecystitis, not manifested.

 5. With 100% appetite.

6. Patient’s significant others will be able to understand discharge instruction well.

EXERCISE OR ABILITIES:

• Gradual increase in activities to bring back energy level.

HEALTH TEACHINGS:

Two major steps on preventing the illness:

1. Foods rich in saturated fats.

- These foods might initiate the reformation of stone for those who suffered already from
this illness.

2. Patient is encouraged to seek for medical advice if she experiences again the signs and
symptoms of the illness.

- Early detection of the recurrent illness would be beneficial to her. New or old
complications might be prevented if it’s detected earlier.

Sources:

Brunner and Suddarth’s. “Medical and Surgical Nursing” 12th ed. Lippincott Williams
and Wilkins. New York.2008