UNIVERSITY OF ILOILO

Phinma Education Network

Rizal St., Iloilo City
COLLEGE OF NURSING

WEST VISAYAS STATE UNIVERSITY-MEDICAL CENTER

(SAN LORENZO RUIZ WARD)

ACUTE CALCULOUS CHOLECYSTITIS

A Case Study

Presented to
Mr. Llue Dex Gabuelo, RN
Clinical Instructor

Presented by
BSN 3-C
Gatuteo, Joan
Genodia, Maria
Guelos, Cindy
Gonzaga, Honeylee
Hilisan, Harlyn
Indico, Rodelyn
Iwag, Erick Laine
Laguerder, Tresza Shane
Laquian, Raymun Edward
Laurino, Sandra
August 26, 2010

NURSING ASSESSMENT
I.

BIOGRAPHIC DATA
NAME: Ms. N. S.
ADDRESS: San Pedro, Jaro Iloilo City
AGE: 70 Years Old
BIRHT DATE: April 21, 1940
GENDER: Female
RELIGION: Roman Catholic
RACE: Filipino
STATUS: Single
OCCUPATION: Health Worker
SOURCE OF HEALTH FINANCING: Herself
DATE AND TIME OF ADMISSION: August 12, 2010 (7:50 PM)

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

the patient.
ADMITTING DIAGNOSIS: Choledocholithiasis Beginning Cholangitis
FINAL DIAGNOSIS: Acute Calculus Cholecystitis
II. CLINICAL ASSESSMENT

A. NURSING HISTORY
1. HISTORY OF PRESENT ILLNES
According to her since she got an illness, there is a great change in her lifestyle. She
couldnt do all her usual tasks. She experienced the symptoms 2 months ago in the middle of July.
It was sudden and often since then. She pointed out that the exact location of the pain was in the
epigastric area radiating to her lower back. Over fatigue was her primary reason of how the
problem occurred. She experienced the symptoms such as nausea, vomiting, and body malaise.
The problem aggravates during her eating time and alleviates when she takes a nap. She denies
any family members having related disease as hers.

2. PAST HISTORY OF ILLNESS

According to her, she wasnt able to complete the different immunizations offered
at her time. She already had Chicken pox; she had allergies to dust, and drugs such as
afloxacin. She had Diabetes Mellitus when she was 59 and been prescribed with
Dimetron and soon discontinued. She only managed it by having a proper diet.
Whenever she perspires, she often experience flushed skin and diminishes when
wiping it. She had suffered from minor trauma brought by a vehicular accident when she
was a child but immediately coped up.
3. FAMILY HISTORY OF ILLNESS
Her father has hypertension as well as her 2 siblings: her Mother died with
unknown cause; the uncle in her mother side also has Diabetes Mellitus. And there is no
family history of Osteoarthritis, Malignant Neoplasia and Cholecystisis.
GENOGRAM

89

87

/A

89

88

86

84

82

79

37

85

85

Legend:

72

70 ,DM
Calculous Cholecystitis

--Male

--Deceased

--Female

--Deceased

67

63

--Hypertension -- Unknown

--Alive and well

--Old Age

4. PATIENTS EXPECTATIONS
She expects to get well during her stay at the hospital; she wanted also to be
educated regarding the Dos and Donts of her disease as well as the right foods and
proper management. She said that the nursing care nowadays is better than before and her
needs are always attended.
5. PATTERNS OF FUNCTIONING
a. Breathing Pattern:
Respiratory Problems: Shortness of breath caused by her operation alleviated
when put in semi- Fowlers position.
b. Circulation: Her usual blood pressure before was 110/70 mmHg but now it
increased to 140/90 mmHg. She experienced palpitations whenever she was
surprised and she suffers mild hypertension.
c. Sleeping Pattern:
Usual Bedtime: 10:00 PM- 4:00 AM
No. of Pillows: Only one under head
Bedtime Rituals: Doing rosary or watching television at times
Problems regarding sleep: None
d. Drinking Pattern
Type of Fluid

No. of Bottles/Glasses per Day

Pattern of drinking

1. Water

8 glasses

Everyday

2. Juice

2 glasses

Weekends

2 cup

Morning, afternoon

1 Bottle

Weekends

3. Coffee
4. Soft drinks

e. Eating Pattern
Meal

Type and Amount of Food

Time

Breakfast

Oatmeal (1 bowl)

6-7 am

Morning Snacks

Skyflakes(2 pieces)

9-10am

Lunch

Rice (1/2 cup)

Vegetable (1 serve preparation)
Fish (1 serve preparation)

11-12nn

Afternoon Snacks

Skyflakes (2 pieces)

3-4 pm

Dinner

Rice (1/2 cup)

4-5pm

Grilled fish (1 piece)

Midnight Snacks

Skyflakes (1 whole pack)

10-11pm

Food Likes: Ice Cream, cake, chocolates

Food Dislikes: None

f. Elimination Pattern
1. Bowel Movement
Frequency: Once a day
Problems or Difficulties: None
Usual Remedy: N/A
2. Urination
Frequency: 5-7x/ day
Problems or Difficulties: None
Usual Remedy: N/A
g. Exercise-walking, jogging and aerobics
h. Personal Hygiene
1. BATH
Type: Full Bath
Frequency: 2x a day
Time of Day: 8-9am and 8-9pm
2. ORAL CARE
Frequency: 3x a day
Care of Dentures: Tooth Brushing
3. SHAVING: N/A
4. USE OF COSMETICS: Make-up occasionally, Pedicure

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

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

function.

