I.

INTRODUCTION Cholecystolithiasis- The medical name for hard deposits (gallstones) that may form in the gallbladder or the occurrence of gallstones within the gallbladder. Gallstones or calculi usually form in the gallbladder from the solid constituents of bile; they vary in size, shape, and composition. There are two major types of gallstones: Cholesterol Stones- most common type, When cholesterol levels are high enough in the bile that crystals form, then tiny stones which go on to grow. Mix cholesterol stones- composed of more than 10% cholesterol, are usually smaller than the pure cholesterol stones and are often faceted and multiple. Pigment stones-is formed from excess bilirubin, a waste product created by the breakdown of the red blood cells in the liver. (form when unconjugated pigments in the bile precipitate to form stones) Four times more women than men develop cholesterol stones and gallbladder disease, the women are usually past age 35, multiparous (most common after pregnancy), and obese. The course of cholecystolithiasis varies among individuals. Some people with cholecystolithiasis have no symptoms at all, while others may have severe abdominal pain, nausea and vomiting, and complete blockage that may pose the risk of infection. Cholecystolithiasis can lead to cholecystitis, inflammation of the gallbladder. Left untreated, cholecystolithiasis can lead to serious complications such as tissue damage, tears in the gallbladder, and infection that spreads to other parts of your body. Cholecystolithiasis affects approximately 10% of adult population in the United States. In the Philippines, some patients with gallstones choose to have their gallbladders removed for peace of mind. Some even choose to have their gallbladders removed for overseas employment purposes. In the country alone, an extrapolated prevalence of 5,073,040 people are affected by the disease last 2007. According to the hospital statistic report of Northern Mindanao Medical Hospital there is 0.72% of discharge diagnosis (primary) in January to December 2009. Excision of the gallbladder (cholecystectomy) to cure gallstone disease is among the most frequently performed abdominal
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procedures. Unless the patients condition deteriorates, surgical intervention is delayed until the acute symptoms subside and a complete evaluation can be carried out.

The diet immediately after an episode is usually limited to low-fat liquids. The patient can stir powdered supplements high in protein and carbohydrate into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas forming vegetables, bread, coffee, or tea may be added as tolerated. The patient should avoid eggs, cream, pork, fried foods, cheese and rich dressings, gasforming vegetables, and alcohol. It is important to remind patient to avoid fatty foods may bring on an episode. Dietary management may be the major mode of therapy in patients who have had only dietary intolerance to fatty foods and the vague gastrointestinal symptoms.

Specific Objectives: The student nurses aim to achieve the following objectives in 2hours of case presentation: 1. Accurately present a thorough general assessment of the client which includes physical assessment and family history taking. 2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited by the client. 3. Thoroughly discuss, explain, and elaborate the nature of the disease process. 4. Provide appropriate and proper nursing diagnosis in line with the clients medical condition. 5. Formulate nursing care plans for the different problems identified. 6. Provide nursing intervention according to the standards of nursing practice. 7. Apply the learned concepts and theories of disease. 8. Appraise the effectiveness and efficacy of nursing interventions rendered to the client. 9. Showcase the outcome of the rendered nursing interventions. 10. Convey the significance of clients response to the rendered nursing interventions.
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11. Provide concise and concrete information to the audience with regards to the patients disease condition. 12. Provide appropriate environment for learning for the audience.

SCOPE AND LIMITATION

This Case Presentation will attempt to cover and discuss the disease process and present

condition of the patient as assessed in the four days of assessment and duty, at Northern Mindanao Medical Center. It will also present the nursing and medical care as provided during the 16hours duty (Oct. 8 & 9, 2012). This case presentation will be limited to the patients verbalizations and significant other who partly served as informant, laboratory results, signs and symptoms as evidenced by and observed from the patient within the engaged days. We consider October 10, 2012 as our follow-up visit and final assessment to our patient.

II. PATIENTS PROFILE

Name: Galupo, Cysethe Sex: Female Birthday: July 2, 1980 Age: 30 years old Address: Gingoog City Religion: Roman Catholic Nationality: Filipino Occupation: Entrepreneur Civil status: Married Spouse name: Aljames Galupo Occupation: Farmer Educational Attainment: Business Management Graduate; Xavier University (2003) Date of admission; October 5, 2012 Diagnosis: Cholecystolithiasis

Heredo-Familial Disease According to the patient, her mother was hypertensive and her father (deceased) suffered from diabetes and then later on turned into multi organ failure. She was the 3 rd among the 4 children. Her eldest brother Constantine Cana, 42 years old suffered from meningitis after delivery .He is mentally retarded as a result of the disease. The second child, 32 years old, died because of a gunshot wound. And she was the 3 rd child, who according to her was the only one in the family that developed cholecystolithiasis. And lastly, the youngest was Cerobim Cana, deceased as well caused by a gunshot wound when he was 15 years old.

Gynaecological History The client had her menarche at the age of 11, with a duration of about a week. But with the onset of her puberty her monthly decreased to just 3 days. She has a regular monthly period which she expects every 3 rd week of the month. She doesnt experience any irregularities with her monthly period.

Food and Drug allergy Patient has no known food and drug allergies.

Diet and Lifestyle Patient is not a picky eater as stated by her. She eats anything and drinks soda every day. She also said that she cant eat without a glass or a bottle of soda together with her meal. She has a history of smoking and drinking alcoholic beverages occasionally and has since quit after giving birth to her eldest child.

History of Admission She was previously admitted last August 24, 2012 at NMMC because she gave birth to her 3rd child via caesarean section. She had also tubal ligation done after the 3 rd delivery because she had delivered all three babies via caesarean section which was advised by her Ob-Gyne. The patient was admitted at northern Mindanao Medical Center with complaints of abdominal pain that is radiating to the back.

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS Patient X went to Maria Reyna Hospital for check-up due to severe abdominal pain and she was then diagnosed with Cholecystolithiasis. She was advised to undergo an operation worth 80,000.00 but then refuse to it due to lack of financial assistance and then decided to transfer at Northern Mindanao Medical Center.

Two days prior to admission Patient complains of severe abdominal pain that is radiating to the back. Patients chief complaint is severe abdominal pain radiating to the back.

III.

DEVELOPMENTAL DATA

Erik Erickson 8 Stages of Development Young Adulthood: 18 to 35 Ego Development Outcome: Intimacy and Solidarity vs. Isolation Basic Strengths: Affiliation and Love

In the initial stage of being an adult we seek one or more companions and love. As we try to find mutually satisfying relationships, primarily through marriage and friends, we generally also begin to start a family, though this age has been pushed back for many couples who today don't start their families until their late thirties. If negotiating this stage is successful, we can experience intimacy on a deep level. If we're not successful, isolation and distance from others may occur. And when we don't find it easy to create satisfying relationships, our world can begin to shrink as, in defense, we can feel superior to others. Our significant relationships are with marital partners and friends. Erikson's sixth stage, Intimacy vs. Isolation, occurs during young adulthood. Intimacy with other people is possible only if a reasonably well integrated identity emerges from stage five.

Robert J. Havighurst *Assisting teenage children to become responsible and happy adults. * Achieving adult social and civic responsibility. * Reaching and maintaining satisfactory performance in ones occupational career. *Developing adult leisure time activities. * Relating oneself to ones spouse as a person.
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* To accept and adjust to the physiological changes of middle age. *Adjusting to aging parents.

INTERPRETATION The information listed above made by these two famous theorist are being exhibited by our patient. Basing on what we have assessed and upon interviewing we have known that some characteristics that a normal 30 year old are present. On the first developmental theory which is from Eric Erickson wherein the major conflict a person may encounter when he will reach this stage is intimacy and solidarity vs. Isolation, our patient has successfully entered this stage even though she still wasnt able to achieve most of her dreams but she believed starting to build a family and having a wonderful children are one of her greatest dream. In this stage, people are starting to build there own lives and to be established as a person that every is dreaming of like having a degree after studying in college, having descent work with good financial outcomes, to live independently without asking some financial support from their parents, and one of the highlights in this stage is to find a partner who will become a companion for the rest of their lives and having a children. Being unable to achieve our goals and aspiration prior to what we have planned will cause us a sense of isolation, we are having difficulty in accepting facts that we have failed to achieve what we have planned before specially people are trying to seize and compare you from other people who become successful in their chosen careers. Unable to find a perfect partner or having no mature relation ship to someone when you reach this stage will cause us an isolation, people tend to seek attention more to their partners and to someone special because they can express more of their feeling to them rather to their parents and friends. On the second theory by Robert Havighurst, people tend to exhibit the characteristics of parenting muchtime. They act us a protector and a guide to their children by leading them to the right attitude in order for their children to become a good person when they grow. so that people will not blame the parents. Their major role is to guide their children so that they will not be mislead to something that is inappropriate, it always reflect on how the parents have raised their children.

