case study repaired)

UNIVERSITY OF ILOILOPhinma 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, JoanGenodia, MariaGuelos, Cindy

Gonzaga, HoneyleeHilisan, HarlynIndico, Rodelyn

Iwag, Erick LaineLaguerder, Tresza Shane

Laquian, Raymun EdwardLaurino, 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

couldn’t 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 wasn’t 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♥ ᴥ ᴥ

89 ♥ 88♀ 86♀ 84ᴥ 82ᴥ 79ᴥ

85♥ 85♥ 72♥ 70 ♥,DM 67☺ 63☺ Calculous Cholecystitis

Legend: --Male --Deceased ♥--Hypertension ᴥ-- Unknown

--Female --Deceased ☺--Alive and well ♀--Old Age

N/A

37

4. PATIENT’S EXPECTATIONS

She expects to get well during her stay at the hospital; she wanted also to be

educated regarding the Do’s and Don’ts 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- Fowler’s 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

3. Coffee 2 cup Morning, afternoon

4. Soft drinks 1 Bottle Weekends

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)

Grilled fish (1 piece)

4-5pm

Midnight Snacks Skyflakes (1 whole pack) 10-11pm

Food Likes: Ice Cream, cake, chocolates

Food Dislikes: None

f. Elimination Pattern

1. Bowel MovementFrequency: Once a dayProblems or Difficulties: NoneUsual Remedy: N/A

2. UrinationFrequency: 5-7x/ dayProblems or Difficulties: NoneUsual Remedy: N/A

g. Exercise-walking, jogging and aerobicsh. Personal Hygiene

1. BATHType: Full BathFrequency: 2x a dayTime of Day: 8-9am and 8-9pm

2. ORAL CAREFrequency: 3x a dayCare of Dentures: Tooth Brushing

3. SHAVING: N/A4. 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. AGE: 70 YEARS OLD HOSPITAL: WEST VISAYAS STATE MEDICAL CENTER DATE: 08-19-10

THEORYERICK ERICKSON theory of psychosocial development

SIGMUND FREUD theory of psychosexual development theory

JEAN PIAGET theory of cognitive development

LAWRENCE KOHLBERGtheory of moral development

STAGE

OLD AGE / LATE ADULT

PSYCHOLOGICAL CRISIS:INTEGRITY VS. DESPAIR,DISGUST

GENITAL STAGE

FORMAL OPERATIONS

POST CONVENTIONAL

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.

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- 36.8 C⁰ RR: 17 cpm

PR- 82 bpm BP: 140/90 mm Hg

1. Height: 4’11’’2. Weight: 50 kg3. Physical Assessment

A. Integumentary SystemBrown complexion, uniformly warm to touch, and moist with skin turgor of

approximately 1second. No lesions noted.

B. Neurologic SystemAlert, 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 SystemPR- 82bpm, BP- 140/90 mmHg, capillary refill of approximately 2 seconds in upper and

lower extremities.

E. Gastrointestinal SystemLips 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 SystemLiver not palpable.

G. Genitourinary SystemWith 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 SystemFull ROM in upper and lower extremities, muscle strength of 5/5 in both extremities.

J. Lymphatic SystemLymph nodes are not palpable.

K. Hematopoetic SystemHematology 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

SIGNIFCANCE OF ABNORMAL RESULTS

SODIUM This is the predominant cation in the extracellular

To assess for level of sodium in relation to loss

8/12/10 142.3 mmol/L

135-148 mmol/L

fluid, including plasma.

