FINAL OUTPUT pERI

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INTRODUCTION
“Surgery is always second best. If you can do something else, it's better.”
- Dr. John Kirklin
Gallstones develop in the gallbladder from crystals of either cholesterol or

bilirubin. Stones can be too small to be seen with the eye (biliary sludge), or can range
from the size of grains of sand to the size of ping-pong balls. There may be one or
hundreds of stones in the gallbladder. When gallstones are present, the condition is
called cholelithiasis.
Cholelithiasis is a calculi, or gallstones usually form in the gallbladder from the

solid constituents of bile; they vary greatly in size, shape and composition. They are
uncommon in children and young adults but become increasingly prevalent after 40
years of age. The incidence of Cholelithiasis increases thereafter to such an extent that
up to 50% of those over the age of 70 and over 50% of those over 80 will develop
stones in the bile duct.
Gallstones develop in the gallbladder from crystals of either cholesterol or

bilirubin. Stones can be too small to be seen with the eye (biliary sludge), or can range
from the size of grains of sand to the size of ping-pong balls. There may be one or
hundreds of stones in the gallbladder. When gallstones are present, the condition is
called cholelithiasis.
Gallstone disease is said to be a common medical problem that affects 25 million

people. Between 10-20% of all adults over 40 have gallstones, however only 1-3%
complaint of symptoms during the course of a year.
Cholelithiasis is responsible for nearly 800,000 hospital admissions at a cost of

more than 2 billion dollars worldwide every year. The incidence of gallstones increases
with age.
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In United States of America, nearly 25 million people have gallstones, and about
500,000 people have their gallbladders removed each year.
In the Philippines, there were 131 males (18%) and 609 (82%) females, with a
female ratio male 4.6:1. Benign lesions comprised 99% (mean age 36), mostly chronic
cholelithiasis (97%)and acute cholelithiasis which constituted 15 cases only (2%),
malignant lesions comprised only7 cases for example 1% of all lesions (mean age 65).
This is the case of our patient, Peter 53 years old who was admitted at Southern
Philippines Medical Center last September 11, 2010 at around 8:41 in the morning.
The purpose of this case study is to be familiar with the patient that undergo
cholecystectomy; how it starts, what are the causes and what are the signs and
symptoms; especially how to prevent, treat and manage the patient by giving
medication for treatment and providing rapport. This case study would present pertinent
information and facts about the disease along with its medical treatment and
interventions for the patient having the said condition. Data gathered are relevant for
further acquisition of knowledge. However, personal information regarding the patient is
considered and remains to be confidential.
Our group has chosen Cholelithiasis as our case study for the Peri-operative
concept because we find the case interesting and challenging and because this is our
first time that we’ve encountered a case like this in our entire rotation. With this, we
hope to share our knowledge about this case to other groups for additional learning.
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OBJECTIVES
General:
Within the three weeks of hospital exposure having a concept of Perioperative
Nursing, we, group 2 BSN 3C, will be able to research and apprehend the diagnosis of
the patient thoroughly, to apply what we had learned from classroom discussions, and
processes of completing this case study inorder to provide appropriate and effective
nursing interventions that will meet the patient’s need for the improvement of his
welfare, and to establish nurse-patient relationship which will help to us to gain the
patient’s trust and cooperation.
Specific:
The specific goals of this study are:
 To build rapport to the patient and his significant others inorder to gain
trust and cooperation;
 To have a therapeutic communication to the patient in order to provide
reverse care which allows the patient to feel secure enough to share
information;
 To gather data precisely including the patient’s data, family background,
health history, doctor’s order, and surgical procedure through the patient’s
chart, the patient himself, and his significant others inorder to have a
complete data that will serve as the foundation of this case study;
 To define and comprehend the patient’s complete diagnosis;
 To discuss and understand the human anatomy and physiology of the
systems involved in the disease process;
 To accumulate and incorporate the possible causes and the symptoms he
experienced that may propose the patient’s current condition;
 To research and assimilate the disease process of the patient’s condition;
 To determine and interpret the medical management applied - laboratories
and diagnostic procedures;
 And to identify and know the drugs prescribed and administered to the
patient which affects the patient’s current condition;
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 To conduct a comprehensive physical assessment using cephalocaudal

approach and interpret it;
 To formulate nursing care plans and apply it to fill the partient’s need;
 And to make a discharge plan for the patient using M.E.T.H.O.D and
validate the patient’s prognosis according to categories.
PATIENT’S DATA
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Name: Peter
Age: 53 years old
Sex: Male
Birthday: January 6, 1957
Nationality: Filipino
Religion: Roman Catholic
Occupation: Farmer
Name of Spouse: Cristala
Spouse’s occupation: Babysitter
Educational Attainment: High school graduate
Address: Purok ilang-ilang, Tagbobo, Kaputian, Island Garden City of Samal
Socioeconomic Status: Marginal
Basis:
Status Amount
High P34,000 or more
Middle P22,000-P33,000
Low P10,000-P21,000
Marginal Below P10,000
Ordinal Rank: 3rd, in the 8 children

Number of Children: 4
Clinical Data
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Ward: General Surgery Ward, Bed # 13

Date of Admission: September 11, 2010
How Admitted: Per Wheelchair
Chief Complaint: Abdominal pain
Vital Signs upon Admission:
BP: 160/90 mmHg RR: 22 cpm
PR: 79 bpm TEMP: 37 ºC

Attending Physician: Dr. Lobert A. Padua
Impression/ Tentative Diagnosis: Cholelithiasis
Surgical Procedure: Cholecystectomy
Date of Operation: September 14, 2010
Source of Information: Patient himself and Patient’s wife

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GENOGRAM
LOLA 1
LOLO 1 LOLA 2
LOLA 1
TITO POPSIE TITA 2

TITA 1 MOMSIE
PETER ALEX
EDITH MARIA ANA
SAM MARK
BETH
DECEASED
DIABETIC
HYPERTENSIVE
ARTHRITIS
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FAMILY HEALTH BACKGROUND & HEALTH HISTORY
A. Family Background
Our client Peter is 53 years of age. He is the son of Kaloy and Kalay. His father Kaloy
died because of Bone Cancer at the age of 57 while his mother Kalay died due to aging. He had
7 siblings namely Edith, Maria, Alex, Sam, Ana, Mark, Beth. His eldest sister named Edith was
diabetic and died at 50 years old. His second sibling named Maria was diagnosed with diabetes
mellitus type 2 and died at age of 48.
Peter’s grandparents on both sides already passed away because of old age. His
mother has 1 sibling while his father has 2 siblings named Tiago and Fe. According to him, his
relatives have a history of Illness like Hypertension, Diabetes and Arthritis.
Peter is married to her wife Mary. They have 2 children, 2 boys and 2 girls. Honey, 21
years of age is the eldest child of Peter who took the course of IT and graduated last March and
who also now helping the family in their daily needs. The second child named BJ 18 years of
age who is now in manila and currently working on a carwash. His third child Biboy 16 years old
just graduated in High School last March and having an extra income by making a wooden
hammock. While the fourth child Nina 12 years of age is still currently studying as a grade 6
student. Peter works as a maintenance employee and earns around Php150 a day while his
wife works in a family as a babysitter and earns around P2,000 a month. But since no one will
take care of Peter, his wife decided to stop on her work and just put the whole attention in taking
good care of Peter. They can have an average income of P4,000-P5,000 a month. His wife is
the one who budgets their money. They eat normally 3 times a day and their meal consist of
poultry and vegetables but they frequently eat fatty foods. He sleeps together with his wife and
children. He sleeps 7-8 hours a day. The patient doesn’t have any vices. He drinks alcohol
together with his friends every time they received their monthly salary. They can drink 1 gallon
of palm wine and sometimes with tanduay of 2 to people. As a family, they bond together every
Sunday by attending masses. Peter is close to his sons and daughters. When it comes to
decision making, he is the one taking charge.
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B. Health History
Past Illness:
Peter stated that he has no allergies to any kind of food, drinks or medications. He has
no maintenance in medication. He doesn’t recall if he was fully immunized. He has not
undergone any operations before. According to him, he never had any serious illness during his
childhood and adolescent years. He only experienced common illness such as cough, fever and
colds.
Present Illness:
He was first admitted at Samal District Hospital on May 10 because of severe pain in the
abdomen. The pain just started on April 2010 but was just ignored until it came to a point that it
is not bearable. The Samal District Hospital referred him to the Southern Philippines Medical
Center (SPMC) due to the lack of facilities for ultrasound test. After he was referred at SPMC,
he and his wife immediately undergone an ultrasound test in the SPMC lab and found out that
there were stones in his gallbladder. After knowing, they immediately scheduled by the Doctor
and must be admitted to SPMC and undergo cholecystectomy of the removal of the gallbladder.
Peter and his wife immediately followed the advice and did the things they needed to do for
Peter’s major operation.
Effects/ Expectations of Illness to Self/ Family
The patient verbalized that what happened to him really made his family anxious
because they are afraid of the fear of the unknown. Nevertheless, his wife as well as his kids is
very supportive. When the doctor advised them something, they immediately follow it so that he
may cope up with the situation.
Despite of his illness, they all pray together for a better outcome after the surgery. His
family was also able to understand that they are also at risk for this illness that is why they
should slow down on what they are eating. Peter was brave enough to pass by this trial of his
life.
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DEVELOPMENTAL DATA
Developmental data contains records and analysis of an increase or stagnancy in

the complexity of function and skill progression. It manifests the person’s capability and
skills in adapting to a dynamic environment. It begins in the infancy stage and ends in
the old age stage while attaining intelligence, developing problem-solving ability and
coping and adapting to the environment in all aspects. Development is the behavioral
aspect of growth such as person’s ability to walk, talk, run and even feelings of
sensation and emotion. It proceeds from simple to complex such as from single acts to
integrated ones. In an attempt to analyze a person’s developmental data a
developmental delay is monitored. A developmental delay is any significant lag in a
child's physical, cognitive, behavioral, emotional, or social development, in comparison
with norms.
ERIK H. ERIKSON’S PSYCHOSOCIAL THEORY
Erikson developed eight stages of development, which encompasses the entire

life span. He believed that people continue to develop throughout life.
Erikson envisions life as a sequence of levels of achievement. Each stage