B. PSYCHOSOCIAL ASSESSMENT
NAME: N. S.
CENTER

AGE: 70 YEARS OLD

DATE: 08-19-10

HOSPITAL: WEST VISAYAS STATE MEDICAL

THEORY

ERICK ERICKSON theory

of psychosocial development

SIGMUND
FREUD theory of
psychosexual
development
theory

OLD AGE / LATE ADULT

JEAN PIAGET
theory of
cognitive
development

LAWRENCE
KOHLBERG
theory of moral
development

STAGE

PSYCHOLOGICAL CRISIS:
INTEGRITY VS.
DESPAIR,DISGUST

DEFINITION As the aging process creates

physical and social looses the
adult also suffered loss status
and function such as through
retirement or illness this
external struggles met also
with internal struggles, such
as search for meaning in life.
Meeting this challenge
creates the potential for
growth and wisdom. Many
elders review their lives with
the sense of satisfaction even
with the inevitable mistakes.
Others see them selves as
failures with marked
contempt and disgust.

GENITAL
STAGE

FORMAL
OPERATIONS

POST
CONVENTION
AL

True maturity
requires the
timing of
aggressive and
sexual urges,
allowing them to
release.

The person at
this stage can
think
abstractive.

An individual
reaches this stage
acts out universal
principals based
upon equality
and worth of all.

C. CLINICAL INSPECTION
Date and Time Taken: Aug. 20, 2010 (6:00 am)
Vital Signs
T- 36.8C

RR: 17 cpm

PR- 82 bpm

BP: 140/90 mm Hg

1. Height: 411
2. Weight: 50 kg
3. Physical Assessment
A. Integumentary System
Brown complexion, uniformly warm to touch, and moist with skin turgor of
approximately 1second. No lesions noted.
B. Neurologic System
Alert, conscious and coherent. Oriented to person, place and able to recall previously
done activities.
CN I (Olfactory): intact as able to identify aroma of coffee.
CN II (Optic): intact as evidenced by ability to see and recognize nurses and folks and
able to read magazine.
CN III (Oculomotor); IV (Trochlear), VI ( Abducens): intact as evidenced by the ability
of eyes to move in a smooth, coordinated motion of six ocular movements, P E R R L A.
CN V (Trigeminal): intact as evidenced by ability to differentiate sharp and blunt points
of pencil, ability to clench teeth. Eyelids blink bilaterally.
CN VII (Facial): intact as evidenced by ability to smile, frown, wrinkles forehead, raise
eyebrows, close eyes, purses lip and puff cheeks symmetrically in symmetrical manner.
CN VIII (Auditory): intact as evidenced by the ability to hear the ticks of a wrist watch 5
inches away from the ears.

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

by side, uvula and soft palate rise bilaterally and symmetrically on phonation.
CN X (Vagus): intact as evidenced by ability to swallow foods and fluids. Gag reflex
intact.
CN XI (Spinal Accessory): intact as evidenced by ability to move head from side by side.
CN XII (Hypoglossal Nerve): intact as evidenced by ability to protrude tongue at the
midline and move from side by side in apparent strength.
C. Respiratory System
Nose at midline, both nares are patent as evidenced by ability to identify the aroma of
coffee. RR- 17cpm, regular in rate and rhythm, shallow inhalation, deep expiration. Clear
lung sounds upon auscultation of all lung fields.
D. Cardiovascular/ Circulatory System
PR- 82bpm, BP- 140/90 mmHg, capillary refill of approximately 2 seconds in upper and
lower extremities.
E. Gastrointestinal System
Lips dark red, moist; pink moist tongue; grade 1 tonsils; gag reflex present, able to
swallow foods and fluids, abdomen not tender upon palpation.
F. Hepatobiliary System
Liver not palpable.
G. Genitourinary System
With Foley catheter attached to urobag, drained at approximately 50cc/hr of light yellow
urine. Bladder not distended.
H. Reproductive System
Symmetrical breast. No lumps upon palpation and unnecessary discharge noted.
I.

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

J. Lymphatic System
Lymph nodes are not palpable.
K. Hematopoetic System
Hematology result as of 8/18/10
Hgb= 117g/L
Hct=
RBC=

D. LABORATORY FINDINGS
A. Clinical Chemistry

NAME OF
EXAMINATION

DEFINITION

PURPOSE

DATE

RESULTS

NORMAL
VALUES

SODIUM

This is the
predominant
cation in the
extracellular
fluid, including
plasma.

To assess for
level of
sodium in
relation to loss
of water.

8/12/10

142.3
mmol/L

135-148
mmol/L

This is the
predominant
cation in the
cellular fluid.

To determine
changes in
serum
concentration
of potassium
that could
produce
profound
effects on the
nerve
excitation,
muscle
contraction,
and
myocardial
potential

8/12/10

POTASSIUM

SIGNIFCANCE
OF
ABNORMAL
RESULTS

Normal

4.06
mmol/L

3.5- 5.3
mmol/L
Normal

CREATININE

8/12/10

96.3
mmol/L

53.0115.0
umol/L

CHOLESTEROL

8/13/10

5.86
mmol/L

1.3- 5.2
mmol/L

LDLCHOLESTEROL

8/13/10

4.3
mmol/L

0.0- 3.9
mol/L

REV.
TRIGLYCRIDE

8/13/10

1.27
mmol/L

0.17-1.7
mmol/L

Normal

HDLCHOLESTEROL

8/13/10

1.02
mmol/L

0.9- 1.55
mmol/L

Normal

8/13/10

7.32
mmol.L

3.9- 6.1
mml/L

GLUCOSE

This is the
principal sugar
of the body;
permits all body
water.

B. Hematology

To assess level
of glucose in
the blood
resulting from
either failure
to synthesize
or ingestion of
superfluous
quantities.

Normal

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

To serve as baseline data.

To detect any abnormalities or disease process in the body.

NAME OF EXAMINATION

RESULTS

NORMAL
VALUES

Significance

Decreased in RBC
may indicate anemia
and it may result
from decreased
production of RBC in
spleen and kidney
because of
inflammatory
response.

