1

INTRODUCTION
Calculi, or gallstones, usually form in the solid constituent 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, especially in women. The incidence of cholelithiasis increases after the age of 40 years, affecting 30% to 40% of the population by the age of 80 years. There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigments stones probably form when unconjugated pigments in the bile precipitate to form stones. The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment stones can not be dissolved and must be removed surgically. Two to three times more women than men develop cholesterol stones and gallbladder disease; affected women are usually older than 40 years of age, multiparous, and obese. The incidence of stone formation is grater among people who use medications are known to increase biliary cholesterol saturation. The incidence of stone formation increases with age as a result of increased hepatic secretion of cholesterol and decreased bile acid synthesis. The incidence also increases in people with diabetes. Gallstones may be silent producing no pain and only mild gastrointestinal symptoms. Such stones may be detected incidentally during surgery of evaluation for unrelated problems. The patient with gallbladder disease resulting from gallstones may develop two types of symptoms: those due to the disease of the gallbladder itself and those due to obstruction of the bile passages by a gallstone. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distension, and vague pain in the right upper quadrant of the abdomen, may occur. This distress may follow a meal rich in fried or fatty foods. Standard treatment of acute cholelithiasis is to begin intravenous fluids, antibiotics, pain medication, and to consider immediate surgery during the same hospitalization. Inflammation, edema, and adhesions around the gallbladder increase the likelihood of requiring a cholecystectomy (removal of the gallbladder). However, dramatic changes have occurred in the surgical management of gallbladder disease. There is now widespread use of laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). This procedure requires general anesthesia and decompression of the stomach and urinary bladder with a nasogastric and Foley catheter. Three additional trocars are placed under direct vision one just inferior to the xiphoid (10 mm), and two in the right abdomen (5mm). Grasping instruments are used to retract the gallbladder superiorly and to the right to expose the

triangle of Calot through which the cystic duct and artery are identified, clipped, and divided. In contrast, an open cholecystectomy is performed through a right vertical midline incision of 12 to 20 cm. Under direct vision, the connections between gallbladder, cystic duct, and the common bile duct are identified and separated. As a result, surgical risks have decreased, along recovery period required after standard surgical cholecystectomy. As with any surgery, there are certain risks, which may include excessive bleeding or blood clots, difficulty with anesthesia, or infection. As a preventive measure, the surgeon may administer antibiotics through I.V. After surgery, most patients will spend several hours recovering at the hospital and then be released either the same day or the next day, barring complications. Once the anesthesia has worn off, the patient may be asked to walk around to help prevent blood clots. The patient may be given a liquid diet for a few hours after surgery, but in most cases, the patient may return to a regular diet the next day and to the regular routine within a few days. The diet required immediately after an episode is usually limited to low-fat liquids. These can include powdered supplements high in protein and carbohydrate stirred into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be tolerated. The patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the patient that fatty foods may bring on an episode of cholecystitis. Dietary management may be the major mode of therapy in patients who have had only dietary intolerance to fatty foods and vague gastrointestinal symptoms. The Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (chenodiol or CDCA) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Patient with significant, frequent symptoms; cystic duct occlusion; or pigment stones are not candidates for this therapy. Laparoscopic or open cholecystectomy is more appropriate for symptomatic patients with acceptable operative risk.

THEORETICAL FRAMEWORK

Virginia Henderson has been called the First Lady of Nursing and the First Truly International Nurse. Hendersons metaparadigm viewed person as a patient. She stated that the person is an individual who requires assistance to achieve health and independence or in some cases, a peaceful death. Then she viewed health as a quality of life and is very basic for a person to function fully. As a vital need, health requires independence and interdependence heath is a multi factor phenomenon. It is influenced by both internal and external factors which play independent and interdependent roles in achieving health. It is important for a healthy individual to control the environment, but as illness occurs, this ability is diminished or affected. She stated that, in caring for the sick, it is the responsibility of the nurse to help the patient manage her surroundings to protect from harm or any mechanical injury. And she viewed nursing that function independently from the physician, but they must promote the treatment plan prescribed by the physician. The theory involved in Virginia Henderson is the 14 Basic Needs that conceptualizes the 14 fundamental needs of humans. These needs are: 1. 2. 3. 4. 5. 6. 7. Breathing normally Eating and drinking adequately Eliminating body wastes Moving and maintaining a desirable position Sleeping and resting Selecting suitable clothes Maintaining normal body temperature by adjusting clothing and modifying the environment 8. Keeping the body clean and well groomed to promote integument (skin) 9. Avoiding dangers in the environment and avoiding injury to others 10. Communication with others in expressing emotions, needs, fears or opinions 11. Worshiping according to ones faith 12. Working in such a way that one feel a sense of accomplishment 13. Playing or participating in various forms of recreation 14. Learning, discovering or satisfying the curiosity that leads to normal development and health, and using available health facilities

We decided to apply in our case the theory of Virgina Henderson, 14 basic needs because it comprises the needs of our client that a health care provider must be

knowledgeable and must have the ability to assess in order to meet the needs of our client. The needs and the interventions that we implement are as follows: In order to breathe normally, postoperatively we encourage our client to do some deep breathing exercises to promote lung expansion. We also encourage our client to eat nutritious food like vegetables and avoid foods that rich in fats and sodium, we also encourage her to drink plenty of water that may help her in eliminating body wastes and to prevent having constipation. After her operation, we encourage to move and to maintain desirable position in a well- ventilated room and can maintain her body temperature in order for her to rest comfortably, also we encourage her to early ambulate to promote circulation and keep her body clean especially in the operative site to prevent having infection. And then during stress periods, it is important for her to express her emotions, fear and needs by communicating with others or by participating in various forms of recreation especially with our God Almighty to enlighten her mind.