IV. MEDICAL MANAGEMENT

a. Medical Orders with Rationale Date/time 10-5-2012 @ 9:00 p.m Doctors Order Please admit under Surgery Annex 2 Floor 1 Secure consent to care Rationale of Order To provide management fitted for patient To provide understanding in the part of the client including significant others for any medical, surgical, and nursing intervention and also for legal documentation purposes. Low Fat Diet This Diet decreases Fat intake which is beneficial in reducing the pain brought about the disease. The presence of fat in he duodenum stimulates the release of cholecystokinin. This hormone causes the gallbladder to contract and release bile. If gallbladder is inflamed or has stones present, the contraction will cause severe pain to the patient. Start venoclysis D5LR iL @ 30gtts/min To provide immediate access to the vascular system for the rapid
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delivery of specific solutions without the time required for gastrointestinal tract absorption. Is a Hypertonic solutions raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy. LABS: CBC with Platelet Count, Blood Typing, Serum Creatinine, RBS, SGPT, SGOT, PTPA, Alkaline PO4

To check or evaluate any deviation from normal in blood count; blood typing to check for what type of blood the patient has for possible blood transfusion; creatinine is an indicator of the renal function; RBS measure the blood glucose levels without the need of fasting; SGPT and SGOT assists in differentiating whether the jaundice requires surgical treatment, as in case of obstructive jaundice due to gall bladder stones; PTPA (obsolete name for prothrombin time) measures how long it takes blood to clot and is used to check for bleeding
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problems; Alkaline PO4 to test liver functions Meds: 1.Cefuroxime 750mg IVTT 8 hrs., ANST( - ) every An antibacterial used to treat for bacterial infection/ prophylaxis treatment post operatively. An antacid used to reduce gastric acid secretion 3.Tramadol 50mg IVTT every 8 hrs, A non-opiod analgesic for 4. Hyoscine-N-ButylBromide 10mg IVTT every 8 hrs. antispasmodic drug used to treat conditions associated with spasms of the gastrointestinal tract, such as cramping. I & O every shift Monitor Abdominal Status every 4 hours For Elective cholecystectomy Secure consent for procedure To determine fluid retention To monitor signs for any possible complications related to the case To remove the inflamed Gallbladder. The surgery is an invasive procedure, the consent indicates the willingness of the patient of such procedure.
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2.Ranitidine 50mg IVTT every 8 hrs.

acute to severe pain

 Refer accordingly

To Inform the attending physicians for any complications and reactions

10-6-2012 7am

Low Fat Diet

This diet decreases Fat intake which is beneficial in reducing the pain brought about the disease.

Continue Meds IVFTF: D5LR iL @ 30gtts/min For Elective Open Cholecystectomy on 10/9/2012 Secure consent for procedure

For continuity of treatment regimen To provide fluid and electrolyte balance and for hydration purposes To remove the inflamed Gallbladder. The surgery is an invasive procedure, the consent indicates the willingness of the patient of such procedure

Inform OR and Anesthesiologist

For the OR staff and Anesthesiologist to reserve the date and prepare for the upcoming surgery

Refer Accordingly

To Inform the attending physicians for any complications and reactions

10-7-2012 7am

Low fat Diet

This diet decreases Fat intake which is beneficial in

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reducing the pain brought about the disease IVFTF: D5LR iL @ 30gtts/min Continue all medications For Elective Open Cholecystectomy on Tuesday (10/9/2012) Vital signs every 4 hours To monitor the Vital signs of patient for any untoward complications I & O every shift Low fat diet Continue medications To determine fluid retention 10-8-2012 To prevent exacerbation of pain For compliance of medications For open cholecystectomy on 10/9/12 Secure consent to procedure Inform OR and anesthesiologist For the removal of gall bladder For legal purposes In preparation for the OR and have the anesthesiologist visit the patient For ECG 12 lead with LLII and TSH, T3, T4 Refer accordingly To check patients heart rhythm and abnormalities To Inform the attending To provide fluid and electrolyte balance and for hydration purposes For continuity of treatment regimen To remove the inflamed Gallbladder.

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physicians for any complications and reactions

Pre- Operative Order 4:00 pm Operating room 2nd case NPO post midnight For prepare patient for surgery To prevent aspiration during surgery Meds: Omeprazole90 40 mg 1 tab HS Nothing per Orem To prevent aspiration during surgery Operating room on call To prepare patient for surgery -Post Operation Order To PACU S/P Operation Chole/Epidural Oxygen inhalation at 4lpm/face mask and fully awake Monitor VS every 15 minutes x 2 hours then hourly until stable NPO Flat on bed x 8 hours then may turn to sides and elevate head To maintain pulmonary ventilation and thus prevent hypoxemia To know any abnormalities and have a baseline vital signs To prevent aspiration To prevent aspiration, to prevent headache, for range of motion exercise For patients recovery. Inhibits gastric secretion

10-9-2012

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and for good circulation IVF to follow D5LR 1 liter at 30 gtts/min. Medications: Tramadol 50 mg slow IVTT 8 hours x 3 doses then PM Binds to opiod receptors and inhibits reuptake of norepinephrine and serotonin. Anti-bacterial, 2nd Cefuroxime 350 mg IVTT every 8 hours Morphine Precaution refer if: BP: 90/60 RR: 12 HR: 60 Vomiting Pruritus Spo2 92% Nausea and To watch out after side effects of the drug and for prompt intervention. To correct unusualities as soon as possible and to inform the AP of the patients condition Intake and Output every shift Refer accordingly To monitor patients physiologic status Referral is done to correct unusualities as soon as possible and to inform the attending physician on the patients condition. 10-9-12 May transport patient back to ward For continuity of care generation cephalosporin To maintain fluid electrolyte balance

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10-10-2012 2:00 am Temp: 38.7 degree Celsius

Please give paracetamol 300 milligrams IVTT now.

For fever PRN

6:30 am

NPO Change dressing Continue meds Vital Signs per shift Intake and output per shift D5LR 1 Liter 30gtts/min. Please refer

To prevent aspiration To prevent infection For compliance of medications To monitor patients physiologic status To monitor patients physiologic status To replace fluid and electrolyte loss Referral is done to correct unusualities as soon as possible and to inform the attending physician on the patients condition.

2:00 pm Still on Intake and Output per shift Epidural catheter remove aseptically 5:00 pm Temperature : 38 degree Celsius
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To monitor patients physiologic status To prevent infection For fever PRN

Paracetamol 600 mg IVTT q 4 hours RTC

b. Drug Study Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action: Cefuroxime October 5, 2012 Antibiotic 750mg IVTT every 8hrs This drug binds to one or more of the penicillinbinding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death Specific Indication: Treatment of infections of lower respiratory tract, urinary tract, skin and skin structures. Contraindication: Side Effects: Hypersensitivity to cephalosporins.

Nausea, vomiting, diarrhea, stomach pain Headache, dizziness Sleep problems (insomnia) Vaginal itching or discharge.

Nursing Precaution:

a. Advise patient to take with meals to enhance absorption. If tablet must be crushed, mix with food or beverage. b. Advise patient to maintain normal fluid intake while using this medication. c. Instruct patient to report these symptoms to health care provider: bruising, bleeding, muscle or joint pain. d. Instruct patient to seek emergency care immediately if wheezing or difficulty breathing occurs.

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Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Ranitidine October 5, 2012 Histamine H2 Antagonist 50mg IVTT every 8hrs Selectively block histamine-2 receptors sites. This blocking leads to a reduction in gastric acid secretion and reduction in overall pepsin production.

Specific Indication:

relief of GIT drug adverse effects/Reduce Gastric Acid Secretion

Contraindication:

Hypersensitivity to Ranitidine

- Caution should be used with hepatic of renal dysfunction

Side Effects:

CNS: vertigo, malaise, headache, somnolence, confusion hallucinations EENT: blurred vision GI: diarrhea, constipation CV: arrhythmias, hypotension

Nursing Precaution:

provide comfort and safety measures if CNS effects occur monitor of potentially serous adverse effects, including cardiac arrhythmias Given before meal

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Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Tramadol October 5, 2012 Non-Opioid Analgesic 50mg IVTT every 8hrs Binds to opioids receptors and inhibits the reuptake of norepinephrine and serotonin.