signals a task that must be achieved. The resolution of a task can be complete, partial
or unsuccessful. Erikson believes that the greater the task achievement, the healthier
the personality of the person; failure to achieve a task influences the person’s ability to
achieve the next task. These developmental tasks can be viewed as a series of crises
and successful resolution of these crises is supportive to the person’s ego while failure
to resolve the crises damages the ego.
The stages included in this theory involve both positive and negative aspects a
person is anticipated to perform during his life. With resolution to previous stages, a
person is able to move to the next phase. Provided that he has resolved the conflict and
successfully passed the previous stage, that person will also be functioning well in the
society. (Kozier, 2008)
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Our patient is under the stage of middle adulthood, which includes the age range
of 25 to 65 years old. The central task in this stage is generativity vs. stagnation. It is at
this period that a person is characterized by positive parental love and care for their
offspring as well as creativity, productivity, and concern for others.
According to the conversation we had with Peter, he is happily married to his wife
for almost 22 years and has four children on their own. He divides his time equally with
his work and his family. They spend quality time together watching television every night
and going to church on Sundays. He added that it is in their family practice that all
family members pray together every six in the evening. He said that he is very thankful
that although he is only a farmer he was able to send his children to school and had his
first child graduated in college. “Naga-pasalamat intawon mi na maski maguuma ra ko
makalingkawas gihapon mi ug napaskwela nako akong mga anak, napahuman pa
namo among kinamaguwangang anak sa college” uttered by Peter. He also said that
although two of his siblings were not living with them anymore he still manages to
communicate with them through the cell phone his first son gave him. Peter is an active
citizen in their barangay; he and his wife are GKK officials. They both motivate their
neighbors especially the young ones to participate in the chapel’s activities like every
kasaulugan sa pulong. He said that by motivating the young ones to participate, he
could provide them opportunities to be closer to God.
ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY
Havighurst believed that learning is fundamental to life and that people continue
to learn throughout life. He developed 6 stages with 6 to 10 tasks to accomplish.
A developmental task is a task which arises at or about a certain period in the life
of an individual. Successful achievement of which leads to his happiness and to
success with later tasks, while failure leads to unhappiness in the individual, disapproval
by society, and difficulty with later tasks. (Kozier, 2008)
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Our client belongs to middle age stage. It has seven tasks. Our patient achieved
all of these tasks.
• Achieving adult social and civic responsibility.
- He was able to take part in civic affairs and practiced civic responsibilities by
vote-taking during election. In terms of social responsibility, he and his wife
actively participate in their barangay. They are both GKK officials in their
chapel and always attend kasaulugan sa pulong.
• Assisting teenage children to become responsible and happy adults.
- He and his wife both played the role of mentoring their children. He explained
to us that he always remind his children to be serious in their studies because
it is the only way for them to be successful in life. “ginapaningkamutan jud
namo ug tambag among mga anak na magseryoso sa ilang skwela aron
makapangita ug maayong trabaho ug dili lang mapareho sa amo na wala
nakahuman” explained by Peter.
• Reaching and maintaining satisfactory performance in one’s occupational career.
- According to Peter, his salary is really not enough for their family but since his
wife is also working, they are able to sustain their family’s needs.
• Developing adult leisure time activities.
- As a family, they develop quality time together in watching television every

night and every Sunday they go to church together. He often hangs out with
his neighbors whenever they invite him to drink with them.
• Relating oneself to one’s spouse as a person.
- He is happily married to his partner for 22 years. He relates himself to his wife
by respecting and valuing each other. Also whenever problems occur in the
family, they always consult each other’s opinion and resolve it together.
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• To accept and adjust to the physiological changes of middle age.
- He told us that it is normal for a person to undergo different changes as we

grow old. As Peter verbalized “normal raman siguro na sa tao nang daghan
bati-on pagnagatiguwang na tanan man tam aka-agi ana”.
• Adjusting to aging parents.
- According to him, at a very young age he was trained to venture things on his
own because his parents died early, his siblings were still young and he had
nothing to depend on except his own self.
LAWRENCE KOHLBERG’S MORAL DEVELOPMENT THEORY
The theory holds that moral reasoning, the basis for ethical behavior, has six
identifiable developmental stages, each more adequate at responding to moral
dilemmas than its predecessor. Kohlberg followed the development of moral judgment
far beyond the ages studied earlier by Piaget, who also claimed that logic and morality
develop through constructive stages. Expanding on Piaget's work, Kohlberg determined
that the process of moral development was principally concerned with justice, and that it
continued throughout the individual's lifetime, a notion that spawned dialogue on the
philosophical implications of such research. The morality of an individual’s decision was
not Kohlberg’s concern rather he focused on the reasons an individual makes a
decision. Levels and stages are not always linked to a certain developmental stage
because some people progress to a higher level of moral development than others.
The postconventional level of moral reasoning is typical of middle-age or older

adult. It consist stage five and six of moral development. There is a growing realization
that individuals are separate entities from society, and that the individual’s own
perspective may take precedence over society’s view; they may disobey rules
inconsistent with their own principles. These people live by their own abstract principles
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about right and wrong—principles that typically include such basic human rights as life,
liberty, and justice. Because of this level’s “nature of self before others”, the behavior of
post-conventional individuals, especially those at stage six, can be confused with that of
those at the pre-conventional level.
People who exhibit postconventional morality view rules as useful but

changeable mechanisms—ideally rules can maintain the general social order and
protect human rights. Rules are not absolute dictates that must be obeyed without
question. Contemporary theorists often speculate that many people may never reach
this level of abstract moral reasoning.
Stages:
Social Contract and Individual Rights (stage 5). the world is viewed as holding different
opinions, rights and values. Such perspectives should be mutually respected as unique
to each person or community. Laws are regarded as social contracts rather than rigid
edicts. Those that do not promote the general welfare should be changed when
necessary to meet “the greatest good for the greatest number of people”. This is
achieved through majority decision, and inevitable compromise. Democratic
government is ostensibly based on stage five reasoning. At stage 4, people want to
keep society functioning. However, a smoothly functioning society is not necessarily a
good one. A totalitarian society might be well-organized, but it is hardly the moral ideal.
At stage 5, people begin to ask, "What makes for a good society?" They begin to think
about society in a very theoretical way, stepping back from their own society and
considering the rights and values that a society ought to uphold. They then evaluate
existing societies in terms of these prior considerations. They are said to take a "prior-
to-society" perspective (Colby and Kohlberg, 1983, p. 22).
Universal Principles (stage 6). moral reasoning is based on abstract reasoning using
universal ethical principles. Laws are valid only insofar as they are grounded in justice,
and a commitment to justice carries with it an obligation to disobey unjust laws. Rights
are unnecessary, as social contracts are not essential for deontic moral action.
Decisions are not reached hypothetically in a conditional way but rather categorically in
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an absolute way, as in the philosophy of Immanuel Kant.This involves an individual

imagining what they would do in another’s shoes, if they believed what that other person
imagines to be true. The resulting consensus is the action taken. In this way action is
never a means but always an end in itself; the individual acts because it is right, and not
because it is instrumental, expected, legal, or previously agreed upon. Although
Kohlberg insisted that stage six exists, he found it difficult to identify individuals who
consistently operated at that level.
At stages 5 and 6 people are less concerned with maintaining society for its own
sake, and more concerned with the principles and values that make for a good society.
At stage 5 they emphasize basic rights and the democratic processes that give
everyone a say, and at stage 6 they define the principles by which agreement will be
most just.
In our client’s case, when making a decision he does not disregard the feelings
and rights of other people. He take into consideration that as much as possible no one
will get hurt whenever he makes certain decisions. It does not really matter to him if he
did not abide the social norms as long as he making the right thing.
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DEFINITION OF COMPLETE DIAGNOSIS
Diagnosis: Cholelithiasis
CHOLELITHIASIS
• Presence of gallstones in the bile. Gallstones are crystalline structures formed by

concretion (hardening) or accretion (adherence of particles, accumulation) of
normal or abnormal bile constituents.
(Medical-Surgical Nursing, Clinical Mangement for Positive outcomes by: Joyce

M. Black, Jane Hokanson Hawks, Annabelle M. Keene)
• Is gallstone formation in the gallbladder. Gallstones are composed of cholesterol,

bile salts, calcium, bilirubin, and proteins.
(Medical-Surgical Nursing, a Nursing Process Approach, 3rd edition by: Long,

Phipps, Cassmeyer)
• Presence of stones in the bilary tract. Stones are composed largely of

cholesterol, bile pigments and calcium.
(Medical-Surgical Nursing, concepts and clinical Nursing by: Phipps, Long,

Woods)
• Cholelithiasis, calculi or gallstones, in the bladder usually form in the bladder

from the solid constituents of bile; they vary greatly in size, shape and
composition
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(Textbook of Medical-Surgical Nursing by: Brunner and Suddarth’s)
• Cholelithiasis is characterized by the formation of gallbladder stones in the

gallbladder that are usually composed primarily of cholesterol
(Understanding Medical Surgical Nursing, third edition by:Linda Williams and

Paula D. Hopper)
PHYSICAL ASSESSMENT
INITIAL PHYSICAL ASSESSMENT
Date and Time of Assessment: September 13, 2010 @ 10:00pm
General Survey
Examined a conscious, cooperative and coherent patient: 53 years old; with good
hygiene and grooming; has good memory, good speech and can express self; 157.5 cm or 5’4’’
in height and 65 kgs in weight. Afebrile patient, not in respiratory distress with the following Vital
Signs:
Vital signs
BP: 110/80mmHg RR= 16 cycles/min
PR: 68 bpm Temp= 36.5 ºC
Skin
His skin is uniform in color which is dark brown. There were no rashes, non-edematous,
without lesions, smooth and with good skin turgor of 2 seconds, fairly returning back to normal
after being pinched. It is warm to touch and dry.
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Head
With normocephalic head. Facial movements are symmetrical. Scalp has no dandruff,
lice or lesions. The hair is not evenly distributed. No tenderness and abnormal masses were
noted on head region on palpation.
Eyes
Eyebrows are evenly distributed and symmetrically aligned with equal movement.
Eyelashes are also evenly distributed. Eyelids are intact and with no discharges and
discoloration noted. Lids are closed symmetrically and also blink bilaterally. Conjunctiva is
slightly pinkish in color. Pupils are brown in color in 3mm diameter and constrict briskly to light
accommodation. Patient is not wearing supporting aid such as eyeglasses.
Ears
Ears have similar color with his facial skin. Both external pinnae are aligned to the outer
canthi of his eyes and are symmetrical in shape and form. Ears are normally movable. If pulled
upward, downward and backward. They are firm, and recoil after they are folded. There were no
discharges (earwax) noted at the external portion of the ear canals of both ears. Tympanic
membrane appears to be intact since no abnormalities on gross hearing were noted on the
patient. No lesions on ears were noted. No inflammations or nodules palpated at the back of the
ear (mastoid process) and at the auricle. Client was able to hear and comprehend immediately
during our interview.
Nose
Nasolabial folds are symmetrical. No discharges noted. There were no lesions noted.
Septum located at the midline, patent nares noted, with moist mucous membrane. Nasal flaring
was noted.
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Mouth
Lips are pale. Teeth are slightly yellowish in color and incomplete, central incisor is
lacking. Tongue is in midline. There was no speech abnormalities, neither swelling nor bleeding
noted.
Neck
Anterior neck is symmetrical at both sides with no masses palpated. Muscle equal in
size and head is centered. Client shows good coordinated movements with no discomforts on
doing activities. Lymph nodes are slightly palpable. The thyroid gland is not visible upon
inspection.
Chest and Lungs
Chest is symmetrical on size and shape. The chest rises and falls equally upon inhaling
and exhaling. Breathing pattern was regular and respiratory rate was 16 cpm.
Abdomen
Abdomen appears to be flat and soft, bowel sounds are normoactive upon auscultation.
No masses or tenderness were palpated. Patient complains of discomfort.
Genito –Urinary
Due to privacy purposes, we were not able to inspect the genito-urinary area. Patient is
able to void freely.
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Back and Extremities
Spine is situated midline with no deformities on the spine were noted. Extremities are
movable and are at maximum range of motion. Patient is ambulatory and is able to walk without
any ambulatory devices or any personal assistance.
FINAL PHYSICAL ASSESSMENT
Date and Time of Assessment: September 15, 2010 @ 9:00pm
General Survey
Received lying on bed, awake and coherent with IVF of D5LR @120cc/hr infusing well at
right metacarpal vein no infiltration noted. Patient is wearing a hospital gown. He has a
mesomorphic body. He is aware with the time, place and person surrounding him.
Vital signs
BP: 120/90mmHg RR=22cycles/min
PR: 72 bpm Temp=37 ºC
Skin
His skin is uniform in color which is dark brown. There were no rashes, non-edematous,
smooth and still has a skin turgor of 2 seconds, fairly returning back to normal after being
pinched. It is warm to touch and dry.
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Head
With normocephalic head. Facial movements are symmetrical. Scalp has no dandruff,
lice or lesions. The hair is not evenly distributed. No tenderness and abnormal masses were
noted on head region on palpation.
Eyes
Eyebrows are evenly distributed and symmetrically aligned with equal movement.
Eyelashes are also evenly distributed. Eyelids are intact and with no discharges and
discoloration noted. Lids are closed symmetrically and also blink bilaterally. Conjunctiva is
slightly pinkish in color. Pupils are brown in color in 3mm diameter and constrict briskly to light
accommodation. Patient is not wearing supporting aid such as eyeglasses.
Ears
Ears have similar color with his facial skin. Both external pinnae are aligned to the outer
canthi of his eyes and are symmetrical in shape and form. Ears are normally movable. If pulled
upward, downward and backward. They are firm, and recoil after they are folded. There were no
discharges (earwax) noted at the external portion of the ear canals of both ears. Tympanic
membrane appears to be intact since no abnormalities on gross hearing were noted on the
patient. No lesions on ears were noted. No inflammations or nodules palpated at the back of the
ear (mastoid process) and at the auricle. Client was able to hear and comprehend immediately
during our interview.
Nose
Nasolabial folds are symmetrical. No discharges noted. There were no lesions noted.
Septum located at the midline, patent nares noted, with moist mucous membrane. Nasal flaring
was noted.
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Mouth
Lips are pale. Teeth are slightly yellowish in color and incomplete, central incisor is
lacking. Tongue is in midline. There was no speech abnormalities, neither swelling nor bleeding
noted.
Neck
Anterior neck is symmetrical at both sides with no masses palpated. Muscle equal in
size and head is centered. Client shows good coordinated movements with no discomforts on
doing activities. Lymph nodes are slightly palpable. The thyroid gland is not visible upon
inspection.
Chest and Lungs
Chest is symmetrical on size and shape. The chest rises and falls equally upon inhaling
and exhaling. Breathing pattern was regular and respiratory rate was 22 cpm.
Abdomen
Abdominal bowel sounds are heard and normoactive upon auscultation. No masses or
tenderness were palpated. No abdominal distention is noted. With dressing at right lower
quadrant, dry and intact.
Genito –Urinary
Due to privacy purposes, we were not able to inspect the genitor-urinary area. Patient is
able to void freely.
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Back and Extremities
Spine is situated midline with no deformities on the spine were noted. Extremities are
movable and are at moderate range of motion. Patient is not ambulatory and cannot able to
walk yet without any ambulatory devices or any personal assistance.
ANATOMY AND PHYSIOLOGY

