I.

INTRODUCTION

The gallbladder is a small pear-shaped organ which aids in the digestive process. Its function is to
store and concentrate bile, a digestive liquid continually secreted by the liver. The bile in turn emulsifies
fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many
people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can
live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken
for granted, ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and
age are just some factors that contribute for gallbladder complications to occur.
This case study is about Cholelithiasis. Cholelithiasis is the presence of one or more calculi or
gallstones in the gallbladder. In developed countries, about 10% of adults and 20% of people more than
60 years old have gallstones. Gallstones tend to be asymptomatic and do not cause dyspepsia or fatty food
intolerance. More serious complications include cholecystitis, biliary tract obstruction (from stones in the
bile ducts or choledocholithiasis), sometimes with infection or cholangitis, and gallstone pancreatitis.
Diagnosis is usually by ultrasonography. If cholelithiasis causes symptoms or complications,
cholecystectomy is necessary. About 80% of people with gallstones are asymptomatic. The remainder
have symptoms ranging from biliary-type pain or biliary colic to cholecystitis to life-threatening
cholangitis. Biliary colic is the most common symptom.
This study is a case of a 48 year old male, admitted at Medical II unit of Manila Adventist
Medical Center due to abdominal pain in the RUQ, nausea and vomiting, and productive cough. The
patient has been diagnosed with Obstructive Jaundice secondary to Cholelithiasis, Fatty Liver, and Low
Risk Community Acquired Pneumonia. The scope of this study encloses the admission date, August 27,
2010 until his discharged date on September 03, 2010. The study includes the demographic data, present
and past medical history of the client. The disease process will provide the students the knowledge on
how the disease acquired and progresses. The laboratory exams and diagnostic procedures use to diagnose
cholelithiasis is also included as well as nursing interventions, medications, and discharge planning given.
The purpose of this study is to let the students understand and have the knowledge on how to deal with
clients with Cholelithiasis.

1
II. DEMOGRAHIC DATA

This is a case of a 48-year-old male, born on March 04, 1962. For confidentiality reason, the
client was named as SpongeBob to protect his identity. SpongeBob is a Born-Again Christian, married,
and a Filipino citizen. He is currently working as an Audio Engineer in a recording company in Pasay
City. In the course of this study our informant was the client himself.
SpongeBob was admitted at Medical II Unit of Manila Adventist Medical Center on August 27,
2010 with initial diagnoses of Choledocholelithiasis, Fatty Liver, and Low Risk Community Acquired
Pneumonia. He was discharged on September 03, 2010 with the final diagnoses of Obstructive Jaundice
secondary to Cholelithiasis, Fatty Liver, and Low Risk Community Acquired Pneumonia.

III. CHIEF COMPLAINT

Abdominal pain in the RUQ, nausea and vomiting, and productive cough:
“Nasusuka ako at ang sakit-sakit ng tiyan ko, inuubo pa ako.” as verbalized by the client.

IV. HISTORY OF PRESENT ILLNESS

Eight weeks prior to admission, the client had generalized abdominal pain radiating to the back at
lumbosacral area with the pain scale of 8/10 usually occurring from 10 pm to 4 am, not related to food
intake as claimed by the client. No symptoms of fever, nausea, and vomiting. No changes in bowel and
bladder movement noted. He consulted at the Manila Doctor’s Hospital where he was given Buscopan
and provided a relief. No recurrence of pain since then.
Three weeks prior to admission, the pain recurred of same intensity and characteristics. He
consulted at the same institution where he was diagnosed to have ulcer-like dyspepsia. Buscopan was
given again which provided a temporary relief. The pain became on and off since then.
Two weeks prior to admission, the client had the same complaint with nausea and vomiting
noted. Symptoms relieved by vomiting and administration of Buscopan.
Four hours prior to admission, client sought consult to Manila Adventist Medical Center.
Abdominal pain in the RUQ with the P/S of 8/10, nausea and vomiting, productive cough, and icteria was
noted. Ultrasound results revealed contracted gallbladder with lithiasis as well as dilated common bile
duct with choledocholelithiasis, and fatty liver. The client was advised for ERCP hence this admission.

2
V. PAST MEDICAL HISTORY

Prior to diagnosis of having Cholelithiasis, SpongeBob had a history of Hepatitis A fifteen years
ago. No medications were taken. He was also diagnosed to have Pulmonary Tuberculosis and completed
the course of treatment for six months.
SpongeBob did not undergone any major operations and never been admitted to the hospital
before. He is hypertensive, non-diabetic and non-asthmatic. He has no known allergies to any food or
drugs.

3
VI. FAMILY MEDICAL HISTORY WITH GENOGRAM

Most of the family members of SpongeBob are well aside from his mother and sister who have
hypertension. The genogram shows that there is no known history of diabetes mellitus, asthma, cancer,
and cholelithiasis within his family. Cholelithiasis may be a caused by a combination of factors including
inherited body chemistry, body weight, gallbladder motility or movement, and perhaps diet.

Old Old
Old Age Old Age
Age Age

81 79
Old Age HPN

48
58 54 53 51 Cholelithi-
Well Well HPN Well asis

LEGEND:
Male (Deceased)

Female (Deceased)

Male (Alive)

Female (Alive)

Patient

4
VII. PERSONAL, SOCIAL, ENVIRONMENTAL HISTORY

SpongeBob is an active member of Born-Again Christian denomination and attends every social
gathering of his church. He is fond of joining different exercise program during his free time. He is
currently working as an Audio Engineer in a recording company in Pasay City. He is a dedicated
employee and a very good provider to his family.

VIII. DEVELOPMENTAL TASKS

 Havighurst’s Developmental Task: Middle Age

Robert Havighurst recognized that each human has three sources of developmental tasks. They are
task that arise from physical maturation, tasks that arise from personal values, and task that have their
source in the pressures of society. Learning is basic to life and that people continue to learn throughout
life.
SpongeBob is employed as an Audio Engineer, meets civic and social responsibilities, establishes
satisfactory living arrangement and develops affiliation with his group. He had established satisfactory
living management.

 Erikson’s Psychosocial Theory: Generativity vs. Stagnation

According to Erik Erikson, on this phase of adulthood people continue to build their lives and focus
on their career and family. Those who are successful during this phase will feel that they are contributing
to their world by being active in their home and community. Those who fail to attain this skill will feel
unproductive and uninvolved in the world.
Spongebob achieved this phase. He is happily married with three wonderful children. He has a good
job that can suffice all their needs. He is also an active member of their church community.

 Kohlberg’s Stages of Moral Development: Post-Conventional

Lawrence Kohlberg recognized that a person’s moral development is influenced by cultural effect on
ones perception of justice and interpersonal relationship. The patient had experienced struggles and trials
in life that helped mold his moral judgments and behavior.
SpongeBob achieved this stage. He understands the principle of human right and personal conscience
and believes that trust is the basis of relationship. He knows what is right and wrong and he shared it to
his children. He believes in his own principle and not what others believe.

5
  Fowler’s Stages of Faith Development: Universal Faith
According to James Fowlers, faith is seen as holistic orientation, and is concerned with the
individual’s relatedness to the universal. On this stage of faith development, there is awareness of truth
from variety of viewpoints.
SpongeBob is on the stage of universalizing faith, having met the spiritual development of Fowler.
He is a Born-Again Christian and very active in church activities and social gatherings.

6
IX. GORDON’S ASSESSMENT

 Health-Perception/Health Management Pattern

Before SpongeBob was admitted, he eats nutritious food and takes herbal supplements to keep
himself healthy. He usually takes over-the-counter medications and rest whenever he does not feel well.
Four hours prior to admission, Spongebob consulted to our institution because of abdominal pain in the
RUQ, nausea and vomiting, and productive cough. He was advised to undergo different tests and was
subsequently admitted to our institution.
Upon hospitalization SpongeBob had been diagnosed with Obstructive Jaundice secondary to
Cholelithiasis, Fatty Liver, and Low Risk Community Acquired Pneumonia. He had no idea on how and
where he acquired this kind of disease. He believes that this hospitalization will help him recover to his
illness and prevent any further complications.

 Nutritional/Metabolic Pattern
SpongeBob was fond of eating fatty foods and usually goes to fast-food restaurant three to four times
a week. He said, he does not have any food restrictions and drinks four to six glasses of fluids in a day
including juices and soft drinks. Prior to his admission he has poor appetite because of the symptoms he is
experiencing.
During his hospitalization, his appetite was gradually improved. He was advised to refrain from
taking any vitamins and herbal supplements during the course of his hospitalization.

 Elimination Pattern
Before SpongeBob was admitted, he usually experience flatulence and had one bowel movement in a
day. He urinates four to six times a day that varies from yellowish to tea-color.
During his hospitalization, his bowel movement has not changed. His urine has the same color as
before.

 Activity/Exercise Pattern
SpongeBob actively participates in his church activity and attends every social gathering. During
his free time, he usually join different exercise program. He enjoys brisk walking every afternoon on the
way home from his work. He does not smoke or drink alcoholic beverages as he claimed.
During his hospitalization, his movement was limited and cannot perform any of his usual activities
because of his condition.

7
  Sleep/Rest Pattern
Before SpongeBob was admitted, his average sleeping hours per day was six to eight hours. He
usually sleeps at around 10:00 pm and wakes-up at 5:00 am. He does not have any difficulty in sleeping
and does not experience any nightmares. He said whenever the pain on his abdomen occurred, his sleep
pattern was disturbed.
During his hospitalization, his sleep pattern was still disturbed whenever the pain on his abdomen
occurred. It was relieved by the pain reliever administered to him whenever he had an attack.

 Cognitive/Perceptual Pattern
SpongeBob wears eye-glasses for his Hyperopia. He said he does not remember the last time he had
an eye examination. He does not experience any problems on hearing, smell, taste, and touch. Three
weeks before he was hospitalized, the pain on his RUQ of the abdomen recurred of same intensity and
characteristics. He consulted at the Manila Doctor’s Hospital and was given Buscopan which provided a
temporary relief. The pain became on and off since then. Every time the pain recurred, he needs to stop
what he was doing and prayed to God to overcome the pain.
During his hospitalization, he still experienced the same type of pain and was given Tramadol
(dolcet) and Hyoscine (Buscopan) to relieve the pain.

 Self-perception Pattern
SpongeBob said he is very happy and fulfilled with his life although he had a problem with his health.
He had so many plans for his family and thinks that he will overcome this illness.
During his hospitalization, he feels very anxious and worried when the doctor said he needs to
undergo an operation but when he thinks that it will help him to recover from his illness it gives him
strength and courage.

 Role/Relationship Pattern
Spongebob is the youngest among his siblings. He has two sisters and two brothers. He is happily
married with three children. He is the one who makes decision in the family.
During his hospitalization, he stated that “Ang swerte ko pa rin kasi ‘andyan ang pamilya ko para
tulungan ako.” His illness makes their family draw closer together. He finds strength through his
relationship with God and his family.

8
  Sexuality/Reproductive Pattern
When asked about his sexual activity, SpongeBob said that at his age they still engage in doing it and
does not use any kind of contraceptives. His relationship with his wife is very strong. They have three
wonderful children, two sons and a daughter. He does not perform testicular self-examination and never
had infections of the reproductive tract.

 Coping/ Stress Management Pattern

According to SpongeBob in the past year there were no major changes in his life. He is very
blessed with regards to his career and family. Whenever they encounter a problem, they just pray together
and put their trust to the Lord.
During his hospitalization, he never ceased to praise the Lord. His faith with the Lord gave him
strength and assurance that he can overcome all of his problems.