GENERAL INFORMATION

I.

BIOGRAPHIC DATA Name: Mrs. N.D.C. Case no: 87381 Address: # 1508 Pastol Muzon San Jose Del Monte Bulacan Age: 58 years old Birthday: December 25, 1957 Birthplace: Manila Sex: Female Marital Status: Married Occupation: House wife Religion: Catholic

II.

PRESENTING PROBLEM Chief Complaint: Abdominal pain Date Admitted: September 10, 2010 Time: 5:25 pm Department: P2 (Sta. Cecilla) Attending Physician: Dra. C.L. Admitting Diagnosis: to consider Peptic Ulcer Disease, Gallstone Symptomatic Admitting Vital Signs: BP: 120/70 mmHg RR: 22 cpm CR: 87 bpm T: 36C Date Handled: September 13, 2010 and September 14, 2010 Date Discharge: September 14, 2010 Time: 3:30 pm Final Diagnosis: Gallstone S/P Cholecystectomy S/P Laparoscopic Cholecystectomy, Multiple Duodenal Ulcers

III.

HISTORY OF PRESENT ILLNESS Mrs. N.D.C stated that she experienced bloatedness two weeks before she had check up. Then she experienced frequent burping and hyperacidity with or without meal. Last August 13, 2010, she decided to have a consultation in Mendoza Hospital and ultrasound was done. The physician suggested an operation but Mrs. N.D.C refused it because she preferred to have a home medication. One day prior to admission, Mrs. N.D.C experienced severe right upper abdominal pain with scale of 8/10 in the afternoon while watching television and her daughter decided to brought her to NCHF at around 5 pm and Dra. C.L. advised her to be confined for further evaluation. RECORD OF OPERATION

IV.

Name: N.D.C. Age: 58 years old Date: September 11, 2010 Operation proposed: Esophago Gastro Duodenoscopy Surgeon: Dra. C.L Preoperative diagnosis: T/C Peptic ulcer disease Operative Name: N.D.C. Diagnosis: Multiple Duodenal Ulcers Age: 58 years old FinalOperation Performed: S/P cholescystectomy S/P Lap cholecystectomy, Multiple Diagnosis: Gallstone EGD with Biopsy Anesthesiologist: Dr. L.T Duodenal Ulcer Premedication: Remarks: Improved Dipenhydramide 50 mg IV Anesthetic: Demerol .5 Time Began: 1:20 pm Room Bed No: Sta Cecilia mg IV Midazolam 2mg IV Time Operation: 1:23 pm Hospital No: 87381 Technique: IV Sedation Time Operation ended: 1:28 pm Surgeon: Dr: F.D. First Assistant: Dr. A.D. Date of Operation: September 11, 2010 Time started: 5:55 pm Anesthesiology: Dr. J.D Time finished: 7:35 pm Anesthetic agent: Propofol 100 mg Succinylcholine 90 mg Detailed technique: General Intubation Anesthesia Pre-operative Diagnosis: Cholecystolithiasis Post-operative Diagnosis: Cholecystolithiasis Material Forwarded to laboratory for examination: Gallbladder Operation Performed: Lap Cholecystectomy S/P EGD Description of operation: Patient supine under general anesthesia Asepsis and antisepsis Sterile drapes in place 10mm umbilical incision carried down to peritoneum Left and right anchoring sutures applied at fascia 10 mm blunt trochar inserted, abdomen in sulfated with CO2 at 14 mm pressure at high flow rate 10 mm, zero degrees laparoscope inserted, abdomen inspected, no bleeding, no injuries to bowel/ vessel noted Skin crease incision done in epigastric, right midclavicular and right anterior axillary 10mm, 5mm, 5mm trochars inserted at epigastric, right midclavicular, right anterior axillary respectively under direct vision Intra operative findings: calcolous cholecystitis Gall bladder fundus retracted inferiorly and laterally Hart mans pouch retracted inferiorly and laterally Common bile duct and cystic artery identified; dissected, doubly clip proximally and singly clip distally using titanium clips and divided Gall bladder separated from liver bed using electrocautery with no spillage Gall bladder extracted from umbilical part Hemostasis, suction, irrigation done Titanium clips inspected, liver bed, no bile leak, no injury to visceral organs noted Trochars removed under direct vision Abdomen desufflated Trochar sites closed using chromic 0 at fascia in figure of eight manner, vicryl 4/0 subcuticularly at skin

V.

PAST HEALTH HISTORY

Childhood Illness: Mrs. N.D.C. had a measles when she was 7 years old and chicken pox when she was 10 years old. Childhood Immunization: Mrs. N.D.C.was fully immunized. Allergies: Mrs. N.D.C. has allergies in seafoods and chicken. Accidents and Injuries: Mrs. N.D.C. has no history of any accidents and injuries. Hospitalization for Illness: Mrs. N.D.C. had been hospitalized due to Premature Rupture of Membrane and she was undergone with cesarean section. Obstetrics history: G3P3 (3004) Mrs. N.D.C. was 22 years of age when she got pregnant to her first baby, and was delivered NSD at the house by a midwife. Then after two years she had her twin delivery in her second delivery that was delivered NSD by a midwife. When she was 26 years of age, she delivered on a cesarean section because of Premature Rupture of Membrane in Malolos Provincial Hospital. VI. FAMILY HISTORY OF ILLNESS Disease 1. 2. 3. 4. 5. 6. 7. 8. Hypertension Diabetes mellitus Cancer Heart Disease Obesity Hepatitis Kidney Disease Chronic Lung Disease 9. Other Disease Paternal Maternal -

VII.