8/12/10

8/17/10

8/18/10

HEMOGLOBIN

131g/L

87g/L

117g/L

120160g/dL

ERYTHROCYTE

0.34L/L

0.26L/L

0.34L/L

0.370.47L/L

ERYTHROCYTE NO.
CONCENTRATION

3.811012L

2.711012L

3.631012L

4.25.41012L

LEUKOCYTE NO.
CONCENTRATION

8.51012L

10.71012L

12.61012L

4.511.010L

NEUTROPHIL No. Fraction

(SEGMENTER)

LYMPHOCYTE NUMBER
FRACTION

0.76

0.86

0.76

0.50-0.70

Increase in no.
concentration of
leukocytes indicates
inflammation.
Increased in response
to breakdown of
RBCs marginated
polymorphonuclear
neutrophils mobilize
and the sphlenic
reserve of PMNs is
exhausted.
Normal

0.24

EOSINOPHIL NUMBER
FRACTION

0.12

0.22

0.20-0.40
Normal

0.01

0.02

0.01-0.04

C. Radiological Exams
RESULTS:
Follow up study done as compared with previous study taken 5/7/10 shows normal- sized
liver with hyperechogenic parenchyma. No focal masses seen. The intrahepatic ducts are not
dilated.
The common bile duct measures 0.5 cm in its widest visualized diameter.

The gallbladder measures 7.4 x 3.8 x 3.7 cm (L x W x AP) with thickened wall measuring 0.9
cm. Multiple high intensity echoes with posterior sonic shadowing are still seen intraluminally,
the largest measuring 1.3 cm.
The pancreatic head is normal in size and parenchymal echopattern. The pancreatic body and
tail are obscured. The pancreatic duct is not dilated.
The spleen is normal in size and parenchymal echoppattern. No focal masses seen.
There is no disparity in the size of the kidneys. The right kidney measures 9.7 x 4.8 x 4.2 cm
(L x W x AP) with cortical thickness of 0.9 cm, while the left kidney measures 10.2 x 4.1 x 3.9
cm (L x W x AP) with cortical thickness of 1.0 cm. The central echo complexes are intact. The
cortico- medullary demarcations are well defined. No lithiasis seen.
The urinary bladder is well distended. Its wall is not thickened. Intraluminal echoes noted.
The uterus is atrophic measuring 3.4 x 2.9 x 2.6 cm (L x W x AP) with an endometrial stripe
thickness of 0.4 cm (previously 4.0 x 2.4 x 1.0 cm). No focal masses noted. No adnexal masses
ascites demonstrated.
Impression:
FATTY LIVER
CALCULOUS CHOLECYSTITIS
ATROPHIC UTERUS
NORMAL PANCREATIC HEAD, SPLEEN, KIDNEYS AND URINARY BLADDER
ULTRASONOGRAPHICALLY

D. Other Special Exams

a. Chest X-ray
RESULT:
Poor inspiratory film shows crowding of the pulmonary vascular markings.
The trache is deviated to the right due to positional obliquity
The heart appears enlarged with CT-ratio of 0.56.
The aorta is atherosclerotic.
The costophrenic sulci are intact
The hemidiaphragms are elevated
The rest of the findings are unremarkable
IMPRESSION:
CARDIOMEGALY.
ATHEROSCLEROTIC AORTA.
FOLLOW-UP WITH BETTER INSPIRATORY EFFORT
SUGGESTED FOR FURTHER EVALUATION.

b. Urinalysis
PHYSICAL PROPERTIES:
Color: Straw
Transparency: hazy

MICROSCOPIC FINDINGS:
Pus Cells: 2-4/hpf
Red blood cells: 14-16/hpf

Reaction: Acidic (6.5)

Specific Gravity: 1.010

CHEMICALS TESTS

Cast:
Hyaline:
Fine granular:
Coarse granula:/lpf
Crystals
Amorphous: Many urates

Sugar:
Albumin:
Ketone:
Others:

Negative

Squamous Epithelial Cells: few

Round Epithelial Cells: few
Mucus Threads:

c. ECG
Interpretation: Sinus Bradycardia

III. DRUG STUDY

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4
Chief Complaints: persistent epigastric pain

Patients Name: Ms. N.S.

Age: 70y.o.

DRUGS

CLASSIFICATION/
MECHANISM OF ACTION
Classification:

Generic:
Ranitidine
Brand:
Zantac
Dosage: 50
mg
Route:
IVTT
Frequency:
q 8H
Timing: 10
AM 6 PM
2AM

Histamine 2 antagonist
Competitively inhibits the
action of histamine at the H2
receptors of the parietal cells f
the stomach, inhibiting basal
gastric
acid secretion and gastric acid
secretion that is stimulated by
food,
insulin, histamine, cholinergic
agonist, gastrin, and
pentagastrin.

INDICATION
Post surgery antacid to
prevent ulcer formation

CONTRAINDICATION
Hypersensitivity to
ranitidine, lactation.

Impression/ Diagnosis: Acute Calculous Cholecystitis

Attending Physician: Dr. T

SIDE EFFECTS/ ADVERSE

REACTION

SPECIAL PRECAUTION/ NURSING

RESPONSIBILITY

Side Effects: headache, rash,

dizziness, vertigo, constipation,
diarrhea, nausea, vomiting, abdominal
discomforts, local burning or itching
at IV site

1. Assess patient for contraindication.

2. Assess for baseline data.
3. Tell patient that he may experience
side effects brought about by the drug.
4. Instruct patient to take his meal if
nausea or vomiting occurs.
5. Oral care if vomiting occurs.

Adverse Effects: malaise, insomnia,

somnolence, urticaria, tachycardia,

6. Adjust lighting and temperature and

avoid noise if he experiences headache
and instruct him to report if it is
intolerable so that medication may be
given.

bradycardia,
leukopenia,
pancytopenia,
thrombocytopenia,
gynecomastia, impotence, hepatitis

7. Instruct him to report intolerable side

effects so as prompt
intervention could be done.
8. Instruct him to report adverse effects
that he may experience.