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DIGESTIVE SYSTEM
The Gastrointestinal tract or the alimentary tube is part of the digestive system. This extends from the
mouth to the anus and mainly consists of the oral cavity, pharynx, esophagus, stomach, small and large
intestines (colon). These are series of hollow organs joined in a long, twisting tube from the mouth to
the anus—and other organs that help the body break down and absorb food . Organs that make up
the digestive tract are the mouth, esophagus, stomach, small intestine, large intestine—also
called the colon—rectum, and anus. Inside these hollow organs is a lining called the mucosa.
In the mouth, stomach, and small intestine, the mucosa contains tiny glands that produce
juices to help digest food. The digestive tract also contains a layer of smooth muscle that helps
break down food and move it along the tract.
Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder.

Gallstones tend to be asymptomatic. The most common symptom is biliary colic; gallstones 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 (cholangitis); and gallstone pancreatitis. Diagnosis is usually by ultrasonography. If
cholelithiasis causes symptoms or complications, cholecystectomy is necessary.
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LIVER
The liver is located at the right upper quadrant of the abdominal cavity and below the
diaphragm. It lies t the right of the stomach and overlies the gallbladder. It is connected to two
large blood vessels one called the hepatic artery and one called the portal vein. The hepatic
artery carries blood from the aorta whereas the portal vein carries blood containing digested
nutrients from the small intestine and the descending colon. These blood vessels subdivide into
capillaries which then lead to a lobule. Each lobule is made up of millions of hepatic cells which
are the basic metabolic cells.
FUNCTIONS:
- Aids in digestion and removes waste products and worn-out cells

P a g e | 27
- Synthesize, store, and process (metabolize) fats, including fatty acids (used for
energy) and cholesterol
- Metabolize and store carbohydrates, which are used as the source for the sugar
(glucose) in blood that red blood cells and the brain use
- Form and secrete bile that contains bile acids to aid in the intestinal absorption
(taking in) of fats and the fat-soluble vitamins A, D, E, and K.
- Eliminate, by metabolizing and/or secreting, the potentially harmful biochemical

products produced by the body, such as bilirubin from the breakdown of old red blood cells
and ammonia from the breakdown of proteins
PANCREAS
The pancreas is a fish-shaped spongy grayish-pink organ about (6 inches 15 cm) long that
stretches across the back of the abdomen, behind the stomach. The head of the pancreas is
on the right side of the abdomen and is connected to the duodenum (the first section of the
P a g e | 28
small intestine). The narrow end of the pancreas, called the tail, extends to the left side of the
body.
It is both an endocrine gland producing several important hormones, including insulin,

glucagon, and somatostatin, as well as an exocrine gland, secreting pancreatic juice containing
digestive enzymes that pass to the small intestine. These enzymes help to further break down
the carbohydrates, proteins, and fats in the chyme.
FUNCTIONS:
*ENDOCRINE:
- Produce several important hormones, including insulin, glucagon, and

somatostatin. Insulin controls the amount of sugar in the blood.
- Resides in the million cellular islands (the islets of Langerhans) embedded

between the exocrine units of the pancreas. Beta cells of the islands secrete insulin,
which helps control carbohydrate metabolism. Alpha cells of the islets secrete
glucagon that counters the action of insulin
*EXOCRINE:
- Secretes digestive enzymes that pass to the small intestine. These enzymes
help to further break down the carbohydrates, proteins, and fats in the chyme.
PANCREATITIS
Gallstones are a common cause of pancreatitis. It

is produced in the gallbladder, can block the bile
duct, stopping pancreatic enzymes from traveling
to the small intestine and forcing them back into
P a g e | 29
the pancreas. The enzymes then begin to irritate the cells of the pancreas, causing
the inflammation associated with pancreatitis.
CYSTIC DUCT
It is the short duct that joins the gall bladder to the common bile duct. It usually lies next to the
cystic artery. Bile can flow in both directions between the gallbladder and the common hepatic
duct and the (common) bile duct.
During a cholecystectomy, the cystic duct is clipped two or three times and a cut is made
between the clips, freeing the gallbladder to be taken out.
P a g e | 30
Gallstones can enter and obstruct the cystic duct, preventing the flow of bile. The increased
pressure in the gallbladder leads to swelling and pain. This pain is sometimes referred to as a
gallbladder "attack" because of its sudden onset.
GALLBLADDER
P a g e | 31
The gallbladder is a small pear-shaped organ that sits just beneath the liver. In adults, the
gallbladder measures approximately 8 cm in length and 4 cm in diameter when fully distended.
It is divided into three sections: fundus, body and neck. The neck tapers and connects to the
biliary tree via the cystic duct, which then joins the common hepatic duct to become the
common bile duct. It is approximately 3 to 4 inches (7.6 to 10.2 cm) long and about 1 inch (2.5
cm) wide.
FUNCTIONS:
- The function of the gallbladder is to store bile and concentrate. Bile is a digestive
liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in
partly digested food. A muscular valve in the common bile duct opens, and the bile flows
from the gallbladder into the cystic duct, along the common bile duct, and into the
duodenum (part of the small intestine).
P a g e | 32
ETIOLOGY
Predisposing Factors:
PREDISPOSING PRESENT ABSENT RATIONALE JUSTIFICATION

FACTORS
Most internal functions Peter’s current age is 53.

decline as people age. His body is slowly adjusting
Inevitably resulting in to aging, thus his immune
system is weakening.
organ degeneration which
also affects the body's
metabolism of lipids. Less
than 5-6% of the
AGE populations under age 40

have stones, in contrast to
25-30% of those over 80.
SOURCE: Carol Mattson

Porth, Pathophysiology,
Concepts of Altered Health
Sciences
P a g e | 33
Increase level of estrogen Although the disease is

stimulates the liver to not exclusive to one
remove more cholesterol gender, statistics show
from blood and divert it into that women are more
the bile. Female sex prone to develop
hormones have long been cholelithiasis than men.
suspected to have a side
effect of gallstone
formation by altering
respective bile constituents
(mainly the FAT
GENDER metabolism). Women have

2 to 3 times the risk as
men of developing
cholesterol gallstones
because estrogen
increases biliary
cholesterol secretion.
SOURCE: Barbara Gould,

Pathophysiology for the
Health Professions, Third
Edition, Saunders Elsevier
RACE  Native Americans,

Hispanic, and those of
Peter is a pure Filipino.
northern European
Therefore, he is an
descent develop gallstones
Asian.
more frequently than any
other ethnicity in the US.
Gallstones occur less
frequently among Asians
and African-Americans.
Such cases are most likely
due to a combination of
P a g e | 34
genetic and dietary factors,

particularly fat intake.
SOURCE:http://www.lifesc
ript.com/Health/A-
Z/Conditions_A-
Z/ConditionsInDepth/C/Ch
olelithiasis/Risk_Factors.as
px
GENETIC  The patient is the only

Having a family member
one in his family who
or close relative with
experiences
gallstones may increase
cholelithiasis.
the risk. Up to one-third
of cases of painful
gallstones may be
related to genetic
factors. A mutation in the
gene ABCG8
significantly increases a
person's risk of
gallstones. This gene
controls a cholesterol
pump that transports
cholesterol from the liver
to the bile duct. It
appears this mutation
may cause the pump to
continuously work at a
high rate.
SOURCE:https://online.ep
ocrates.com/noFrame/sho
wPage.do?
P a g e | 35
method=diseases&Monogr
aphId=873&ActiveSectionI
d=32
Precipitating Factors:
PRECIPITATING
PRESENT ABSENT RATIONALE JUSTIFICATION
FACTORS
DIETARY FACTORS  Excessive intake of high fat Peter admits that he

or cholesterol food can drinks albeit moderately.
result to an increase in He also craves for fatty
cholesterol level in the foods, as told by his
body, making it hard for the wife.
liver to make bile enough to
metabolize the all
cholesterol present. Excess
cholesterol present builds
up and increases the
cholesterol serum level.
Normal Liver function
would then try to
compensate and excrete
excess cholesterol to the
bile plus the body would
reabsorb water from the
bile making it more
P a g e | 36
concentrated.
Supersaturation of
Cholesterol along with
other constituents of the
bile (bilirubin, lecithin etc.)
builds up microcrystals.
When microcrystals
aggregate it would result to
Gallstones.