LIFESTYLE Diet: Mrs. N.D.C. usually eats 5 times a day and she drinks 4 glasses of water a day. She is the one who is preparing for their foods. And she usually cooks meat and fish.

Personal Habit: Mrs. N.D.C. loves to drink coffee. She usually takes 4 glasses of coffee a day. Rest and Sleep pattern: Mrs. N.D.C. goes to bed at around 11:00 pm and she wakes up at around 6:00 am. She had difficulties in initiating and maintaining sleep because she cannot sleep when the time she lies on bed. According to her it takes 2 to 3 hours before she attain to sleep. Recreation and Activities: Mrs. N.D.C. has a small poultry in their backyard. Taking care and feeding of her hens and gardening is a form of her recreation. And also watching T.V. is a form of her relaxation. VIII. SOCIAL DATA Family Relationship: Mrs. N.D.C. lives with her husband. She has intact relationship with her family. Ethnic Affiliations: Mrs. N.D.C. doesnt believe in any Faith healing or rituals, whenever she got sick she will consult to a doctor. Educational Attainment: Primary: Rizal Elementary School (1965) Secondary: Rizal National High School (1969) Tertiary: La Salle-Araneta University (1978) (Bachelor of Education Major in Physical Education) Occupational History: Mrs. N.DC. is a P.E. and Filipino teacher since 1979 in Meycauayan College. She also becomes a P.E. coordinator in Meycauayan College. She retired last 2006. Economic Status: Mrs. N.D.C. is financially stable. Her husband is the one who is providing for their needs. IX. PHYSIOLOGIC DATA Major Stressors: Mrs. N.D.C. had no particular major stressor at this time. Usual Coping Pattern: She is always praying to God for their guidance and safety. Communication Style: Mrs. N.D.C. talks in a clear and good manner.

ACTIVITIES OF DAILY LIVING

Activities
Nutrition

Pre-confinement
(September 9, 2010)

Intra-confinement
(September 10-11, 2010)

Post-Confinement
(September 20, 2010)

Mrs. N.D.C. usually eats Mrs. N.D.C had Nothing Mrs. N.D.C. had low

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meat and fish and drinks 4 glasses of water a day. She eat breakfast at around 7:00 am, lunch at 12:00 noon and dinner at 8:00 pm.

Per Orem before and after operation. After 18 hours on the NPO diet, she had her soft diet at around 1:30 in the afternoon which include lugaw, oatmeal, soft bread, and skyflakes.

sodium low fat diet. She doesnt drink coffee and carbonated drinks anymore; instead she drinks 6-8 glasses of water a day. She ate fresh fruits and vegetables. Mrs. N.D.C had already adjusted for her regular pattern of defecation since the operation had been done.

Bowel Elimination

Mrs. N.D.C. has a During hospital stays Mrs. regular pattern of N.D.C defecate two times. defecation at least once a day and she immediately responds to her urge to defecate.

Urination

According to Mrs. N.D.C, Mrs. N.D.C. urinates 7 Mrs. N.D.C. urinates 6 she usually urinates 6 times a day during in the times a day with times a day. hospital. yellowish color of urine. Mrs. N.D.C usually takes Sponge bath is a form of Mrs. N.D.C. takes a a bath once a day and her hygiene. bath in the morning. usually in the afternoon. She brush her teeth She brush her teeth every after meal. every after meal. Mrs. N.D.C. has no particular means of exercise. Taking care of her plants and feeding her hens is a form of her routine exercise. Mrs. N.D.C. was advised Mrs. N.D.C. had a to sit and walk around simple exercise in the after 12 hours of morning like walking operation. and stretching.

Hygiene

Exercise

PHYSICAL ASSESSMENT
A. General Appearance
Area Findings Normal Values Remarks

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Height

52 feet

4-6 ft or 129-182 cm (Basic Nutrition of Filipinos By Claudio and Dirige) 97.5-122 lbs. (Basic Nutrition of Filipinos By Claudio and Dirige) Relaxed, erect, posture; coordinated movement. (Fundamentals of Nursing by Kozier and Erbs 8th Edition pg. 572) Neat and clean (Fundamentals of Nursing by Kozier and Erbs 8th Edition pg. 572)

Normal

Weight

135 lbs

Not normal due to sedentary life style

Posture/gait

Stand erect, with coordinated movements

Normal

Personal Hygiene

Neat and clean

Normal

B. Physiologic Cues
Vital Signs Normal findings Actual findings Interpretation

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Temperature

Axillary: 36.5C to 37.4C Reference: Kozier and Erbs Fundamental of Nursing 8th edition

37.4C

Normal

Cardiac rate

60-100bpm Reference: Kozier and Erbs Fundamental of Nursing 8th edition

85 bpm

Normal

Respiratory rate

12-20 cpm Reference: : Kozier and Erbs Fundamental of Nursing 8th edition

15 cpm

Normal

Blood pressure

100-130/60-80 mmHg Reference: Kozier and Erbs Fundamental of Nursing 8th edition

120/70 mmHg

Normal

HEAD-TO-TOE ASSESSMENT
Area Normal findings Actual Findings Interpretation

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Head Skull Size, shape and symmetry

INSPECTION Rounded (Normocephalic and symmetric with frontal Reference: Health assessment in nursing 3rd edition. PALPATION Smooth, uniform, consistency, absence of nodules or masses Reference: Health assessment in nursing 3rd edition. INSPECTION Evenly distributed hair, thick, silky, resilient, no infection or infestation Reference: Health assessment in nursing 3rd edition. INSPECTION Symmetrical facial movement Reference: Health assessment in nursing 3rd edition.

