I.

INTRODUCTION

A. Overview of the care

Acute cholecystitis is the sudden onset of inflammation of the gallbladder, a small

pear-shaped organ in the upper right area of the abdomen, resulting in severe,

steady upper abdominal pain (biliary colic), which may occur repeatedly. The

gallbladder holds bile produced by the liver. The bile is released into the small

intestine where it aids in digestion, especially the absorption of fats. If the

gallbladder is removed,that function is performed directly by the liver.

At least 95% of people with acute cholecystitis have gallstones. The inflammation

almost always begins without infection, although infection may follow later.

Rarely, acute cholecystitis occurs in a person without gallstones (acalculous

cholecystitis). Acalculous cholecystitis is a serious disease. It tends to occur after

major injuries, operations, burns, bodywide infections (sepsis), and critical

illnesses—particularly in people receiving prolonged intravenous feedings. It can

occur in young children as well, perhaps originating as an infection (viral or

other).

In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder.

Severe illness, alcohol abuse and, rarely, tumors of the gallbladder may also

cause cholecystitis.

1
B. Objective of the study

The aim of this study is to help and give much information for the patient’s

condition and providing also comfort while the patient is not well and not on right

condition and helps the patient while having some discomfort in his recovery from

the surgery of her gallbladder. Having this information and reference can help

other students having the same case.

All the given care to the patient while she is admitted in the female

surgical ward is reflected in this study in the one week rotation at Northern

Mindanao Medical Center. This could be a guide and helps to improve skills in

handling patient having the same case of acute cholecystitis. It helps also to be a

reference for more studies to come.

C. Scope and limitation of the Study

This study focuses on determining the main concern or problems of

the patient that impedes their progress towards the improvement of health

condition. This care study covers the assessment from January 13, 14 and 15 of

2008. During this short span of our Hospital exposure at medical ward through

duties at Northern Mindanao Medical Center, Cagayan de Oro City, and data

gathered through interview and observation were recorded. It mainly covers

about Anna Marie Estaňol, history of his present illness, his lifestyle, and current

condition.It is however limited only up to what it is written on the chart of the

patient and to the extent of the resources (verbal and non verbal) provided to us

by Anna Marie A. Estaňol.

2
II. HEALTH HISTORY

A. PROFILE OF THE PATIENT

Name: Anna Marie A. Estaňol Age: 26 years old

Address: Cuerdo ext.,Gingoog City, Misamis Oriental Sex: Female

Birthday: September 08, 1981 Civil Status: Single

Placed of Birth: Gingoog City, Misamis Oriental Religion: R. Catholic

Occupation: Housekeeper Nationality: Filipino

Date Admission: Jan. 10, 2008 Time: 11:00 am

Attending Physician: Dr. Wencito A. Daya

Admitting Clerk: Shiryl M. Guirra

Father’s name: Danilo Estaňol

Mother’s name: Lorena Estaňol

Height: 4’11”

Weight: 37 kgs

Blood pressure: 120/80 mmHg

Pulse rate: 98 bpm

Respiratory Rate: 20 cpm

Temperature: 37º C.

3
 B. FAMILY and PERSONAL HEALTH HISTORY

Anna Marie A. Estaňol has never undergone any major surgical operations in

the past, aside from her normal child delivery. She has not received any blood

transfusion in the past.

She also stated that she has no allergies to food and drugs

C. HISTORY OF THE PRESENT ILLNESS

1 month prior to admission. Patient noted on and off epigastric pain/ Right

Upper Quadrant pain radiating to the back, (+) nausea and vomiting persistence

of sign and symptoms.

D. CHIEF COMPLAINT

The patient was admitted due to the Chief Complaint Abdominal Pain.

III. DEVELOPMENTAL DATA

In Erik Erickson’s developmental stages, the patient, Anna Marie A.

Estaňol belong to the adulthood (25 to 65 years), in which the ego development

outcome is Generative vs. Stagnation. Each stage signals a task that must be

achieved. The resolution of the task can be complete, partial, and unsuccessful.