of water. Normal

POTASSIUM 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 4.06 mmol/L

3.5- 5.3 mmol/L

Normal

CREATININE 8/12/10 96.3 mmol/L

53.0- 115.0 umol/L

Normal

CHOLESTEROL 8/13/10 5.86 mmol/L

1.3- 5.2 mmol/L

LDL-CHOLESTEROL

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

HDL-CHOLESTEROL

8/13/10 1.02 mmol/L

0.9- 1.55 mmol/L

Normal

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

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

8/13/10 7.32 mmol.L

3.9- 6.1 mml/L

B. Hematology

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

8/12/10 8/17/10 8/18/10

HEMOGLOBIN 131g/L 87g/L 117g/L 120-160g/dL

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

ERYTHROCYTE 0.34L/L 0.26L/L 0.34L/L 0.37-0.47L/L

ERYTHROCYTE NO. CONCENTRATION

3.81×1012L 2.71×1012L 3.63×1012L 4.2-5.4×1012L

LEUKOCYTE NO. CONCENTRATION

8.5×1012L 10.7×1012L 12.6×1012L 4.5-11.0×10L

Increase in no. concentration of leukocytes indicates inflammation.

NEUTROPHIL No. Fraction (SEGMENTER)

0.76 0.86 0.76 0.50-0.70

Increased in response to breakdown of RBCs marginated polymorphonuclear neutrophils mobilize and the sphlenic reserve of PMNs is exhausted.

LYMPHOCYTE NUMBER FRACTION

0.24 0.12 0.22 0.20-0.40

Normal

EOSINOPHIL NUMBER FRACTION

0.01 0.02 0.01-0.04

Normal

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: MICROSCOPIC FINDINGS:Color: Straw Pus Cells: 2-4/hpfTransparency: hazy Red blood cells: 14-16/hpf

Reaction: Acidic (6.5) Cast:Specific Gravity: 1.010 Hyaline:

Fine granular: Coarse granula:/lpf

CHEMICALS TESTS CrystalsAmorphous: Many urates

Sugar:Albumin: Negative Squamous Epithelial Cells: fewKetone: Round Epithelial Cells: few Others: Mucus Threads:

c. ECG

Interpretation: Sinus Bradycardia

III. DRUG STUDYUniversity of Iloilo

Phinma Education NetworkCOLLEGE OF NURSING

Rizal Street, Iloilo CityDRUG STUDY

Patient’s Name: Ms. N.S. Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis Age: 70y.o. Chief Complaints: persistent epigastric pain Attending Physician: Dr. T

DRUGS

CLASSIFICATION/ MECHANISM OF ACTION INDICATION

CONTRAINDICATIONSIDE EFFECTS/ ADVERSE REACTION

SPECIAL PRECAUTION/ NURSING RESPONSIBILITY

Generic:

Ranitidine

Brand:

Zantac

Dosage: 50 mg

Route: IVTT

Frequency: q 8H

Timing: 10 AM 6 PM 2AM

Classification:

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.

Post surgery antacid to prevent ulcer formation

Hypersensitivity to ranitidine, lactation.

Side Effects: headache, rash, dizziness, vertigo, constipation, diarrhea, nausea, vomiting, abdominal discomforts, local burning or itching at IV site

Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia,

bradycardia,

leukopenia,

pancytopenia,

thrombocytopenia,

gynecomastia, impotence, hepatitis

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.

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.

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.

University of IloiloPhinma Education NetworkCOLLEGE OF NURSING


Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician: Dr. T.

DRUGS




Generic:

Simvastatin (synvinolin)

Brand:

Lipex, Zoc

Dosage: 20 mg 1 tab

Route: PO

Frequency: OD @ HS

Timing: 6 PM

Classification: HMG- CoA reductase inhibitor, antihyperlipemic

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

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.

CNS: Headache

Asthenia

GI: Abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea.

Respiratory: Upper Respiratory Tract infection.

1. Assess patient’s 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 patient’s 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.

University of IloiloPhinma Education Network

COLLEGE OF NURSINGRizal Street, Iloilo City

DRUG STUDYPatient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician:Dr. T.

DRUGS




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 hydrogen- potassium adenosine triphosphate on secretory surface of gastric parietal cells to block formation of gastric acid. Relives symptoms caused by excessive gastric acid.

Gastric Ulcer. Hypersensitivity to omeprazole.

CNS: Headache, dizziness

GI: diarrhea, abdominal pain, nausea, vomiting, constipation, flatulence.