Rounded, smooth, skull contour

Normal

Nodules, masses and depressions

Smooth, uniform, consistency, absence of nodules or masses

Normal

Scalp and Hair

Evenly distributed hair, no presence of infection

Normal

Symmetry of facial movement

Symmetric facial movements

Normal

Eyes Eyebrows (Hair Distribution, alignment, skin quality and movements)

INSPECTION Equally distributed, curled, slightly outward Reference: Health assessment in nursing 3rd edition. INSPECTION Skin intact; no discharge; no

Equally distributed hair and eyelashes are slightly curled outside

Normal

Eyelids

No discharge, skin intact, no discoloration

Normal

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discoloration; lids closes symmetrically Reference: Health assessment in nursing 3rd edition. Cornea INSPECTION Transparent, shiny and smooth, details of iris are visible Reference: Health assessment in nursing 3rd edition. INSPECTION Black in color, equal in size, round, smooth, border and reactive to light Reference: Health assessment in nursing 3rd edition. INSPECTION Transparent, capillary sometimes evident; sclera appears white (Yellowish in dark skin clients) Reference: Health assessment in nursing INSPECTION Shiny, smooth, and pick or slightly red in color Reference: Health assessment in nursing 3rd edition. INSPECTION Color same as facial skin, mobile, firm, no tender Transparent, shiny and smooth details of iris are visible Normal

Pupils

Equal in size, black in color and reactive to light

Normal

Bulbar conjunctiva

Sclera appears white

Normal

Palpebral Conjunctiva

Slightly red in color and shiny

Normal

Ears Auricles

Color same as facial skin

Normal

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Nose

INSPECTION Symmetric and straight, no discharge or flaring, uniform color, air moves freely as the client breaths to the nares Reference: Health assessment in nursing 3rd edition.

Symmetric and straight, no discharge uniform in color, air moves freely as the client breaths to the nares

Normal

Mouth Teeth and gums

INSPECTION 32 adult teeth, smooth, white, shiny tooth enamel, pink gums moist, firm texture to gums Reference: Health assessment in nursing 3rd edition.

Upon inspection there were two upper canine, two incisors and one molar. While on the lower part there were four molars, two canine and two incisors.

Normal .

Tongue

Inspection Central Position, pink in color, raved papillae, moves freely; no tenderness Reference: Health assessment in nursing 3rd edition.

Central position, pink color moves freely

Normal

Neck

Inspection, Palpation Muscle equal in size, Head center coordinated, smooth movement Reference: Kozier and Erbs Fundamentals of Nursing 8th Edition

Muscle equal in size, with smooth movement

Normal

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Thorax

Inspection, Palpation Percussion, Auscultation Skin intact, uniform in color, no tenderness, no lesions, quite rhythmic and effortless respiration Reference: Kozier and Erbs Fundamentals of Nursing 8th Edition

Quite rhythmic and effortless respiration

Normal

Heart

Auscultation Normal heart beat is 60-100 bpm. Reference: Kozier and Erbs Fundamentals of Nursing 8th Edition

85 bpm

Normal

Abdomen

Inspection, Auscultation Unblemished skin, uniform in color, flat, rounded, audible bowel sounds, no tenderness Reference: Kozier and Erbs Fundamentals of Nursing 8th Edition

Upon inspection there are four incision sites. One in the umbilical area, two in the right upper quadrant and one in the right lower quadrant. Dressing is dry and intact. There is also a presence of cesarean section scar. Upon auscultation there are three borbourygmic sounds per minute.

Normal

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Upper Extremities Muscle Strength and tone

Inspection, Palpation Normally firm, equal strength in each body size Reference: Kozier and Erbs Fundamentals of Nursing 8th Edition

Firm, uniform in color, equal strength on each body sides

Normal

Joint Range of Skin motion

Lower Extremities muscle strength and tone Nails

Joint Range of Motion

Smooth coordinated Joints move smoothly, INSPECTION movements and joints no tenderness Inspection reveals No prominent moves smoothly evenly colored skin discoloration, light Reference: Kozier and tone without unusual or brown in color, no Erbs Fundamentals of prominent edema Nursing 8th Edition discoloration. No edema. Reference: Health assessment in nursing Inspection, Palpation Muscle strength and 3rd edition. Normally firm, equal tone are normally firm strength in each body and equal size INSPECTION Reference: Kozier and Pink tones should be Nail bed is vascular, Erbs seen. Some Fundamentals of pink in color, no Nursing 8th ridging is Edition longitudinal curvature normal. Dark-skinned client may have Joint moves smoothly, Joints move smoothly, freckles or pigmented no swelling, nails. no tenderness streaks in their no tenderness Reference: Health Reference: Kozier and assessment in nursing Erbs Fundamentals of 3rd edition. Nursing 8th Edition