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.

4
Erickson viewed the developmental task as a series of crises, and successful

resolution of these crises is supportive to the person’s ego and enables the

person to function effectively in society. Erickson emphasized the people must

change and adapt their behavior to maintain control over their lives.

In Robert Havighurst Theory, It provides a framework that the nurse can

use to evaluate a person’s general accomplishments. Believed that learning is

basic to life and that people continue to learn throughout life..

In Sigmund Freud theory, the unconscious mind is the part of a person’s

mental life that the person is unaware of. The id resides in the unconscious and,

operating on the pleasure principle, seeks immediate pleasure and gratification.

The ego, operating on the reality principles, balances the gratification demands

of the id with the limitations of social and physical circumstances. The methods

the ego uses to fulfill the needs of the id in a socially acceptable manner that are

called Defense mechanism or adaptive mechanisms.

In Jean Piaget’s Theory which is the cognitive development. This refers to the

manner in which people learn to think, reason, and use language. It involves a

person’s intelligence, perceptual ability, and ability to process information. It is an

orderly, sequential process in which a variety of new experiences must exist

before intellectual abilities can develop.

5
IV. MEDICAL MANAGEMENT

A. Medical orders and rationale

1/14/08

8 pm - PRE-OP orders RATIONALE

8 pm  to OR on call  For preparation for the operation

NPO post midnight except  To remove gastric secretions

needs that stimulates release of
cholecystokinin and gallbladder
construction

IVF TF: D5LR 1L x 30gtts/min  To maintains patients fluid

balance

midozolom 15 mg ½ tab at Hs  Maintenance of anesthesia.

& ½ tab at 6 am

colecoxib 400 mg 1 cap at 6  adjunctive treatment in the

am reduction of adenomatous
colorectal polyps & relief pain
omeprazole 20 mg 1 cap w/
 treatment of active benign
sips of water
gastric ulcer
Holds lumiracoxib

Please follow-up availability of  For the preparation of the

FWB of px’s Bt, screened and x- operation, to help store loss
matched blood

Oral and Body hygiene in am  For proper body hygiene

Please prepare IVF & meds for

OR use.  To maintain fluids in the body
and Medicine for treatment.
Refer accordingly
 To check appropriate order

6
1/15/08
4:00 pm - POST-OP orders
4:00 pmStill NPO except meds
Flat on bed until 9 pm turn to
sides/ sit-up on bed w/ precaution
RATIONALE
 To remove gastric secretions
that stimulates release of
cholecystokinin and gallbladder
construction
 For the pt. to rest.

IVF: 1. D5LR 1L rates at 30  To maintain body fluid

gtts/min

2. D5LR 1L rates at 30
gtts/min

Meds

1. Cefuroxime 750 mg  Lower resp tract infections

IVTT q 6° ANST

2. Omeprazole 400 mg 1
tab OD

Cont. pain meds as

ordered by anesthesia

Refer accordingly  To ensure order

 To determine, evaluate and

For CBC in AM (5am) 1/16
diagnose pt. condition and to
visualize if there are
/08
abnormalities
Luminacoxib 400 mg 1 tab
starting tomorrow

Turn to sides/sit-up on bed w/

precaution

CBC in 5 am – 1/16/08

7
LABORATORY TESTS

Hematology report

TEST RESULT UNIT REFERENCE

8
 WBC 8.8 10^3/ul 5.0-10.0

4.27 10^6/ul 4.2-5.4

RBC
12.6 g/dl 12.0-16.0
Hemoglobin
37.5 % 37.0-47.0
Hematocrit
87.8 fL 82.0-98.0
MCV
29.5 pg 27.0-31.0
MCH
33.6 g/dl 31.5-35.0
MCHC
12.5 % 12.0-17.0
RDW-CU