Specific Indication: Contraindication:

Moderate to severe pain Acute intoxication with opioids or psychoactive drugs

Side Effects:

CNS: Sedation, Dizziness, Headache, and Confusion CV: Hypotension, Tachycardia, Bradycardia Dermatologic: Sweating

Nursing Precaution:

Administer with food if GI upset occurs; Monitor patient response, Give the drug before the pain becomes intense

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Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Hyoscine N butylbromide October 5, 2012 Anti spasmodic 10mg IVTT every 8hrs stops the spasms in the smooth muscle by preventing acetylcholine from acting on the muscle. It does this by blocking the receptors on the muscle cells that the acetylcholine would normally act on. By preventing acetylcholine from acting on the muscle in the GI and GU tracts, hyoscine reduces the muscle contractions. This allows the muscle to relax and reduces the painful spasms and cramps

Specific Indication:

Spasms of the stomach, intestines or bile duct (gastro-intestinal tract), including those associated with irritable bowel syndrome (IBS).

Spasms of the bladder or urinary system (genitourinary tract).

Contraindication:

Abnormal muscle weakness (myasthenia gravis). Abnormally large or dilated large intestine (megacolon).

Closed angle glaucoma. Rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucraseisomaltase insufficiency (Buscopan tablets contain sucrose).

Buscopan tablets are not recommended for children under six years of age.

Side Effects:

Uncommon

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Increase in heart rate (tachycardia). Dry mouth. Reduced ability to sweat. Allergic skin reactions.

Rare

Difficulty in passing urine (urinary retention). Hypersensitivity reactions such as narrowing of the airways (bronchospasm), swelling of the lips, throat and tongue (angioedema), or itchy rash.

Unknown frequency

Anaphylactic reaction.

Nursing Precaution:

Give by direct IV after diluting it with sterile water Monitor I and O ratio, retention commonly causes decreased urinary output Assess for constipation Assess for tolerance over long term therapy

Generic Name:

Omeprazole

Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

October 8, 2012 Proton pump inhibitor 40mg 1tab HS An anti-secretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+, ATPase enzyme system in the partial cells.

Specific Indication:

Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing..

Contraindication:

Long-term use for gastro esophageal reflux disease,

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duodenal ulcer. Side Effects:

Nausea, vomiting, diarrhea, stomach pain Headache, dizziness Sleep problems (insomnia) Malaise, vertigo and fatigue.

Nursing Precaution:

e. Report sore, throat, fever, bleeding, tarry stool, confusion. f. Give with or without food, simultaneous administration does not appear to reduce absorption or serum. g. Administer adjunctive antacid treatment 2h before or after drug.

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Paracetamol October 10, 2012 Antipyretic 600mg IVTT every 4hrs RTC Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or other substances than sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulation center.

Specific Indication: Contraindication:

Mild pain and fever. Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients.

Side Effects:

Jaundice Hypoglycemia

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Rash Headache Chest pain Dyspnea

Nursing Precaution:

a. Alert: Many OTC and prescription products contain acetominophen; be aware of this when calculating total daily dose.

Laboratory Results

COMPLETE BLOOD COUNT OCTOBER 4, 2012 MRXUH LABORATORY

Test WBC

Results 13.7

Reference (4.50 11.0)x10^9/uL

Rationale Indicates infection; acute stress/trauma

RBC

4.52

(4.2-5.0)mm3

Within normal values

Hemoglobin

11.70

(12-16.)%

May indicate bleeding; acute stress/trauma

Hematocrit

37.20

(36.0 -46.0)%

Within normal limits Within normal

MCV

82.3

(80.0-100.0)fl

Limits Slightly low;

MCH

25.90

(26.10-33.30)pg

indicates Vit. B12

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deficiency MCHC 31.5 (31.0 37.0)g/dl Within normal limits Platelet count 310 (150-390)x10^9/L Within normal limits

Neutrophils

78.6

(37.00 72.00)%

Indicates bacterial infections; inflammation

Lymphocytes

15.0

(20.00 50.00) %

Indicates infections; autoimmune disorders

Monocytes

5.9

(8.00-14.00)%

Low,usually not medically significant(repeated low result indicate

Eosinophils Basophils RDW- CV

0.4 0.1 15.6

(0.00-6.00)% (0.00-1.00)% (11.5-14.5)%

bone marrow failure or damage) Within normal limits Within normal limits Indicates mixed populations of small and large RBCs

Blood Typing

AB(+)

Blood Type AB its signifies a need for a donor with a blood type AB+, A+ or B+

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ULTRASOUND OCTOBER 4, 2012

Gallbladder is dilated measuring 13.33 x 4.88cms. ( LW) with thickened walls measuring 4.5 mms. High Level shadowing echoes within the urinary bladder and one with a diameter of 1.95 cms. Is impacted in gallbladder neck. No dilated biliary ducts. Liver, pancreas and spleen are of normal size and echo pattern with no focal masses. Right kidney measures11.1 x 5.3 cm ( LW) with corticomedullary thickness of 1.7 cms. Normal echo pattern with no stones nor focal masses. No localized dilatation in the gallbladder aorta. No echoes within the urinary bladder. Uterus is anteverted and measures 7.7 x 4.9 x 6.9cms ( LHW) with endometrial thickness of 9.2 mm. no adrenal mass. CONCLUSION: Acute Cholecystitis with multiple gallstones. Stone with a diameter of 1.95cms. impacted in the gallbladder neck. Normal liver, pancreas, spleen, genitor-urinary tract and abdominal aorta.

COMPLETE BLOOD COUNT OCTOBER 5, 2012 NMMC LABORATORY

Test WBC

Results 21.7

Reference (5.00 10.0)x10^3/uL

Rationale Indicates infection; acute stress/trauma

RBC

4.50

(4.2-5.4)x10^6/uL

Within normal values

Hemoglobin

12.1

(12-16.)%

Within normal limits

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Hematocrit

37.3

(37.0 - 47.0)%

Within normal limits

MCV

82.9

(82.0-98.0)fl

Within normal Limits

MCH

26.90

(27.0-31.0)pg (31.0 35.0)g/dl

Slightly low; indicates Vit. B12

MCHC

32.4

deficiency Within normal limits

Platelet count

330

(150-400)x10^9/L Within normal limits

Neutrophils

82.3

(43.4 76.2)%

Indicates bacterial infections; inflammation

Lymphocytes

11.6

(17.4 48.2) %

Indicates infections; autoimmune

Monocytes Eosinophils

6.0 0.1

(4.5-10.5)% (1.0-3.0)%

disorders Within normal limits An occasional low result is not

Basophils RDW- CV PDW MPV

0.0 15.9 9.1 8.9 AB(+)

(0.00-2.00)% (12.0-17.0)% (9.0 1.0)fL (8.0-12.0)fL

medically significant Within normal limits Within normal limits Within normal limits Within normal limits Blood Type AB its signifies a need for a donor with a blood type AB+, A+ or B+

Blood Typing

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BLOOD CHEMISTRY RESULT OCTOBER 5, 2012 NMMC LABORATORY

Test glucose Creatinine SGOT SGPT ALP

Results 88 0.9 18.9 29.2 252.7

Reference (60-100)mg/dl (0.6-1.2)mg/dl (0.0-37.0)U/l (0.0-42.0)u/l (80.0-306.0)u/l

Rationale Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits

Na+ K+

135.0 3.71

(135-148)mmol/L (3.5-5.3)mmol/L

Within normal limits Within normal limits

Prothrombin time Protime Control I.N.R. 13.7 sec. 11.6 sec. 1.18 10.2-15.2 sec. Within normal limits

APTT APTT Control

28.4 sec. 27.5 sec.

23.4-38.5 sec

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V. ANATOMY and PHYSIOLOGY The Gallbladder The gallbladder is a pear-shaped sac lying on the undersurface of the liver, measuring about 7.5 to 10 cm (3 to 4 inches) long. It has a capacity of 30 to 50 ml and stores bile, which it