MUSKULOSKELETAL: backpain

RESPIRATORY: cough

SKIN rash

1. Assess contraindication.2. Lower doses that aren’t needed for

patients with renal or hepatic impairment.3. Advise OTC drug isn’t 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.



Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Cholecystitis .

DRUGSCLASSIFICATION/ MECHANISM OF ACTION

INDICATION CONTRAINDICATIONSIDE EFFECTS/ ADVERSE REACTION


Generic:

Metformin hydrochloride

Brand: Glucophage

Dosage: 500 mg/tab

Route: PO

Frequency: bid PC

Timing: 8 AM 6PM

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.

Adjunct to diet to lower blood glucose with non-insulin 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.

ENDOCRINE: hypoglycemia, lactate acidosis

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

Hypersensitivity: allergic skin reactions

Monitor urine or serum glucose levels frequently to determine effectiveness of drug and dosage

Arrange for transfer to insulin therapy during period of high stress

Use IV glucose if severe hypoglycemia as a result of overdose

Report fever, sore throat, unusual bleeding or bruising, rash, dark urine, light colored stools, 1or hyperglycemia or hypoglycemia reactions

Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician:Dr. T.

University of IloiloPhinma Education Network

1

COLLEGE OF NURSINGRizal Street, Iloilo City

DRUG STUDYPatient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician:Dr. T. Cholecystitis




Gneric: losartan potassium

Brand: Cozaar

Dosage: 50 mg /tab

Route: PO

Frequency: OD

Timing: 6 AM

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 rennin-angiotensin system as well as the release of aldosterone leaading to decreased BP

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

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

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

Cautiously with lepatic or renal dysfunction, hypovolemia

CNS: dizziness, headache, syncope

GI: diarrhea, abdominal pain, nausea

RESP: URI symptoms, cough,

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 volume-excessive respiration, dehydration, vomiting, diarrhea-excessive hypotension can occur.

University of IloiloaPhinma Education NetworkCOLLEGE OF NURSING


DRUGS CLASSIFICATION/ MECHANISM OF ACTION

INDICATION CONTRAINDICATION SIDE EFFECTS/ ADVERSE REACTION


Generic: celecoxib

Brand: Celebrex

Dosage: 200mg /tab

Route: PO

Frequency: t.i.d

Timing:

NSAIDs, analgesic (non narcotic), specific COX-2 enzyme blocker

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.

Acute and long-term treatment of signs and symptoms of rheumatoid arthritis and orteoarthritis.

Management of acute pain.

Contraindicated with allergies to sulfonamides, celecoxib, NSAIDs or aspirin; significant renal impairement; pregnancy, lactation.

Use cautiously with impaired hearing, hepatic and cardio vascular condition.

CNS: headache, dizziness, somnolence, insomnia,

DERMATOLOGIC:rush, pruritus, sweating

GI: dyspepsia, abdominal pain, flatulence.

OTHER: anaphylactoid reactions to anaphylactic shock

Administer drug with food or after meals if GI upset occur.

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.

Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Cholecystitis .



Patient’s Name: Ms. N. S. Ward/ Bed No. FSSW4 Impression/ Diagnosis:Acute Calculous Cholecystitis Age: 70 y.o. Chief Complaints: persistent epigastric pain Attending Physician:Dr. T.

DRUGS CLASSIFICATION/ MECHANISM OF ACTION

INDICATION CONTRAINDICATION SIDE EFFECTS/ ADVERSE REACTION


Generic:

Morphine sulfate

Brand: Estramorp, Avinza,

Classification: Narcotic agonist analgesic

Dosage: 0.015%, 10 cc

Route: via epidural catheter

Frequency: q 12 H

Timing: 8 8

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

CV: hypotension, flushing, bradycardia cardiac arrest

GI: nausea and vomiting, constipation

Hematologic: Thrombocytopenia

Respiratory: Respiratoty depression

Skin: Pruritus

Physical dependence

Assess patient’s pain before starting therapy

May mask or worsen gallbladder pain

Monitor for respiratory depressioncheck RR for 30-60 mins.