 Value/Belief Pattern
SpongeBob believes that everything that is happening in our lives have a reason. He said, our body is
the temple of God and we are only the caretaker of it so we must be responsible in everything we do.
He stated “Wala naming kinalaman ang Diyos sa sakit ko”. What happened to him made him closer
and more prayerful to God.

9
X. PHYSICAL ASSESSMENT

Physical August 27, 2010 September 01, 2010

Assessment (Admission Day) (Initial Visit)

a. General Appearance: Admitted this 48 year old male,
afebrile, awake, conscious, coherent,
with IVF #1 of PNSS 1Lx10cc/hr on
left hand, not in cardiorespiratory
distress, with (+) weight loss.
Assessed this 48 year old male
admitted on 08/27/10, afebrile, calm,
awake, on supine position with IVF
#8 of D5NR x 30gtts/hr on left hand,
patent and infusing well.

b. Vital Signs: BP – 140/90 mmHg BP – 130/90 mmHg

T – 37.2 °C T – 36.8 °C
PR – 86 beats/min PR – 79 beats/min
RR – 24breaths/min RR – 18breaths/min
Ht- 162.6 cm. (5’4” ft) Ht- 162.6 cm. (5’4” ft)
Wt – 66.3 kg. (146 lbs.) Wt – 64.5 kg. (142 lbs.)

c. Skin: Warm, good skin turgor Warm, good skin turgor

d. Head and Neck: No neck vein engorgement, no No neck vein engorgement, no

cervical lymphadenopathy cervical lymphadenopathy

e. Eyes: Pupil reactive to light, icteric sclera Pupil reactive to light, icteric sclera

f. Ears: Intact tympanic membrane, no Intact tympanic membrane, no

discharge discharge

g. Nose: Symmetrical, no deformity, no skin Symmetrical, no deformity, no skin

lesions, no swelling, no discharge lesions, no swelling, no discharge

h. Mouth and Throat: Dry lips, moist buccal mucosa Dry lips, moist buccal mucosa

i. Breasts: Not assessed No masses and tenderness upon

palapation

j. Chest/Lungs: Symmetrical chest expansion, with Symmetrical chest expansion, no

10
 cough retractions, clear breath sounds

k. Heart: Dynamic precordium, normal rate, Dynamic precordium, normal rate,

regular rhythm, no murmurs regular rhythm, no murmurs

l. Abdomen: Flat, soft, normoactive bowel sound Flat, soft, normoactive bowel sound,
with slight tenderness on RUQ, (+) presence of four surgical wounds on
Murphy’s sign abdomen area with dry and intact
dressings.

m. Back (+) lumbosacral pain Not assessed

n. Extremities: Full and equal pulse, no edema Full and equal pulse, no edema

o. Genitalia: Not assessed Not assessed

p. Rectal: Not assessed Not assessed

q. Neurologic Awake, conscious, coherent Awake, calm

Assessment:

11
X1. REVIEW OF SYSTEMS

Systems August 27, 2010 September 01, 2010

(Admission Day) (Initial Visit)

a. Skin: (-) rashes (-) rashes

(-) lumps (-) lumps
(-) itching (-) itching
(-) dryness (-) dryness
(+) jaundice (-) jaundice
(-) changes in hair and nails (-) changes in hair and nails

b. Head: (-) headache (-) headache

(-) head injury (-) head injury

c. Eyes: (+) glasses (+) glasses

(+) icteric sclera (-) icteric sclera
(-) pain (-) pain
(-) redness (-) redness
(-) double vision (-) double vision
(-) glaucoma (-) glaucoma
(-) cataracts (-) cataracts

d. Ears: (-) hearing loss (-) hearing loss

(-) tinnitus (-) tinnitus
(-) discharge (-) discharge

e. Nose and Sinuses: (-) frequent colds (-) frequent colds

(-) nasal stuffiness (-) nasal stuffiness
(-) nose bleeds (-) nose bleeds

f. Mouth and Throat: (-) lesions on gums (-) lesions on gums

(-) sore throat (-) sore throat
(-) hoarseness (-) hoarseness

g. Neck (-) goiter (-) goiter

h. Breasts: (-) lumps (-) lumps

(-) pain (-) pain
(-) nipple discharge (-) nipple discharge

12
i. Respiratory: (+) cough (-) cough
(+) sputum: yellowish phlegm (-) sputum
(-) hemoptysis (-) hemoptysis

j. Cardiac: (-) heart problem (-) heart problem

(-) hypertension (-) hypertension
(-) pain (-) pain

k. GIT: (-) hematemesis (-) hematemesis

(-) food intolerance (-) food intolerance
(+) nausea and vomiting (-) nausea and vomiting
(-) melena (-) melena
(-) hemorrhoids (-) hemorrhoids

l. Urinary: (-) incontinence (-) incontinence

(-) nocturia (-) nocturia
(-) dysuria (-) dysuria
(-) hematuria (-) hematuria
(+) tea-colored urine (-) tea-colored urine

m. Genital: (-) discharges (-) discharges

(-) decrease libido (-) decrease libido
(-) sexual difficulties (-) sexual difficulties
(-) STD’s (-) STD’s
(-) hernias (-) hernias

n. Musculoskeletal: (-) joint pains (-) joint pains

(-) joint stiffness (-) joint stiffness
(-) weakness (-) weakness
(-) limitation of movement (-) limitation of movement
(-) paralysis (-) paralysis

o. Peripheral Vascular: (-) cramps (-) cramps

(-) thrombophlebitis (-) thrombophlebitis

p. Neurological: (-) fainting (-) fainting

(-) blackouts (-) blackouts
(-) seizures (-) seizures
(-) tingling sensation (-) tingling sensation
(-) numbness (-) numbness

13
q. Psychiatric: (-) nervousness (-) nervousness
(-) tension (-) tension
(-) depression (-) depression

r. Hematologic: (-) anemias (-) anemias

(-) easy bruising or bleeding (-) easy bruising or bleeding
(-) past transfusions (-) past transfusions

14
 XII. COURSE IN THE WARD

Nursing Observations and

Date and Time Doctor’s Order
Evaluation

27 August 2010

1:30 pm -Please admit patient to room of
choice under the service of Dr.
Oliva
- Admitted this 48 y/o male per
wheelchair to Room 214 under
the service of Dr. Oliva with
chief complaints of abdominal
pain in the RUQ, nausea and
vomiting, and productive
cough.

-Refer to Dr. Manley Uy (GS) -Referred

for possible ERCP

-Diet as tolerated -Wt: 146 lbs

-V/S q4 BP – 140/90 mmHg

T – 37.2 °C
PR – 86 beats/min
RR – 24breaths/min

-IVF #1PNSS 1Lx10/hr -PNSS hooked @ 1:30pm &

regulated @ ordered rate

Diagnostic Procedures: -12 lead ECG done:

-12 lead ECG IMPRESSION: Normal sinus
rhythm

-Abdominal UTZ -Abdominal UTZ done:

IMPRESSION: Contracted
gallbladder with lithiasis;
Dilated common bile duct with
choledocholelithiasis, fatty
liver.
Labs:
-CBC - CBC: Normal
-FBS, BUN, Crea, Na, K -FBS: 5.8 (N), BUN: 3.9(N)
-PSA -PSA: 1.850 Normal
-ALT, AST, Alk Phos,TB -ALT: ↑614, AST: ↑270, Alk
Phos: ↑160, TB: ↑25.3

6:45 pm -Take Tramadol (Dolcet) 50mg -Management for moderate to

IV severe pain.

15
 -Inform Dr. Oliva -Informed Dr. Oliva

-Rounds with Dr. Uy

-Start Ciprofloxacin (Xipro) 200 -Ciprofloxacin started for

mg IV BID ANST Respiratory tract infection.

-Soft diet -patient was shifted from DAT

to soft diet.

-For possible ERCP tomorrow

c/o Dr. Frederick Dy

8:00 pm Addendum:
-For ERCP tomorrow @ 9 am,
UST Hospital, Endoscopy Unit

- NPO post midnight -Patient was informed.

-Follow-up prothrombine time

and allay results ASAP

-Please arrange ambulance -Informed superior, inquired

conduction with patient admitting office.

-If normal may go ahead with -IMPRESSION: Patient is a low

procedure. clinical risk for a low surgical
procedure.
- (+) icteric sclera
- (+) slight tenderness RUQ
-BP: 130/90 – 140/100 mmHg
-HR: 78 bpm

Pre-op orders:
-NPO post midnight
-CBG monitoring q4 while NPO
-200 mg/dl – 4 ‘u’ hr SQ

8:30pm -Strict Nicardipine (Cardepine) -To maintain BP <160/9mmHg

drip if BP systolic is 160/90
mmHg

-Start Olmesartan (Olmetec) 20 -1st dose given tonight

mg/tab 1tab OD, please give 1st
dose tonight.

16
28 August 2010

4:35am -shift IVF#1 to D5NR 1Lx8h -IVF shifted to D5NR 1Lx8h @

4:35 am

6:35am -Assess patient -Patient seen and examined:

Comfortable, not in distress.

- Facilitate ERCP today, pre-op

orders as above.

-Please facilitate ambulance -Ambulance conduction

conduction. facilitated.

9:00 am -For ERCP c/o Dr. Dy. -IMPRESSION: S/P ERCP;

CBD stone extracted.

-Please do the ff. post-ERCP:

-FBS, BUN, Na, K, Cl, -FBS: 5.5, BUN: ↑2.3, Na: 140,
Amylase, ALT, AST K: 3.9, Cl: 103, Amylase: 49,
ALT: ↑619; AST: ↑233

-Please inform Dr. Oliva post- -Informed Dr. Oliva

ERCP

12:40 pm -IVF#3 D5NR 1Lx12/hr -D5NR hooked @ 12:40 pm &

regulated @ ordered rate

5:05 pm - Patient may have soft diet -shifted to soft diet

7:10 pm - Rounds with Dr. Uy

- Please regulate IVF to KVO -IVF regulated to KVO

-Discontinue CBC monitoring - CBC monitoring discontinued

8:30 pm -Please shift IVF#3 to IVF#4 - IVF#3 shifted to IVF#4 PNSS

PNSS 1LxKVO 1LxKVO

-Hyoscine (Buscopan) PRN - For epigastric pain

- (+) Occasional epigastric pain

-Refer accordingly -Referred

29 August 2010

8:00 am -Rounds with Dr. Uy

17
10:00 am -Refer to Dr. La Madrid for -Referred
Laparoscopic Cholecystectomy

10:15 am -Rounds with Dr. La Madrid

- Possible Open
Cholecystectomy tomorrow
(August 30, 2010) @ 8 am

-Secure signed consent for -Secured consent

contemplated procedure.

-NPO post midnight

- Continue Ciprofloxacin -Ciprofloxacin continued

(Xipro)

-Ranitidine (Dynastin) 1 amp IV - Prophylaxis of GI hemorrhage

q8 while on NPO from stress ulceration in
patients at risk of developing
acid aspiration during general
anesthesia.

-Hyoscine (Buscopan) 1 amp IV -For abdominal pain

PRN

-Refer back to Dr. Uy for CP -Referred to Dr. Uy

clearance.