Patients Name:
Age: 70 y.o.

Ms. N. S.

DRUGS

CLASSIFICATION/
MECHANISM OF
ACTION

Generic:

Classification: HMGCoA reductase inhibitor,

antihyperlipemic

Simvastatin (synvinolin)
Brand:
Lipex, Zoc
Dosage: 20 mg 1 tab
Route: PO

Inhibits HMG-CoA
reductase. This enzymeis
early (and rate limiting)
step in synthetic pathway
of cholesterol. Lowers
LDL and total cholesterol
level.

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4
Impression/ Diagnosis: Acute Calculous Cholecystitis
Chief Complaints: persistent epigastric pain
Attending Physician: Dr. T.
CONTRAINDICATION

INDICATION

To reduce total
cholesterol and LDL in
patients with homozygous
familial
hypercholesterolemia.

Hypersensitivity to
simvastatin and in those
with active liver disease or
conditions that have
unexplained persistent
elevations of transaminase
levels.

Frequency: OD @ HS

SIDE EFFECTS/ ADVERSE

REACTION

CNS: Headache
Asthenia

GI: Abdominal pain,

constipation, diarrhea,
dyspepsia, flatulence, nausea.

Respiratory: Upper Respiratory

Tract infection.

Timing: 6 PM

University of Iloilo
Phinma Education Network

SPECIAL PRECAUTION/
NURSING RESPONSIBILITY

1. Assess patients history of

LDL and total cholesterol
levels.
2. Monitor patient for myalgia
and for elevated CK level
during treatment.
Rhabdomyolysiswith and
without acute renal
sufficiency has been reported.
3. Assess patients dietary fat
intake
4. Give drug with evening meal
for enhanced effectiveness,
5. Teach patient dietary
management of
lipids(restricting total fat and
cholesterol intake) and
measures to control other
cardiac disease risk factors.

Patients Name:
Age: 70 y.o.

DRUGS

Ms. N. S.

CLASSIFICATION/
MECHANISM OF ACTION

COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4
Chief Complaints: persistent epigastric pain

INDICATION

Impression/ Diagnosis: Acute Calculous Cholecystitis

Attending Physician:Dr. T.

CONTRAINDICATION

SIDE EFFECTS/
ADVERSE REACTION

Hypersensitivity to
omeprazole.

CNS: Headache,
dizziness

SPECIAL PRECAUTION/ NURSING

RESPONSIBILITY

Generic:
Omeprazole
Brand:
Losec,
Prilosec, Risek
Dosage: 40 mg
1cap
Route: PO
Frequency: OD
Timing: 6 AM

Classification: Proton Pump

Inhibitor
Inhibits acid (proton) Pump
and binds to hydrogenpotassium adenosine
triphosphate on secretory
surface of gastric parietal cells
to block formation of gastric
acid. Relives symptoms
caused by excessive gastric
acid.

Gastric Ulcer.

GI: diarrhea, abdominal

pain, nausea, vomiting,
constipation, flatulence.

MUSKULOSKELETAL:
backpain
RESPIRATORY: cough
SKIN rash

1. Assess contraindication.
2. Lower doses that arent needed for patients
with renal or hepatic impairment.
3. Advise OTC drug isnt intended for
immediate relief of heartburn or to treat
infrequent heartburn
4. Warn patient not to crush or chew tablets
or capsules.
5. Inform patients wthat the OTC drug may
require 1-4 days for full effect, although
some patients may get complete reliefof
symptoms within 24 hours.

Patients Name:
.

Ms. N. S.

CLASSIFICATION/
MECHANISM OF ACTION

DRUGS
Generic:
Metformin hydrochloride
Brand: Glucophage
Dosage: 500 mg/tab
Route: PO
Frequency: bid PC
Timing: 8 AM 6PM

Age:

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4

70 y.o.

Classification: Antidiabetic
agents
Exact mechanism is not
understood; possibly increases
peripheral utilization of
glucose, increase production
of insulin, decreases hepatic
glucose production and alters
intestinal absorption of
glucose.

Impression/ Diagnosis:Acute Calculous Cholecystitis

INDICATION

CONTRAINDICATION

Adjunct to diet to
lower blood
glucose with noninsulin dependent
diabetes mellitus
(type 2) in patient
less than or equal:;
extended released
in patient less than
17 years old.

Allergy to metformin; CHF;

diabetes complicated with
fever,severe infections, severe
trauma, major surgery, ketosis,
acidosis, coma (use insulin); type 1
or juvenile diabetes, serious hepatic
impairement, serious renal
impairement, uremia, thyroid or
endocrine impairement, glycosuria,
hyperglycemia associated with
primary rernal disease; labor and
delivery- if metformin is used
during pregnancy, discontinue drug
atleast 1month before delivery;
lactation, safety not established.

Chief Complaints: persistent epigastric pain

SIDE EFFECTS/
ADVERSE
REACTION

SPECIAL PRECAUTION/ NURSING

RESPONSIBILITY

ENDOCRINE:
hypoglycemia,
lactate acidosis

Monitor urine or serum glucose levels

frequently to determine effectiveness of drug
and dosage

GI: anorexia,
nausea, vomiting,
epigastric
discomfort,
heartburn, diarrhea

Arrange for transfer to insulin therapy during

period of high stress

Hypersensitivity:
allergic skin
reactions

Report fever, sore throat, unusual bleeding or

bruising, rash, dark urine, light colored stools,
1
or hyperglycemia or hypoglycemia reactions

Use IV glucose if severe hypoglycemia as a

result of overdose

Attending Physician:Dr. T.

Patients Name: Ms. N. S.