Normal Normal

Normal

Normal

Normal

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ANATOMY AND PHYSIOLOGY

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The gastrointestinal tract is a long pathway that extends from the mouth to the esophagus, stomach, small and large intestines and rectum, to the terminal structure, the anus. Mouth is responsible for the intake of food. It is lined by stratified squamuos oral mucosa with keratin covering those areas subjects to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping action of the teeth. The tongue, a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialized sensors known as papillae. Esophagus is located in the mediastinum anterior to the spine and posterior to the trachea and heart. This hollow muscular tube passes through the diaphragm at an opening called the diaphragmatic hiatus. Stomach is situated in the left upper portion of the abdomen under the left bone of the liver and the diaphragm overlying mast of the pancreas. A hollow muscular organ with a capacity of approximately 1500 ml the stomach stores food during eating, secretes, digestive fluids and propels the partially digested food into the small intestine. 1. 2. 3. 4.
5.

The function of the stomach includes: The short- term storage of ingested food. Mechanical breakdown of food by churning and mixing motions. Chemical digestion of proteins by acids and enzymes. Stomach acid kills bugs and germs. Some absorption of substances such as alcohol.

Liver often start in hepato- or hepatic from the Greek word for liver, hpar (). Four pounds of highly efficient chemical-processing tissues, the liver is the largest solid organ in the body. You can locate it by placing your left hand over your right, lowermost ribs; your hand then just about covers the area of the liver. More than any other organ, the liver enables our bodies to benefit from the food we eat. Without it, digestion would be impossible, and the conversion of food into living cells and energy practically nonexistent. Insofar as they affect our body's handling of foodall the many processes that go by the collective name of nutritionthe liver's functions can be roughly divided into those that break down food molecules and those that build up or reconstitute these nutrients into a form that the body can use or store efficiently. Bile, bitter, neutral, or slightly alkaline fluid secreted by the liver and passed through a duct into the gallbladder, where it is stored and, as necessary, released into the duodenum. As formed in the liver, bile is a thin, watery fluid to which the gallbladder adds a mucous secretion, forming a complex thickened and stringy substance consisting of salts and bile salts, proteins, cholesterol, hormones, and enzymes. The gallbladder returns water containing salts and other materials to the circulation and concentrates the complex further by a

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tenfold reduction of the bile salts, which the liver synthesizes from cholesterol. Such foods as fats, egg yolk, and foods rich in cholesterol cause concentrated bile, together with secretions from the pancreas, to be discharged into the duodenum to promote digestion, to stimulate peristalsis and absorption, and to carry off excess cholesterol and the disintegration products of overage red blood cells. The hemoglobin of such disintegrating cells degrades rapidly into reddishyellow bilirubin, predominant in the bile of carnivorous and omnivorous animals, and biliverdin, a green pigment that appears in the bile of herbivores. Under normal conditions, the liver efficiently clears these pigments. Gallbladder- 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, releases bile through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Bile stored in the gallbladder is much more concentrated and thicker than bile that is fresh from the liver. This allows the three-inch gallbladder to store a great deal of bile components. But the thickening process can also create problems in the form of extremely painful gallstones, which are dried, crystallized bile. Fortunately, the entire gallbladder can be removed with little or no lasting ill effect. All that is missing is a small storage sac for bile. 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). Small intestine is the largest segment of the GIT, accounting for about two thirds of the total length. It folds back and forth on itself, providing surface area for secretion and absorption of the process by which nutrients enter the bloodstream through the intestinal walls. It has three sections, the duodenum, jejunum and ileum. They terminate at the ileocecal valve which controls the flow of digested material from the ileum into the oecal portion of the large intestine and prevents reflux of bacteria into the small intestine. Large intestine consists of an ascending, segment, on the right side of the abdomen, a transverse segment that extends from right to left in the upper abdomen and a descending segment on the left of the abdomen completing the terminal portion of the large intestine are the sigmoid colon, the rectum and anus. Regulating the anal outlet is a network of striated muscle that forms both the internal and external anal sphincters. All cells of the body require nutrients. These nutrients are derived from the intake of food that contains proteins fats, carbohydrates, vitamins, minerals, and cellulose fibers

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and other vegetable matter, some of which has no nutritional value. Primary functions of the GI tract are the following: The breakdown of food particles into the molecular form for digestion The absorption into the bloodstream of small nutrient molecules produced by digestion. The elimination of undigested, unabsorbed food stuffs and other waste products.

Digestive Process The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes. After being chewed and swallowed, the food enters the esophagus. It uses rhythmic, wave-like muscle movements to force food from the throat into the stomach. Food in the stomach that is partly digested and mixed with stomach acids is called chyme. After being in the stomach, food enters the duodenum in the small intestine, bile, pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food. After passing through the small intestine, food passes into the large intestine. In the large intestine some of the water and electrolytes are removed from the food. Many microbes in the large intestine help in the digestion process. Solid waste is then stored in the rectum until it is excreted via the anus and end of the process.