concentrates by absorbing water. The gallbladder is

divided into the fundus, the body and the neck. The fundus is rounded and

projects below the inferior margin of the liver, where it comes in contact with the anterior abdominal wall at the level of the tip of the ninth right costal cartilage. The body lies in contact with the visceral surface of the liver and is directed upward, backward and to the left. The neck becomes continuous with the cystic duct, which turns into the lesser omentum to join the common hepatic duct to form the bile duct. The peritoneum completely surrounds the fundus of the gallbladder and binds the body and neck to the visceral surface of the liver. Functions of the Gallbladder The gallbladder functions as a storage depot for bile. Bile is a viscid alkaline fluid secreted by the liver where it aids in the emulsification and absorption of fats. Human normally produce 400-800 ml of bile daily. When digestion is not taking place, the sphincter of Oddi remains closed and bile accumulates in the gallbladder. The gallbladder concentrates bile; stores bile; selectively absorbs bile salts, keeping the bile acid; excretes cholesterol and secretes
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mucus. To aid in these functions, the mucous membrane is thrown into permanent folds that unite with each other giving the surface a honeycomb appearance. The columnar cells lining the surface have numerous microvilli on the free surface. Bile is delivered to the duodenum as a result of contraction and partial emptying of the gallbladder. This mechanism is imitated by the entrance of fatty foods into the duodenum. The fat causes release of the hormone cholecystokinin from the mucous membrane of the duodenum; the hormone that enters the blood, causing the gallbladder to contract. At the same time, the smooth muscle around the distal end of the bile duct and the ampulla is relaxed, thus allowing the passage of concentrated bile into the duodenum. The bile salts in the bile are important in emulsifying the fat in the intestine and in assisting with its digestion and absorption. Functions of the Bile 1. Digestion and absorption of fats for bodily consumption 2. Serves as a means for the body to excrete waste products from the blood 3. Contains waste products from haemoglobin breakdown, known as Bilirubin, and helps in its excretion outside of the body. Approximately half of the bilirubin, a pigment derived from the breakdown of red blood cells, is a component of bile. It is converted by the intestinal flora into the urobilinogen, a highly soluble substance. Urobilinogen is either excreted in the fecs of returned to the portal circulation, where it is re-excreted into the bile. Bilirubin has two types. First is the unconjugated bilirubin which is insoluble in water and not excreted in the urine. Second, is the conjugated bilirubin which is soluble in water and excreted in the urine. About 5% of it is normally absorbed into the general circulation and then excreted by the kidneys.

Source: Snell, Richard S. Clinical Anatomy by Regions. 8th Edition. Lipincott Williams & Wilkins. 530 Walnut Street, PA. 2008.

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IDEAL PATHOPHYSIOLOGY OF CHOLECYSTOLITHIASIS

Definition: The formation of one or more gallstones in the gallbladder or in the bile ducts which results into obstruction and subsequent inflammation.
PREDISPOSING FACTORS Advancing Age: 40 years old and above Gender: Female Family history of gallstones Family history of DM PRECIPITATING FACTORS High fat and High Cholesterol Diet Pregnancy, most especially multiparity Use of oral contraceptives Excessive intake of alcohol

Imbalance ratio between bile and bile components resulting to insolubility of bile

Increased cholesterol

Increased bilirubin

Increased calcium carbonate

Super saturation and precipitation of excess cholesterol

Super saturation and precipitation of excess bilirubin

Super saturation and precipitation of excess calcium carbonate

Increased viscosity of bile leading to bile stasis

Increased viscosity of bile leading to bile stasis

Increased viscosity of bile leading to stasis

Solidification and aggregation of precipitates to a calculi

Solidification and aggregation of precipitates to a calculi

Solidification and aggregation of precipitates to a calculi

CHOLESTEROL STONES

PIGMENT STONES CHOLELITHIASIS Stone dislodges and obstructs opening of gallbladder preventing outflow of bile, thus, leading to distention of gallbladder

MIXED STONES

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ACTUAL PATHOPHYSIOLOGY OF CHOLECYSTOLITHIASIS (AS SEEN IN OUR PATIENT)

Definition: The formation of one or more gallstones in the gallbladder or in the bile ducts which results into subsequent inflammation. PREDISPOSING FACTORS Gender (Female) PRECIPITATING FACTORS High fat and High Cholesterol Diet Multiple Parity Obesity History of Smoking and Drinking

DYSFUNCTIONAL BILE PRODUCTION IN THE GALL BLADDER

Increased cholesterol concentration in the bile with insufficient bile salts and lecithin

Super-saturation of bile results to progressive dissolution of vesicles wherein cholesterolcarrying capacity is exceeded

Increased bile viscosity leading to bile stasis within the gallbladder and its ducts

Precipitation of cholesterol in bile forms cholesterol monohydrate crystals which aggregates and solidifies

CHOLELITHIASIS

Presence of gallstones, particularly cholesterol stones in the bladder

32

Cholesterol stone dislodges into opening of gallbladder causing obstruction

S/s -Complaints of

discomfort after consuming

No bile outflow to the duodenum to aid in fat digestion

S/s

S/s -Low grade

Autolysis, wherein bile acid causes irritation and damage to the Tunica mucosa of the gallbladders smooth muscle wall

-Complaints

of sudden right upper quadrant

fever of
S/s

Prostaglandins are released by the body as an inflammatory response to endothelial damage

-Increased

WBC of

S/s

CHOLECYSTITIS
Ultrasound result of inflamed gallbladder at

Inflammation of the gallbladder

No further complication noted since patient was able to immediately undergo CHOLECYSTECTOMY, or the removal of her cholesterol stone.

33

VI. NURSING ASSESSMENT NURSING SYSTEM REVIEW CHART Name: Mrs. G. Age: PR: 80bpm Date: October 7, 2012(pre-op) RR: 20cpm BP: 120/80mmhg

V/S: c Temp: 36.9 C EENT: [] impaired vision [ ] blind

[ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose, and throat For abnormality [ x] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopenea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp.rate, rhythm, depth, and pattern Breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [] stong pulses X Assess heart sounds, rate, rhythm, pulse, bp, Circulation, fluid retention, comfort [x ] no problem GASTRO INTESTINAL TRACT: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] noctoria Assess urine freq., control, color, odor, comfort /
Abdominal Gird: 46 cm
D5lr @30 gtts/min

Anxiety (moderate)

Pain in the abdomen with pain scale of 8/10 x

34

Gyn-bleeding, discharge [x] no problem

NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethartic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech [x] No problem MUSCULOSKELETAL & SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [] poor turgor [ ] cool [ ] deformity [ ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist Assess mobility, motion, galt, alignment, joint function/ Skin color, texture, turgor, integrity [x] no problem

SUBJECTIVE COMMUNICATION: [ ] hearing loss [] visual changes [] others: language [x] denied Comments: wala man pud koy problema bahin ana. As verbalized. [] glasses

OBJECTIVE [] languages [ ] hearing aide

[ ] contact lenses

[ ] speech difficulties Pupil size & reaction: 2 mm-3mm PERRLA (pupils equally round and reactive to light accommodation

35

OXYGENATION: [ ] dyspnea [X] smoking history [ ] cough [ ] sputum [ ] denied Comments: Oo, gapanigarilyo ako sauna pero wala na sukad na nagbreastfeed ko . as verbalized.

Resp.

[x] regular

[ ] irregular

Describe: normal breathing patterns with respiratory rate of 20 cpm

R: Right lung is symmetrical to the left L: Left lung is symmetrical to the right

CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x] denied

Comments:. wala man pud akoy problema bahin ana.as verbalized by patient.

Heart Rhythm [x] regular [ ] irregular Ankle Edema Pulse Fem* R: L: Comments: Pulses are strong and easy to palpate. Car none Rad. AP

NUTRITION: Diet: soft diet []N[]V Character [ ]recent change in weight and appetite [ ] swallowing Difficulty [x] denied Lower [] [ ] Comments: maayo ra [ ]dentures man pud ang akong pag-kaon. As verbalized by the patient Upper [] [ ] Full Partial [x]none

36

ELIMINATION: Usual bowel pattern Once a day [ ] constipation Date of last BM October 7, 2012 [ ] diarrhea [ ] urinary frequency 5 times a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [x] denied

Comments: Bowel sounds are audible and normoactive

Bowelsound: normoactive _(20/min)____ Abdominal Distention Present [x] yes [] no Urine* (color, consistency, odor)

urine color is yellow

MGT. OF HEALTH & ILLNESS: [x] alcohol [ ] denied [ ] SBE Last Pap Smear: LMP: N/A

Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present): The patient is able to follow treatments and medications instructed to her.

SKIN INTEGRITY: [ ] dry [ ] itching [ ] other [x] denied

Comments: Mao raman japon, wala may nabag-o sa akong pamanit as verbalized..

[ ] dry [ ] flushed [ ] moist

[ ] cold [ ] warm [ ] cyanotic

[ ] pale

Rashes,ulcers,decubitus (describe size, location,drainage) : no rashes, ulcers, decubitus noted

37

ACTIVITY/SAFETY

Comments: dili kayo ko makalihok-

[ ]LOC and orientation: client is alert, oriented to time and place Gait: [ ] walker [ ] cane

[ ] drowsiness [ ] dizziness [ ] limited motion of joints Limitation in ability to [ ] ambulate [ ] bathe self [x] denied

lihok labi na ug mutukar ang sakit. as verbalized.

[ ] other [x] none

[ ] sensory and motor losses in face or extremities: there is no alteration in sensory & motor function [ ] ROM limitations: with limitations [ ] facial grimaces [ ] guarding [ ] other signs of pain: [ ] side rail release form signed [x] none

COMFORT/SLEEP/AWAKE Comments: [ ] pain [ ] nocturia [x] sleep difficulties [] denied medyo alimuotan man gud ko inig gabie. as verbalized by the patient. COPING Occupation: Businesswoman Members of household: husband, children, mother

Observed non-verbal behavior: She is very attentive and cooperative. She entertains our every questions and query.