Chief Complaints: persistent epigastric pain
DRUGS
Gneric: losartan
potassium
Brand: Cozaar
Dosage: 50 mg
/tab
Route: PO
Frequency: OD

CLASSIFICATION/ MECHANISM
OF ACTION
Classification:
Selectively blocks the binding of
angiotensin II to specific tissue
receptors, found in the vascular
smooth muscle and adrenal glands;
this action blocks the
vasoconstriction effect of the renninangiotensin system as well as the
release of aldosterone leaading to
decreased BP

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4
Attending Physician:Dr. T.

Impression/ Diagnosis:Acute Calculous Age:

Cholecystitis

INDICATION

CONTRAINDICATION

Treatment of
hypertension, alone or in
combination with other
anti hypertensive agent

Contraindicated with
hypersensitivity with to
losartan, pregnancy, lactation
use .

Treatment of diabetic
neuropathy with an
elevated serum createnine
and proteinuria in patient
with type 2 diabetes and a
history of hypertension.

Cautiously with lepatic or

renal dysfunction,
hypovolemia

Timing: 6 AM

University of Iloilo

SIDE EFFECTS/
ADVERSE
REACTION
CNS: dizziness,
headache, syncope
GI: diarrhea,
abdominal pain,
nausea
RESP: URI
symptoms, cough,

70 y.o.

SPECIAL PRECAUTION/
NURSING RESPONSIBILITY
Alert surgeon and marks patient
chart with notice that losartan is
being taken. The blockage of the
renin-angiotensin system
following surgery can produce
problems. Hypotension maybe
reversed with volume expansion.
Monitor patient closely in any
situation that may lead to a
decrease in BP secondary to
reduction in fluid volumeexcessive respiration,
dehydration, vomiting, diarrheaexcessive hypotension can occur.

aPhinma Education Network

COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
DRUGS

CLASSIFICATION/ MECHANISM OF
ACTION

INDICATION

CONTRAINDICATION

SIDE EFFECTS/
ADVERSE REACTION

SPECIAL
PRECAUTION/
NURSING
RESPONSIBILITY

Generic:
celecoxib

NSAIDs, analgesic (non narcotic), specific

COX-2 enzyme blocker

Acute and long-term

treatment of signs
and symptoms of
rheumatoid arthritis
and orteoarthritis.

Contraindicated with allergies to

sulfonamides, celecoxib,
NSAIDs or aspirin; significant
renal impairement; pregnancy,
lactation.

CNS: headache, dizziness,

somnolence, insomnia,

Administer drug with food

or after meals if GI upset
occur.

Management of
acute pain.

Use cautiously with impaired

hearing, hepatic and cardio
vascular condition.

GI: dyspepsia, abdominal

pain, flatulence.

Brand:
Celebrex
Dosage:
200mg /tab
Route: PO

Analgesic and anti-inflammatory activities

related to inhibition of the COX-2 enzyme,
which is activated in inflammation to cause
the signs and symptoms associated with
inflammation; does not affect the COX-1
enzyme, which protect the lining of the GI
tract and has blood clotting and renal
function.

Frequency:
t.i.d

DERMATOLOGIC:rush,
pruritus, sweating

OTHER: anaphylactoid
reactions to anaphylactic
shock

Provide further comfort

measure to reduce pain,
and to reduce
inflammation.
Report sore throat, fever,
rush, itching, weight gain,
swelling in ankles and
fingers: changes in vision.

Timing:

Patients Name:
.

Ms. N. S.

Ward/ Bed No. FSSW4

University of Iloilo

Impression/ Diagnosis:Acute Calculous Cholecystitis

Patients Name: Ms. N. S.

Age:
70 y.o.

Phinma Education Network

COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4
Chief Complaints: persistent epigastric pain

Impression/ Diagnosis:Acute Calculous Cholecystitis

Attending Physician:Dr. T.

DRUGS

CLASSIFICATION/ MECHANISM
OF ACTION

INDICATION

CONTRAINDICATION

SIDE EFFECTS/
ADVERSE REACTION

SPECIAL PRECAUTION/
NURSING
RESPONSIBILITY

Generic:

Natural opium alkaloid with agonist of

by binding with the same receptors as
endogenous opioid peptides. Narcotic
agonist effects of identified with
different locations of receptors:
analgesia at supraspinal level, euphoria,
respiratory depression and physical
dependence; analgesia at spinal level,
sedation and myosis; and dysphoric,
hallucinogenic

Relief of moderate to
severe acute and chronic
pain.

Hypersensitiviy to
Narcotics; diarrhea
caused by poisoning until
toxins are eliminated;
during labor or delivery
or premature infant; after
billiary tract surgery or
following surgical
anastomosis; pregnan cy;
labor.

CNS: dizziness,
headache, somnolence,
nightmares

Assess patients pain before

starting therapy

Morphine sulfate
Brand: Estramorp,
Avinza,
Classification:
Narcotic agonist
analgesic

CV: hypotension,
flushing, bradycardia
cardiac arrest
GI: nausea and vomiting,
constipation

Dosage: 0.015%, 10
cc

Hematologic:
Thrombocytopenia

Route: via epidural

catheter

Respiratory: Respiratoty
depression

Frequency: q 12 H

Skin: Pruritus

Timing: 8 8

Physical dependence

May mask or worsen

gallbladder pain
Monitor for respiratory
depressioncheck RR for 3060 mins.
Be alert for adverse reactions
Instruct not to use alcohol
during therapy

Patients Name: Ms. N.S.

Age:
70

DRUGS
Generic:
Tramadol
HCl
Brand:
Ultram
Dosage:
50mg q 8h
Route: IVTT
Frequency:
BID
Timing: 8`8

CLASSIFICATION/
MECHANISM OF
ACTION
Classification:
Analgesic, centrally acting
Binds to mu-opioid
receptors and inhibits the
reuptake of norepinephrine
and serotonin; causes many
effects similar to opioids
dizziness, somnolence,
nausea, constipation but
does not have the
respiratory effects.