-Refer to anesthesia group for -Informed Dr. Rabe

ANS care

3:30 pm -IVF#5 PNSS 1LxKVO -IVF#5 hooked @ 3:30 pm &

regulated to KVO

3:50 pm -For CP clearance -CP clearance done by Dr. La

Madrid
-Patient is a minimal risk for a
minimal surgical risk procedure.
May go ahead with laparoscopic
cholecystectomy.

Pre-op Orders:
-NPO post midnight
-IVF#6 D5NR 1Lx8
-CBG monitoring q4 while on
NPO
-If >200mg/dl – 4 ‘u’ hr SQ
-May give Olmesartan
(Olmetec) 20mg 1 tab in AM
pre-procedure with little sips of

18
 H20
-May hook to O2 @ 2-3LPM

Post-op please do:

-12 lead ECG
-Crea, BUN, Na, K
-CBC

Please inform Dr. Oliva once

post-op.

4:45 pm -For CXR PA view IMPRESSION: with pneumonia

5:20 pm -Patient seen and examined

-History and chart received
-Anesthesia type/risks
explained, understood and
accepted by the patient.
-Secure consent for anesthesia -Secured consent
-NPO post midnight
-Oral and body hygiene PTOR
-Premeds prior to OR:
1. Promethazine (Phenergan) -for pre-operative sedation.
25mg, IM
2. Nalbuphine (Nubaine) 10mg
IM

-Please relay all lab results once All lab results relayed to AROD
into AROD

-Inform AOD -AOD informed

-Refer PRN

10:00 pm -Refer back to Dr. Oliva for CP -Referred to Dr. Oliva, CP

clearance. clearance done.
IMPRESSION:
(+) Crackles left base, ↓ Cough

30 August 2010

12:25am -Defer Laparoscopic -Lap Chole deferred, OR and

Cholecystectomy for now Surgery informed

6:50 am -IVF#6 PNSS 1LxKVO -IVF#6 hooked @ 6:50 am &

regulated to KVO

9:00 am -Do final clearance with Dr. -CP Clearance done by Dr.
Oliva for possible surgery on Oliva.
Wednesday.

19
 IMPRESSION:
↓ Crackles, ↓ Cough,
↓Abdominal discomfort, (-)
fever

-For laparoscopic -Patient no objection to

cholecystectomy tomorrow. laparoscopic cholecystectomy

11:00 am -Secure consent -Secured consent

-NPO post midnight

-Ranitidine (Zantac) 50 mg IV
q8 once on NPO

-Raise Chest and Back Chest and back fomentation

fomentation BID done BID

11:30 am -Noted deferral of laparoscopic IMPRESSION:

cholecystectomy Minimal coarse crackles left
base, afebrile

-Please do CBC with diff., RBC: 5.02, Hct: 0.43, Hgb: 152
please relay results

-May resume diet with strict -diet resumed

aspiration precautions.

-Take Ciprofloxacin (Xipro)

400mg IV q12

-Start Azithromycin
(Xithromax) 500mg/tab QD

-If with normal WBC count, WBC: 6.46 (Normal)

will clear patient for
Laparoscopic Cholecystectomy

-May give Paracetamol 500mg -Administered Paracetamol, (+)

IV PRN For temperature fever: 37.8 °C
>37.5C

1:00 pm -IVF#7 PNSS 1LxKVO -IVF#7 hooked @ 1:00 pm &

regulated to KVO

4:20 pm -Inform Dr. Oliva -Dr. Oliva informed

4:30 pm -Refer PRN

20
31 August 2010
7:50 am -Rounds with Dr. Oliva
9:26 am -Please inform Dr Uy and Dr.
La Madrid for CP Clearance
--Please carry out previous pre-
op anesthesia orders done last
August 29, 2010
01 September 2010
(1st DUTY DAY)
8:00 am -To OR
11:00 am -S/P Laparoscopic
Cholecystectomy under General
Anesthesia
-NPO until further orders
-Vital signs q15 min. until
stable, then q1 x 24h with
temperature
-O2 inhalation @ 5LPM
-IVF#8 D5NR x 30gtts/hr
Medications:
-Parecoxib (Dynastat) 40 mg
slow IV BID x 2 days
-Tramadol 37.5 mg and
Paracetamol 35 mg (Dolcet) 1
cap PO QID once on DAT
-Informed Dr. Uy and Dr. La
Madrid. CP clearance done.
-BP: 120/80, T: 36°C, PR: 60
IMPRESSION:
(-) Crackles left base
CAP resolved, patient is cleared
for a minimal surgical risk. May
go ahead with the laparoscopic
cholecystectomy.
-Previous pre-op anesthesia
orders carried out.
-Transferred to OR @ 8 am
-Received from RR, asleep
-Informed Dr. Oliva
BP: 130/90 mmHg, T: 36.8 °C
P: 79 bpm R: 18 bpm
Administered O2 inhalation @
ordered rate.
-IVF#8 hooked @ 11:00 am &
regulated at ordered rate.
-Encouraged deep breathing
exercises.
-Management for post-op pain.
21
 -Tramadol (Dolcet) 50 mg IV -Management for moderate to
PRN q6 severe pain
(+) moderate pain in suture site

-Ranitidine (Zantac) 50 mg IV
q8 while on NPO

-Ciprofloxacin (Xipro) 400 mg

IV q12

-Refer PRN

11:10 am -Continue Azithromycin

(Zithromax) 500 mg tab OD

-CBG monitoring q4 while on

NPO as previously ordered.

-May discontinue CBG

monitoring once in soft diet.

2:25 pm -May give post-op medications

as ordered by anesthesiologist

2:30 pm -Please do HBSAg, Anti HBC, -HBSAg, Anti HBC, Anti HCV:
Anti HCV Non-reactive

4:15 pm -Update Dr. Oliva -Updated Dr. Oliva

6:30 pm -Once on soft diet shift to -Patient is on soft diet

IVF#9 PNSS 1L x KVO -IVF shifted to PNSS 1L x
KVO
-Discontinued CBG monitoring

-Start KCl 30cc mixed with - Started KCl. Use as an

juice BID electrolyte replenisher.
K: ↓3.0 Mmol/L

-Repeat CBC tomorrow

-Follow-up post-op labs. Please -Post-op lab results relayed.

relay results.

Medications:
-Ciprofloxacin 400 mg IV BID
– Day 5, continue until Day 7
then D/C
-Azithromycin (Zithromax) 500
mg 1 tab QD – Day 3, continue
until Day 5 then D/C

22
 -Olmesartan (Olmetec) 20 mg 1
tab QD

-Refer -Referred

02 September 2010

10:20 am -If patient can tolerate may start

solid food.

-Low Na, low fat diet

-Shift IVF to heplock -IVF shifted to heplock

-May give tramadol (Dolcet) 50 -Management for moderate to

mg IV PRN; Ciprofloxacin severe pain
(Xipro) - Day 6, Azithromycin
(Zithromax) – Day 7 shift to
Levofloxacin 500 mg/tab 1 tab
QD

-Give last dose of Azithromycin

(Zithromax) tomorrow

-Start Potassium Chloride Potassium Chloride started.

(Kalium Durule) 1 tab BID x 2
days

-Refer accordingly

11:00 am -Change dressings -Dressings changed.

No erythema and discharge seen
on surgical wound.

03 September 2010

8:00 am -Continue present medications Present medications continued.

8:20 am -Rounds with Dr. La Madrid

-May go home from surgical -Encouraged the patient to

standpoint ambulate.

-Give Tramadol (Dolcet) 1 tab -For moderate pain.

TID PRN

-Please inform attending MD -Attending MD and MROD

and MROD informed.

23
11:00 am -For CP clearance with Dr.
Oliva and Dr. Uy
-Give ursodeoxycholic acid
(Ursofalk) 25 mg TID
11:20 am May go home order
Home medications:
-Levofloxacin 500 mg/tab 1 tab
OD for 1 week
-Dolcet PRN for pain
-CP clearance done by Dr.
Oliva and Dr. Uy
-Ursodeoxycholic acid given.
-Home medications and
discharge instructions given:
-Diet: Low salt, low fat
-Follow up after 2 weeks
-Patient was discharged with
improved condition
24
XIII. LABORATORY RESULTS/DIAGNOSTIC PROCEDURES

(1) Hematology Test

Dates: 27 August 2010 – 02 September 2010
Results with Dates Reference
Test Name Unit
Aug 27 Aug 30 Sep 01 Sep 02 Range
RBC 5.09 5.02 4.94 4.42 10^12/L 4.00-6.00
Hematocrit 0.43 0.43 0.42 0.37 L/L 0.37-0.47
Hemoglobin 153 152 148 135 g/L 110-160
WBC 6.09 6.46 ↑15.93 ↑11.95 10^9/L 5.00-10.00

Purpose and Interpretation of Results:

The CBC includes the red blood cell (RBC) count, hemoglobin, hematocrit, red cell indices, white
blood cell (WBC) count with or without differential, and platelet count. CBC is done to determine general
health status and to screen for a variety of disorders such as anemia and infection. It provides important
information about the kinds and number of cells in the blood, especially red blood cells, white blood cells,
and platelets.
Based on the client’s laboratory test results, he has normal results with regards to RBC, hematocrit,
and hemoglobin. The client has elevated WBC which may indicate stress (surgery), acute hemorrhage or
hemolysis, infectious diseases, inflammatory disorders, and use of drugs (epinephrine, histamine, lithium,
heavy metals, heparin, digitalis, ACTH).

(2) Fasting Blood Sugar

Dates: 27 August 2010 – 28 August 2010
Results with Dates
Test Name Unit Reference Range
August 27 August 28
Fasting Blood
5.8 5.5 Mmol/L 4.2-6.1
Sugar

Purpose and Interpretation of Results:

Fasting blood sugar is a method for learning how much glucose there is in a blood sample taken
after an overnight fast. It is commonly used in the detection of diabetes mellitus.
Based on the client’s laboratory test results, he has normal levels of sugar in the blood. It means
the patient is not diabetic.