Most supportive person: husband

The person & her phone number that can be reached anytime: 09163894562

38

NURSING SYSTEM REVIEW CHART Name: Mrs. G. Age: 30 years old RR: Date: October 8, 2012(pre-op) cpm BP: 120/80mmhg

V/S: Temp: 36.9 C PR: 85bpm

EENT: [] impaired vision [ ] blind [ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose, and throat For abnormality [ ] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopenea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp.rate, rhythm, depth, and pattern Breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [] stong pulses X Assess heart sounds, rate, rhythm, pulse, bp, Circulation, fluid retention, comfort [x ] no problem GASTRO INTESTINAL TRACT: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] noctoria Assess urine freq., control, color, odor, comfort /
39 D5lr @30 gtts/min Pain in the abdomen with pain scale of x 5/10

Abdominal Gird: 46 cm

Gyn-bleeding, discharge [x] no problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethartic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech [x] No problem MUSCULOSKELETAL & SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [] poor turgor [ ] cool [ ] deformity [ ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist Assess mobility, motion, galt, alignment, joint function/ Skin color, texture, turgor, integrity [x] no problem

SUBJECTIVE COMMUNICATION: [ ] hearing loss [] visual changes [] others: language [x] denied Comments: Wala man pud koy problema bahin ana. As verbalized. [] glasses

OBJECTIVE [] languages [ ] hearing aide

[ ] contact lenses

[ ] speech difficulties Pupil size & reaction: 2mm-3mm PERRLA (pupils equally round and reactive to light accommodation

40

OXYGENATION: [ ] dyspnea [X] smoking history [ ] cough [ ] sputum [ ] denied Comments: Oo, wala na karon . as verbalized.

Resp.

[x] regular

[ ] irregular

Describe: normal breathing patterns

gapanigarilyo ako apan with respiratory rate of 20 cpm

R: Right lung is symmetrical to the left L: Left lung is symmetrical to the right

CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x] denied

Comments:. wala man pud akoy problema bahin ana.as verbalized.

Heart Rhythm [x] regular [ ] irregular Ankle Edema Pulse Fem* R: Car none Rad. AP

L: Comments: Pulses are strong and easy to palpate. NUTRITION: Diet: soft diet []N[]V Character [ ]recent change in weight and appetite [ ] swallowing Difficulty [x] denied Lower [] [ ] Comments: maayo ra [ ]dentures man pud ang akong pag-kaon. As verbalized by the patient Upper [] [ ] Full Partial [x]none

41

ELIMINATION: Usual bowel pattern Once a day [ ] constipation Date of last BM October 9, 2012 [ ] diarrhea [ ] urinary frequency 5 times a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foley in place [x] denied

Comments: Bowel sounds are audible and normoactive

Bowelsound: normoactive _(20/min)____ Abdominal Distention Present [x] yes [] no Urine* (color, consistency, odor)

urine color is yellow MGT. OF HEALTH & ILLNESS: [x] alcohol [ ] denied [ ] SBE Last Pap Smear: LMP: N/A Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present): The patient is able to follow treatments and medications instructed to her. SKIN INTEGRITY: [ ] dry [ ] itching [ ] other [x] denied Comments: Mao raman japon, wala may nabag-o sa akong pamanit as verbalized by the patient. [ ] dry [ ] flushed [ ] moist [ ] cold [ ] warm [ ] cyanotic [ ] pale

Rashes,ulcers,decubitus (describe size, location,drainage) : no rashes, ulcers, decubitus noted

42

ACTIVITY/SAFETY

Comments: kaya ra man nako maglihok-lihok. as verbalized by the patient

[ ]LOC and orientation: client is alert, oriented to time and place Gait: [ ] walker [ ] cane

[ ] drowsiness [ ] dizziness [ ] limited motion of joints Limitation in ability to [ ] ambulate [ ] bathe self [x] denied

[ ] other [x] none

[ ] sensory and motor losses in face or extremities: there is no alteration in sensory & motor function [ ] ROM limitations: with limitations

COMFORT/SLEEP/AWAKE Comments: Ok [ ] pain [ ] nocturia [ ] sleep difficulties [x] denied raman pud akong pagkatulog as verbalized.

[ ] facial grimaces [ ] guarding [ ] other signs of pain: [ ] side rail release form signed [x] none

COPING Occupation: Members of household: husband, children, mother

Observed non-verbal behavior: She is very attentive and cooperative. She entertains our every questions and query.

Most supportive person: husband

The person & her phone number that can be reached anytime: 09163894562

43

NURSING ASSESSMENT NURSING SYSTEM REVIEW CHART Name: Mrs. G. Age: 30 years old RR: 19cpm Date: October 9, 2012(post-op) BP: 120/80mmhg

V/S: Temp: 37.5 C PR:75bpm

EENT: [x] impaired vision [ ] blind [ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose, and throat For abnormality [ ] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopenea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp.rate, rhythm, depth, and pattern Breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [] strong pulses X Assess heart sounds, rate, rhythm, pulse, bp, Circulation, fluid retention, comfort [x ] no problem GASTRO INTESTINAL TRACT:
44 Body weakness C foley bag catheter attached to urobag draining to a tea colored urine #6 D5lr @30 gtts/min Epidural catheter in front and back Pain in the surgical site with pain scale of 7/10 Surgical site with attached Penrose draining to a deep gold colored drainage Abdominal Gird: 39 cm

[ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia Assess urine freq., control, color, odor, comfort / Gyn-bleeding, discharge [x] no problem

NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethartic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech [x] No problem MUSCULOSKELETAL & SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [] poor turgor [ ] cool [ ] deformity [ ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist Assess mobility, motion, galt, alignment, joint function/ Skin color, texture, turgor, integrity [x] no problem

SUBJECTIVE COMMUNICATION: [ ] hearing loss [] visual changes [] others: language [ ] denied Comments: mao ra man pud gihapon adtong bag-o siya natulog. As verbalized. [] glasses

OBJECTIVE [] languages [ ] hearing aide

[ ] contact lenses

[ ] speech difficulties Pupil size & reaction: 2 mm-3mm PERRLA (pupils equally round and reactive to

45

light accommodation

OXYGENATION: [ ] dyspnea [X] smoking history [ ] cough [ ] sputum [ ] denied Comments: Oo, gapanigarilyo na siya sauna as verbalized.

Resp.

[x] regular

[ ] irregular

Describe: normal breathing patterns with respiratory rate of 20 cpm

R: Right lung is symmetrical to the left L: Left lung is symmetrical to the right

CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x] denied

Comments:. sakit lang jud daw ang iyang samad.as verbalized

Heart Rhythm [x] regular [ ] irregular Ankle Edema Pulse Fem* R: Car none Rad. AP

L: Comments: Pulses are strong and easy to palpate. NUTRITION: Diet: NPO []N[]V Character [ ]recent change in weight and appetite [ ] swallowing Difficulty Lower [] [ ] Comments: dili sad aw siya pakan-on ingon ang doctor. As verbalized Upper [] [ ] Full Partial [ ]dentures [x]none

46

[x] denied

ELIMINATION: Usual bowel pattern Once a day [ ] constipation Date of last BM October 10, 2012 [ ] diarrhea [ ] urinary frequency 5 times a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ x ] foley in place [] denied

Comments: Bowel sounds are audible and normoactive

Bowelsound: normoactive _(20/min)____ Abdominal Distention Present [x] yes [] no Urine* (color, consistency, odor) with a tea-colored urine,aromatic

MGT. OF HEALTH & ILLNESS: [x] alcohol [ ] denied [ ] SBE Last Pap Smear: LMP: N/A

Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present): The patient was able to follow medicationsand treatments as prescribed to her.

SKIN INTEGRITY: [ ] dry [ ] itching [ ] other [x] denied

Comments: Mao raman japon, wala may nabag-o sa iyahang pamanit as verbalized.

[ ] dry [ ] flushed [ ] moist

[ ] cold [ ] warm [ ] cyanotic

[ ] pale

Rashes,ulcers,decubitus (describe size, location,drainage) : no rashes, ulcers, decubitus noted

47

ACTIVITY/SAFETY [ ] drowsiness [ ] dizziness [x ] limited motion of joints Limitation in ability to [ ] ambulate [ ] bathe self [] denied Comments: luya lang gyud siya karon, di sa siya ipa.sturya, papahulayon lang sa jud siya. as verbalized. [ ]LOC and orientation: client is alert, oriented to time and place Gait: [ ] walker [ ] cane

[ ] other [x] none [ ] sensory and motor losses in face or extremities: there is no alteration in sensory & motor function [ ] ROM limitations: with limitations

COMFORT/SLEEP/AWAKE Comments: Ok [ ] pain [ ] nocturia [ ] sleep difficulties [x] denied raman iyahang pagkatulog as verbalized

[ x ] facial grimaces [ ] guarding [ ] other signs of pain: [ ] side rail release form signed [] none

COPING Occupation: businesswoman Members of household: husband, children, mother

Observed non-verbal behavior: She is very attentive and cooperative. She entertains our every questions and query.