WEIGHT GAIN  Obesity (BMI<30) is The patient’s body mass

strongly associated with index is 26.3. Thus, he is
increased gallstone overweight for his height.
prevalence. The risk is
proportional to the increase
in total body fat. Obese
people synthesize more
cholesterol in both hepatic
and nonhepatic tissues,
transport it to the liver, and
secrete more of it into the
bile, leading to bile that is
often greatly
supersaturated with
cholesterol.
SOURCE:https://online.epo
crates.com/noFrame/show
Page.do?
P a g e | 37
d=32
PROLONGED  Starvation decreases The patient does not

FASTING/ RAPID gallbladder movement practice fasting. There
WEIGHT LOSS causing the bile to become was no written record of
over concentrated with him rapidly losing
cholesterol. The liver also weight.
secretes extra cholesterol
into bile adding to the super
saturation causing stone
formation. Also, fasting
persons have diminished
bile salt pool and lithogenic
bile. Gallbladder stasis
plays a key role in
permitting stone formation.
Weight loss is associated
with an increased risk of
gallstones because weight
loss increases bile
cholesterol supersaturation,
enhances cholesterol
crystal nucleation, and
decreases gallbladder
contractility. Obese patients
undergoing rapid weight
loss (1-2% of body weight
or approximately 1-2
kg/week), either by very
low caloric dieting or gastric
stapling, have a 25-40%
chance of developing
gallstones within 4 months.
During rapid weight loss,
biliary cholesterol
P a g e | 38
saturation increases
acutely as cholesterol is
mobilized from adipose
tissue and skin and
secreted into bile.

With some medical care it

is necessary to provide
nutrition through the veins.
The intestines are
bypassed and the
gallbladder is less
stimulated since there is no
food to process. This He was only fed
increases your risk of parenterally after being
TOTAL gallstones. This causes admitted in SPMC but
PARENTERAL gallbladder hypomotility
 during our assessment
NUTRITION and the resulting bile stasis there was no IVF
increases the risk for the inserted.
development of gallstones.
Page.do?
d=32
CLOFIBRATE USE  Drugs that lower the serum The patient did not use
AND OTHER level of cholesterol, notably any of this medication
ANTILIPEMIC clofibrate, are associated since he has no concern
P a g e | 39
with an increased incidence

of gallstones. Clofibrate
presumably increases the
secretion of cholesterol into
the bile and apparently also
decreases bile acid
synthesis, so increasing the
cholesterol saturation of the to weight loss as well as
bile. Clinical reflection of hyperlipidemias or

DRUGS condition of abnormally
these physiologic
abnormalities has been elevated levels of any or
found in the overwhelming all lipids and/or
association between lipoproteins in the blood.
clofibrate therapy and

gallstones.

Sciences
TERMINAL ILEUM  The loss of bile salts from The patient never had a
DISEASE / the enterohepatic terminal ileum disease
RESECTION circulation increases the and he had never been
risk of gallstones. Crohn in need of surgical
disease is the most manipulation except for
common disease affecting cholelithiasis.
the terminal ileum and has
been shown to be
associated with an
increased risk of gallstones
compared with matched
controls.
P a g e | 40
Page.do?
d=32
Pregnancy is an
independent risk factor for
cholesterol gallstone.
During pregnancy, there is
an increasing level of
estrogen causes increased
cholesterol saturation of
bile, making these patients
more prone to the
development of sludge and
gallstones. Higher levels of This is not applicable to
progesterone cause our patient because he
PREGNANCY/ gallbladder hypomotility. is male and he does not
EXOGENOUS produce estrogen

 Use of exogenous estrogen
ESTROGEN hormone Y and cannot
for contraceptive or bear a child.
hormone replacement
increases risk of gallstones
as a result of increased
cholesterol secretion into
bile.
Page.do?
d=32
DIABETES  Despite obesity and Patient does not have

MELLITUS increased total body diabetes mellitus but he
P a g e | 41
cholesterol synthesis and

decreased gallbladder
motility seen in patient with
diabetes, diabetes mellitus
itself does not appear to be
an independent risk factor has a family history of it.
for cholelithiasis.
SOURCE: Harrison’s
Principle of Internal
Medicine, 16th Edition
SYMPTOMATOLOGY
SIGN AND JUSTIFICATION

PRESENT ABSENT RATIONALE
SYMPTOMS
Jaundice results from an The patient doesn’t have

abnormally high jaundice since there has
accumulation of bilirubin in no sign of it present like
the blood as a result of yellowish color of the
which there is a yellowish schlera and skin.
discoloration to the skin
and deep tissues.
Jaundice becomes evident
JAUNDICE
 when the serum bilirubin
level rises above 2.0 to 2.5
mg/dL.
Principle of
Internal Medicine, 16th

Edition
PALE STOOL  Bilirubin together with The patient verbalized

cholesterol is normally that the color of his stool
absorbed in the intestines is normal (shades of
P a g e | 42
and is usually excreted brown) and never that

within the feces. The bile clay-colored.
gives the stool its brown to
black color. Obstruction in
the bile flow lessens and
may hinder the absorption
of bile in the intestines
making the stool pale in
color.
Principle of

Edition
Normally urine are not dark The patient verbalized

in color, excess bilirubin that the color of his urine
are excreted by the is either white or yellow
kidneys as a not that dark orange to
compensatory mechanism brown urine.
DARK URINE to balance the bile level in


the body.

PRURITUS OR  Pruritus is the most The patient verbalized

GENERALIZED common presenting that he didn’t
ITCHING symptom in persons with experienced any
cholelithiasis, probably itchiness all over his
related to an elevation in body except of insect
plasma bile acids. bites. No scratches
noted.
P a g e | 43
Principle of

Edition
PAIN  Due to the gallstones and The patient verbalized

microcrystals present pain scale of 6 out of 10
inside the gall bladder, the during the encounter at
gallbladder can't contract Surgical West at the right
properly which creates upper quadrant of the
pain in the epigastric area abdomen.
(right side of the abdominal
area), often with referred
pain, above the waist ,
the right shoulder and the

right scapula or the
midscapular region. A
gallstone produces visceral
pain by obstructing the
cystic duct or ampulla of
Vater, resulting in
distention of the
gallbladder or biliary tree.
The most common
symptom is in pain the
right upper part of the
abdomen or epigastrium.
This can cause an attack
of abdominal pain, called
biliary colic, which:
develops quickly, is
severe, lasts about one to
three hours before fading
gradually, isn't helped by
over-the-counter and isn't
P a g e | 44
helped by passing wind.

The pain may radiate to
the back, right scapula or
shoulder. The pain often
begins suddenly following
a meal. The pain of biliary
colic is caused by the
functional spasm of the
cystic duct when
obstructed by stones,
whereas pain in acute
cholecystitis is caused by
inflammation of the
gallbladder wall.
Principle of

Edition
Less or absence of bile The patient verbalized

acid in the duodenum that the he didn’t
means less or no digestion experienced the urge to
of fats. These signs and vomit nor vomit during
symptoms may cholelithiasis is present.
accompany a gallbladder
EPIGASTRIC attack. Pain is usually
DISTRESS 
accompanied by nausea
and vomiting.

Health Professions, 3rd
Edition, saunders Elsivier
P a g e | 45
Palpation of the abdomen No tenderness noted to

frequently elicits localized the patient’s abdomen.
tenderness in the right
upper quadrant which is
associated with guarding
TENDERNESS and rebound tenderness.


Gallstones sometimes get The patient doesn’t

trapped in the neck of the experience fever nor chill
gallbladder and can cause since the temperature of
persistent pain that lasts the patient is within the
more than several hours normal range which is
and is accompanied by 36.5 C and 37 C.
fever, also due to the
irritation and inflammation
of the gallbladder wall. The
FEVER AND CHILLS fever tends to rise

gradually to
Above 100.4° F (38° C)

and may be accompanied
by chills.

Sciences
P a g e | 46
PATHOPHYSIOLOGY
SCHEMATIC DIAGRAM
P a g e | 47
PATHOPHYSIOLOGY
Predisposing Factors Precipitating Factors
 Age  Lifestyle: Diet
 Over Weight
Liver cells secrete cholesterol

into the bile.
Decreased bile Increased cholesterol

acid synthesis synthesis in the liver
Bile supersaturated
with cholesterol
Supersaturation sets the stage

for cholesterol crystal formation
or formation of “microstones”
P a g e | 48
More crystals then aggregate

on the mircrostones, which
grow to from “macrostone.”
Decreased motility in the

gallbladder
The stones become lodged in

the cystic or common duct
causing pain and cholecystitis.
CHOLELITHIASIS
(Formation of gallstones)
- The stones accumulate and

fill the entire gallbladder
Gallstone tries to go out of

the bladder
Obstruction of the common bile duct by

gallstones (choledocholelithiasis)
P a g e | 49
If treated:
If untreated
 Open cholecystectomy
 Laparoscopic
 Cholecystectomy
Cholestasis Good prognosis
Absence of bile in Increase levels of

the duodenum bilirubin/bile pigments in
the circulation
S/S: jaundice, ectenic

sclera, pruritus, dark
urine S/S: jaundice, ectenic
sclera, pruritus, dark
urine
P a g e | 50
DOCTOR ’S ORDER
Date Ordered: Doctor’s Order: Rationale: Remarks:
09/11/2010 • Please admit Patients that needs

under GS 2- west to undergo surgery
9 AM are admitted in this
DONE
area for a series of
tests and to prepare
patient for the
operation
• Secure Consent It is a standard

operating procedure
in all institutions to
secure an informed
DONE
consent from the
patient allowing the
surgeon to perform
certain procedures,
• Monitor VS q4° Vital signs

and record monitoring in
important for DONE
monitoring patient’s
health status
DAT Client does not DONE

have any
restrictions with
regards to food,
P a g e | 51
Attach labs to chart Lab results are

important data that
needs to be kept for DONE
documentation and
legal purposes
No IVF This serves as

verification that the
DONE
patient does not
need any IVF
Inform GS2 of this Proper

admission endorsement is
always important for
proper relay of DONE
information and
proper transfer of
patient
Refer Proper referral of

client facilitates
organization to the
DONE
members of the
health team caring
for the patient
11 PM For OR scheduling It is important to

schedule the patient
DONE
for OR for
prioritization
To secure OR It is important that

materials on that materials
are already secured DONE
prior to surgery to
avoid delays
Refer DONE
09/12/2010 NO DOCTOR’S ORDER GIVEN

P a g e | 52
09/13/2010 Pls. schedule for Cholecystectomy is

open done on patients
10 AM cholecystectomy with symptomatic
DONE
tomorrow 2nd table gallstones, it is the
removal of the
gallbladder.
Secure Consent Securing patient’s

informed consent
verifies that patient
DONE
is well informed of
the procedure he is
going to
Inform OR This is to inform the

OR staff to prepare
for the said
DONE
operation to
accommodate the
patient
IVF D5LR 1L @ Inserting an IVF is

120cc/hr important for
administration of
medications and DONE
providing fluids to
the patient since he
will be put on NPO
NPO post midnight Placing patient on

NPO is essential to
prevent
complications and
DONE
difficulties in the
surgery due to the
presence of feces in
the GI tract
Ampicillin/Sulbactam For the prevention