Be alert for adverse reactions

Instruct not to use alcohol during therapy


Rizal Street, Iloilo City

DRUG STUDYPatient’s Name: Ms. N.S. Ward/ Bed No. FSSW4 Impression/ Diagnosis: Acute Calculous Cholecystitis Age: 70 Chief Complaints: persistent epigastric pain Attending Physician: Dr. T




Generic:

Tramadol HCl

Brand:

Ultram

Dosage: 50mg q 8h

Route: IVTT

Frequency: BID

Timing: 8`8

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.

Relief of moderate to moderately severe pain; post surgery analgesia

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

Side Effects:

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

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

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 (0–10scale), and character of pain (e.g., steady, intermittent, colicky).

->assists in differentiating cause of pain andprovides information about diseaseprogression/resolution, development ofcomplications, 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 measuresmay indicate developing complications/need forfurther intervention

3. Promote bed rest, allowing patient to assume position of comfort.

->bed rest in low-Fowler’s position reduces intraabdominal pressure; however, patient will

naturally assume least painful pos

4. Use soft/cotton linens; calamine lotion, oil(Alpha-Keri) bath; cool/moist compresses as indicated

->reduces irritation/dryness of the skin anditching sensation

5. Control environmental temperature. ->cool surroundings aid in minimizing dermaldiscomfort

6. Encourage use of relaxation techniques, e.g.,guided imagery, visualization, deep-breathing exercises. Provide diversional activities.

->promotes rest, redirects attention, mayenhance coping

7. Make time to listen to and maintain frequentcontact with patient.

->helpful in alleviating anxiety and refocusingattention, which can relieve pain

2. Maintain Adequate Fluid Balance


1. Maintain accurate I&O, noting output less than intake, increased urine specific gravity. Assess skin/mucous membranes, peripheral pulses, and capillary refill.

->provides information about fluidstatus/circulating volume and replacementneeds

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.

->prolonged vomiting, gastric aspiration, andrestricted oral intake can lead to deficits insodium, potassium, and chloride

3. Eliminate noxious sights/smells from environment.

->reduces stimulation of vomiting cen

4. Perform frequent oral hygiene with alcohol-freemouthwash; apply lubricants

->decreases dryness of oral mucous membranes;reduces risk of oral bleeding

5. Assess for unusual bleeding, e.g., oozing frominjection sites, epistaxis, bleeding gums,ecchymosis, petechiae, and hematemesis/melena.

->prothrombin is reduced and coagulation timeprolonged when bile flow is obstructed,increasing risk of bleeding/hemorrhage

3. Teaching the Disease Process


1. Provide explanations of/reasons for test procedures and preparation needed.

->information can decrease anxiety, therebyreducing sympathetic stimulation

2. Review disease process/prognosis. Discusshospitalization and prospective treatment as indicated. Encourage questions, expression of concern.

->provides knowledge base from which patient can make informed choices. Effectivecommunication and support at this time candiminish anxiety and promote healing

3. Review drug regimen, possible side effects. ->Gallstones often recur, necessitating long-term therapy.

4. Discuss weight reduction programs if indicate ->obesity is a risk factor associated withcholecystitis, and weight loss is beneficial in

medical management of chronic condition

5. Instruct patient to avoid food/fluids high in fats(e.g., whole milk, ice cream, butter, fried foods,nuts, gravies, pork), gas producers (e.g., cabbage,beans, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus).

->prevents/limits recurrence of gallbladderattacks

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.

->indicative of progression of diseaseprocess/development of complications requiring further evaluation

7. Recommend resting in semi-Fowler’s position after meals.

->promotes flow of bile and general relaxation during initial digestive process.

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

->promotes gas formation, which can increasegastric distension/discomfort

9. Discuss avoidance of aspirin-containing products,forceful blowing of nose, straining for bowelmovement, contact sports. Recommend use of soft toothbrush, electric razor.

->reduces risk of bleeding related to changes incoagulation time, mucosal irritation, and trauma

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 RATIONALE EVALUATION

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

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

V/S taken as follows:

T: 36.9ºC

PR: 86bpm

RR: 10cpm

BP: 130/70 mmHg

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

>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-Fowler’s position. Support abdomen when coughing and ambulating.