(3) Clinical Chemistry Test (SGPT, Bilirubin)

25
Date: 27 August 2010
Test Name Result Unit Reference Range
PSA 1.850 Ng/ml 0.00-4.00
Alkaline Phosphatase
↑160 u/L 38-126
(ALP)
BUN 3.9 Mmol/L 3.2-7.1
Urea 90-100 umol/L 71-133
SGPT (ALT) ↑614 Mmol/L 64-73
Sodium 138 Mmol/L 137-145
SGOT (AST) ↑270 Mmol/L 17-59
Bilirubin T/D
Total Bilirubin 25.3 umol/L 3-22
Indirect Bilirubin ↑134 umol/L 0-19
Direct Bilirubin ↑11.9 umol/L 0-5
Potassium 4.0 Mmol/L 3.6-5.0

Purpose and Interpretation of Results:

Alkaline Phosphatase (ALP) is enzyme that cleaves phosphate from compounds with a single
phosphate group. Alanine aminotransferase (ALT), formerly SGPT, assess functions of the liver, heart,
kidney, and muscle cells and if there are damages to those organs. Elevations of this test accompany acute
hepatocellular alteration. Serum bilirubin measures direct and indirect levels together. Aspartate
aminotransferase (AST), formerly known as serum glutamic-oxaloacetic transaminase (SGOT) catalyzes
the reversible transfer of an amino between the amino acid, aspartate, and ketoglutamic acid. ALT exists
in large amounts in both liver and myocardial cells and in smaller but significant amounts in skeletal
muscles, kidneys, pancreas, and brain. Direct bilirubin is increased with impaired biliary excretion,
causing conjugated fraction to accumulate in plasma. Indirect bilirubin is increased with excessive
erythrocyte hemolysis.
Based on the client’s laboratory results, he has elevated Alkaline Phosphatase (ALP), ALT, AST,
indirect blilrubin and indirect bilirubin. Signs and symptoms of disorders associated with elevated ALP
levels include biliary obstruction, hepatobiliary disease, and bone disease including malignant processes.
Elevated serum ALT levels are considered a sensitive index of liver damage resulting from a variety of
disorders and numerous drugs, including alcohol. Elevations also may be seen in nonhepatic disorders
such as muscular dystrophy, extensive muscular trauma, myocardial infarction, congestive heart failure
(CHF), and renal failure, although the increase in ALT produced by these disorders is not as great as that
produced by conditions affecting the liver. Serum AST rises when cellular damage occurs to the tissues in
which the enzyme is found. Serum bilirubin levels are measured as total bilirubin, indirect bilirubin, and
direct bilirubin. Total bilirubin reflects the combination of unconjugated and conjugated bilirubin in the
serum and can be used to screen clients for possible disorders involving bilirubin production and

26
excretion. When total bilirubin levels are elevated, indirect and direct bilirubin levels are measured to
determine the source of the overall elevation. Elevated direct bilirubin may indicate bile duct disease and
extrahepatic bile duct obstruction like gallstone. Elevated indirect bilirubin may indicate defective
hepatocellular uptake or conjugation like viral hepatitis.

(4) Coagulation Test

Date: 27 August 20109

Test Name: PT Result Unit Reference Range
Patient 11.4 Sec 10.8-13.8
Activity >100 %
INR 0.08

Purpose and Interpretation of Results:

The prothrombin time (PT, pro time) test is used to evaluate the extrinsic pathway of the
coagulation sequence. It represents the time required for a firm fibrin clot to form after tissue
thromboplastin (coagulation factor III) and calcium are added to the sample. These added substances
directly activate factor X, the key factor in all three coagulation pathways. Neither platelets nor the
factors involved in the intrinsic pathway are necessary for the clot to form.
Based on the client’s laboratory test results, he has normal results with regards to PT test, which
indicates normal intrinsic coagulation process of clotting factors. He has no deficiencies with fibrinogen
concentration.

(5) Clinical Chemistry Test

Date: 28 August 2010
Test Name Result Unit Reference Range
Amylase 49 Mmol/L 30-110
BUN ↓2.3 Mmol/L 3.2-7.1
Chloride 103 Mmol/L 98-107
SGPT (ALT) ↑619 Mmol/L 64-73
Potassium 3.9 Mmol/L 3.6-5.0

27
Sodium 140 Mmol/L 137-145
SGOT (AST) ↑233 Mmol/L 17-59
Urea 82 Umol/L 71-133

Date: 01 September 2010

Test Name Result Unit Reference Range
BUN ↓3.0 Mmol/L 3.2-7.1
Sodium 140 Mmol/L 137-145
Potassium 3.6 Mmol/L 3.6-5.0
Urea 85 Mmol/L 71-133

Purpose and Interpretation of Results:

Urea is a nonprotein nitrogenous compound that is formed in the liver from ammonia. Although
urea diffuses freely into both extracellular and intracellular fluid, it is ultimately excreted by the kidneys.
Blood urea levels reflect the balance between production and excretion of urea. Changes in protein intake,
fluid balance, liver function, and renal excretion affect blood urea levels.
Based on the client’s laboratory results, he has decreased level of BUN which may indicate
severe liver disease, water overload, nephrotic syndrome, malabsorption syndromes, and effect of use of
drugs (IV dextrose, Phenothiazines, Thymol).

(6) Immunology
Date: 01 September 2010
Test Name: Results Interpretation
Anti-HCV 0.09 Non-reactive
HBsAg 0.34 Non-reactive
Anti-HBc Total 2.930 Non-reactive

Hepatitis C is a parenterally acquired disease usually caused by blood transfusion but also by IV drug
abuse. The disease can lead to chronic hepatitis and cirrhosis of the liver. The test is performed to detect
the antibodies to hepatitis C virus (Anti-HCV) in the blood of those at risk for the infection and
transmission of the virus as a blood donor. Antibody formation can take as long as a year after exposure
to the virus. Hepatitis B, also known as the Australian antigen, is a more serious, prolonged disease that

28
can result in liver damage and chronic active hepatitis. HBV can be found in the blood, feces, saliva,
semen, sweat, urine, or any body fluid of infected individuals and can be transmitted by exposure to blood
products or parenteral contact with articles contaminated with material containing the virus. Diagnosis is
made by identification of the hepatitis B surface antigen (HBsAg) circulating in the blood before and
during the acute early stage before enzyme elevations or in chronic carriers after an acute illness. It is the
first indicator of acute hepatitis infection. Total hepatitis B core antibody (Anti-HBc Total) appears on the
onset of symptoms in acute hepatitis B and persists for life. The presence of anti-HBc indicates previous
or ongoing infection with HBV in an undefined time frame.
Based on the client’s laboratory results, he has non-reactive serum on all three tests. It means the
client has never been exposed or infected with hepatitis B and C viruses.

(7) Liver/Biliary System Ultrasonography

Date: 27 August 2010
Purpose and Interpretation of Results:
Liver and biliary system ultrasonography consists of studies performed to determine the size,
shape, and position of the liver and the gallbladder, located in the upper right quadrant (URQ) of the
abdomen. Gallbladder ultrasonography is especially helpful when performed in clients whose gallbladder
is unable to opacify gallstones with oral or intravenous radiologic studies.
Based on the diagnostic result of the patient’s ultrasonography, he has contracted gallbladder with
lithiasis and dilated common bile duct with choledocholelithiasis, and fatty liver.

XIV. NURSING OR DIAGNOSTIC PROCEDURES WITH NURSING RESPOSIBILITIES

1. Endoscopic Retrograde Cholangiopancreatography (ERCP) – is a technique that combines the use of

endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal
systems.

A. Indications for procedure

The procedure is used to identify any problems of the pancreas or bile ducts that can cause abdominal
pain usually in the right upper or middle stomach area and yellowing of the skin and eyes. These include
bile duct strictures, bile duct tumors, chronic pancreatitis, gallstones, primary biliary cirrhosis,
cholangitis, pancreatic pseudocysts, pancreatic strictures, and pancreatic tumors.

29
B. Procedure with Nursing Responsibilities
Before the procedure, inform the client that he needs to fast for at least 4 hours and sign a consent
form. Inform the client that an x-ray will be taken before the procedure and several x-ray films during the
procedure after the endoscope has been inserted and that additional medication can be administered to
relax the sphincter of the duodenal papilla. Advise the client that the position will be changed to prone
after the endoscope reaches the small intestine to accommodate the visualization of the duodenal papilla
and injection of a dye into the ducts. Inform him that a flushed feeling can be experienced when the dye is
injected. Obtain a history that includes known or suspected gastrointestinal disorders, treatment regimen,
and information about sensitivity to iodine to prevent possible reaction to the dye (Demerol) as a
preprocedural medication.
During the procedure, the client is placed on an x-ray table in the supine position and a plain film (flat
plate) of the abdomen is taken to observe for any residual contrast media from previous studies, such as
barium studies or scans using contrast media, which can interfere with a successful procedure. Because
the client will lie on the table for approximately 1 to 2 hours, it is desirable that the table be padded and
that measures be taken to ensure client comfort. The oropharynx is sprayed or swabbed with a topical
local anesthetic. If an IV access such as a heparin lock or IV line has not been established, it is done at
this time. The IV access device or line is placed in the right hand or arm because the client will be
positioned on the left side during the procedure until the endoscope is passed into the duodenum.31
Cardiac rhythm and pulse oximetry for oxygen saturation and vital signs should be monitored throughout
the procedure, and cardiopulmonary resuscitation equipment should be available. The client is then
assisted to the left lateral position with the left arm positioned behind the back, the right hand at the side,
and the neck slightly flexed. A protective guard is inserted into the mouth to cover the teeth, and a bite
block can also be inserted to maintain an adequate opening of the mouth without client effort or control.
Additional sedative and analgesic medications are administered through the IV line at this time. The
endoscope is passed through the mouth with a dental suction device in place to drain secretions. The
scope is then advanced down the esophagus and into the stomach. Air can be introduced to smooth out the
folds of the stomach for better visualization of all areas. When the endoscope reaches the duodenum,
medications such as simethicone (Mylicon) can be instilled via the scope to reduce the bubbling caused
by bile secretions. Atropine sulfate and glucagon can be administered through the IV line at this time to
relax the duodenum and reduce motility to allow for cannulation of the ampulla of Vater. The client is
then turned to the prone position, and the duodenal papilla is visualized and cannulated with a catheter.
The client is requested to remain very still during this phase of the procedure. Occasionally the client can
be turned slightly to the right side to aid in visualization of the papilla. Dye (contrast medium) is injected
into the pancreatic and biliary ducts via the catheter, and a series of fluoroscopic x-ray films are taken.

30
ERCP manometry can also be performed to measure the pressure in the bile duct, pancreatic duct, and
sphincter of Oddi at the papilla area via the catheter as it is placed in the area before the dye is injected.
Specimens and biopsies for cytologic analysis can be obtained during the procedure. These are placed in
appropriate containers, properly labeled, and promptly sent to the laboratory. When the examination is
completed, the dental suction device is removed, the endoscope is withdrawn, and the tooth guard and
bite block are removed.
After the procedure, assess the ability to resume usual voiding patterns. Resuscitation equipment
should be available to treat respiratory depression with hypoxemia, cardiac complications, or adverse
effects of drugs used before and during the procedure. Note and report tachycardia, palpitations,
hyperpnea, hypertension, or reactions to the dye, such as pallor, hypotension, restlessness, and
diaphoresis. Administer ordered antihistamines and initiate resuscitation procedure if needed. Note and
report neck or chest pain, pain on swallowing, hemoptysis, or changes in vital signs for potential
hypovolemia. Initiate IV line for fluid volume replacement. Prepare for intervention to repair damaged
area. Note and report breathing difficulty, apnea, cyanosis, hypoxemia, hypotension, bradycardia, or
bronchospasm.. Administer oxygen or narcotic antagonist (naloxone), if ordered and perform
resuscitation and mechanical ventilation if needed. Note and report temperature elevation, upper
abdominal pain, culture results identifying escherichia coli or pseudomonas species from release of
organisms in infected bile into the bloodstream and administer ordered antibiotic and analgesic therapy.
Note and report severe epigastric and abdominal pain radiating to the back, abdominal distention,
hypoactive bowel sounds jaundice, or temperature elevation and administer ordered analgesia. Obtain
blood specimen for amylase and bilirubin as levels rise in pancreatitis, although they are usually elevated
as a result of the procedure itself from the pressure and volume of the dye injected into the pancreatic
duct. Note and report dysrhythmias, chest pain, or alterations in blood pressure and pulse and administer
cardiac medications as ordered.

C. Risks and Complications

Reaction to the anesthesia, dye, or drug used during this procedure may include blurred vision,
breathing problems, dry mouth, feeling of burning or flush, hives, low blood pressure or slow heart rate,
nausea, throat spasm, and urine retention. Risk related to procedure include bleeding, perforation (hole) of
the bowel, pancreatitis, which can be very serious. Long-term complications include return of stones and
abscess.