750 IVTT 1 hr PTOR of infection and DONE
bacterial growth
Refer DONE
P a g e | 53
10:30 PM Start Pre operative

Ampicillin/Sulbactam medications are
750 mg IVTT 1hr important to be
PTOR administerd at the
DONE
right time prior to
surgery to prepare
the patient well for
the surgery
4 PM NPO PTOR To prevent vomiting

and presence of
DONE
feces during the
surgery
General /Oral Proper hygiene is

Hygiene important to prevent
DONE
the spread of
microorganisms
IVF of D5LR 1L @ An intravenous fluid

120cc/hr once on is important to
NPO facilitate the
DONE
administration of
medications once
patient is on NPO
Ranitidine 50 mg To prevent
IVTT once on NPO ulceration and DONE
gastric pain
VS enroute to OR Checking the vital

signs before the
surgery is important
DONE
to assess whether
the patient is stable
for the surgery
Empty bladder To prevent the

PTOR bladder from DONE
distended
Refer DONE
Salamat
P a g e | 54
09/14/2010 To PACU until The post

stable, send to SE anesthesia care unit
12:20 AM is where patients
are placed
DONE
(Post-Op Orders) immediately after
the surgery to be
monitored until the
patient is stable
NPO temporarily To prevent nausea

and vomiting
DONE
caused by
anesthesia
VS Q15min until To properly monitor

stable, then Q hourly the vital signs of the
patient that might
constantly change DONE
due to problems in
the surgery or the
effect of anesthesia
IVF D5LR 1L @
DONE
120cc/hr
Meds: DONE
1. Tramadol 50 mg To prevent fever

IVTT Q6° and pain
management
2. Ketorolac 30 mg For post operative
IVTT Q6°
pain management
3. Ranitidine 50 mg
IVTT Q6° while To prevent ulcers
on NPO
and hyperacidity
4. Metochlopramide
10 mg IVTT Q8° due to NPO
PRN for PONV
For prevention of
post operative
nausea and
vomiting
P a g e | 55
O2 via FM @ 4 LPM To provide the

patient with enough
oxygen supply,
since the
DONE
respiratory system
may be depressed
due to the
anesthesia
Moderate – high To promote breast

back rest expansion to allow
for the anesthesia DONE
to be excreted from
the body
Keep patient warm To keep patient

thermoregulated
DONE
and promote blood
circulation
Refer accordingly To facilitate proper

transfer of patient
DONE
from one unit to
another
Salamat
DIAGNOSTIC EXAMS
P a g e | 56
OPD HEMATOLOGY
CBC And Platelet
Date Diagnostic Result Unit Normal Rationale

Ordered Test Range
09-03-10 Hemoglobi L 130.0 g/L 135.FBS To identify

n the amount
of oxygen
carrying
protein
contained
within the
RBC.
To obtain
data for
calculating
the MCH and
MCHC.
High
hemoglobin
count
indicates an
above-
average
concentration
of oxygen-
carrying
proteins in
P a g e | 57
the blood.
Low
hemoglobin
count can be
caused by an
abnormality
or disease.
Hematocrit L 0.36 0.36 – 0.48 To identify

the
percentage
of blood
volume
occupied by
red blood
cells.
To aid in the
circulation of
erythrocyte
indices.
Low
hematocrit is
referred as
anemic.
Red Blood 4.35 x10^9/L 4.20 – 6.10 To know the

Cell Count amount of
RBC in the
P a g e | 58
blood.
To provide
data for
calculating
MCV and
MCH, this
reveals RBC
size and Hb
content.
White 8.44 x10^9/L 5.0 – 10.0 To determine

Blood Cell inflammation
Count or infection.
DIFFERENTIAL COUNT
Date
P a g e | 59
Ordered Diagnostic Result Unit Normal Rationale

Test Range
09-03-10 Neutrophil L 35 2 55-75 To indicate

the
presence of
bacterial
infection
and amount
of
leukocyte.
To reveal
whether
neutrophils
are present
in normal
proportion
to one
another, if
one cell
type is
increased or
decreased,
or immature
cells are
present.
P a g e | 60
Lymphocytes H 41 2 20-35 To identify if

there is an
abnormal
amount of
lymphocyte
that may
indicate viral
infection. A
decreased
number of
lymphocytes
in the
peripheral
circulation
occurring as
malignancy
or infection.
Monocytes 7 2 2-10 To
determine
lymphocyte
blood count.
Eosinophil H 16 2 1-8 High

percentage
of
eosinophil
may
indicate
bacterial
infestation.
P a g e | 61
Basophil 1 2 0-1 To
determine
the number
of basophils
in a
peripheral
blood
smear.
Platelet 218 x10^3/uL 150-400 To aid in

Count determining
specific
conditions
related to
basophil
counts.
Mean 88.0 fl 80-100 To measure

Corpuscular the average
Volume blood cell
volume.
(MCV)
Mean 29.90 pg 25.60- To measure

Corpuscular 32.20 the Hb-
Hemoglobin MCH.
P a g e | 62
(MCH)
Mean 33.9 g/dL 32.20- To measure

Corpuscular 38.50 the Hb
Hemoglobin weight to
Concentration hematocrit.
(MCHC)
BLOOD TYPE (ABO-Rh)

Ordered Test Range
09-03-10 Blood Type O 135.FBS To establish a

patient’s blood
group according
to the ABO
system.
To check the
compatibility of
the donor and the
recipient before
the transfusion.
P a g e | 63
Blood Type Rh To classify blood

Rh Positive according to the
presence and
absence of Rh
antigen.
IMMUNOLOGY

Ordered Test Range
09-08-10 Hepatitis B Qualitativ To determine

Surface e Non- the existence of
Antigen reactive Hepatitis B
antigen.
(HBsAg)
To screen
people for at
high risk of
contracting
Hepatitis B.
P a g e | 64
OPD CHEMISTRY
Date Chemistry Result Unit Normal Range

Ordered
09-03-10 Creatinine 103.00 umol/L 53.0-115.0
Sodium 144.10 mmol/L 136.0-155.0
Potassium 3.63 mmol/L 3.5-5.5

P a g e | 65
URINALYSIS
Tests Result Rationale Interpretation
To be able to
Color Yellow If it is yellow to

examine the color, clear, you are
getting enough fluid.
appearance,
albumin, reaction,
specific gravity,
sugar, pus cells,

Appearance Clear The result of the
epithelial cells, appearance should
be clear for it to be
protein and bacteria normal.
that consists the
urine.
Albumin Negative There is an absence

of albumin in the
client’s urine. There
is no means of
infection.
P a g e | 66
Reaction 5.0 The reaction is not

acidic. Has a normal
value of 4.6-8.
Specific Gravity 1.030 The client has no

either renal disease
or increase loss of
fluids from the body.
Sugar Negative It shows that the

urine content of
client is negative of
sugar therefore he
does not have
diabetes.
Pus Cells 0-1 hpf There is no

presence of pus
cells in the client’s
urine.
Epithelial Cells Few There is a positive

Squamous sign of epithelial
cells in minimum
amount.
P a g e | 67
Renal Negative There is no

presence of
bacteria.
Electrocardiographic Report
Rhythm: Sinus, Axis: -30, Atrial Rate: 54 BPM, Ventricular: 5PR,
Interval: 0-12 Seconds, QRS: 0.08 Seconds
Chest PA Adult (09-03-10)
Lungs are clear, tracheal air column is at midline, heart is not enlarged,
both hemidiaphrame and costophrenic sulci are intact, the rest of inc. structure are
unremarkable.
P a g e | 68
SURGICAL PROCEDURE
Date of operation: September 14, 2010
Time Begun: 10:10 am
Time Ended: 12:20 am
Pre-op Diagnosis: Cholelithiasis
Post-op Diagnosis: Cholecystolithiasis
Operation Open Cholecystectomy

Performed:
Type of Anesthesia: General – General Endotraqueal Anesthesia (GETA), O2

Isuflurane
Name of Surgeon: Dr. Cosep and Dr. Lonzaga
Anesthesiologist: Dr. Panuda
Vital Signs: BP: 170/100 ; P: 124 bpm ; R: 16 bpm ; T: not taken (on chart)
I. Definition of Open Cholecystectomy
Open cholecystectomy is a surgery in which the abdomen is opened to permit

the removal of the gallbladder. This operation has been employed for over 100
years and is a safe and effective method for treating symptomatic gallstones,
ones that are causing significant symptoms. At surgery, direct visualization and
palpation of the gallbladder, bile duct, cystic duct, and blood vessels allow safe
and accurate dissection and removal of the gallbladder. The surgeon removes
the gallbladder through a single, large incision in the abdomen (usually right
subcostal). General anaesthesia is needed, and surgery will lasts 1 to 2 hours.
The surgeon will make the incision either under the border of the right rib cage or
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in the middle of the upper part of the abdomen (between the belly button and the
end of the breastbone).
II. Position of the client
The patient undergoing cholecystectomy is in a supine position.
III. Illustration of Instruments
Mayo scissors Metzenbaum Suture

needle
Suture thread Knife/Scalpel

Babcock
Cautery Kelly Debakey

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Towel clip Thumb forceps Tissue forceps
Retractors Skin stapler
DRUG STUDY
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Generic Name: Ampicillin/ Sulbactam
Brand Name: Unasyn
Classification: Anti-infective
Dosage and 750 ivtt 1hour ptor

Frequency:
Mode of Action: Ampicillin is an antibiotic that inhibits cell-wall synthesis during

bacterial multiplication, while sulbactam is an irreversible inhibitor of
beta-lactamase; it binds the enzyme and does not allow it to interact
with the antibiotic.
Indication: Prevention of intra abdominal infections prior to OR
Contraindications: • Hypersensitivity to ampicillin and other penicillins
Adverse CNS:
Reactions:
- lethargy, hallucinations, seizures, anxiety, confusion,, agitation,
depression, dizziness, fatigue.
CV:
- vein irritation, thrombophlebitis
GI:
- nausea, vomiting,diarrhea, glositis, stomatitis, gastritis,

abdominal pain, enterocolitits, pseudomembranous colitis,
black hairy tounge
GU:
- interstitial nephritis, nephropathy, vaginitis

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Hematologic:
- anemia, thrombocytopenia, thrombocytopenia purpura,

eosinophilia, leukopenia, hemolutic anemia, agranulocytosis
Skin:
- pain at injection site
Other:
- Hypersensitivity reactions, overgrowth of non susceptible

microorganism
Nursing 1. Determine previous hypersensitivity reactions to penicillins,

Repsonsibilities: cephalosporins, and other allergens prior to therapy.
2. Do not mix with other durgs when given IV to avoid drug
interactions.
3. Monitor patient carefully during the first 30 min after initiation
of IV therapy for signs of hypersensitivity and anaphylactoid
reaction . Serious anaphylactoid reactions require immediate
use of emergency drugs and airway management.
4. Instruct client to report any signs of allergic reaction such as
rashes, fever or chills.
5. Monitor I&O ratio and pattern. Report dysuria, urine
retention, and hematuria.
6. Provide a safe and quiet environment if possible to reduce
the risk of CNS adverse reactions
7. Check the IV site for signs of vein irritation.
8. Observe patients for signs and symptoms of anaphylaxis
(rash, pruritus, laryngeal edema, wheezing). Discontinue the
drug and notify the physician immediately if these occur.
9. Keep epinephrine, an antihistamine, and resuscitation
equipment close by in the event of an anaphylactic reaction.
10. Observe for and report symptoms of superinfections.
Withhold drug and notify physician.
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Generic Name: Ranitidine
Brand Name: Zantac
Classification: Antiulcer drug, Histamine H 2 antagonist
Dosage and 50 mg IVTT once on NPO