PATHOPHYSIOLOGY
Advancing age Lifestyle

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Decrease activity

Increase intake of fats and salt

Decrease burning of fats

Exceeds bile Cholesterol

High level cholesterol irritates gallbladder mucosa

Inability of the bile to dissolve it

Change in bile composition

Allow low-solubility bile components to come out of the solution

Cholesterol precipitate out of the bile

Formation of small crystals on the gallbladders mucosal surface

Blockage in the common hepatic or bile ducts

Epigastric pain

Abdominal distention

Vague pain in RUQ of the abdomen

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DRUG STUDY
September 11, 2010 GENERIC NAME Vitamin K BRAND NAME Phytonadione MECHANISM OF ACTION An antihemorrhagic factor that promotes hepatic formation of active coagulation factors. INDICATIONS ADVERSE REACTION DOSAGE, NURSING ROUTE & CONSIDERATION FREQUENCY 10 mg IV q8 -Check label for administration route restrictions -Explain purpose of drug -Watch for flushing, weakness, tachycardia and hypotension

HypoprothromCNS- dizziness binemia caused by Vitamin k CVmalabsorption flushing,transient hypotension, Hypoprothromafter IV binemia caused by administration effect of oral rapid and weak anticoagulants pulse SKINdiaphoresis, erythema

September 11, 2010

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GENERIC NAME Omeprazole

BRAND NAME Omepron

MECHANISM OF ACTION -Proton pump inhibitor that reduces gastric acid secretions and decreases gastric acidity

INDICATION

ADVERSE REACTION CNS- headache GI- dry mouth, diarrhea, abdominal pain, nausea, flatulence, vomiting, constipation

DOSAGE, NURSING ROUTE & CONSIDERATION FREQUENCY 40 mg IV q12 -Give drug at least one hour before meals -Monitor for rash or signs and symptoms of hypersensitivity -Tell patient to inform prescribed of worsening sign and symptoms of pain -Warn patient not to chew or crush drug because this inactivates the drug

Gastroesophag eal reflus disease (symptomatic) To eliminate Helicobacter pylori To reduce the risk of gastric ulcers in patients receiving continuous NSAIDS therapy

September 11, 2010

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GENERIC NAME Cefuroxime

BRAND NAME Pantrexon

MECHANISM OF ACTION -Second generation cephalosporin that inhibits cell wall synthesis promoting osmotic instability, usually bactericidal

INDICATION

ADVERSE REACTION CV- phlebitis, thrombophelebitis, GI- nausea, vomiting diarrhea, anorexia SKINerythematous rashes Hematologiceosionophilia, hemolytic anemia

DOSAGE, ROUTE & FREQUENCY 1gm IV q12

NURSING CONSIDERATION -Before giving drugs ask patient if he is allergic to pencillins or cephalosporins -Obtain specimen for culture and sensitivity test before giving first dose -Tell patient to notify prescriber about loose stools or diarrhea -Advise patient receiving drug IV to report discomfort at IV insertion site

-Perioperative prevention

September 11, 2010 GENERIC BRAND MECHANISM INDICATION ADVERSE DOSAGE, NURSING

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NAME Tramadol hydrochloride

NAME Tramal

OF ACTION -A centrally acting analgesic compound not chemically related to opioids thought to bind to opiate receptors and inhibit reuptake of norepinephrine and serotonin -Moderate to moderately severe pain

REACTION CNSdizziness, vertigo, headache, somnolence, confusion CVvasodilation GU- urine retention, urinary frequency, menopausal symptoms

ROUTE & FREQUENCY 50 mg IV q6

CONSIDERATION -Tell patient to take drug as prescribed and not to increase dose or dosage interval unless ordered by prescribed -Reassess patients level of pain at least 30 minutes after administration -Monitor cardivascular and respiratory status -Monitor bowel and bladder function

September 12, 2010 GENERIC NAME BRAND NAME MECHANISM OF ACTION INDICATION ADVERSE REACTION DOSAGE, ROUTE & NURSING CONSIDERATION

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FREQUENCY Metoclopramide hydrochloride Plasil -Stimulates motility of upper GI tract, Increases lower esophageal sphincter tone and blocks dopamine receptors at the chemoreceptor s trigger zone -To prevent or reduce postoperative nausea and vomiting CNSrestlessness, anxiety, fever, depression GI- nausea, bowel disorders, diarrhea CVhypotension, bradycardia GU-urinary frequency, incontinence Skin- rash, urticaria 10 mg IV q8, RTC -Tell patient to avoid activities that require alertness for 2 hours after doses -Urge patient to report persistent or serious disease reactions promptly -Advise patient not to drink alcohol during therapy -Monitor bowel sounds

September 13, 2010 GENERIC NAME BRAND NAME MECHANISM OF ACTION INDICATION ADVERSE REACTION DOSAGE, ROUTE & FREQUENCY NURSING CONSIDERATION

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Bisacodyl

Dulcolax

Works by stimulating enteric nerves to cause colonic mass movements. it increases fluid and NaCl secretion. Stimulant laxatives mainly promote evacuation of the colon.

Stimulant laxative. It acts directly on the bowels, stimulating the bowel muscles to cause a bowel movement, relieving occasional constipation and irregularity.