University of Iloilo
Phinma Education Network
COLLEGE OF NURSING
Rizal Street, Iloilo City
DRUG STUDY
Ward/ Bed No. FSSW4
Chief Complaints: persistent epigastric pain

INDICATION

CONTRAINDICATION

Relief of moderate to
moderately severe pain; post
surgery analgesia

Hypersensitivity to
tramadol or opioids or
acute intoxication with
alcohol, opioids, or
psychoactive drugs

Impression/ Diagnosis: Acute Calculous Cholecystitis

Attending Physician: Dr. T

SIDE EFFECTS/
ADVERSE REACTION

SPECIAL PRECAUTION/
NURSING RESPONSIBILITY

Side Effects:

1. Assess for contraindications.

2. Assess for baseline data.
3. Tell patient that he may
experience side effects brought
upon by the drug.
4. Instruct him to report side
effects that are intolerable.
5. Control environment
(temperature, lighting) if
sweating or CNS effects occur.
6. Encouraged small frequent
meals if vomiting occurs.
7. Oral care for dry mouth and
vomiting.
8. Encourage him to increase
oral fluid intake

Nausea, constipation,
dizziness, headache,
drowsiness,
vomiting, somnolence,
sedation, headache, dry
mouth, sweating,
diarrhea, rash, visual
disturbances, vertigo

Adverse Effects:
Confusion, anxiety,
seizure, tachycardia,
bradycardia, pallor,
anaphylactoid reactions

9. Instruct patient to report

adverse effects that he may
experience.

IV. TEXTBOOK DISCUSSION

1. Definition:
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining.
There are two types of cholecystitis, Calculous and Acalculous Cholecystitis. We are focused
to Acute Calculous Cholecystitis, in which a gallbladder stone obstruct the bile outflow. Bile
remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the
blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene
of the gallbladder may result. Bacteria play a minor role in acute cholecystitis.
Anatomy and Physiology
Gallbladder, a muscular organ that serves as a reservoir for bile, is usually present in most
vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the right lobe
of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and 2.5 cm (1
in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body
(corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The
wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge
of the liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a
middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous
membrane coat (tunica mucosa) The function of the gallbladder is to store bile, secreted by the
liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the
digestive process.
The gallbladder, when functioning normally, empties through the biliary ducts into the
duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and
emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes
called lipases. The purpose of bile is to; help the lipases to work, by emulsifying fat into smaller
droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins:
Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes cholesterol and bilirubin.

2. Signs and Symptoms

Intense and sudden pain in the upper right part of the abdomen
Recurrent painful attacks for several hours after meals
Pain (often worse with deep breaths, and extending to the lower part of the right shoulder blade)
Nausea andvomiting
Rigid abdominal muscles on right side
Slight fever
Jaundice - yellowing of the skin and eyes
Loose, light-colored bowel movements
Abdominal bloating.
4. Management
A. Medical Management
1. Intake and Output
I&O measurement provide another means of assessing fluid balance. This data provide
insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. This
measurement is not that accurate as body weight, however, because of relative risk of errors in
recording.
2. Electrocardiogram
The ECG is an essential tool in evaluating cardiac rhythm. Electrocardiography detects
and amplifies the very small electrical potential changes between different points on the surface
of the body as a myocardial cell depolarize and repolarize, causing the heart to contract.
3. Intravenous Rehydration
When the fluid loss is severe or life threatening, intravenous (IV) fluids are used for
replacement.
4. Cholecystectomy
Removal of the gallbladder. This procedure may be performed to treat chronic or acute
cholecystitis, with or without cholelithiasis, to remove a malignancy or to remove polyps.
5. Cholecystotomy
the establishment of an opening into the gallbladder to allow drainage of the organ and removal
of stones. A tube is then placed in the gallbladder to established external drainage. This is
performed when the patient cannot tolerate cholecystectomy.
6. Choledochoscopy
the insertion of a choledochoscope into the common bile duct in order to directly
visualize stones and facilitate their extraction.
B. Nursing Management
1. Pain Management
ACTIONS / INTERVENTIONS

RATIONALE

1. Observe and document location, severity (010

scale), and character of pain (e.g., steady,
intermittent, colicky).

->assists in differentiating cause of pain and

provides information about disease
progression/resolution, development of
complications, and effectiveness of interventions

2. Note response to medication, and report to

physician if pain is not being relieved.

->severe pain not relieved by routine measures

may indicate developing complications/need for
further intervention

3. Promote bed rest, allowing patient to assume

position of comfort.

->bed rest in low-Fowlers position reduces

intraabdominal pressure; however, patient will
naturally assume least painful pos

4. Use soft/cotton linens; calamine lotion, oil

->reduces irritation/dryness of the skin and

(Alpha-Keri) bath; cool/moist compresses as

indicated

itching sensation

5. Control environmental temperature.

->cool surroundings aid in minimizing dermal

discomfort

6. Encourage use of relaxation techniques,

e.g.,guided imagery, visualization, deep-breathing
exercises. Provide diversional activities.
7. Make time to listen to and maintain frequent
contact with patient.

->promotes rest, redirects attention, may

enhance coping
->helpful in alleviating anxiety and refocusing
attention, which can relieve pain

2. Maintain Adequate Fluid Balance

ACTIONS / INTERVENTIONS

RATIONALE

1. Maintain accurate I&O, noting output less than

intake, increased urine specific gravity. Assess
skin/mucous membranes, peripheral pulses, and
capillary refill.
2. Monitor for signs/symptoms of
increased/continued nausea or vomiting,abdominal
cramps, weakness, twitching, seizures, irregular
heart rate, paresthesia, hypoactive or absent bowel
sounds, depressed respirations.
3. Eliminate noxious sights/smells from
environment.