Frequency:
Mode of Action: Competitively inhibits action of histamine on the H2 at receptor sites

of parietal cells, decreasing acid secretions.
Indication: Prevention of ulcerations and secretion of gastric acids
Contraindications: • Hypersensitivity to drug

• Acute porphyia
• Use cautiously in patients with hepatic dysfunction
Adverse CNS:
Reactions:
- vertigo, malaise, headache
EENT:
- blurred vision
Hepatic:
- jaundice
Other:
- burning and itching at injection site, anaphylaxis,

angioedema
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Nursing 1. Assess patient for abdominal pain, Note presence of blood in

Repsonsibilities: stool or gastric aspirate.
2. No anti-inflamatories should be given. This includes aspirin
and the like.
3. Watch for signs of GI bleeding.
4. Inform patient that it may cause drowsiness or dizziness.
5. Inform patient to increased fluid and fiber intake to minimize
constipation.
6. Advise patient to report onset of black, tarry stools; fever,
sore throat; diarrhea; dizziness; rash; confusion; or
hallucinations immediately.
7. Inform patient that medication may temporarily cause stools
and tongue to appear gray black.
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Generic Name: Tramadol
Brand Name: Ultram
Classification: Central acting analgesic
Dosage and 50 mg IVTT Q6°

Frequency:
Mode of Action: Unknown. A centrally acting synthetic analgesic compound not

chemically related to opioids. Thought to bind to opioid receptors and
inhibit reuptake of norepinephrine and serotonin.
Indication: For pain management of operative site
Contraindication • Hypersensitivity to tramadol and other opioids

s: • Lactating/ breastfeeding women
• Acute intoxication from alcohol, hypnotics, centrally-acting
analgesics, opioids and psycotropic drugs
• History of anaphylactic reaction to codeine and other opioids
Adverse CNS:
Reactions:
- dizziness, vertigo, headache, somnolence, CNS stimulation,
asthenia, anxiety, confusion, coordination disturbances,
euphoria, nervousness, sleep disorder, seizures, malaise
CV:
- vasodilation
EENT:
- visual disturbances
GI:
- nausea, constipation, vomiting, dyspepsia, abdominal pain,

dry mouth, diarrhea, anorexia, flatulence
GU:
- urine retention, urinary frequency, menopausal symptoms,

proteinuria
Muskuloskeletal:
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- hypertonia
Respiratory:
- respiratory depression
Skin:
- pruritus, diaphoresis, rash
Nursing 1. Obtain specimen for culture and sensitivity test before first dose.
Repsonsibiliti Therapy may begin pending test results.
es: 2. Document indications for therapy, location, onset, and
characteristics of symptoms. Use a pain rating scale.
3. Assess for history of drug addiction, allergy to opiates or
codeine, or seizures; drug may increase the risk of convulsions.
4. Monitor VS, I & O before and periodically during administration.
5. Instruct patient not to perform activities that require mental
alertness; drug may cause drowsiness and impair mental or
physical performance.
6. Instruct patient to report any signs of adverse reactions such as
constipation, abdominal pain and difficulty in breathing.
7. Assess bowel function routinely. Prevention of constipation
should be instituted with increased intake of fluids and bulk and
with laxatives to minimize constipating effects.
8. Encourage patient to cough and breathe deeply every 2 hr to
prevent atelactasis and pneumonia.
9. Monitor patient for seizures. May occur within recommended
dose range. Risk increased with higher doses and inpatients
taking opioid analgesics, or other drugs that decrease the
seizure threshold.
10. Provide adequate lighting to prevent visual disturbances
Generic Name: Ketorolac
Brand Name: Toradol
Classification: Non Steroidal Anti-inflammatory Drug

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Dosage and 30 mg IVTT Q6°

Frequency:
Mode of Action: Unknown. May inhibit prostaglandin synthesis, to produce anti-

inflammatory, analgesic and antipyretic effects.
Indication: For treatment of moderately severe pain and anti inflammatory
Contraindications: • hypersensitivity to drug

• active peptic ulcer disease
• recent GI bleeding or perforation
• Advanced renal impairment
• Cerebrovascular bleeding
• Hemorrhagic diathesis or incomplete hemostasis
• At risk for renal impairment
• At risk for volume depletion
• At risk for bleeding
• Children younger than 2 years old
• Past allergic reactions to Aspirin and NSAIDs
Adverse CNS:
Reactions:
- drowsiness, sedation, dizziness, headache
CV:
- edema, hypertension, palpitations, arrhythmias

GI:
nausea, dyspepsia, GI pain, diarrhea, peptic ulceration,

-
vomiting, flatulence, constipation, flatulence
Hematologic:
- decreased platelet adhesion, purpura, prolonged bleeding

time
Skin:
- pruritis, rash, diaphoresis
Nursing 1. Rule out hypovolemia before administrating ketorolac.

Repsonsibilities: 2. Check history of allergic reactions to drug and perform
allergy test to determine hypersensitivity to drug.
3. Use as a part of a regular analgesic schedule rather than on
an as needed basis.
4. Assess pain (note type, location, and intensity) prior to and
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1-2 hr following administration.

5. Advise patient to consult if rash, itching, visual disturbances,
tinnitus, weight gain, edema, black stools, persistent
headche, or influenza-like syndromes (chills,fever,muscles
aches, pain) occur.
6. Effectiveness of therapy can be demonstrated by decrease
in severity of pain. Patients who do not respond to one
NSAIDmay respond to another.
7. Report any unusual bruising/bleeding, weight gain, swelling
of feet and ankle, increased joint pain, change in urine
patterns or lack of response.
8. Monitor patient closely while on therapy.
9. Advise patient to avoid activities that require CNS functions.
Assist patient in ADL.
10. Keep bedrails up when patient is on bed.
Generic Name: Metochlopramide
Brand Name: Reglan
Classification: Gastro Intestinal Stimulant, emetic
Dosage and 10 mg IVTT Q8° PRN for pain

Frequency:
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Mode of Action: A "prokinetic" drug that stimulates the muscles of the

gastrointestinal tract including the muscles of the lower esophageal
sphincter, stomach, and small intestine by interacting with receptors
for acetylcholine and dopamine on gastrointestinal muscles and
nerves.
Indication: Given as needed for pain and to prevent postoperative nausea and
vomiting
Contraindications: • Hypersensitivity to drug

• Epilepsy or other seizure disorders
• Pheochromocytoma
• Stimulation of GI motility might be dangerous
• Use cautiously in patients with history of depression, Parkinson’s
disease or hypertension
Adverse CNS:
Reactions:
- restlessness, anxiety, drowsiness, fatigue, lassitude, fever,
depression, akathisia, insomia, confusion, suicide ideation,
seizures, neuroleptic malignant syndrome, hallucinations,
headache, dizziness, extrapyramidal symptoms, tardive
dyskinesia, dystonic reactions
CV:
- transient hypertension, hypotension, supraventricular

tachycardia, bradycardia
GI:
- nausea, bowel disorders, diarrhea

GU:
- urinary frequency, incontinence
Hematologic:
- neutropenia, agrnulocytosis
Skin:
- rash, urticaria
Other:
- prolactin secretion, loss of libido
Nursing 1. Monitor bowl sounds

Repsonsibilities: 2. Do not use drug for more than two weeks
3. Assess patient’s psychologicall history and present status
prior to administration of drug
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4. Check for history of depression and other CNS diseases and

hypertension
5. Check for hypersensitivity
6. Watch out for adverse effects, use dyphenhydramine to
counteract EPS
7. Monitor VS and I & O periodically during therapy
8. Tell patient to avoid activities that require alertness for 2
hours after doses
9. Assist patient with ADL
10. Instruct patient to report any signs of adverse reactions
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NURSING THEORIES
Virginia Henderson:
Her famous definition of nursing was one of the first statements clearly
delineating nursing from medicine: "The unique function of the nurse is to assist the
individual, sick or well, in the performance of those activities contributing to health or its
recovery (or to peaceful death) that he would perform unaided if he had the necessary
strength, will or knowledge. And to do this in such a way as to help him gain
independence as rapidly as possible" (Henderson, 1966, p. 15). She was one of the first
nurses to point out that nursing does not consist of merely following physician's orders.
Henderson defined nursing in terms of the function of the nurse, to wit: “the unuique
function of the nurse is to assist the individual, sick, or well, in the performance of those
acitivites contributing to health of its recovery (or to peaceful death) that he would
perform unaided if he had the necessary strength, will, or knowledge and to do this in
sucha way as to help him gain independence as rapidly as possible” (Harmer and
Henderson, 1995)
Henderson believed nursing as primarily complementing the patient by supplying

what he needs in knowledge, will or strength to perform his daily activities and to carry
ot the treatment prescribed to perform his daily activities and to carry out the treatment
prescribed for him by the physician. She strongly believed in “getting inside the skin” of
her patients in order to know what he or she needs. The nurse should be the substitute
for the patient, helper to the patient and partner with the patient. Her contribution to the
nursing profession is the identification of the fourteen basic human needs upon which
nursing care is based.
Hendersons’s fourteen basic human needs include:

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1.) Breath normally
2.) Eat and drink adequately
3.) Eliminate body wastes
4.) Move and maintain desirable postures
5.) Sleep and rest
6.) Select suitable clothes; dress and undress
7.) Maintain body temperature within a norma range by adjustin clothing and
modifying the environment
8.) Keep the body clean and well groomed and protect the integument
9.) Avoid danger in the environment and avoid injuring others
10.) Communicate with others in expressin emotion, need, fears, or opinions
11.) Worship according to one’s faith
12.) Work in such way that there is a sense of accomplishment
13.) Play or participate in various forms of recreation
14.) Learn, discover, or satisfy the curiosity tht leads to noram development and
health and use the available health facilities
Henderson supported emphatic understanding and believes the nurse must “get
inside the skin of each patient in order to know what he needs”. She believes that
nurses work interdependently with other members of the healthcare team and not
just with the members of the medical profession.
In relation to the patient:

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In relation to the patient’s case, the theory can be applied through doing bedside care.
The student nurses had actions towards the fulfillment of the fourteen basic needs
which according to Virginia Henderson is the basis of nursing care.
To comply with the fourteen basic human needs, the student nurses, first, provided
proper ventilation so it wouldn’t be a hindrance for normal breathing. A healthy diet was
promoted, a diet appropriate for the client’s condition which also included eating and
drinking only the right amount. Elimination was promoted through encouraging the
patient to include in the diet food and drinks high in fiber to allow release of body
wastes. Movement was encouraged through passive activities and exercises that will
not exert too much effort or stress to the patient, activities only limited to his capabilities.
Rest and sleep was promoted through providing comfort to the patient by providing an
environment he is comfortable. Suitable clothing was maintained through allowing the
patient wear clothes that would promote comfort and ease to his condition. Body
temperature was monitored every 4 hours. Clean body and protected integument was
promoted through health teachings regarding hygiene and skin care. Communication
need was satisfied through verbalization of the patient and through establishing a
healthy interpersonal relationship with other people in the ward most especially the
health professionals who gave care to him. To satisfy the need of worship, the student
nurses encouraged the patient to express his spiritual goals by praying and exercise
freely religious practices. The student nurses gave their assistance in the fast recovery
of the patient.
Florence Nightingale
Nightingale’s theory emphasized greatly the role of the environment in the care of the
patiet. Environment is defined as the external conditions and influences affecting the life
and development of an organism and capable of preventing, suppressing or contributing
to disease, accidents, or deaths (Murray and Zentner, 1975). Nightingale defined and
described the concepts of ventilation, warmth, light,diet, cleanliness,and noise, all of
which are important components of the environment. Nightingale believed that disease
was a reparative process and that the manipulation of the patient’s surroundings-
ventilation, warmth, light, diet, cleanliness, and noise – would contribute to the
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reparative process and the health of the patient. She contributed to nursing theory by
explicating a philosophical approach to nursing with a focus on nursing and the patient-
environment relationship
Relation to the Patient:
In relation to the patient’s case, we provided good ventilation by opening the

windows to allow air circulation in the patient’s area of confinement. Light was well
provided since the patient’s bed was near the nurse station and the fluorescent light on
the area is functioning well. Cleanliness was promoted only through the bed side care
that the student nurses can provide and the utilized resources that can be found in the
hospital. Health teachings on cleanliness were also done to help the patient promote a
healthy process of wellness. Healthy diet was promoted through the health teachings.
Faye Glenn Abdellah
Faye Glenn Abdellah viewed nursing as both an art and a science that molds the
attitude, intellectual competencies and technical skills of the individual nurse into the
desire and ability to help people cope with their health needs, whether they are ill or
well. Faye Glenn Abdellah’s work is based on the problem-solving method. Problem
solving was the vehicle for delineating nursing (patient) problems as the patient moved
toward a healthy outcome. Although she believed that nursing actions were carried out
under general or specific medical direction, she formulated 21 nursing problems based
on a review of nursing research studies.. Her contribution to nursing theory
development was the systematic analysis of research reports to formulate 21 nursing
problems that served as an early guide for comprehensive nursing care. The 21 nursing
problems is as follows:
1. To maintain good hygiene and physical comfort.
2. To promote optimal activity: exercise, rest and sleep.
3. To promote safety through prevention of accident, injury or other trauma and

through the prevention of the spread of infection.
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4. To maintain good body mechanics and prevent and correct deformity.
5. To facilitate maintenance of a supply of oxygen to all body cells.
6. To facilitate maintenance of nutrition of all body cells.
7. To facilitate maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory functions
12. To identify and accept positive and negative expressions, feelings and reactions
13. To identify and accept the interrelatedness of emotions and organic illness.
14. To facilitate the maintenance of effective verbal and non-verbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional,

and developmental needs.
19. To accept the optimum possible goals in the light of limitations, physical and
emotional.
20. To use community resources as an aid in resolving problems arising from illness.
21. To understand the role of social problems as influencing factors in the cause of
illness.
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In relation to the patient:
To answer the 21 nursing problems, performing bedside care have been effective. The
ability of the student nurses to address and effectively manage the 21 nursing problems
will spell the patient’s state of health and so, it should be done properly to be able to
help in the swift recovery of the patient.
To maintain good hygiene, the client has been assisted to bathing and other
activities to maintain good hygiene. Health teachings were also given to promote
physical comfort and good hygiene. The patient has been allowed to do activities just
within his limitations. Activities like exercising were minimal and adequate hours of rest
and sleep were observed. To promote safety, side rails were raised, the patient was
assisted in ambulating. Objects around him that could cause harm were removed.
Proper precautionary measures were also taught to prevent the spread infection. The
patient was taught the good body mechanics. Adequate supply of oxygen to body cells
were done by teaching the client deep breathing exercises and administered oxygen
when needed and was put in high back rest. To facilitate nutrition of all body cells, the
patient was given meals that would satisfy his needs, a diet that would aid in his
recovery. For detoxification purposes, the patient was given food high in fiber and was
to drink fluids to allow the patient to defecate freely and eliminate toxins in the body. To
be able to facilitate the balance of fluid and electrolyte, the input and output were
recorded every four hours, to ensure that there is a well-balanced fluid status. To
recognize the response of the body to the disease, the patient was monitored for
progress or whatever unusualities. Vital signs were also monitored and recorded. To
facilitate regulatory mechanisms and functions, the patient was further observed, for his
progress and a he was also assessed physically. This is to ensure normal mechanisms
and functions. To facilitate maintenance of sensory functions, the patient was allowed to
do passive activities and exercises appropriate for him. To identify and accept positive
and negative expressions, feelings and reactions, rapport and a therapeutic nurse-
patient relationship was established. To identify and accept the interrelatedness of the.
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Nursing Care Plans

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Date/
Cues Need Nursing Diagnosis Objective Nursing Intervention Evaluation
Time
Subjective C In the span of 1. Monitor Vital Signs Goal Met
: O
G 8 hours of R- Serves as baseline Data
“Sakit kay N nursing care
na siya I 2. Allow verbalization
pag T management: Of pain After 8 hours of
malihok, I R- nursing
Sept. usahay V The client’s
15, pud mag E Acute Pain 3. Encourage diversional management,
2010 ngul ngul - related to surgical pain scale activities the pain scale
rag kalit” P incision rating will be
3-11 E secondary R- Diverts patient’s attention to rating
Shift R from 6 to 5. pain
to cholecystectomy decreased from
C
Objective: E 4. Provided comfort measures 6 to 4.
P through quite environment
Irritability T
noted U R- A peaceful environment clams
Guarding A and diverts patient’s
behavior L Attention to pain
present
Pain scale P 5. Provide rest periods to
rating of 6 A facilitate comfort sleep and
T relaxation
T
E R- Pain can be exaggerated as
R the
N result of fatigue
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6. Anticipate need for pain relief
R- Early intervention can

decrease the total amount of
analgesic required
7. Whenever possible, reassure

patient that pain is time-limited
and there are many approaches
in easing pain.
8. Notify physician if interventions

are unsuccessful or if current
complaint is a significant change
from patient’s past experience of
pain.
R- Patients who request pain

medications at more frequent
intervals than prescribed may
actually require higher doses or
more potent analysis.
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Date/
Time
C In the span of
O Knowledge deficit 8 hours of
Subjective 1. Provide physical comfort for Goal Partially
G care, the client
: N related to surgical the learner Met
will be able to:
“Wala jud, I incision R- allows patient to concentrate
T
kay dili on what is being discussed or Client was only
I
man ko V Understand demonstrated
able to
swito ana” E more about 2. Provide a quiet atmosphere
- surgical enumerate two
Sept. without interruption
P wound care in causative
15, E his own pace R- This allows patient to
2010 R concentrate more completely factors for
and level of
C cholelithiasis
3-11 understanding 3. Verify client’s knowledge about
E
P , the specific topic and three ways
Shift
T R- Provides opportunity to assure of treatment
U Enumerate at accuracy and completeness of and prevention.
A
least 3-5 knowledge base for future
L
factors that learning
P can lead to
4. Allow learner to identify what is
A Cholelithiasis;
most important to him or her
T 3-5
T ways to R- This clarifies learner
E prevent and expectations and helps the nurse
R
treat disease match the information to be
N
presented to the individual’s
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needs.
Patients may want to focus only
on self-care techniques that
facilitate discharge from the
hospital or enhance survival at
home (e.g., how to take
medications, emergency side
effects, suctioning a tracheal
tube) and are less interested in
specifics of the disease process.
5. Ascertain preferred method of
learning
R- Identifies the best approach in
facilitating the learning process
6. When presenting material,
move from familiar, simple, and
concrete information to less
familiar, complex, or more
abstract concepts
R- provides patient with the
opportunity to understand new
material in relation to familiar
material
7. Focus teaching sessions on a
single concept or idea
R- This allows the learner to
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concentrate more completely on

material being discussed. Highly
anxious and elderly patients have
reduced short-term memory and
benefit from mastery of one
concept at a time
8. Pace the instruction and keep
sessions short
R- Prevent fatigue, learning
requires energy.
9. Encourage questions
R- Learners often feel shy or
embarrassed about asking
questions and often want
permission to ask them
10. Encourage repetition of
information or new skill
R- This assists in remembering.
11. Provide positive, constructive
reinforcement of learning
R- A positive approach allows
learner to feel good about
learning accomplishments, gain
confidence, and maintain self-
esteem while correcting
mistakes. Incorporate rewards
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into the learning process

12. Document progress of
teaching and learning
R- This allows additional teaching
to be based on what the learner
has completed, thus enhancing
the learner’s self-efficacy and
encouraging most cost-effective
teaching
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Date/
Time
Risk for fluid

1. monitor and record fluid intake
N imbalance related to In the span of Goal met
and output accurately (include all
8 hours of
U cholelithiasis sources; PO, IV, liquids with After 8 hours of
care, the
mediacations)
T patient will be nursing care
able to: R- Proper monitoring of fluid management,
R Intake and output may reveal
- maintain fluid volume
significant fluid losses that may
I adequate fluid was maintained
be signs/symptoms of an
volume as
Sept. T abnormality. as evidenced
Objective: evidenced by
I moist mucous 2. Monitor Intake and output on by the intake
13,
Decreased membranes, an hourly basis in critical levels. and output
2010 O
urine good skin data.
3-11 turgor, and R- Urine output less than 500 ml
output N in 24 hours or less than 30 cc/hr
capillary refill
shift A indicates renal failure.
L 3.Monitor Vital signs
- R- Blood pressure, Heart and

respiratory rate often increase
M initially when either fluid deficit or
excess is present
E
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T 4. Weigh daily
A R- Increased weight indicates

overall fluid and nutritional status.
B
5.Note increased lethargy,
O hypotension, muscle cramping
L R- These are signs that
I electrolyte imbalances may be
present
C
6.Secure tubing connections
P longitudinally
A R- Reduces risk of disconnection

and loss of fluids
T
7. Administer IV fluids, as
T
prescribed, using infusion pumps
E to deliver fluids accurately and at
desired rates to prevent either
under/over infusion
8. Discuss individual risk factors/

potential problemsand specific
interventions.
R- Prevents/limits occurrences of
fluid deficit/excess
P a g e | 96
Date/
Time
Subjec During the 1. Assess for level of anxiety, Goal Met
S span of care verbal expression of fear and
tive: given, the reasons for it. Client felt
“Mahad E patient’s relaxed after

Sept. concerns will R- Anxiety ranges from mild to
lok ko kay Mild anxiety related to gaining
13, L severe; a moderate level of
basig be addressed
the upcoming surgery anxiety is desirable and helpful in additional
2010 F properly
maunsa coping with impending surgery.
as evidenced by information
3-11 ko ba, kay - sweaty hands. regarding the
shift wala gud
ta kabalo P 2. Assess for non-verbal operation
unsaon ko expressions of anxiety and fear
E through health
nila such as shaking, restlessness,
pagabot pallor, tense body and facial teaching
R
didto” muscles, irritability, heart
C palpitations, and dilated pupils.
E R- May not be able to