Most supportive person: husband

The person & her phone number that can be reached anytime: 09163894562

48

NURSING ASSESSMENT NURSING SYSTEM REVIEW CHART Name: Mrs. G. Age: 30 years old RR: 19cpm Date: October 10, 2012(post-op) BP: 130/80mmhg

V/S: Temp: 37.7 C PR:75bpm

EENT: [] impaired vision [ ] blind [ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose, and throat For abnormality [x] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopenea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp.rate, rhythm, depth, and pattern Breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain [] stong pulses X Assess heart sounds, rate, rhythm, pulse, bp, Circulation, fluid retention, comfort [x ] no problem GASTRO INTESTINAL TRACT: [ ] pain [ ] urine color [ ] vaginal bleeding
49 C foley bag catheter attached to urobag draining to a yellow colored urine #7 D5lr @30 gtts/min Epidural catheter in front and back removed @ 10 am Slight fever Pain in the surgical site with pain scale of 5/10 Surgical site with attached Penrose, draining to a deep gold colored drainage

Abdominal Gird: 39cm

Limited movements, body weakness

[ ] hematuria [ ] discharge [ ] noctoria Assess urine freq., control, color, odor, comfort / Gyn-bleeding, discharge [x] no problem

NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethartic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech [x] No problem MUSCULOSKELETAL & SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [] poor turgor [ ] cool [ ] deformity [ ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist Assess mobility, motion, galt, alignment, joint function/ Skin color, texture, turgor, integrity [x] no problem

SUBJECTIVE COMMUNICATION: [ ] hearing loss [] visual changes [] others: [x ] denied Comments: maayo ra [] glasses man pud ko bahin ana karon,maghinay-hinay lang k okay sakit. As verbalized.

OBJECTIVE [] languages [ ] hearing aide

[ ] contact lenses

[ ] speech difficulties Pupil size & reaction: 3 mm-3mm PERRLA

50

(pupils equally round and reactive to light accommodation OXYGENATION: [ ] dyspnea [X] smoking history [ ] cough [ ] sputum [ ] denied Comments: Oo, gapanigarilyo ako sauna . as verbalized. R: Right lung is symmetrical to the left L: Left lung is symmetrical to the right CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x] denied Comments:. sakit lang jud dapit sakong samadas verbalized by patient Heart Rhythm [x] regular [ ] irregular Ankle Edema Pulse Fem* R: Car none Rad. AP Resp. [x] regular [ ] irregular

Describe: normal breathing patterns with respiratory rate of 20 cpm

L: Comments: Pulses are strong and easy to palpate. NUTRITION: Diet: NPO []N[]V Character [ ]recent change in weight and appetite [ ] swallowing Difficulty [x] denied Lower [] [ ] Comments: dili sa d aw ko pakan-on ingon ang doctor. As verbalized. Upper [] [ ] Full Partial [ ]dentures [x]none

51

ELIMINATION: Usual bowel pattern Once a day [ ] constipation Date of last BM October 10, 2012 [ ] diarrhea [ ] urinary frequency 5 times a day [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ x ] foley in place [] denied

Comments: Bowel sounds are audible and normoactive

Bowelsound: normoactive _(20/min)____ Abdominal Distention Present [x] yes [] no Urine* (color, consistency, odor) with a yellowcolored urine,aromatic

MGT. OF HEALTH & ILLNESS: [x] alcohol [ ] denied [ ] SBE Last Pap Smear: LMP: N/A

Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present): The patient was able to follow medicationsand treatments as prescribed to her.

SKIN INTEGRITY: [ ] dry [ ] itching [ ] other: rash [x] denied

Comments: nagka-rashes lagi ko tungod sa diaper. As verbalized.

[ ] dry [ ] flushed [ ] moist

[ ] cold [ ] warm [ ] cyanotic

[ ] pale

Rashes,ulcers,decubitus (describe size, location,drainage) : rashes on the pubic area.

52

ACTIVITY/SAFETY [ ] drowsiness [ ] dizziness [x ] limited motion of joints Limitation in ability to [ ] ambulate [ ] bathe self [] denied Comments: ok raman. Musakit lang jud siya pagmalabian ko ug sturya o lihok. as verbalized. [ ]LOC and orientation: client is alert, oriented to time and place Gait: [ ] walker [ ] cane

[ ] other [x] none [ ] sensory and motor losses in face or extremities: there is no alteration in sensory & motor function [ ] ROM limitations: the patient has some difficulty on moving

COMFORT/SLEEP/AWAKE Comments: Ok [ ] pain [ ] nocturia [ ] sleep difficulties [x] denied raman, makapahulay man pud ko ug ayo. as verbalized. COPING Occupation: businesswoman Members of household: husband, children, mother

[ x ] facial grimaces [x ] guarding [ ] other signs of pain: [ ] side rail release form signed [] none Observed non-verbal behavior: She is very attentive and cooperative. She entertains our every questions and query.

Most supportive person: husband

The person & her phone number that can be reached anytime: 09163894562

53

VII. NURSING MANAGEMENT

PROGRESS NOTES

FIRST DAY We had our first assessment and visited as a group last October 7, 2012, Sunday at exactly 1:30 in the afternoon at Northern Mindanao Medical Center, CDOC with our chosen patient S.G. Upon arrival, patient was lying on the folding bed along the hallway with ongoing IVF of D5LR at 850 cc regulated at 30 gtts/min. We had done our head to toe assessment and assessed patients health status through inspection,auscultation, palpation and percussion. Assessment findings included: patient suffered abdominal pain radiating to the back with a pain scale of 8/10, verbalization of anxiety at moderate level and shes irritable and cant sleep properly due some environmental stimuli (ventilation, space and noise). The patient also suffered from activity intolerance due to pain. We also determined the patients diet (Low Fat Diet) and we found out that she has a good apetite. Vital signs are within normal range. With the assessment presented, we prioritized problems and planned interventions based on the existing problems manifested by the patient. Interventions planned were focused on relieving pain and providing comfort to the patient. The following were the interventions rendered and health teachings given: 1. Obtained and recorded vital signs. 2. Encouraged to express feelings regarding feelings toward the upcoming operation. 3. Instructed to avoid food rich in cholesterol such fried foods and egg. 4. Encouraged adequate rest periods 5. Encouraged to do deep breathing exercise during onset of pain. 6. Placed patient to comfortable position. 7. Encouraged to do diversional activities like listening to music. 8. Instructed significant others to assist the patient in doing daily activities. 9. Emphasized compliance of prescribed medications.

SECOND DAY We had our second assessment last October 8, 2012 Monday. Since two of our groupmates had their duty at the surgical ward, they were assigned to take care of the

54

patient chosen for our GCP. Upon arrival, patient was lying on bed at Female ward with the same IV infusion and rate. The two members of our group have done their head-to-toe assessment. Assessment findings included: verbalization of pain in the abdomen with a pain scale of 5/10, anxiety at moderate level. We also assessed patients diet and found out that she has poor apetite. Vital signs are within normal range. With the assessment presented, we prioritized problems and planned interventions based on the existing problems manifested by the patient. Interventions planned were focused on relieving pain, and promotion of comfort. The following were the interventions rendered and health teachings given: 10. Obtained and recorded vital signs. 11. Elevated head of the bed. 12. Instructed to take deep breaths every after pain is felt. 13. Instructed the significant others not to leave the patient alone. 14. Encouraged adequate rest periods 15. Instructed to avoid rich in cholesterol such as fried foods and egg 16. Placed patient in a comfortable position. 17. Encouraged patient to verbalize feelings on how shes doing 18. Cleaning and straightening beddings THIRD DAY We had our third assessment and visit last October 9, 2012, Tuesday. Upon arrival, we have done head to toe assessment and found out the same problems as the second day. That day, she was scheduled on her operation (cholecystectomy) at 10 am. She verbalized that she was a liitle tense and we encouraged her to express her feelings to lessen her anxiety.