PDW 12.9 fL 9.0-16.0

MPV 10.8 fL 8.0-12.0

Differential Count

Lymphocyte (%) 15.6 % 17.4-48.2

78.3 % 43.4-76.2
Neutrophil (%)
5.9 % 4.5-10.5
Monocyte (%)
0.2 % 1.0-3.0
Eosinophils (%)
0.0 % 0.0-0.2
Basophils (%)
% 1.0-2.0
Bands stabs (%)
10^3/ul
Platelet

Blood Chemistry Result

TEST RESULTS UNIT FLAG REFERENCES VALUES

9
 GLUC 88.3 mg/dL 6.0 110.0

K+ 3.1 mg/dL L 3.5 5.3

CREA 0.56 mg/dl L 0.60 1.20

NA+ 140.0 mg/dl 135..0 148.0

Urinalysis

Color: Dark yellow Date: 1-14-08

Clarity: Hazy Protiens: negative

Ph: 7.0 Glucose: negative

Specific gravity: 1.025

Sedment / Microscopic examination

Epithelial cells: moderate

Pus cells (WBC): 1-2 Mucus threads: plenty

Bacteria: plent others: amorphous

phosphate - moderate

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 B. Drug Study

Generic Date Dose/

Brand Mechanism Specific Contra- Nursing
name of Order- Classification Frequen- Side Effects
Name of Action Indication Indication Precaution
ordered drug ed cy/ Route

omeprazole Omepr 1/14/08 Antacids & 10 mg 1 Suppresses Adult: 20 Hypersen Diarrhoea, Malignancy;
one Antiulcerants tab OD gastric acid mg as a sitivity. nausea, prolonged
Risekl secretion by single daily Lactation fatigue, use; hepatic
osec specific dose or 40 constipation, impairment.
inhibition of mg in vomiting, Pregnancy,
the enzyme severe flatulence, childn,
H+/K+ ATPase cases, given arthralgia, neonates
present on for 4 wk for myalgia,
the secretory duodenal urticaria, dry
surface of the ulcer and 8 mouth,
gastric wk for dizziness,
parietal cell. gastric headache,
ulcer. paraesthesia,
Maintenanc abdominal
e: 10-20 mg colic, skin
once daily. rashes.

Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Effects Nursing

11
 name of Order- Frequen-
Name of Action Indication Indication Precaution
ordered drug ed cy/ Route

Cefuroxime Ceftin 1/15/08 Anti-infectives 750 mg binds to one Adult: 250- Hypersen Large doses Severe
IVTT or more of the 500 mg bid. sitivity to can cause renal
penicillin- Child: >3 cephalosp cerebral impairment;
binding mths: 125 orins. irritation and pregnancy,
proteins mg bid or 10 convulsions; lactation;
(PBPs) which mg/kg. nausea, hypersensiti
inhibits the vomiting, vity to
final diarrhoea, GI penicillins.
transpeptidati disturbances;
on step of erythema
peptidoglycan multiforme,
synthesis in Stevens-
bacterial cell Johnson
wall syndrome,
epidermal
necrolysis.

12
V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

Acute Cholecystitis refers to acute inflammation of the gallbladder wall. The

incidence of cholecystitis is increased in clients who are overweight, especially
those with a sedentary lifestyle

Gallstone move into liver (via Hepatic Ducts)

Obstruction of common bile duct

Icterus
jaundice Acholic stools

Primary hepotocellular disease

Hemolytic processes

Inflammation of Gallbladder

13
Acute cholecystitis is traditionally thought of as a triad of right upper quadrant

pain, fever, and leukocytosis. However, this triad is not specific and must be

accompanied by additional clinical manifestations to improve the predictive value

for diagnosing this syndrome. Many patients have nausea, vomiting, anorexia,

pain that is steady and severe, and a temporal relationship between the ingestion

of a fatty meal and the onset of pain at least an hour later. The pain persists for

longer than four hours unlike biliary colic, which typically reaches a crescendo

over several hours and then resolves completely2. Most of the time a gallstone

lodges in the cystic duct and leads to distention and inflammation of the

gallbladder. Patients with acute cholecystitis often show signs of local peritoneal

inflammation and therefore, are often very tender on examination. Obstruction of

the cystic duct occurs in both biliary colic and acute cholecystitis, but the latter

involves damage to the gallbladder from inflammatory mediators and irritants to

the mucosa. Lysolecithin and various prostaglandins are found in the bile of

patients with acute cholecystitis.