31
2. Liver/Biliary System Ultrasonography - Liver and biliary system ultrasonography consists of studies
performed to determine the size, shape, and position of the liver and the gallbladder, located in the upper
right quadrant (URQ) of the abdomen. Gallbladder ultrasonography is especially helpful when performed
in clients whose gallbladder is unable to opacify gallstones with oral or intravenous radiologic studies.

A. Indications for procedure

The procedure is done to determine the cause of RUQ pain, differentiating between obstructive and non-
obstructive jaundice by identifying the cause, diagnosing acute or chronic cholecystitis revealed by an
enlarged gallbladder with wall thickening, determining gallstones within the gallbladder or biliary ducts
revealed by dilation or obstruction, or both, of the biliary tree or ducts and increased bilirubin level.

B. Procedure with Nursing Responsibilities

Before the procedure, obtain a history that includes liver or gallbladder disorders and therapy to treat
a tumor or obstruction. Administer an enema before the study, if ordered, to remove feces or barium that
can interfere with imaging.
The client is placed on the examination table in a supine position, although the prone or side-lying
positions can also be used during the study. The abdomen is exposed and draped for privacy. The
conductive gel is applied to the skin of the RUQ and the transducer manipulated over the area. During the
procedure, the client is requested to hold the breath on inspiration as patterns are displayed on a screen
and photographed for future viewing. Several planes of scanning are obtained. Each lobe and border of
the liver and border of the gallbladder is examined. The cystic and common bile ducts are examined for
patency. Gallbladder contractibility to expel the bile stored within it can be achieved with the
administration of a fatty substance (Lipomul) to allow examination of the organ’s function. When the
studies are completed, the gel is removed from the abdomen.
After the procedure, care and assessment are the same as those for any ultrasound procedure. Inform
the client that food intake can be resumed. Note and report pain, redness, and swelling every hour for 4
hours, then every 4 hours for 24 hours.

C. Risks and Complications

When properly performed, ultrasound imaging is virtually without risk or side effects. Although the
possibility exists that biological effects on humans may be identified in the future, currently most doctors
feel that based on available information the benefits to patients outweigh the risks.

32
XV. NORMAL PHYSIOLOGY

The Liver and Gallbladder

The liver and gallbladder are accessory organs associated with the small intestine. The liver, one
of the body’s most important organs, has many metabolic and regulatory roles. However, its digestive
function is to produce bile for export to the duodenum. Bile is a fat emulsifier, it breaks up fats into tiny
particles so that they are more accessible to digestive enzymes. Although the liver also processes nutrient-
laden venous blood delivered to it directly from the digestive organs, this is a metabolic rather than a
digestive role. The gallbladder is chiefly a storage organ for bile.

The Liver

33
 The ruddy, blood-rich liver is the largest gland in the body, weighing about 1.4 kg (3 lb) in the
average adult. Shaped like a wedge, it occupies most of the right hypochondriac and epigastric regions,
extending farther to the right of the body midline than to the left. Located under the diaphragm, the liver
lies almost entirely within the rib cage, which provides some protection.
Typically, the liver is said to have four primary lobes. The largest of these, the right lobe, is
visible on all liver surfaces and separated from the smaller left lobe by a deep fissure. The posteriormost
caudate lobe and the quadrate lobe, which lies inferior to the left lobe, are visible in an inferior view of
the liver. A mesentery, the falciform ligament, separates the right and left lobes anteriorly and suspends
the liver from the diaphragm and anterior abdominal wall. Running along the inferior edge of the
falciform ligament is the round ligament, or ligamentum teres, a fibrous remnant of the fetal umbilical
vein. Except for the superiormost liver area (the bare area), which touches the diaphragm, the entire liver
is enclosed by the visceral peritoneum. As mentioned earlier, a dorsal mesentery, the lesser omentum,
anchors the liver to the lesser curvature of the stomach. The hepatic artery and the hepatic portal vein,
which enter the liver at the porta hepatis (“gateway to the liver”), and the common hepatic duct, which
runs inferiorly from the liver, all travel through the lesser omentum to reach their destinations. The
gallbladder rests in a recess on the inferior surface of the right liver lobe.
The traditional scheme of defining liver lobes has been criticized because it is based on
superficial features of the liver. Some anatomists emphasize that the primary lobes of the liver should be
defined as the territories served by the right and left hepatic ducts. These two territories are delineated by
a plane drawn from the indentation of the inferior vena cava to the gallbladder recess. Those to the right
of the plane are the right lobe and those to its left constitute the left lobe. According to this scheme, the
small quadrate and caudate lobes are part of the left lobe. Bile leaves the liver through several bile ducts
that ultimately fuse to form the large common hepatic duct, which travels downward toward the
duodenum. Along its course, that duct fuses with the cystic duct draining the gallbladder to form the bile
duct.

Composition of Bile
Bile is a yellow-green, alkaline solution containing bile salts, bile pigments, cholesterol,
triglycerides, phospholipids (lecithin and others), and a variety of electrolytes. Of these, only bile salts
and phospholipids aid the digestive process.
Bile salts, primarily cholic and chenodeoxycholic acids, are cholesterol derivatives. Their role is
to emulsify fats, to distribute them throughout the watery intestinal contents, just as a dish detergent
breaks up a pool of fat drippings in a roasting pan. (Another example of emulsification is
homogenization, which distributes cream throughout the watery phase of milk.) As a result, large fat

34
globules entering the small intestine are physically separated into millions of small, more accessible fatty
droplets that provide large surface areas for the fat-digesting enzymes to work on. Bile salts also facilitate
fat and cholesterol absorption and help solubilize cholesterol, both that contained in bile and that entering
the small intestine in food. Although many substances secreted in bile leave the body in feces, bile salts
are not among them. Instead, bile salts are conserved by means of a recycling mechanism called the
enterohepatic circulation. In this process, bile salts are (1) reabsorbed into the blood by the ileum, (2)
returned to the liver via the hepatic portal blood, and then (3) resecreted in newly formed bile.
The chief bile pigment is bilirubin, a waste product of the heme of hemoglobin formed during the
breakdown of worn-out erythrocytes. The globin and iron parts of hemoglobin are saved and recycled, but
bilirubin is absorbed from the blood by the liver cells, excreted into bile, and metabolized in the small
intestine by resident bacteria. One of its breakdown products, stercobilin, gives feces a brown color. In
the absence of bile, feces are gray-white in color and have fatty streaks because essentially no fats are
digested or absorbed.
The liver produces 500 to 1000 ml of bile daily, and production is stepped up when the GI tract
contains fatty chyme. Bile salts themselves are the major stimulus for enhanced bile secretion, and when
the enterohepatic circulation is returning large amounts of bile salts to the liver, its output of bile rises
dramatically. Secretin, released by intestinal cells exposed to fatty chyme, also stimulates liver cells to
secrete bile.

The Gallbladder
The gallbladder is a thin-walled green muscular sac about 10 cm (4 inches) long. Roughly the
size of a kiwi fruit, it snuggles in a shallow fossa on the ventral surface of the liver. Its rounded fundus
protrudes from the inferior margin of the liver. The gallbladder stores bile that is not immediately needed
for digestion and concentrates it by absorbing some of its water and ions. In some cases, bile released
from the gallbladder is ten times as concentrated as that entering it. When empty, or when storing only
small amounts of bile, its mucosa is thrown into honeycomb-like folds that, like the rugae of the stomach,
allow the organ to expand as it fills. When its muscular wall contracts, bile is expelled into its duct, the
cystic duct, and then flows into the bile duct. The gallbladder, like most of the liver, is covered by visceral
peritoneum.

Regulation of Bile Release into the Small Intestine

When no digestion is occurring, the hepatopancreatic sphincter (guarding the entry of bile and
pancreatic juice into the duodenum) is closed and the released bile backs up the cystic duct into the
gallbladder, where it is stored until needed. Although the liver makes bile continuously, bile does not

35
usually enter the small intestine until the gallbladder contracts. The major stimulus for gallbladder
contraction is cholecystokinin (CCK), an intestinal hormone released to the blood when acidic, fatty
chyme enters the duodenum. Besides causing the gallbladder to contract, CCK (1) stimulates secretion of
pancreatic juice, and (2) relaxes the hepatopancreatic sphincter so that bile and pancreatic juice can enter
the duodenum. Parasympathetic impulses delivered by the vagus nerves are a minor stimulus for
gallbladder contraction.

36
 XVI. PATHOPHYSIOLOGY

A. Pathophysiology Diagram

LR COMMUNITY ACQUIRED PNEUMONIA CHOLELITHIASIS

August 27, 2010

Bacteria enter the lungs Risk factors: (SGPT) ALT: ↑614 Mmol/L
CP Clearance (SGOT) AST: ↑270 Mmol/L
Modifiable Non-modifiable August 28, 2010
August 29, 2010
(+) Crackles L base, -Obesity -Older age (48yo) (SGPT) ALT: ↑619 Mmol/L
minimal cough -Rapid weight loss (SGOT) AST: ↑230 Mmol/L
The client developed LR CAP CXR: with Pneuminia September 01, 2010
August 30, 2010
-Diet (↑fat, ↑cholesterol)
BUN: ↓3.0 Mmol/L
↓coarse crackles, ↓cough

Cholecystectomy was deferred

due to LR CAP

August 27, Supersaturation of cholesterol in Liver reduces the rate it breaks

2010 the bile down and removes fat
(+) Productive Medications given:
cough -Ciprofloxacin (Xipro) 200 mg IV BID;
400 mg IV q12
-Azithromycin (Zithromax) 500 mg 1 tab OD
Decrease bile acid synthesis Increased cholesterol in the liver

LR CAP resolved August 27, 2010

CP Clearance Gallstone formation HEPATIC/BILIARY
August 29, 2010 (Cholelithiasis) ULTRASONOGRAPHY
(-) Crackles left base Impression: Contracted
CAP resolved, patient is gallbladder with lithiasis;
cleared for a minimal September 01, 2010 dilated common bile duct
surgical risk. May go Cholecystectomy with choledocholelithiasis,
ahead with the Stones passed out of the fatty liver.
laparoscopic gallbladder
cholecystectomy

CAP resolved, patient

is cleared for a Pre-op meds:
minimal surgical risk. -Ranitidine (Dynastin) 1 amp IV q8
May go ahead with Post-op meds:
the laparoscopic -Parecoxib (Dynastat) 40 mg slow IV BID
cholecystectomy. 37
 Lodge in the cystic duct Lodge in the common/hepatic
duct (Choledocholelithiasis)

August 27, 2010

ALP: ↑160 u/L Flow of bile from the liver is August 28, 2010
Indirect Bilirubin: ↑134 umol/L obstructed ERCP done.
Direct Bilirubin: ↑11.9 umol/L Result: Common
Bile Duct stone
Back-up of bile in the liver extracted
(Cholestasis)

August 27, 2010

Medications given:
-Tramadol/Paracetamol (Dolcet)
50 mg IV
-Hyoscine/Scopolamine
(Buscopan) 1 amp IV PRN
Physical Assessment:
Triggers release of inflammatory Build up of the bilirubin in the - (+) Jaundice
response (Phospolipase A) body - (+) Icteric sclera
- (+) Tea-colored urine
Conversion of lecithin to
lysolecithin
(Mediates inflammation)

Medication given:
Damaged mucosa secretes more -Tramadol/Paracetamol LEGEND:
fluids (Dolcet) 50 mg IV
August 27, 2010 - Manifestations
Physical Assessment:
- (+) Abdominal pain RUQ - Medications
Distention of the duct and
gallbladder
- Surgical procedure
August 27, 2010
Physical Assessment: August 30, 2010
Triggers further inflammatory Temperature: - Lab/diagnostic proc.
- (+) Nausea and vomiting mediators (Prostaglandins) - (+) Fever 37.8 °C 38
B. Pathophysiology Narrative

In case of SpongeBob, the risk factors that contribute in the formation of his gallstones were
obesity, rapid weight loss, diet, and advancing age. Researchers have found that people who are obese
may produce high levels of cholesterol. This leads to the production of bile containing more cholesterol
than it can dissolve. When this happens, gallstones can form. Rapid weight loss may cause a shift in the
balance of bile salts and cholesterol in the gallbladder. The cholesterol level is increased and the amount
of bile salts is decreased. If the gallbladder does not contract often enough to empty out the bile,
gallstones may form. Diets high in fat and cholesterol and low in fiber increase the risk of gallstones due
to increased cholesterol in the bile and reduced gallbladder emptying. Advancing age is a major risk
factor for gallbladder disease. In older people the bile becomes more lithogenic. The client was also
diagnosed to have fatty liver as manifested by the laboratory and diagnostic tests done to him.
Normally, bile acids, lecithin, and phospholipids help to maintain cholesterol solubility in bile.
When the ratio of cholesterol to bile acids or phospholipids is increased, bile becomes supersaturated with
cholesterol. It crystallizes and forms a gallstone (Cholelithiasis). The gallstone passed out of the
gallbladder and lodge in the cystic duct, hepatic duct and common bile duct. When the gallstone lodged in
the hepatic duct it prevents free flow of bile from the liver into the upper intestine and causes cholestasis.
Because of the obstruction of the gallstone in the bile ducts, the bilirubin accumulates in the body and
turns the skin and the whites of the eye yellow. Jaundice, icteric sclera, and tea-colored urine were
manifested to the client. ERCP was done and common bile duct stone was extracted. When the gallstone
lodged in the cystic duct, the flow of bile was also obstructed and causes bile stasis. Bile stasis triggers
release of inflammatory enzymes Phospholipase A, which converts lecithin to lysolecithin, which mediate
inflammation. The damaged mucosa secretes more fluid into the gallbladder lumen than it absorbs. This
will cause distention of the duct and gallbladder and resulted in abdominal pain in the right upper
quadrant and nausea and vomiting to the client. Tramadol/Paracetamol (Dolcet) 50 mg IV and
Hyoscine/Scopolamine (Buscopan) 1 amp IV PRN were given to relieved the pain. The resulting
distention further releases inflammatory mediators (Prostaglandins), worsening mucosal damage and
causes fever. Again, Tramadol/Paracetamol (Dolcet) 50 mg IV was given to relieve the fever.
The patient has to undergo Laparoscopic Cholecystectomy but it was deferred because he had
Low Risk Community Acquired Pneumonia (LR CAP). Ciprofloxacin (Xipro) 200 mg IV BID; 400 mg
IV q12, and Azithromycin (Zithromax) 500 mg 1 tab OD were given until his LR CAP was resolved. His
operation was done on September 01, 2010.

39
XVII. NURSING CARE PLAN

Problem Prioritization
1. Pain
2. Productive cough
3. Fever
4. Risk for infection
5. Risk for nutritional imbalance
6. Lack of knowledge about the disease

40
 NURSING
DIAGNOSIS with RATIONALE FOR
NURSING PROBLEM (SMART) NURSING EXPECTED
RATIONALE INTERVENTIONS EVALUATION
with CUES GOALS/OBJECTIVES INTERVENTIONS OUTCOMES
(with references) (with references)

1. Pain Alteration in Short term goal: 1. Observed and 1. Assists in 1. Client Short term goal:
Date: August 27, 2010 comfort: Pain documented location, differentiating cause of verbalizes
related to Within 15-30 minutes severity (0–10 scale), pain, and provides relief of pain Goal met. The client
obstruction of of nursing and character of pain. information about and verbalized relief of
Subjective: gallstone in the interventions, the disease discomfort. pain and discomfort
cystic/common bile client will verbalize progression/resolution, as evidenced by the
“ ..ang sakit-sakit ng ducts relief of pain and development of 2. Client will client’s report of P/S
tiyan ko..”, as discomfort as complications, and be free from from 8/10 to 2/10
verbalized by the evidence by the effectiveness of pain and and by being calm.
client. Rationale: client’s report of P/S interventions. (Nursing discomfort.
from 8/10 to 2/10 and Care Plan, Med/Surg,
When gallstones by being calm. F.A. Davis) Long term goal:
Objective: form, they may
resist evacuation and 2. Responded 2. Prompt responses to Goal partially met.
• P/S of 8/10 stay in the Long term goal: immediately to complaints may result in The client has
• V/S as follows: gallbladder or complaint of pain. decrease anxiety in recurring pain and
-BP – 140/90 mmHg obstruct the ducts After 2-3 days of client. (Nursing Care discomfort during
-T – 37.2 °C causing pain and nursing interventions, Plans, Gulanick et al, 3rd hospitalization.
-PR – 86 beats/min other symptoms. client will be free ed., p50)
-RR – 24breaths/min (www.ehow.com/ho from pain and
• Guarding w_2097176- discomfort as 3. Eliminated 3. Client may experience
• Facial grimace recognize-gallstone- evidenced by absence additional stressors or exaggeration in pain or a
• (+) Murphy’s sign pain,html) of pain and being sources of discomfort decreased ability to
calm. whenever possible. tolerate painful stimuli if
environmental,
intrapersonal, or
intrapsychic factors are
further stressing them.
(Nursing Care Plans,
Gulanick et al, 3rd ed.,

41
 p50)

4. Anticipated and 4. Careful pain

checked the patient management can
from time to time for improve relief.
onset of pain. (Nursing Diagnosis
Reference Manual 7th ed.
p.509)

5. Administered pain 5. Relief of mild to

medication as ordered, moderate pain. (MIMS)
Tramadol (Dolcet)
50mg IV; Hyoscine /
Scopolamine
(Buscopan) 1amp IV
PRN.

6. Encouraged use of 6. Relieves muscle and

non-pharmacologic emotional tension,
method to relieve pain enhances sense of
(relaxation control and may
techniques). improve coping abilities.
(Nursing Care Plans,
Gulanick et al, 3rd ed.,
p50)

42
 NURSING
DIAGNOSIS with RATIONALE FOR
NURSING PROBLEM (SMART) NURSING EXPECTED
RATIONALE INTERVENTIONS EVALUATION
with CUES GOALS/OBJECTIVES INTERVENTIONS OUTCOMES
(with references) (with references)

2. Productive Cough Ineffective airway Short term goal: 1. Assessed 1. Respiratory rate, 1. The client Short term goal:
Date: August 27, 2010 clearance related to respiratory rate, rhythm, and depth will be free
copious amount of After 8 hours of rhythm, and depth by changes are early signs from Goal met. After 8
phlegm nursing interventions, listening to breath of impending respiratory secretions. hours of nursing
Subjective: client’s airway is free sounds at least every difficulties. (Nursing interventions,
of secretions as shift. Care Plans, Gulanick et 2. The client client’s airway was
“….inuubo pa ako.” as Rationale: evidence by eupnea al, 3rd ed., p 211) has normal free of secretions as
verbalized by the and clear breath breathing and evidenced by eupnea
client. When the lungs sounds after 2. Assisted client with 2. To improve coughing. clear breath and clear breath
become irritated or coughing. coughing and deep (Nursing Care Plans, sounds. sounds after
infected, a large breathing as necessary. Gulanick et al, 3rd ed., p coughing.
Objective: amount of thick 211) 3. The client
mucus is produced. Long term goal: will be free
• (+)Cough This extra mucus 3. Placed patient in 3. To facilitate clearing from any Long term goal:
• (+) Crackles L base can block the After 3 days of semi-Fowler’s secretions. (Nursing signs and
• V/S as follows: airway passages nursing interventions, position. Care Plans, Gulanick et symptoms of Goal not met. After
-BP – 140/90 mmHg and can lead to client’s breathing al, 3rd ed., p 211) pneumonia. 3 days of nursing
-T – 37.2 °C problems in pattern is maintained interventions, client
-PR – 86 beats/min maintaining open as evidence by 4. Administered 4. Treatment for was diagnosed to
-RR – 24breaths/min airway. absence of signs and Ciprofloxacin (Xipro) respiratory tract have pneumonia.
(Outline for symptoms of 200 mg IV BID as infection. (PPD’s
respiratory system, pneumonia. ordered. Nursing Drug Guide)
BDSRA, Nov.
2000) 5. Collaborated with 5. Chest and back
PT department for fomentation increases
chest and back circulation and decreases
fomentation. chest congestion.
(www.docstoc.com)

43
 NURSING
DIAGNOSIS with RATIONALE FOR
NURSING PROBLEM (SMART) NURSING EXPECTED
RATIONALE INTERVENTIONS EVALUATION
with CUES GOALS/OBJECTIVES INTERVENTIONS OUTCOMES
(with references) (with references)

3. Fever Increase body Short term goal: 1. Monitored client’s 1. Temperature of 38.9- 1. The client Short term goal:
Date: August 30, 2010 temperature related temperature (degree 41°C suggests acute will
to body’s response After 2 hours of and pattern. infection due to disease demonstrate Goal met. After 2
to infection. nursing interventions process. normal hours of nursing
Subjective: the client’s body temperature of interventions, the
temperature will 2. Monitored 2. Room temperature 37.5°C. client’s body
“Nilalagnat ako.”, as Rationale: decrease as evidence environmental and number of blanket temperature
verbalized by the by temperature from temperature; should be altered to 2. The client decreased as
client. Fever is the most 37.8°C to 37.5°C. limited/added bed maintain near-normal will be free evidenced by
common sign of a linens as indicated. body temperature. from any normal body
systemic response to complications. temperature from
Objective: infection, and it is Long term goal: 3. Encouraged to 3. Supports circulating 37.8 to 37.5°C..
most likely caused increase fluid intake. volume and tissue
• Skin warm to touch by endogenous After 3 days of perfusion,
• Flushed skin pyrogens released nursing interventions Long term goal:
• V/S as follows: from neutrophils and the client’s body 4. Provided tepid 4. May help to reduce
-BP – 140/90 mmHg macrophages. These temperature will be sponge baths, avoid fever. Alcohol can cause Goal met. After 3
-T – 37.8 °C substances reset the stable as evidence by use of alcohol chills and elevates body days of nursing
-PR – 91 beats/min hypothalamic temperature within temperature and can also interventions the
-RR – 19 breaths/min thermostat, which normal range. dry the skin. client’s body
• Hematology: control the body temperature was
-WBC: 6.46 10^9/L temperature and 5. Administered 5. Use to reduce fever by stable as evidenced
produces fever. Paracetamol 500 mg its central action on the by temperature
(Smeltzer, 2004, p IV as ordered. hypothalamus. within normal range
92) and absence of any
(Nursing Care Plans, complications
Gulanick et al, 3rd ed., p
37)