GI: abdominal cramping, abdominal distension, diarrhea, CNS: faintness

10 mg suppository stat

-Do not give if the patient had allergy in Dulcolax Suppositories -Do not give if the patient has severe stomach pain; appendicitis; severe constipation; stomach, intestinal, or rectal bleeding; or intestinal blockage

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LABORATORY RESULTS
Ultra Sound
Mendoza General Hospital Poblacion Sta. Maria Bulacan Date: August 13, 2010

Name: N.C. Age: 58 years old Sex: Female

Impression: Diffused fatty infiltration of the liver and pancreas suggest Clinical correlation Non- obstructing Cholelithiasis Normal sonogram of the specimen Non- Dilated ducts

HEMATOLOGY RESULT
PARAMETER Hemoglobin Hematocrit RBC Count RDW-SD RDW-CD WBC Neutrophils Lymphocytes Monocyte Eosinophil Basophil Platelet Count MVC MCH MCHC RESULT 134g/L 0.399 4.29 10^12/L 43.30 fl 13.10% 7.31 10^12g/L 0.486 0.404 0.068 0.031 0.008 386 10^12g/L 93 fl 31 Pg 33.60 % NORMAL VALUE 120-150g/L 0.38-0.48 4.2-5.410^12/L 37-54 fl 11-16% 5-10 10^12g/L 0.45-0.65 0.25-0.4 0.02-0.1 0.020-0.040 0-0.010 150-450 10^12g/L 80-100 fl 27-31 Pg 31-36% September 10, 2010 SIGNIFICANCE Normal Normal Normal Normal Normal Normal Normal Not normal due to possible infection Normal Normal Normal Normal Normal Normal Normal September 10, 2010

Examination: Chest X-ray (PA) Roentgenological Report

Impression: Normal Chest Findings

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September 10, 2010

Prothrombin time
Pt: 13.4 sec. Control: 12.9 sec INR: 1.12 % activity: 68.7%

September 10, 2010

Partial Thromboplastin time

Pt: 27.9 sec Control: 34.3 sec

September 11, 2010

Fluid Serum
Test Creatinine Sodium Potassium ALKP Result .9 mg/dl 147 mmol/L 4.6 mmol/L 117. u/L Normal Range .7-1.2 137-145 3.5-5.1 38.-126. September 10, 2010

*Increase sodium due to increase intake, either orally or parentally Blood Typing Pt result: B Rh (+)

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September 11, 2010 Fasting Blood Sugar Test Glucose Result 97mg/dl Normal Range 74-106

September 12, 2010

Prothrombin time
Pt: 10.2 sec. Control: 13.3 sec INR: .55 % activity: 101.4%

September 14, 2010

Fecalysis
Color: Brown Consistency: Formed A . Lymbriocoides: None Found T Trichiura: None Found Hookworm: None Found E. Histolytica: None Found WBC:0-1/hpf RBC: 0-1/hpf Mucus: Rare Yeast cells: Rare Fat Globules: None Found Occult Blood: Negative

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NURSING CARE PLAN: PHYSIOLOGIC

ASSESSMENT Subjective data: I usually dont touch my incision because it might have an infection, as verbalized by the client. . Objective data: -Warm to touch -Post op pain with the pain scale of 3 out of 10. Vital signs: BP: 120/70 mmHg CR: 85 bpm RR: 15 cpm T: 37.4C Vital signs: BP: 120/70 mmHg CR: 85 bpm RR: 15 cpm T: 37.4C Laboratory results Lymphocytes= 0.404 Sodium=147 mmol/L NURSING DIAGNOSIS Risk for infection related to abdominal incision as manifested by: -Warm to touch -Post op pain with the pain scale of 3 out of 10. PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION After 4 hours of effective nursing interventions such as proper hygiene, proper cleaning of incision site and administering antibiotic as ordered, the client was able to remains free from infection as evidenced by good healing of incision site that is free of redness, swelling, purulent discharge and by normal body temperature. Latest vital signs: BP:120/70 mmHg CR: 90 bpm RR: 15cpm T: 36.5C

Within 4 hours INDEPENDENT: of effective 1. Monitor vital signs nursing interventions such as proper 2. Assess incisions for hygiene, proper redness, drainage, cleaning of swelling and increase incision site pain. and administering 3. Maintain and teach antibiotic as asepsis for dressing ordered, the changes and wound client will be care. able to remains free from 4. Instruct the client and infection. relatives to wash hands. 5. Encourage coughing and deep breathing exercise 6. Advise the patient to avoid lifting heavy objects for 1 week

1. To obtain

baseline data
2. To check for

signs of infection

3. To decrease the

chances of infection 4. To reduces the risk of infection 5. To reduce stasis of secretions in the lungs and bronchial tree 6. To prevent bleeding of the incision site

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Laboratory results: Lymphocytes= 0.404

7. Instruct the patient to wash the puncture site with mild soap and water 8. Increase fluid intake 9. Advise the patient to comply to her follow up check up DEPENDENT: 1. IVF as ordered 2. Administer antibiotics as ordered INTERDEPENDENT: 1. Monitor WBC

7. To maintain asepsis in the incision site 8. To promote proper hydration 9. To evaluate the patients condition after hospitalization 1. To promote proper hydration 2. To prevent infection
1. To monitor risk

for infection

NURSING CARE PLAN: PSYCHOLOGIC

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ASSESSMENT Subjective data: Im not able to eat my favorite foods, as verbalized by the client. Objective data: -verbalization of inability to cope -fatigue -sleep disturbance Vital signs: BP: 120/70 mmHg CR: 85 bpm RR: 15 cpm T: 37.4C

NURSING DIAGNOSIS Ineffective coping related to recent change in health status as manifested by: -verbalization of inability to cope -fatigue -sleep disturbance Vital signs: BP: 120/70 mmHg CR: 85 bpm RR: 15 cpm T: 37.4C

PLANNING Within 6 hours of effective nursing interventions such as therapeutic communication, the client will be able to understand the importance of healthy lifestyle and she will be able to set a goal for her balance diet.