->provides information about fluid

status/circulating volume and replacement
needs

4. Perform frequent oral hygiene with alcohol-free

mouthwash; apply lubricants

->decreases dryness of oral mucous membranes;

reduces risk of oral bleeding

5. Assess for unusual bleeding, e.g., oozing from

injection sites, epistaxis, bleeding gums,
ecchymosis, petechiae, and hematemesis/melena.

->prothrombin is reduced and coagulation time

prolonged when bile flow is obstructed,
increasing risk of bleeding/hemorrhage

->prolonged vomiting, gastric aspiration, and

restricted oral intake can lead to deficits in
sodium, potassium, and chloride
->reduces stimulation of vomiting cen

3. Teaching the Disease Process

ACTIONS / INTERVENTIONS

RATIONALE

1. Provide explanations of/reasons for test

procedures and preparation needed.

->information can decrease anxiety, thereby

reducing sympathetic stimulation

2. Review disease process/prognosis. Discuss

hospitalization and prospective treatment as
indicated. Encourage questions, expression of
concern.

->provides knowledge base from which patient can

make informed choices. Effective
communication and support at this time can
diminish anxiety and promote healing

3. Review drug regimen, possible side effects.

->Gallstones often recur, necessitating long-term

therapy.
->obesity is a risk factor associated with
cholecystitis, and weight loss is beneficial in
medical management of chronic condition

4. Discuss weight reduction programs if indicate

5. Instruct patient to avoid food/fluids high in fats

(e.g., whole milk, ice cream, butter, fried foods,

->prevents/limits recurrence of gallbladder

nuts, gravies, pork), gas producers (e.g., cabbage,

beans, onions, carbonated beverages), or gastric
irritants (e.g., spicy foods, caffeine, citrus).
6. Review signs/symptoms requiring medical
intervention, e.g., recurrent fever; persistent
nausea/vomiting, or pain; jaundice of skin , itching;
dark urine; clay-colored stools; blood in urine,
stools; vomitus; or bleeding from mucous
membranes.

attacks

7. Recommend resting in semi-Fowlers position

after meals.
8. Suggest patient limit gum chewing, sucking on
straw/hard candy, or smoking.

->promotes flow of bile and general relaxation

during initial digestive process.
->promotes gas formation, which can increase
gastric distension/discomfort

9. Discuss avoidance of aspirin-containing

products,
forceful blowing of nose, straining for bowel
movement, contact sports. Recommend use of soft
toothbrush, electric razor.

->reduces risk of bleeding related to changes in

coagulation time, mucosal irritation, and trauma

->indicative of progression of disease

process/development of complications requiring
further evaluation

V. PROBLEM LIST
1. Ineffective breathing pattern related to pain of the operation site as evidenced by respiratory
depth changes, holding breath and reluctance to cough.
2. Acute Pain related to inflammation and distortion of tissues
3. Knowledge deficit regarding condition, treatment, and self-care related to lack of knowledge
4. Risk for fluid volume deficit related to nausea and vomiting.

VI. NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

OUTCOME CRITERIA

INTERVENTIONS

S: Nabudlayan ako
maginhawa kay kasakit sa
akon nga inoperahan, daw
utod bala haw,as
verbalized by patient.

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

After 3 hours of nursing

interventions, patient will
be able to establish
effective breathing pattern.

Independent

O: RR=10cpm shallow in
inhalation and deep in
exhalation.

V/S taken as follows:

T: 36.9C
PR: 86bpm
RR: 10cpm
BP: 130/70 mmHg

>Observe respiratory depth/

rate.

>Auscultate breath sounds.

>Assist patient to turn,

cough, and deep breathe
periodically. Show patient
how to splint incision.
Instruct in effective
breathing techniques.
>Elevate head of bed;
maintain lo-Fowlers
position. Support abdomen
when coughing and
ambulating.
Collaborative:
>Administer analgesics
before breathing treatments/
therapeutic activities.

fgh

RATIONALE

EVALUATION
Goal met:

>Shallow breathing, splinting

with respirations, holding
breath may result in
hypoventilation/ atelectasis.
>Areas of decreased or absent
breath sounds suggest
atelectasis, whereas
adventitious sounds reflect
congestion.
>Promotes ventilation of all
lung segments and
mobilization and
expectoration of secretions.
>facilitates lung expansion.
Splinting provides incisional
support/ decrease muscle
tension to promote
cooperation with therapeutic
regimen.
>Facilitates more effective
coughing, deep breathing, and
activity.

After 3 hours of nursing

interventions, patient was
able to establish effective
breathing pattern.

ASSESSMENT

S: Masakit ang
tiyan ko, as
verbalized by the
patient. Pain scale
rated as 7/10
O: Grimaced face
With guarding
behavior
Restlessness
Rigidity of the
abdomen
Splinted
respiration with
short and shallow
breathing
V/s
taken as
follows:
BP:
130/90mmHg
T: 36.7C
PR: 89bpm
RR: 32cpm

NURSING
DIAGNOSIS

SCIENTIFIC
BACKGROUND

OUTCOME
CRITERIA

INTERVENTIONS

RATIONALE

EVALUATION

Acute Pain related

to

Characterized by
its intensity,
location and
duration. It is
initiated by
stimulation of
nociceptors in the
peripheral nervous
system, or by
damage to or
malfunction of the
peripheral or
central
nervous systems.

After 8 hours of
rendering proper
nursing intervention,
the client will
verbalize pain scale
rated from 7/10 to
4/10.

1. V/s taken and recorded

Serve as baseline data

2. Observe and document

location, severity
and character of
pain.

Assists in differentiating
cause of pain and provides
information about
disease progression/ resolution,
development of complications
and effectiveness of
interventions.

Goal met:
The patient
verbalized pain
scale
rated to 4/10.

3. Administer analgesic as
prescribed

To relieve the pain

inflammation
and
distortion of
tissues

4. Promote bedrest,
allowing patient to
assume position of
comfort.
5. Encourage use of
relaxation techniques
such as deep breathing
exercises.
6. Provide diversional
activities such as watching
television.

Bedrest in Fowlers position

reduces intraabdominal pressures;
however, patient will naturally
assume least painful position.
Promotes rest, redirects
attention, may enhance coping.

Helpful in alleviating
anxiety and
refocusing
attention, which
can relieve pain.

ASSESSMENT

NURSING DIAGNOSIS

OUTCOME CRITERIA INTERVENTIONS

S: Ano ni akon sakit

man? Ano ang dapat
ko himuon para
malikawan ang mga
komplikasyon? as
verbalized by the
patient.

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

After 8 hours of nursing

interventions, patient
will be able to verbalize
understanding of the
disease process,
treatment and able to
initiate necessary
lifestyle changes and
participate in treatment
regimen.

O: K,eep on asking,
Inapparopriate
behavior, statement of
misconception

V/S taken as follows:

T: 36.7C
PR: 85bpm
RR: 16 cpm
BP: 140/80 mmHg

RATIONALE

Independent

Goal met.

>Review disease process.

Encourage questions and
expressions of concern.

>Provides knowledge base on

which patient can make informed
choice.

>Review drug regimen, possible

side effects

>Gallstones often recur,

necessitating long-term therapy.

>Instruct patient to avoid foods or

fluids high in fats.

>Prevents/limits recurrence of
gallbladder attacks.

>Review signs and symptoms

requiring medical intervention.

>Indicative of progression of
disease process/ development of
complications requiring further
intervention.

>Recommend resting in semiFowlers position after meals

>Promotes flow of bile and general

relaxation during initial digestive
process.

>Suggest patient to limit gum

chewing, sucking on straw/ hard
candy, or smoking.
>Discuss avoidance of aspirincontaining products, forceful
blowing of nose, straining of bowel
movement, contact sports.
Recommend use of soft toothbrush,
electric razor.

EVALUATION

>Promotes gas formation, which

can increase gastric
distention/discomfort.
>Reduce risk of bleeding related to
changes in coagulation time,
mucosal irritation and trauma.

After 8 hours of
nursing
interventions,
patient was able to
verbalize
understanding of the
disease process,
treatment and able
to initiate necessary
lifestyle changes
and participate in
treatment regimen.

ASSESSMENT

NURSING
DIAGNOSIS

SCIENTIFIC
BACKGROUND

OUTCOME
CRITERIA

INTERVENTIONS

RATIONALE

EVALUATION

S: Ginasuka
ko ang akun
nga gina kaun, as
verbalized by
the patient.

O:
240 mL
vomitus.
Pallor,
Skin turgorgreater than
3sec.,
Dry skin.

Risk for fluid

volume deficit
related to
nausea and
vomiting.

Nausea and vomiting

are not diseases, but
rather are symptoms
of many different
conditions, such as
infection, food
poisoning, motion
sickness, overeating,
blocked intestine,
illness, concussion,
or brain injury,
appendicitis, and
migraines. Nausea
and vomiting can
sometimes be
symptoms of more
serious diseases such
as heart attacks,
kidney or liver
disorders, central
nervous system
disorders, brain
tumors, and some
forms of cancer.

After 8H of nursing
interventions,
patient will
demonstrate
adequate fluid
balance as
evidenced by stable
vital signs, moist
mucous
membranes, good
skin turgor, and
absence of
vomiting.

INDEPENDENT
-Maintain accurate I and O, noting output
less than intake, increased urine specific
gravity. Assess skin/ mucous membranes,
peripheral pulses, and capillary refill.
-Monitor for s/sx of increased/continued
n/d normal value, abdominal cramps,
weakness, twitching, seizures, irregular
heart rate, paresthesia, hypoactive/absent
bowel sounds, depressed respirations.
-Eliminate noxious sights/smell from
environment.
COLLABORATIVE:
-Administer antiemetics, e.g.
prochloperazine (Compazine.)

-Provides info about fluid

status/ circulating volume
and replacement needs.
-Prolonged vomiting, gastric
aspiration, and restricted oral
intake can lead to deficits in
sodium, potassium and
chloride.

-Reduces stimulation of
vomiting center.
-Decreases GI secretions and
motility.Reduces nausea and
prevents vomiting.

-Review lab studies, e.g. Hgb/Hct;

electrolytes; ABGs( pH;) Clotting times.

-Aids in evaluating
circulating volume, identify
deficits, and influences
choice of intervention for
replacement/correction.

-Administer IV fluids, electrolytes, and

vit. K.

-Maintains circulating
volume and corrects
imbalances.

After 8H of nursing
interventions, patient
will demonstrate
adequate fluid
balance as evidenced
by stable vital signs,
moist mucous
membranes, good
skin turgor, and
absence of vomiting.

VII. DISCHARGE PLAN

Discharging N. S.,70y/o, female, RC; with working diagnosis of Acute Calculous Cholecystitis;
under the service of Dr. T; with the following discharge criteria:
1.
2.
3.
4.
5.
6.

Within normal range.

Intravenous solution discontinued and pulled out.
Pulled out Epidural Catheter.
Signs and symptoms of Acute Calculous Cholecystitis, not manifested.
With 100% appetite.
Patients significant others will be able to understand discharge instruction well.

EXERCISE OR ABILITIES:

Gradual increase in activities to bring back energy level.

HEALTH TEACHINGS:
Two major steps on preventing the illness:
1. Foods rich in saturated fats.
- These foods might initiate the reformation of stone for those who suffered already from
this illness.
2. Patient is encouraged to seek for medical advice if she experiences again the signs and
-

symptoms of the illness.

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

Sources:
Brunner and Suddarths. Medical and Surgical Nursing 12th ed. Lippincott Williams
and Wilkins. New York.2008

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