14
 VI. NURSING ASSESSMENT

NURSING SYSTEM REVIEW CHART

NAME: Ann Marie A. Estaňol DATE: January 14, 2008

Vital Signs:
HR: 98bpm RR:20cpm BP: 120/80 mmHg Temp: 37ºC Height: 4’11” Weight:37
kg

An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the
location of the problem in the figure using [X].
EENT: ________________
[ ] impaired vision [ ] blind ____________
[ ] pain redden [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf ________________
[ ] burning [ ] edema [ ] lesion teeth ____________Dry_
[ ] assess eyes ears nose _________Abdomi
[ ] throat for abnormality [ x ] no problem nal_____
RESP: Pain__________SO
[ ] asymmetric [ ] tachypnea [ ] barrel chest
[ ] apnea [ ] rales [ ] cough B__________post
[ ] bradypnea [ ] shallow [ ] rhonchi operative__
[ ] sputum [ ] diminished [ x] ]dyspneadyspnea wound dry and__
[ ] orthopnea [ ] labored [ ] wheezing intact_________Intr
[ ] pain [ ] cyanotic a venous____ Fluid
[ ] assess resp. rate, rhythm, pulse blood
[ ] breath sounds, comfort [ ]x ]nonoproblemproblem
of D5LR__ 1L @
CARDIOVASCULAR: 30 gtts/___
[ ] arrhythmia [ ]x tachycardia
] tachycardia[ []numbness
]numbness min_1-15-08___
[ ] diminished pulses [ ] edema [ ] fatigue Heplock 1-14-15
[ ] irregular [ ] bradycardia [ ] mur mur Catheter attached
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, blood to_urobag________
Pressure, circ., fluid retention, comfort ________________
[x
[ ]]no
noproblem
problem ________________
GASTROINTESTINAL TRACT: ________________
[ ] obese [ ] distention [ ] mass ________________
[ ] dyspagea [ ] rigidity [x] [ ] pain
[ ] assess abdomen, bowel habits, swallowing ________________
[ ] bowel sounds, comfort [ ]x ]nonoproblem
problem _______________E
GENITO – URINARY AND GYNE pidural_______
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding cath_____________
[ ] hematuria [ ] discharge [ ] nucturia ________________
[ ] assess urine frequency, control, color, odor, comfort
[ ] gyne bleeding [ ] discharge [x [ x ]] no
no problem
problem
________________
NEURO: ________________
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure ________________
[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors ________________
[ ] confused [ ] vision [ ] grip ________________
[ ] assess motor, function, sensation, LOC, strength
[ ] grip, gait, coordination, speech [x [ x ]] no
no problem
problem
________________
MUSCULOSKELETAL and SKIN: ________________
[ ] appliance [ ] stiffness [ ] itching [ ] petechie ________________
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling ________________
[ ] lesion [ ] poor turgor [ ] cool [ ]]wound flushed[ ] flushed ________________
[ ] atrophy [ ]x ]pain
pain[ [] ]ecchymosis
ecchymosis[ [] ]diaphoretic
diaphoretic [ ]moist
moist
[ ] assess mobility, motion gait, alignment, joint function _______
[ ] skin color, texture, turgor, integrity [ x] ]no noproblem
problem15
 SUBJECTIVE OBJECTIVE
Communication:
[] hearing loss Comments “walay problema [] glasses [] languages
[] visul changes akong pandungog ug pananaw” [] contact lens [] hearing aide
[x] denied as verbalized by the patient. R L
Pupil size: 3mm [] speech difficulties
Reaction: Pupil equally round and reactive to light and
accomodation
Oxygenation:
[x] dyspnea Comments “kung magsakit Resp. [x] regular [ ] irregular
[] smoking history akong tiyan ug likod maglisod Describe: the pt’s respiration is regular 20cpm
NONE ko ug ginhawa” as verbalized R symmetrical
[] cough the patient L symmetrical
[] denied
________________________
Circulation:
[] chest pain Comments “dili man pud ga Heart Rhythm [x] regular [] irregular
[] leg pain sakit akong lawas” as verbalized Ankle Edema ________________________
[]numbness of by the patient
extremities Pulse Car. Rad. DP. FEM*
[x]denied R + 98bpm + Not Obtain
L + 98bpm + Not Obtain
Comments right and left pulse are palpable