NURSING PROBLEM NURSING (SMART) NURSING RATIONALE FOR EXPECTED

44
 DIAGNOSIS with
RATIONALE INTERVENTIONS
with CUES GOALS/OBJECTIVES INTERVENTIONS OUTCOMES EVALUATION
(with references) (with references)

4. Risk for Infection Risk for infection Short term goal: 1. Monitored WBC 1. Rising WBC indicates 1. The client Short term goal:
Date: September 01, related to the count. body’s efforts to combat will remain
2010 presence of surgical Within the shift, the pathogens. free of Goal met. After the
sites. client will remain infection. shift, the client
free of infection as 2. Monitored for signs 2. Redness, swelling, remained free of
Subjective: evidence by normal of infection. increased pain, or 2. The client infection as
Rationale: vital signs, and purulent drainage at will be free evidenced by normal
N/A absence of purulent incision sites indicates from any vital signs, and
Infection is a risk in discharge and infection. signs and absence of purulent
all surgical drainage from the symptoms of discharge and
Objective: procedure no matter wounds. 3. Washed hand before 3. Friction and running infection. drainage from the
how minor it is contact with client, and water effectively remove wounds.
• Presence of surgical because of the between procedures micro-organisms from
sites incision that was Long term goal: with patient. hands.
• V/S as follows: made. The Long term goal:
-BP: 130/90 mm/Hg individual is at After 3 days of 4. Maintained asepsis 4. To prevent the risk of
-T: 36.8 °C increased risk for nursing interventions, for dressing changes transmitting pathogens. Goal met. After 3
-PR: 79 beats/min being invaded by the client will remain and wound care. days of nursing
-RR: breaths/min pathogenic free from any signs interventions, the
• Hematology: organisms. and symptoms of 5. Administered 5. Capable of acting client remained free
-WBC:↑15.93 10^9/L (http://worldwidewo infection as evidence Levofloxacin (Cravit) against infection, by from any signs and
unds.com) by absence of any 500 mg/tab 1 tab QD inhibiting the spread of symptoms of
complications. as ordered. an infectious agent or by infection as
killing the infectious evidenced by
agent outright. absence of any
complications.
(Nursing Care Plans,
Gulanick et al, 3rd ed., p
40)

NURSING PROBLEM NURSING (SMART) NURSING RATIONALE FOR EXPECTED

EVALUATION
with CUES DIAGNOSIS with GOALS/OBJECTIVES INTERVENTIONS INTERVENTIONS OUTCOMES

45
 RATIONALE
(with references) (with references)

5.Risk for Nutritional Risk for nutritional Short term goal: 1. Performed 1. Diet history should 1. The client Short term goal:
Imbalance imbalance: More nutritional assessment include typical pattern/ understands
Date: September 01, than body After 30 minutes of and obtained dietary amount/ type of foods the Goal met. After 30
2010 requirements health teaching, the history. eaten, and any importance minutes of health
related to impaired client will understand information or thoughts of meal teaching, the client
fat digestion due to the importance of the client can share planning. understood the
Subjective: ineffective meal planning as about cause of obesity. importance of meal
regulation of bile evidence by the 2. The client planning as
“ Sabi ni Dok flow client’s 2. Encouraged the 2. As memory is demonstrates evidenced by the
kailangan ko ng demonstration of client to keep a daily inadequate for appropriate client’s
bawasan ang pagkain appropriate food log of food/liquid quantification of intake. measures to demonstration of
ng matatabang Rationale: selection. ingestion and caloric A visual record may also achieve appropriate food
pagkain,”, as intake. help the client to make healthy selection.
verbalized by the In a normal more appropriate food lifestyle.
client. individual, the bile Long term goal: choices and serving
is secreted by the sizes. Long term goal:
liver. It flows After 3 days of
Objective: through the bile nursing interventions 3. Encouraged the 3. Eating too many Goal met. After 3
duct in to the small and health teaching, client to exercise calories and not days of nursing
• Poor dietary habits intestine where it the client will regularly and have a exercising enough cause interventions and
• S/P Cholecystectomy helps in the demonstrate diet low in fat and obesity. health teaching, the
digestion and appropriate measures calories. client demonstrated
absorption of fat. In to achieve healthy appropriate
individuals in lifestyle as evidence 4. Provided family 4. Identify and include measures to achieve
whom gallbladder by the client’s counseling. the person primarily healthy lifestyle as
is removed, the bile verbalization of plan responsible for grocery evidenced by the
is not stored and it of exercise program shopping and food client’s verbalization
flows directly in to and appropriate diet. preparation. of plan of exercise
the small intestine. program and
If an individual eats appropriate diet.
a meal rich in fat, 5. Consulted a 5. To assist the client in
the fat may not get dietitian. appropriate food
digested well as the selection.

46
 secretion of bile
does not occur in (Nursing Care Plans,
an appropriate way. Gulanick et al, 3rd ed., p
(http://www.steady 45)
health.com/articles/
Diet_After_Gallbla
dder_Removal_a12
51.html)

NURSING PROBLEM NURSING (SMART) NURSING RATIONALE FOR EXPECTED

EVALUATION
with CUES DIAGNOSIS with GOALS/OBJECTIVES INTERVENTIONS INTERVENTIONS OUTCOMES
RATIONALE (with references)

47
 (with references)

6. Lack of Knowledge Knowledge deficit Short term goal: 1. Assessed ability to 1. Cognitive or physical 1. The client Short term goal:
about the Disease related to learn or perform impairments need to be will
unfamiliarity with After 30 minutes of desired lifestyle identified so an demonstrate After 30 minutes of
the disease process health teaching, the changes. appropriate teaching understandin health teaching, the
Subjective: client will plan can be designed. g of the client demonstrated
Rationale: demonstrate disease understanding of the
“Hindi ko nga alam understanding of the 2. Assessed motivation 2. Adults must see need process. disease process as
kung saan at paano There is a presence disease process as and willingness of the or purpose for learning. evidenced by
ako nagkaroon ng of knowledge deficit evidence by client’s client to learn. 2. The client client’s verbalization
ganitong sakit.”, as due to some verbalization of will initiate of accurate
verbalized by the unfamiliar accurate information 3. Provided a quiet 3. This allows the client necessary information about
client. information that about diagnosis, atmosphere without to concentrate more lifestyle diagnosis, prognosis,
causes some prognosis, and interruption. completely. changes. and potential
confusion to the potential complications of the
Objective: client that needs to complications of the 4. Presented material 4. This provides client disease.
be discussed. disease. from familiar to with the opportunity to
• Asking questions (http://www.scribd.c concrete information understand new material
• Unfamiliarity with om) to less familiar or more in relation to familiar Long term goal:
the disease Long term goal: abstract concepts. material.
• Misinterpretation of After 3 days of
information After 3 days of 5. Provided 5. Different people take nursing intervention
nursing intervention information using in information in the client initiated
the client will initiate various mediums different ways. necessary lifestyle
necessary lifestyle (explanations, changes and
changes and explain discussions, explained reasons
reasons for the demonstrations, for the actions.
actions. pictures, written
instructions, etc.).

6. Encouraged 6. Learners often feel

questions. shy or embarrassed
about asking questions

48
 and often want
permission to ask them.

7. Included significant 7. This will give

others in health encouragement and
teaching. support to the client.

8. Assisted the client in 8. This helps the client

integrating the make adjustments in
information into daily daily life that will result
life. in the desired change in
behavior or learning.

(Nursing Care Plans,

Gulanick et al, 3rd ed., p
41)

49
XVIII. MEDICATIONS/TREATMENT
A. INDICATION
A. GENERIC NAME
TO PATIENT
(BRAND NAME)
B. OTHER
B. GENERAL
INDICATIONS
CLASSIFICATION
OF DRUGS
C. DOSAGE
1. (A) Tramadol/ (A) For moderate to
Paracetamol severe pain.
(Dolcet)
(B) Use to relieve fever.
(B) Analgesic
(C) 50 mg IV
2. (A) Ciprofloxacin (A) Respiratory Tract
(Xipro) Infection.
(B) Antibiotic (B) Middle ear, paranasal
sinuses, eyes, kidneys,
and/or urinary tract,
genital organs, skin and
soft tissue, bones and
joints; sepsis, infections.
(C) 200 mg IV BID;
400 mg IV q 12h
3. (A) Nicardipine (A) Management for
(Cardepine) hypertension.
(B)Calcium Antagonist (B) Management of
angina pectoris,
vasopastic angina, CHF.
(C) IV infusion dilute to
10-20mg/100ml
A. SIDE EFFECTS
DRUG ACTION B. PRECAUTIONS
AND SPECIAL
CONSIDERATION
Centrally acting (A) Vasodilation, dizzi-
analgesic not ness/ vertigo, headache,
chemically related to somnolence, stimulation,
opioids but binds to anxiety, confusion,
mu-opiodreceptors coordination disturbance,
and inhibits reuptake euphoria, nervousness,
ofnorepinephrine and sleep disorder, seizure.
serotonin.
(B) Pregnancy Category
C, lactation. Not recom-
mended for children
<16y.o. elderly >75y.o.
Inhibits bacterial (A) Nausea, diarrhea,
DNA gyrase thus injection site reactions,
preventing replication vomiting, transient
in susceptible increase in transaminases,
bacteria. rash.
(B) Severe and persistent
diarrheaduring or after
treatment may mask
symptoms of
pseudomembranous
colitis. Epilepsy.patients
with previous CNS
disorders.
Inhibits calcium ion (A) Peripheral edema,
influx across cell headache, tachycardia,
membrane during palpitation, localized
cardiac thrombophlebitis and
depolarization, hypotension.
produces relaxation of
coronary vascular (B) Pregnancy Category
smooth muscle and C, liver and kidney
peripheral vascular dysfunction; hypotension;
50
 smooth muscle, glaucoma.
dilates coronary
arteries and increase s
myocardial oxygen
delivery in patients
with vascular smooth
muscle.

4. (A) Olmesartan (A) Management for Blocks the (A) Dizziness, vertigo,
Medoxomil essential hypertension. vasoconstrictor and hypotension, angina
(Olmetec) aldosterone secreting pectoris, bronchitis,
(B) Used in the treatment effects of Angiotensin cough, pharyngitis,
(B) Angiotensin II of cardiovascular II to the Angiotensin I rhinitis, abdominal pain,
Receptor Antagonist diseases. receptor in the diarrhea, dyspepsia,
vascular smooth gastroenteritis, nausea,
(C) 20 mg 1 tab OD muscle. rash, arthritis, back pain,
skeletal pain, hematuria,
UTI, fatigue, influenza-
like symptoms, peripheral
edema.

(B) May cause

symptomatic hypotension.
Use with caution in
patient with severe CHF,
renal disease and
hyperkalemia.

5. (A) Hyoscine / (A) Epigastric pain Inhibits acetylcholine (A) Xerostomia,

Scopolamine at receptor sitesin tachycardia, urinary
(Buscopan) (B) Acute GI biliary and autonomic nervous retention. When
genitourinary spasm, system, which administered IV, visual
(B) Gastrointestinal/ include biliary and renal controls secretions, accommodation
Hepatobiliary anti- colic, dysmenorrheal. free acid in stomach: disturbances, dizziness,
spasmodic Parenteral also as an aid block central agranulocytosis,
in diagnostic and muscarinic receptors, pancytopenia, and
therapeutic procedures eg: which decreases bronchospasm
radiology, gastroduodenal involuntary
endoscopy. movements. (B) Pregnancy Category
C, lactation. Avoid
(C) 1amp IV PRN driving and operating
machinery.