19. Obtained and recorded vital signs 20. Elevated head of the bed 21. Instructed deep breathings during onset of pain 22. Encouraged to do diversional activities 23. Nothing per orem maintained 24. Encouraged adequate rest period 25. Placed patient in desired position 26. Encouraged verbalization of feelings
55

FOURTH DAY We had fourth assessment and fourth visit last October 10, 2012, Wednesday at exactly 6 in the evening. Upon arrival, we had witnessed is

FIFTH DAY We had our fifth day of assessment and visit last October 11, 2012, Thursday at 2:30 in the afternoon. Upon arrival, patient was sitting in the bed alone. Foley Bag Catheter was already removed. We assessed from head to toe. Patient verbalized feeling of improvement in her condition, she said that it pain is lessen and cited that pain scale is 2 out of 10 even without taking the pain relivers. Patient is already trying to stand and move in her own without anybody s help. Monitored vital signs dont show any signs of complications. The dressing doesnt show any signs of infections. With the assessment presented, we prioritized problems and planned interventions based on the existing problems manifested by the patient. Interventions planned were focused on relieving pain, and promotion of comfort. The following were the interventions rendered and health teachings given:

56

A. IDEAL NURSING MANAGEMENT Nursing Diagnosis Nursing Interventions Independent: Anxiety (Moderate) related to Hyper Metabollic State (CNS Stimulation) Observe behaviour indicative -Mild of level of anxiety. anxiety may be Rationale

displayed by irritability and insomnia. Severe Anxiety

progressing to panic state may produce feelings of

impending

doom,

terror,

inability to speak or move, shouting/swearing. Monitor physical responses -Increase number of beta noting palpitations, repetitive adrenergic movements, hyperventilation, coupled and insomnia. excess produces manifestations receptor with thyroid sites, of

effects

hormones, clinical of

catecholamine excess even with normal levels of

norepinephrine exists. Stay with patient, maintaining -Affirms calm manner. to patient that

although patient feels out of control, environment is safe.

Acknowledge fear and allow -Avoiding

personal

patients behaviour to belong responses to inappropriate to patient. remarks or actions prevents conflicts/overreaction to

57

stressful situation.

Describe/Explain procedures, -Provides

accurate

surrounding environment, or information, which reduces sounds that may heard by distortion/misinterpretations the patient. that can contribute to

anxiety/fear reactions.

Speak in brief statements, -Attention using simple words. shortened,

span

may

be

concentration

reduced, limiting ability to assimilate information.

Reduce

external

stimuli. -Creates

therapeutic shows that unit may

Place in quiet room; provide environment; soft, soothing music; reduce recognition

bright light; reduce number of activity/personnel persons contacting patient.

increase patients anxiety.

Discuss with patient reasons -Understanding

that

for emotional ability/psychotic behaviour is physically based reaction. enhances situation different responses/approaches. acceptance and of

encourages

Reinforce emotional return process. as

expectation control drug

that -Provides

information

and

should reassures patient that the therapy situation is temporary and will improve in treatment.
58

Collaborative:

Administer agents or

anti-anxiety -May be used in conjunction sedatives and with medical regimen to of

monitor effects.

reduce

effects

hyperthyroid secretion.

Refer to support systems as -Ongoing needed, social care. e.g.,

therapy

support

counselling, may be desired/ required by pastoral patient/SO precipitates alterations. if crisis lifestyle

services,

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Diagnosis

Nursing Interventions Independent:

Rationale

Ineffective Breathing Pattern related to Pain

Observe respiratory rate/depth

-Shallow breathing, splinting with respirations, holding breath may result in hypoventilation/atelectasis.

Auscultate breath sounds.

-Areas of decreased/absent breath sounds suggest atelectasis, whereas adventitious sounds reflect congestion.

Assist patient to turn, cough -Promotes ventilation of all and deep breathe periodically. Show patient how to splint incision. Instruct in effective breathing techniques. lung segments and and

mobilization

expectoration of secretions.

Elevate head of bed; maintain Low-Fowlers position. Support abdomen when coughing, ambulating.

-Facilitates lung expansion. Splinting provides incisional support/decreases tension cooperation therapeutic regimen. to muscle promote with

Collaborative: Assist with respiratory treatments, e.g. Incentive spirometer. -Maximizes expansion of lungs to prevent/ resolve atelectasis.
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Administer analgesics before breathing treatments/therapeutic activities.

-Facilitates more effective coughing, deep breathing and activities.

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Diagnosis Impaired Skin Integrity related to surgical incision

Nursing Interventions Independent: Observe the color and character of the drainage.

Rationale

-Initially, drainage may contain blood and bloodstained fluid, normally changing to greenish brown (bile color) after several hours.

Change dressings as often as necessary. Clean the skin with soap and water. Use sterile petroleum jelly gauze, zinc oxide, or karaya powder around the incision.

-Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation.

Apply montgomery straps

-Facilitates frequent dressing changes and minimizes skin trauma.

Place patient in low- or semi-Fowlers position.

-Facilitates drainage of bile

Check the T-tube and

-T-tube may remain in

incisional drains; make sure common bile duct for 7-10 that they are free flowing. days to remove retained stones. Incision site drains are used to remove any accumulated fluid and bile.
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Correct positioning prevents backup of the bile in the operative area.

Maintain T-tube in closed collection system.

-Prevents skin irritation and facilitates measurement of output. Reduces risk of contamination.

Collaborative: Administer antibiotics as indicated. -Necessary for treatment of abscess/infection.

Monitor laboratory studies, e.g., WBC.

-Leukocytosis reflects inflammatory process., abscess formation/peritonitis.

Nursing Diagnosis

Interventions Independent:

Rationale

Risk for Infection Stress proper hygiene by all -First line defense against caregivers between therapies and client healthcare associated infections (HAIs)

Use gloves when caring for open lesions

-To minimize autoinoculation or transmission of viral diseases

Maintain adequate hydration stand or sit to void

-To avoid bladder distention and urinary stasis

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Maintain sterile techniques for all invasive procedures

-To avoid cross contamination

Maintain adequate nutrition, -For proper nutrition rest, and appropriate exercise program

Nursing Diagnosis

Interventions Independent: Note for pain, including

Rationale

Acute pain related to the incision site

location, characteristics, onset and frequency Monitor skin color, temperature and vital signs

-To rule out worsening of underlying condition or development of complications. -This are usually altered in acute pain.

Provide comfort measures such as touch, repositioning, quiet environment Instruct in and encourage use of relaxation techniques such as focused breathing

-To promote non pharmacological pain management

-To distract attention and reduce tension

. Dependent: Administer NSAIDS(Ibuprofen) as prescribed by the physician -Relief of mild to moderate pain

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B. ACTUAL NURSING MANAGEMENT S O Sakit kaayo akong tibook likod ug tiyan as verbalized by the patient. A P Facial grimace Pain Scale of 8/10, spasmic pain all over the abdominal area Guarding on the abdominal area Self focusing; narrowed focused

Acute Pain related to obstruction in the bile duct Long Term: At the end of 1 hour, patient will demonstrate techniques to alleviate or control pain. Short Term: At the end of 30 minutes nursing interventions, patient will be able to relieved from pain felt. Promoted bed rest and in low fowlers position Use soft cotton linens, cool or moist compress as indicated Control environmental temperature Encouraged use of relaxaton techniques like deep breathing exercises Administered medication as prescribed (Tramadol 50 mg slow IVTT, q8 x 3 doses then PRN)

Long Term: After 1 hour of nursing interventions, the patient was able to demonstrate techniques to alleviate pain like deep breathing exercise. After 30 minutes nursing interventions, patients was relieved from pain after administration of analgesic.

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S O

maglisod ko ug tulog kay igang kaayo as verbalized by the patient. Change in normal sleep pattern Restless Irritable

Disturbed Sleep Pattern related to environmental factors( noise, ambient temperature)

Long term: At the end of 1 day nursing intervention, the patient will be able to report improve sleep and increase sense of well-being. Short term: At the end of 4 hours of nursing intervention the patient will be able to identify interventions to promote sleep.

Provided a quiet environment Provided comfort measures (touch therapy, cleaning and straightening beddings) Use of sleep aids (personal pillows) Instructed to establish routine bed time and arising, think relaxing thoughts when in bed, do not nap in the daytime Adequate rest provided

Long term: After 1 day of nursing intervention, patient have been able to improved sleep and increased sense of well-being. Short term: After 4 hours of nursing intervention, the patient was able to identify interventions to promote sleep.

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Dili kaayo ko kalihok maam kay sakitan ko as verbalized by the patient.

facial grimace guarding sleep disturbance

Activity Intolerance related to decreased range of motion and pain on movement

Long term: After 2 days of nursing interventions, the patient will be able report measurable increase in activity tolerance

Short term: After 1day of nursing interventions, the patient will to identify techniques to enhance activity tolerance I Properly position the patient to avoid straining affected areas in the body Engaged ROM exercises, as tolerated, to reduce muscle stiffness and numbness Assisted ADLs to help reduce discomfort and avoid too much energy exertion Encouraged frequent position changes (side-lying to supine) when on bed rest Encouraged bed rest

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Gakakulbaan ko sa akong operasyon karon kay last nako nga opera, gi intubate man gud ko as verbalized by the patient.