*if applicable
Nutrition:
Diet : low fat diet [] dentures [x] none
[] N [] V Comments “wala man pud
Character problema sa akong pagkaon” Full Partial W/ Patient
[] recent change in as verbalized by the patient
weight, appetite Upper [] [] []
[] swallowing
difficulty Lower [] [] []
[x] denied
Elimination: Comments: “mayayo man Bowel sounds __aud____
Usual bowel pattern [] urinary frequency Pud akong pagkalibang ug
once a day 3 times a day Pagpangihi, wala man Abdominal distention
[] constipation [] urgency Problema” as verbalized Present [] yes [] no
remedy [] dysuria By the patient Urine* (color,
[] hematuria ___________________ consistency, odor)
Date of Last BM [] incontinence ____________________ dark yellow
January 12, 2008 [] polyuria ____________________ no foley bag catheter in
[x] Diarrhea [] foley in place ____________________ place
character [x] denied *if they are in place?
watery brown
MGT. of Health & Illness:
[] alcohol [x] denied Briefly describe the patient’s ability to follow treatments (diet,
(amount, frequency) meds, etc.) for chronic health problems (if present).
“dili man ko ga inom” as verbalized by the
patient_____________________________ The pt was follows her regular diet and follow to take her
[] SBE Last Pap Smear December 31, 2006 medicine.
LMP: 1-12-07______________________

SUBJECTIVE OBJECTIVE
Skin Integrity:
[x] dry Comments: “wala man pud ko [x] dry [] cold [] pale
[] itching nag katol2x sa akong panit” as [] flushed [] warm
[] other verbalized by the patients [] moist [] cyanotic
[] denied *rashes, ulcers, decubitus (describe size, location, drainage)
no rashes, ulcerations, lesions, pigmentation seen.
Activity/Safety:
[] convulsion Comments “ga lisod ko ug lakaw []16
LOC and orientation the patient is oriented to the place,
[] dizziness pagkahuman nako gi operahan, date and time
[] limited motion sakit man gud mo lakaw” as Gait: [] walker [] cane [] other
Of joints verbalized by the pt
 SPECIAL PATIENT INFORMATION

37kg Daily weight N/A PT/OT N/A

120’80 BP q shift dark yellow Urine test 1-14-08

Date ordered Diagnostic/lab. Date done Date ordered I.V. Date Disc.
exam Fluids/BLood

1-14-08 URINALYSIS 1-14-08 1-14-08 D5LR 1L 1-14-08

1-10-08 BLOOD 1-10-08 1-15-08 D5LR 1L 1-15-08

CHEMISTRY

1-10-08 HEMATOLOGY 1-10-08

VII. NURSING MANAGEMENT

IDEAL NURSING MANAGEMENT

NURSING DIAGNOSIS: Ineffective breathing pattern related to pain

ACTIONS/INTERVENTIONS RATIONALE

INDEPENDENT:
Observe Respiratory rate depth Shallow breathing, splinting with
respiration. Holding breath may result in
hypoventilation.

Auscultate Breath sounds Areas of decreased/absent breath

sounds suggest ateleitosis.