6. (A) Ranitidine (A) Use as antacid. Inhibits histamine at (A) Cardiac arrhythmias,
(Zantac) H2 receptor site in the bradycardia. Headache,
(B) Used in various gastric parietal cells, somnolence, fatigue,
(B) Histamine H2- management of GI which inhibits gastric dizziness, hallucinations,
receptor antagonist disorders, such as acid secretion. depression, insomnia,.

51
 dyspepsia, GERD, peptic Alopecia, rash, erythema
ulcer and Zollinger- multiforme. Nausea,
Ellison syndrome. vomiting, abdominal
discomfort, diarrhea,
(C) 1 amp IV q 8h constipation, pancreatitis.
Cholestatic or
hepatocellular effects.

(B) Pregnancy Category

B, lactation, and children.

7. (A) Promethazine (A) Pre-operative sedative Phenothiazine (A) Sedation, confusion,

Hydrochloride derivative that sleepiness. Nausea and
(Phenergan) (B) Nausea and vomiting, competes with vomiting. Hypertension.
allergic rhinitis antihistamine for H- Photosensitivity, rash.
(B) Antihistamine symptoms. receptor sites on
effector cells. Prevent (B) Contraindicated in
(C) 25 mg IM but doesn’t reverse patients with
histamine mediated hypersensitivity to drug,
responses. At high those who have
doses, the drug has experienced adverse
local anesthesia reaction to
effects. phenothiazines, newborns,
premature neonates,
breast feeding women,
and acutely ill dehydrated
children.

8. (A) Nalbuphine (A) Adjunct to balance Binds with opiate (A) Sedation, drowsiness,
Hydrochloride anesthesia. receptors in the CNS, sweating, nausea, dry
(Nubaine) altering perception of mouth and dizziness,
(B) Moderate to severe and emotional headache, vomiting.
(B) Synthetic opioid pain. response to pain.
partial antagonist/ (B) If misuse may cause
analgesics (C) 10 mg IM psychological and
physical dependence.

9. (A) Azithromycin (A) Treatment of Binds to the P site of (A) palpitations, chest
(Zithromax) infections of the 50S bacterial pain, dizziness, headache,
respiratory tract, ribosomal subunits vertigo, somnolence,
(B) Anti-infectives, community acquired thereby inhibiting fatigue, rash,
Macrolides pneumonia protein synthesis; photosensitivity, diarrhea,
bactericidal, or nausea, vomiting,
(B) COPD, bacteriostatic abdominal pain,
Mycobacterium avium depending on the dyspepsia, flatulence,
complex, pelvic concentration with melena, vaginitis, monilia,
inflammatory disease, much greater nephritis, cholestatic
skin and skin structure, spectrum of activity jaundice, angioedema,

52
 and sexually transmitted
diseases caused by
susceptible organisms.
(C) 500 mg/ tab, 1 tab OD
10. (A) Parecoxib (A) Used pre-operatively
(Dynastat) to prevent or reduce post
operative pain.
(B) Analgesic
(B) Short term treatment
of acute pain and post
operative pain.
(C) 40 mg slow IV BID x
2 days
11. (A) Levofloxacin (A) Used to prevent or
(Cravit) treat infections.
(B) Anti-infective (B) Used to treat
infections of the sinuses,
skin, lungs, ears, airways,
bones, joints, urinary
tract, prostitis, and
mastitis caused by
susceptible bacteria.
(C) 500 mg/tab 1 tab QD
12.(A) Potassium (A) Use as an electrolyte
Chloride replenisher.
(Kalium Durule)
(B) Treatment of
(B) Anti-hypokalemia/ hypokalemia.
Electrolytes
(C) 1 tab BID x 2 days
than erythromycin anaphylaxis.
(B) Pregnancy Category
B, Gonorrhea/ Syphilis.
Inhibits prostaglan- (A) Hypersensitivity,
din synthesis by blood pressure changes,
selectively inhibiting peripheral edema,
cyclo-oxygenase-2 dyspepsia, insomnia,
(COX-2). Relieves postoperative anemia,
pain and respiratory insufficiency,
inflammation. pruritus and oliguria.
(B) Use with caution in
patients with
cardiovascular problems
and GI complications.
Inhibits bacterial type (A) Disorientation,
II topoisomerases, dizziness, drowsiness, hot
topoisomerase IV and and cold flashes, nausea,
DNA gyrase. Like slurring of speech,
other swelling and numbness in
fluoroquinolones, it the face
inhibits the A
subunits of DNA (B) contraindicated in
gyrase, two subunits patients with a history of
encoded by the gyrA hypersensitivity to
gene. This results in levofloxacin, to other
strand breakage on a quinolones, or to any of
bacterial the components in this
chromosome, medication
supercoiling, and
resealing; DNA
replication and
transcription is
inhibited.
Work by providing (A) Hyperkalemia, GI
direct replacement of ulceration.
potassium in the
body. (B) Renal or adreno-
cortical insufficiency,
cardiac disease, acute
dehy-dration; extensive
tissue destruction.
53
13.(A)Ursodeoxy- (A) For Ursodeoxycholic acid (A) Diarrhea, pruritus,
cholic acid postcholecystectomy alters the composition increased cholestasis,
(Ursofalk) biliary-type abdominal of bile, increasing nausea and vomiting,
pain caused by bile concentrations of sleep disturbance.
(B) Cholagogues, crystals (microlithiasis) itself and decreasing
Cholelitholytics and amounts of toxic bile (B) Inflammatory bile
Hepatic protectors (B) Primary biliary acids. It also increases duct disease, obstructive
cirrhosis, primary bile flow. hepatobiliary disease,
sclerosing cholangitis, acute cholecystitis,
chronic hepatitis. parenchymal liver disease,
Treatment of biliary starvation diet, pregnant
reflux gastritis and & fertile women who do
dyspeptic complaints. not use contraception.

(C) 25 mg TID

54
XIX. DISCHARGE PLANNING

Medication
Advise the client to continue the prescribed medications like Levofloxacin (Cravit) for the
treatment and prevention of infection and Tramadol (Dolcet) for management of pain.

Exercise
Advise the client not to lift heavy objects for about 10-15 days. Encourage him to do exercise as
tolerated such as walking every day.

Treatment/Therapy
Instruct the client to continue home medications given by the doctor. Explain to him that the
medication must complete the course of treatment. Teach him about wound care to prevent infection and
further complications. Encourage to take multivitamins prescribed by the doctor to strengthen his immune
system.

Health Teaching
Provide the client with written and oral instructions about wound care, activity, diet
recommendations, medications, and follow-up visits. Advise him to gradually resume normal activities
for 24-48 hours after discharge. Inform him that loose stools may occur for several months as the body
adjusts to the continuous flow of bile.

Outpatient follow-up
Advise the client to go back in the hospital in a specific date scheduled by the doctor for a
follow-up after discharge. Consult a doctor for any problems or complications encountered.

Diet
Encourage the client to increase protein intake for tissue repair and maintain a low salt and low
fat diet. Advise him to eat smaller-than-normal amounts of food at mealtime. Encourage to increase fluid
intake if not contraindicated with his condition.

Spiritual
Encourage the client to continue his healthy relationship with God. Prayer and trusting with the
divine power will give him hope for the future and lead him closer to our Almighty God.

55
XX. CONCLUSION AND RECOMMENDATION

Cholelithiasis is the formation of gallstones, which are composed of cholesterol, calcium salts,
and bile pigments. When gallstones block the flow of bile, the gallbladder becomes swollen, leading to
the possibility of pain, inflammation, or infection. The signs and symptoms of cholelithiasis often do not
begin until the gallstone causes blockage in the biliary system. They may include, abdominal pain,
usually in the upper right quadrant of the abdomen, jaundice, tea-colored urine, and fever. We conclude
that the factors that contribute in the formation of the gallstone of Spongebob were obesity, rapid weight
loss, diet, and advancing age.
Studies have shown that ten to thirty percent of patients who undergo gallbladder removal suffer
from diarrhea. Once the gallbladder is removed, this hormone no longer controls the flow of bile and the
flow of bile is continuous. The increased amount of bile salts thus secreted enters the large intestine
causing diarrhea. We recommend that the client should have appropriate diet after gallbladder removal.
The first step in the diet plan is to eat smaller meals and avoid diet rich in fat. The diet should include
fruits and vegetables such as bananas, avocados and apples which are rich in fiber.

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XXI. ACKNOWLEDGEMENT

We students of Manila Adventist College Block 13A from section C want to express our deep
sense of gratitude to all the individuals who have given their heart whelming full support in making this
case study possible.
To our Dear Almighty God for giving us wisdom, knowledge, strength, and patience to keep us
standing and for the hope that keep us believing that this case study would be possible and more
interesting.
We also wanted to thank our family who inspired, encouraged and fully supported us for every
trials that comes our way. To our parents and guardians for their unending financial and emotional
support and understanding, thank you for being our inspiration.
To our blockmates who willingly help us gathered and provided the necessary data and
information needed for this case study.
To Mr. Noel Sarmiento who sincerely shared his knowledge and time in making of this case
study. Thank you for guiding and teaching us the right thing to do.
To Ms. Charisse Belga for the encouragement, guidance and support from the initial to the final
level of this case study enabled us to develop an understanding of the subject.
Again, we thank you all from the bottom of our heart.

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XXII. BIBLIOGRAPHY

Books:
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2003 by F.A. Davis Company, Philadelphia, Pennsylvania.

Doenges, Marilyn E., “Nursing Care Plans”, 4th Edition, Copyright 1997 by F.A. Davis Company,
Philadelphia, Pennsylvania.

Kozier et al. “Fundamentals of Nursing” 8th Edition, Copyright 2007 by Pearson Education South Asia
pte. Ltd.

Lippincott Williams and Wilkins, “Nurses Quick Check: Diagnostic Tests, Copyright 2006 by Wolters
Kluwer Company.

Marieb, Elaine N., “Human Anatomy & Physiology”, 7th Edition, Copyright 2007 by Pearson Education,
Inc.

“PPD’s Nursing Drug Guide: For Nursing Students and Professional Nurses”, 2 nd Edition, Copyright 2008
by Malan Press, Inc.

Sparks Shiela et al. “Nursing Diagnosis Reference Manual” 7th Edition, Copyright 2008 by Wolters
Kluwer Company.

Taylor et al. “Fundamentals of Nursing”, 5th Edition, Copyright 2005 by Lippincott Williams and
Wilkins.

Internet Websites:

http://www.merck.com/mmpe/sec03/ch030/ch030c.html. The Merck Manuals Online Medical Library.

Eldon A. Shaffer, MD. December 2007.

http://www.moondragon.org/health/disorders/gallbladder.html. Moon Dragon's Health & Wellness. Moon

Dragon Birthing Services. 2010.

http://www.acg.gi.org/patients/gihealth/biliary.asp. The American College of Gastroenterology. Young

Choi, MD & William B. Silverman, MD. 2010.

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http://www.medicinenet.com/gallstones/page5.htm. MedicineNet.com. Jay W. Marks, MD & Dennis
Lee, MD. 2010.

http://emedicine.medscape.com/article/774352-overview. emedicine.medscape.com. William K. Chiang,

MD & Faye Maryann Lee, MD. June 07, 2010.

http://womenshealth.about.com/cs/gallbladder/a/dietinggallston_2.htm. About.com. Tracee Cornforth.

November 28, 2003.

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