NURSING INTERVENTIONS INDEPENDENT: 1. Established a therapeutic relationship 2. Assess level of understanding and readiness to learn needed lifestyle changes
3. Assist patients to

RATIONALE

EVALUATION

accurately evaluate the situation and their own accomplishments 4. Explore attitudes and feelings about required lifestyle changes

After 6 hours of 1. To let the patient effective nursing feel secured and interventions such comfortable as therapeutic communication, 2. To provide the client was able to appropriate and understand the accurate importance of information and healthy lifestyle understanding and she was able option to set a goal for 3. To recognize that her balance diet the patient has as evidenced by the skills and verbalization of reserves of understanding strength about her proper diet. 4. To understand how the client respond to changes Latest vital signs: BP:120/70 mmHg CR: 90 bpm RR: 15cpm T: 36.5C

5. Encourage the client to set realistic goals like avoiding

5. To help the client gain control over the situation

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high fatty foods and restriction of carbonated beverages 6. Encourage the client to communicate feelings with significant others 7. Point out maladaptive behaviors 8. Instruct in need for adequate rest and balanced diet 9. Teach use of relaxation exercise and diversional activities as method to cope with stress 6. To decrease stress

7. To help the client to focus on appropriate strategies 8. To promote a healthy lifestyle

9. It can be used

toward assisting client to reduce level of stress

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DISCHARGE PLANNING
Medication
Take full course of medicines in a right time, dosage and frequency to obtain the best result of the drug effect. Take home medications:

Amoxicillin 500 mg capsule BID for 7 days as antibiotic Levofloxacin 500 mg tablet OD for 7 days as antibiotic Omeprazole 20 mg capsule BID for 7 days for gastric acidity Betamethasone cream apply 3 times a day for allergy Tramadol 50 mg capsule TID PRN for pain

Exercise
Encourage the patient to do simple exercise such as stretching and walking in the morning.

Therapy
Stress management to cope up with everyday stressors by having a recreational activity.

Health Teachings
1. 2. 3. 4. Proper hand washing. Encourage client to do deep breathing exercises to promote lung expansion. Avoid heavy work lifting or straining. Instruct the patient and the relatives to wash hands before contact with the postoperative patient and on changing the dressing. 5. Encourage the client to use binder or pillow at the incision site when coughing. 6. Take a complete bed rest to restore energy and stamina. 7. Observe proper hygiene to keep the body clean and well groomed. 8. Encourage the patient to participate in any various forms of recreation 9. Educate the client about the medication she will take at home 10. Encourage measures to promote bowel function such as increase fluid intake, attention to urge to defecate and ambulation

Out-patient follow-up
Advice the patient to comply at the schedule time of follow up check up. The follow-up check up is on September 17, 2010.

Diet
Eat well balanced diet low fat, low sodium, high calorie to have a source of energy, to protein to promote immediate healing in the operative site.

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REFLECTION AND INSIGHTS

Cholecystolithiasis is a disease characterized by the inflammation of gall bladder which extends in forming gallstones. This kind of disease is associated with acute abdominal pain, nausea, vomiting, jaundice, and sometimes low grade fever secondary to inflammation. We the group I, are able to define and understand this case with all of our best and precious time to study this cholecystolithiasis. We are able to meet our learning objectives by describing the appropriate medical, surgical, and also the Nursing management for the patient with Cholecystolithiasis and then during the recovery phase of our patient, we were given a chance to show our post operative care for Mrs. NDC and explained it well to her and also in our presentation. And lastly we were able to use the Nursing process as a framework in giving care to the patient undergoing Laparascopic Cholecystectomy. After constructing our case study, we realized Cholecystolithiasis is fatal if the management is not attain immediately and emergency may occur if chronic inflammation had experienced. We learned that lifestyle has a big factor in developing Cholecystolithiasis because of that, we started to modify our lifestyle in order to prevent this disease. And we will be able to share our knowledge and what we had learned to others. It contributes to our life as a Nursing student by knowing the pathophysiologic changes of this disease, to prevent the occurrence of having gallstones and also giving care to ourselves not only in our patient but also started to us.

REFERENCES

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Medical Surgical Nursing Critical Thinking for Collaborative Care Vol.1 5th Edition Ignativicius Workman Brunner & Suddarths Textbook of Medical-Surgical Nursing Vol. 1 10th Edition Suzanne C. Smeltzer Brenda G. Bare Nursing Care Plan 6th Edition Culanick/Myers Understanding Pathophysiology 3rd Edition Sue E. Muether, Kathryn L. Mc Cance Health Assessment in Nursing 3rd Edition Kozier and Erbs Fundamentals of Nursing Vol 1 & 2 8th Edition Kozier, Erb, Berman and Synder Theoretical Foundation of Nursing: The Philippine Respective Carl E. Balita Eufemia F. Octaviano Lippincotts Drug Handbook 2007 Nurses Pocket Guide Diagnose, Prioritized Intervention and Rationales Marilynn E Doengers Mary Frances Moorhouse Alice C. Murr Basic Nutrition of Filipinos Claudio and Dirige Ultimate Learning Guide to Nurses Review Carl E. Balita