Collaborative:

>Administer analgesics before breathing treatments/ therapeutic activities.

>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.

Goal met:

After 3 hours of nursing interventions, patient was able to establish effective breathing pattern.

fgh

ASSESSMENTNURSING DIAGNOSIS

SCIENTIFIC BACKGROUND

OUTCOME CRITERIA

INTERVENTIONS RATIONALE EVALUATION

S: “Masakit angtiyan ko,” as verbalized by thepatient. Pain scale rated as 7/10

O: Grimaced face

With guardingbehavior

Restlessness

Rigidity of the abdomen Splinted respiration with short and shallow breathing

V/staken asfollows:BP:130/90mmHgT: 36.7°CPR: 89bpmRR: 32cpm

Acute Pain related to

inflammation

and

distortion of tissues

Characterized by its intensity, location and duration. It isinitiated bystimulation ofnociceptors in theperipheral nervoussystem, or bydamage to ormalfunction of theperipheral or centralnervous 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

2. Observe and documentlocation, severityand character ofpain.

3. Administer analgesic as prescribed

4. Promote bedrest, allowing patient to assume position ofcomfort.

5. Encourage use of relaxation techniques such as deep breathingexercises.

6. Provide diversionalactivities such as watching television.

6

Serve as baseline data

Assists in differentiatingcause of pain and providesinformation aboutdisease progression/ resolution, development of complications and effectiveness of interventions.

To relieve the pain

Bedrest in Fowler’s position reduces intraabdominal pressures;however, patient will naturallyassume least painful position.

Promotes rest, redirects attention, may enhance coping.

Helpful in alleviatinganxiety andrefocusingattention, whichcan relieve pain.

Goal met: The patientverbalized pain scalerated to 4/10.

ASSESSMENT NURSING DIAGNOSIS

OUTCOME CRITERIA


S: “Ano ni akon sakit man? Ano ang dapat ko himuon para malikawan ang mga komplikasyon?” as verbalized by the patient.

O: K,eep on asking,

Inapparopriate behavior, statement of misconception

V/S taken as follows:

T: 36.7ºC

PR: 85bpm

RR: 16 cpm

BP: 140/80 mmHg

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.

Independent

>Review disease process. Encourage questions and expressions of concern.

>Review drug regimen, possible side effects

>Instruct patient to avoid foods or fluids high in fats.

>Review signs and symptoms requiring medical intervention.

>Recommend resting in semi-Fowler’s position after meals

>Suggest patient to limit gum chewing, sucking on straw/ hard candy, or smoking.

>Discuss avoidance of aspirin-containing products, forceful blowing of nose, straining of bowel movement, contact sports. Recommend use of soft toothbrush, electric razor.

>Provides knowledge base on which patient can make informed choice.

>Gallstones often recur, necessitating long-term therapy.

>Prevents/limits recurrence of gallbladder attacks.

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

>Promotes flow of bile and general relaxation during initial digestive process.

>Promotes gas formation, which can increase gastric distention/discomfort.

>Reduce risk of bleeding related to changes in coagulation time, mucosal irritation and trauma.

Goal met.

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


S:” Ginasuka ko ang akun nga gina ka-un,” as verbalized by the patient.

O:

240 mL vomitus.

Pallor,

Skin turgor- greater 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.)

-Review lab studies, e.g. Hgb/Hct; electrolytes; ABGs( pH;) Clotting times.

-Administer IV fluids, electrolytes, and vit. K.

-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.

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

-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. Within normal range.

2. Intravenous solution discontinued and pulled out.

3. Pulled out Epidural Catheter.

4. Signs and symptoms of Acute Calculous Cholecystitis, not manifested.

5. With 100% appetite.

6. Patient’s 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 it’s detected earlier.

Sources:

Brunner and Suddarth’s. “Medical and Surgical Nursing” 12th ed. Lippincott Williams and Wilkins. New York.2008

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