Verbalize awareness of feelings Anxious Restlessness Preoccupied from her last operation experience

A P

Anxiety related to threat of death or change in health status Long term: After 1 day of nursing interventions, the patient will appear relaxed and report anxiety reduced to a manageable level.

Short term: After 6 hours of nursing interventions, the patient will verbalize awareness of feelings of anxiety I E Established a therapeutic relationship, conveying empathy and unconditional positive regard. Be available to client for listening and talking Encouraged client to acknowledge and to express feelings Provided information regarding disease process and anticipated treatment Provided comfort measures(e.g., calm/quiet environment, therapeutic touch) Provided adequate rest Instructed in ways to use positive talk, e.g., I can handle this

Long term: After 1 day of nursing interventions, the patient appeared relaxed and reported reduced anxiety manifested by socialization engagement(talking with other patients and laughing with them).

Short term: After 6 hours of nursing interventions, the patient was able to verbalize understanding of her present health status that lessened her anxiety.

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S O

gasakit akong tahi kung mulihok ko as verbalized by patient (+) Facial grimace Pain scale of 5 out of 10, Self-focusing; narrowed focus

A P

Acute pain related to post op surgical incision Long term: After 8 hours of nursing interventions, the patient will demonstrate techniques to alleviate/control pain. Short term: After 30 minutes of nursing interventions, the patient will report relief of pain

Positioned client to where she is comfortable Taught client diversional activities like watching television Encouraged use of relaxation techniques like focused breathing Have the patient splint incision when moving Provided adequate rest periods Provided a calm, quiet environment Administered analgesic (ketorolac 300 mg IVTT,q6 x 4 doses)

Long term: The patient was able to demonstrate techniques to alleviate pain Short term: The patient reported that the pain was lessened

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S O

gasakit akong tahi kung mulihok ko as verbalized by patient Sugical dressing on RUQ Disruption of the skin surface Injury on the skin layers

A P

Impaired skin integrity related to surgical incision Long term: After 2 days of nursing interventions, the patient will achieve timely wound healing without complications Short term: After 1 day of nursing interventions, the patient will demonstrate behaviors to promote healing/prevent skin breakdown

Observed the color and character of the drainage Changed dressings and do wound care as often as necessary Placed patient in low- or semi-Fowlers position Maintained T-tube in closed collection system Administered antibiotics (cefuroxime 350 mg, IVTT q8).

Long term: After 2 days of nursing intervention, the patient was able to maintained the wound intact and free from complications Short term: After 1 day of nursing intervention, the patient verbalized understanding of proper wound care and demonstrated the proper way to do it.

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VII. REFERRAL AND FOLLOW-UP HEALTH TEACHINGS The medications prescribed by the doctor were thoroughly explained including its indication, possible MEDICATION adverse effects, contraindication, precautions to be taken and patients response. And to take it on right time, dose, and route Celecoxib 200mg TID 1cap Cefuroxime 500mg 1tab TID times 5 days.

Encouraged to ambulate every morning for 30 minutes to promote rehabilitation of bodys energy. EXERCISE Taught to do Range of motion exercises. Gradually, encouraged to do normal daily activities. Taught the importance of proper hygiene and hand washing Encouraged to change the dressing everyday TREATMENT Encouraged to apply povidine iodine (Betadine) to the wound before changing the dressing Encouraged to schedule rest periods and sleep periods. Advised to have follow-up check up on October 19, 20012 OUTPATIENT (check-up) at the Outpatient Department, Northern Mindanao Medical Center. Encouraged to eat low fat, low salt diet. Taught about the importance of her diet modification. They lose weight. Their health usually improves. DIET Their risk of developing cardiovascular disease may decrease. They get relief from unpleasant gastrointestinal symptoms.
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Encouraged to increase protein intake Cheese Mature (Large) Beans Lean Veal and Beef Lean Meats (Chicken, Lamb, Pork, Turkey) Lobster and Crab Peanuts Fish

Encourage to increase fluid intake at least 10-12 glasses per day.

Intake of vitamin C like orange, mango fruit.

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PROGNOSIS

Score Legend: 1 Poor Prognosis 2 Good Prognosis 3 Very Good Prognosis

CRITERIA

SCORE

ANAYSIS/IMPLICATION 2 days prior to admission,

A.ONSET OF ILLNESS

onset of epigastric pain, grouping, 7/10 in patient scale, radiating to lower back, associated with shortness of breath no consult, no medication given. Detection of the disease

B. DURATION OF ILLNESS 1

condition was delayed for attaining prevention. Manifestation showed up by mean of pain on the upper quadrant of the abdomen radiating to lower back two days prior to admission. The increasing age of the patient, the gender and her

C. PRECIPITATING AND PREDISPOSING FACTOR 3

diet which is mostly rich in salty and high in cholesterol diet predisposed her and put her at risk for obtaining
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such condition. Such factor manifest by the patient cannot already be altered and prevented. Unfortunately, manifestations showed up but were diagnosed too late for her to prevent from the condition. Thus strictly following the treatment regimen would help her prevent from further complication and faster recovery The patients admission 3 D. ATTITUDE & WILLINGNESS TO TAKE TREATMENT and adherence medication regimen may somehow proved that the patient is very willing to follow treatment that she even had a surgery in order for her to recover the stated condition. Patient is financially capable for her was able to E. FINANCIAL CAPABILITY 3 pay the entire medical and hospital bills by the help of family member and phil. Health.

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Sign of progressive were F. POST-OPERATIVE RECOVERY 3 visible that she was able to stand up and walk around the area with assistance on the first day of post operatively. A daily progressive sign of relief from a surgical procedure especially on the incisions showed a 2 G.PAIN MANAGEMENT good prognosis that she had recovered from the surgical procedure done. Her family was very H. FAMILY SUPPORT 3 supportive that her husband was the one who supported the operation and hospital bills and she was always accompanied by either her husband or her children during admission. This is why patients prognosis is very important for patient having such condition vary greatly on the health, the extent of damage, the regimen given and the patients adherence to it, and most importantly the detection of the disease. Most noted prognosis in the chart shows good prognosis but the detection of the symptoms were too late for her to prevent and to be able treated that may lead to life threatening complication.

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IX.

EVALUATION

At the end of the study the presenters were able to attain the goal that we have set from the start of her study. Thorough gathering of data by means of physical assessment were met and through the gathered data we were able to identify some health problems and were able to skilfully formulate nursing care plan that we had applied to our patient in actual. By means of reviewing, discussing and elaborating the affected anatomy and physiology of the body enabled us to create interventions that could alleviate pain and any discomfort experienced by the patient. With the help of the patient family, we were able to explore part of the patients personality that also helped us increasing interventions appropriate for her. Through the interventions we imparted there was a progress in patients health status such as regained his activity of daily living. The presenters also imparted health teachings not only the patient but to her family as well, in order to lower the risk of having this kind of condition. Choosing the right diet was also elaborated for them to be aware of the precise choice of foods and nutrition right for preventing the disease like avoiding food that is salty, fatty and especially those highly seasoned foods which always pertained to the food we were eating, we should still be conscious with our health especially if we want to live longer. Avoid that life threatening disease which not only shorten our life but caused us some financial problem too.

Lastly, the presenters were also grateful for having the opportunity to have the case study for they not only gain knowledge but also enhanced their skills in the field of nursing by means of planning interventions and rendering care to the patient. The researches were hoping that the readers would be more conscious and be more careful in taking of their health to prevent conditions to persist.

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X.

DOCUMENTATION

BIBLIOGRAPHY BOOKS DRUG HANDBOOK Lippincott Williams & Wilkins Nursing 2004 24th edition. MIMS PHILIPPINES. 123rd edition 2012, Philipine Index Of Medical Specialties Establishment. 1968 Ben Yeo, Lippincott Manulal of Nursing 8th edition, Lipincott Williams & Wilkins PATHOPHYSIOLOGY Lippincott Williams &Wilkins A2-in-1 reference for nurses. Fundamentals of nursing Concepts. Process and Practices 11 th edition. Upper Saddle, Kozier, B. etal New Jersey, 2007. Nursing Care Plans, Nursing Diagnosis and Intervention 6th edition, by Gulanick/Myers WEBSITES WWW.MEDICINENET.COM/CHOLE/ARTICLE.HM www.who.int/topics/chole www.mursingcribs.com www.youtube.com www.google.com www.MIMS.com www.PIMS.com

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