Assist client to turn cough, and deep Promotes ventilation of all lung segment
breathe periodically and mobilization and expectoration of
secretion

Elevate Head of Bed Facilitates lung expansion

17
Dependent:
Administer Analgesic regularly/ Facilitates more effective coughing,
continuously. deep breath and activity

ACTUAL NURSING CARE PLAN

S- “Kung mag sakit akong kilid, mag lisud ko pag-ginhawa” as verbalized by the
patient.

O- The patient experienced shortness of breath every time she experiences

pain in her Gastro-Intestinal Tract

P- LONG TERM
At the end of 30 mins, the client will establish a normal/effective
respiratory pattern
SHORT TERM
At the end of 15 mins, the client will attain towards the desired outcome

I- INDEPENDENT

1. Observe Respiratory rate depth

Shallow breathing, splinting with respiration. Holding breath
may result in hypoventilation.
2. Auscultate Breath sounds

18
 Areas of decreased/absent breath sounds suggest
ateleitosis
3. Assist client to turn cough, and deep breathe periodically
Promotes ventilation of all lung segment and mobilization
and expectoration of secretion
4. Elevate Head of Bed
Facilitates lung expansion
DEPENDENT
1. Administer Analgesic regularly/ continuously.
Facilitates more effective coughing, deep breath and activity

E- At the end of 15 mins, the client was able to attained the desired goals

VIII. REFERRAL & FOLLOW-UP

For the health problems, Ms Anna Marie A. Estaňol, who has Acute
Cholecystitis, should be referred accordingly to any hospital institution. Patient
should report to any of health worker if he felt any unusualities in his body or
report to the physician immediately.

The patient is required to have a follow-up check-up after being

discharged from the hospital. In order to check the patient health status.

HEALTH TEACHING

Medication

The patient is ordered to take her medication appropriately. These are the
medications that was prescribed and ordered by the physician. Never take
unprescribed drug to avoid any complications in the patient’s diagnoses.

Exercise

19
The patient is required to take daily exercise in order to promote health.
Those exercises that the patient can perform, follow the physicians order
about the pt. exercise.

Treatment

The patient is advised to follow the physician with its ordered treatment.
Encourage the pt, not to take high fat food, smoking, and alcohol. It may
worsen her illness.

Out Patient (Check-up)

The patient is ordered to maintain check up to her physician. The physician

had already set the date when the pt. will return at the hospital for follow-up
check-up. This is to check the condition of the pt. in regards t her illness.

Diet

The patient is encouraged to eat foods that are rich in nutrients and avoid
food/fluid, high in fats. this helps the condition of the patient to maintain its
good health and also t maintain its normal body weight.

20
 IX. EVALUATION AND IMPLICATION

This study will serve as a reference material in rendering competent care

to my patient especially those with similar condition. Through this, I will be able to

develop my knowledge as well as my skills and attitudes in applying the

prescribed procedure to improve the health status of the patient.

This study will act as a baseline data as well as guide for coming up with a

good, reliable, accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting. This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases.

The case study paved the way for the researcher to identify and determine

issues related to Acute Cholecystitis. Through this, the importance of following

21
treatment regimen must be exercised to prevent complications. This study

provided the researchers with essential information on disease prevention, health

promotion, and health maintenance.

X. DOCUMENTATION

A. EVIDENCE OF CARE

Anna Marie A. Estaňol

22
 Regulating the patient’s D5LR 1L at 30 gtts/min

C. BIBLIOGRAPHY

WEBSITES

http://;ama-amaassn.org/caj/content/fuls/289/1/124

http://www.nlm.hih.gov/medlineplus/ency/article/000264.htm

http://brighamrad.harvard.edu/Cases/bwh/hcache/96/full.html

http://www.umm.edu/ency/article/000264.htm

BOOK REFERENCES

Doenges, et al., Nursing Care Plan: individualizing client care across the Life
span,7th edition

23
Kozier, et al., Fundamentals of Nursing: concept. Process & practice.7th
edition

Deglin, Vallerand. Drug Guide for Nurses. 10th editon

.MIMS. 107th edition

24