Objec communicate feelings but reveal
P physical responses.
tive:
T
-sweaty
hands I 3. Assess for perceptions of
anticipated surgery as to
O outcome, effect on life-style,
coping skills and if effective.
N
Allows for clarification of
P a g e | 97
- information and ability to cope

with crisis event.
S
E 4. Assess for responses to

L information and treatments.
F R- These may increase or

decrease anxiety.
-
C 6. Provide calm attitude of

acceptance, positive response to
O
behavior without expressing
N disappointment or anger.
C R-Provides emotional support

and enhances nurse-patient
E relationship.
P
7. Provide environment that
T
prevents anxiety-provoking
situations.
R-Decreases anxiety by avoiding

additional stimuli.
8. Provide assurance that pain

medication will be given after
surgery, and treatments will be
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provided to prevent complications

or prolonged recovery.
R- Allays anxiety about pain and

potential changes in health status
and self concept.
9. Teach about relaxation

techniques. R- reduces
anxiety.
10. Teach patient the reasons for
treatments such as enema, NPO,
N/G tube, IV, lab tests, catheter,
medications, and skin
preparation. This allows for better
acceptance of necessary but
unpleasant treatments and
procedures.
P a g e | 99
RECOMMENDATIONS
PATIENT
For our patient Peter, we advise him to practice having a healthy lifestyle.
Proper diet must be emphasized especially on the proper distribution of carbohydrates,
protein and fats. One also of the highest priority is to encourage the patient to eat
nutritious foods such as vegetables and fruits to regain strength after the operation and
continue good and healthy body. Teach also the patient on how to cope up with daily
stressors. He should continue on complying with the prescribed medications and
treatment plans instructed by the attending physician. Encourage patient to have check-
ups regularly for him to achieve a full recovery. Also, let the patient that he might not be
able to consume fatty foods. Lastly, encourage the patient to verbalize or express any
concerns and talk to health professionals.
FAMILY
We encourage the family especially the wife to give full support to the patient.
Guide patient to follow doctors order or comply with the prescribed medications,
instructions and proper diet. Ensure the patient’s safety needs and assist the patient’s
physiological and physical needs. Advise the family to take good care of their food
intake because they might have the same illness as with Peter. They must serve as role
models to the patient in practicing healthy lifestyle.
P a g e | 100
STUDENT NURSES
We, the student the nurses should be aware and give importance to the roles
we have as student nurses towards taking care of our patients. We must give full
attention even to minute details for every step is crucial and perfection in the field of
health and medicine is of great priority. Faster recovery of the patient and continual
health, growth and development lies in our hands even for a brief time of interaction with
our patients. In line with this case study, we would like to emphasize to practice
teamwork and unity among the group so that better output will be formulated. Be
sensitive and respond to the needs of other group members and if you’re done with your
task, try to help the others and contribute something that would make the work better.
Fix the problems in a peaceful manner. Follow the set schedule for this will promote
organization within the group. Be open-minded for suggestions and prevent intensive
discussions so that healthy relationship within the group will be maintained. Lastly be a
role model to the patients we take care of.
P a g e | 101
DISCHARGE PLAN
MEDICATION
a.) Instruct the patient to continue taking the prescribed medications for the full
course of the therapy even if he already feels better or if it is being approved by
his physician.
® To prevent the return of infection and to potentiate drug resistant strains.
b.) Instruct the patient to continue taking medications and its correct time of taking.
Also inform the client about the name of the drug, their actions, the exact dosage,
the frequency and the route of administration.
® To make patient and significant others be aware of the importance of correct

drug
Administration
c.) Explain to the patient the possible side effects of the medication being taken.
® To increase the awareness of the patient and significant others.
d.) Encourage patient to report to the physician any occurrence of side effects or
adverse effects.
® To prevent any unusualities from worsening.
e.) Instruct the patient to place medications at places that are safe, free from insects
and away from the rich of children
® To prevent contamination and accidental ingestion of medications.
EXERCISE
a.) Encourage patient to perform ROM exercises
® To promote good blood circulation
b.) Encourage patient to have enough sleep and rest

P a g e | 102
® To promote faster recovery
c.) Instruct patient that exercises performed should be within normal limits.
® To prevent fatigue and weakness
d.) Instruct patient to avoid strenuous activities such as moving or working too
much
® To prevent straining the patient
e.) Encourage client to have sufficient rest and sleep to promote relation of both
body and mind.
® To promote faster recovery for the patient
TREATMENT
a.) Encourage the patient to comply with the doctor’s order
® Compliance to doctor’s order prevents occurrence of complications and

promotes
faster recovery
b.) Discuss to the patient and significant others the dangers of non compliance to
doctor’s order
® To let the patient and significant others recognize the possible effects if
compliance to the Doctor’s order is not attained
c.) Instruct patient and significant others to do wound dressing as needed
® To decrease risk for infection
d.) If fever occurs, instruct patient’s significant other to perform tepid sponge
bath. If temperature does not lower after TSB performance, refer to health
care professionals for management
® To prevent further complication

P a g e | 103
HEALTH TEACHING
a.) Instruct the patient and his significant other to keep surgical wound clean
always
® To prevent infections to occur.
b.) Instruct patient and significant others about the importance of proper hygiene
and good grooming
® To reduce the risk for infection and promote sense of comfort
c.) Instruct patient’s significant other to report to the physician any abnormalities
® To prevent further complications
d.) Patient is advised to avoid strenuous activities until full recovery is achieved
® To prevent fatigue and further complications
e.) Instruct patient’s significant other and family to provide emotional and social
support to the patient
® Helps the patient feels better for this restores health and promotes
comfort.
OUT- PATIENT ORDERS
a.) Instruct patient and significant others to have follow-up check up.
® To evaluate health status and provide continuity of care
b.) Encourage the patient and significant others to notify the physician
immediately if any changes in the health status or if any unusualities
have occurred
P a g e | 104
® An immediate action take reduces the chances of patient’s condition

from
worsening
c.) Encourage him to comply with all the modifications and instructions
given to him.
® To promote faster recovery
DIET
a.) Instruct patient and significant other to take low residue diet
® Low residue diet aids in keeping stool soft
b.) Explain the importance of low residue diet and its benefits to the patient’s
body
® To increase the awareness of the patient and significant other of the

importance of
following the said diet
c.) Instruct patient and significant others to have small, frequent feedings
® To decrease the transit time of food through the digestive tract
d.) Instruct patient to increase fluid intake
® To keep patient well dehydrated.

P a g e | 105
PROGNOSIS
GOOD(3)
POOR(1) FAIR(2) JUSTIFICATION
P a g e | 106
TALLY: Peter’s age is 53, and he is on the

Age  stage of late adulthood. Thus, he is
more prone to diseases.
Patient’s onset of illness is gradual

because he was able to go to the
Onset of Illness  hospital for treatment. He was able
to comply all the medications that
were given.
Aside from the diagnosed disease,

Peter does not have any other
Duration of illness. Also they prefer to self-
Illness  medicate and waits until the illness
has worsen before they consult a
doctor.
Peter’s family, especially his wife is

very supportive. As what we had
observed his wife was always
Family Support  taking care of him while at the
hospital. They’ve been making
ways to help him cope up and to
return back to health.
He follows his medications. He is

also cooperative to tests that must
Willingness to
be performed. He puts effort on
follow treatment  helping himself in the process of
regimen
treatment so that he could easily
recover with his condition.
Precipitating Diet and weight gain were the only

Factors  factors present in our patient.
Predisposing Only one factor contributed to the

Factors  disease and it was Age.
P a g e | 107
Poor : (1 x 3) = 3 Fair : (2 x 4) =8 Good: (3 x 2) =6

Overall: 17/ 7 = 2.4
IMPRESSION:
Patient prognosis manifested good outcome. He is cooperative in the treatment

regimen and his family is very supportive in different aspects (like his wife who is very
caring and gives emotional support). But, they only seek for medical attention only if the
illness worsens. Since he is already 53 years old, and likes to eat very fatty foods and is
easily tempted by his neighbours in drinking alcohol, these habits of his is very
detrimental to his health. Thus he is prone to cholelithiasis.

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Page |1

Gallstones develop in the gallbladder from crystals of either cholesterol or

Cholelithiasis is a calculi, or gallstones usually form in the gallbladder from the

Gallstones develop in the gallbladder from crystals of either cholesterol or

Gallstone disease is said to be a common medical problem that affects 25 million

Cholelithiasis is responsible for nearly 800,000 hospital admissions at a cost of

 To conduct a comprehensive physical assessment using cephalocaudal

High P34,000 or more

Marginal Below P10,000

Ordinal Rank: 3rd, in the 8 children

Ward: General Surgery Ward, Bed # 13

Vital Signs upon Admission:

BP: 160/90 mmHg RR: 22 cpm

PR: 79 bpm TEMP: 37 ºC

Surgical Procedure: Cholecystectomy

Date of Operation: September 14, 2010

Source of Information: Patient himself and Patient’s wife

TITO POPSIE TITA 2

FAMILY HEALTH BACKGROUND & HEALTH HISTORY

Effects/ Expectations of Illness to Self/ Family

Developmental data contains records and analysis of an increase or stagnancy in

ERIK H. ERIKSON’S PSYCHOSOCIAL THEORY

Erikson developed eight stages of development, which encompasses the entire

Erikson envisions life as a sequence of levels of achievement. Each stage

ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY

• Achieving adult social and civic responsibility.

• Assisting teenage children to become responsible and happy adults.

• Reaching and maintaining satisfactory performance in one’s occupational career.

• Developing adult leisure time activities.

- As a family, they develop quality time together in watching television every

• Relating oneself to one’s spouse as a person.

• To accept and adjust to the physiological changes of middle age.

- He told us that it is normal for a person to undergo different changes as we

• Adjusting to aging parents.

LAWRENCE KOHLBERG’S MORAL DEVELOPMENT THEORY

The postconventional level of moral reasoning is typical of middle-age or older

People who exhibit postconventional morality view rules as useful but

an absolute way, as in the philosophy of Immanuel Kant.This involves an individual

DEFINITION OF COMPLETE DIAGNOSIS

• Presence of gallstones in the bile. Gallstones are crystalline structures formed by

(Medical-Surgical Nursing, Clinical Mangement for Positive outcomes by: Joyce

• Is gallstone formation in the gallbladder. Gallstones are composed of cholesterol,

(Medical-Surgical Nursing, a Nursing Process Approach, 3rd edition by: Long,

• Presence of stones in the bilary tract. Stones are composed largely of

(Medical-Surgical Nursing, concepts and clinical Nursing by: Phipps, Long,

• Cholelithiasis, calculi or gallstones, in the bladder usually form in the bladder

(Textbook of Medical-Surgical Nursing by: Brunner and Suddarth’s)

• Cholelithiasis is characterized by the formation of gallbladder stones in the

(Understanding Medical Surgical Nursing, third edition by:Linda Williams and

INITIAL PHYSICAL ASSESSMENT

Date and Time of Assessment: September 13, 2010 @ 10:00pm

BP: 110/80mmHg RR= 16 cycles/min

PR: 68 bpm Temp= 36.5 ºC

Chest and Lungs

Back and Extremities

FINAL PHYSICAL ASSESSMENT

Date and Time of Assessment: September 15, 2010 @ 9:00pm

BP: 120/90mmHg RR=22cycles/min

PR: 72 bpm Temp=37 ºC

Chest and Lungs

Back and Extremities

ANATOMY AND PHYSIOLOGY

Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder.