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College of Nursing




Presented to:

Presented by:

BSN – 3H
Patient’s Data………………………………………………………………………….
Family History………………………………………………………………………..
Developmental Data…………………………………………………………………...
Physical Assessment……………………….…………………………………………..
Complete Diagnosis……………………………………………………………………
Anatomy and Physiology………………………………………………………………
Doctor’s Order……………………………………………………………………..……
Diagnostic Examiation.………………………………………………………………….
Drug Study………………………………………………………………………………
Procedural Report……………………………………………………………………….
Nursing Theories…………………………………………………………………………
Nursing Care Plans……………………………………………………………………….
Discharge Planning……………………………………………………………………….

The student nurses would like to express their gratitude and

appreciation primarily to Mr. Police for allowing them to have his case as

their study. He had been very accommodating and cooperative to them

during the entire exposure. Moreover, he was also very patient with them

while providing them sufficient information regarding him and his case.

Furthermore, they are grateful to Anna for being supportive and also

for giving them an opportunity to learn more regarding her husband’s case

so that they could provide effective and efficient nursing interventions.

The staff nurses are also acknowledged for their kind accommodation.

Their humility in sharing some of their knowledge was great help to the

student nurses’ learning. Consequently, their efforts and assistance have

made the student nurses efficient in rendering nursing care towards the

valued patients.

The student nurses would also like to thank Ma’am Gisselle Charade A.

Zamora, R.N. for giving them the appropriate orientation and facilitation on

their first exposure to St. Joseph. She had been very patient and

understanding to them, and gave them an enjoyable and unforgettable

experience that made them further appreciate the “journey of our being.”

In addition, they would also want to express their heartfelt thanks to

Sir Anselmo Lafuente, R.N., their substitute clinical instructor at St. Joseph

ward at DMSF Hospital, for guiding and inspiring them with his remarkable
holistic teachings that encouraged them not only to be better nurses, but as

well as better individuals. May they find the right path towards God, as he

wishes them to.

The student nurses would also like to thank their respective families

who have always supported and encouraged them to be confident in what

they are doing; for the financial and moral support and for understanding.

Thank you for the love. The group would also like to extend their gratitude to

the Perpetua family for welcoming them into their home and for securing

them enough provisions and moral support.

And above all, they are very thankful to the Almighty Father for gracing

them with His wonderful blessings. He is their ultimate strength and hope.

They pray for His loving guidance as they continue their journey in their

nursing careers.

The gallbladder is a small pear-shaped organ which aids in the

digestive process. Its function is to store and concentrate bile - a digestive

liquid continually secreted by the liver. The bile in turn emulsifies fats and

neutralizes acids in partly digested food. Despite its importance in the

digestion of fat, many people are unaware of their gallbladder. Fortunately

enough, the gallbladder is an organ that people can live without. Perhaps,

this fact contributes to the laxity of the majority. The gallbladder tends to be

taken for granted – ignored of the proper care and conditioning. Lifestyle

together with heredity, sex, race and age are just some factors that leave a

room for gallbladder complications to occur.

This study is about cholecystitis. The most common cause of

cholecystitis is gallstones (90% of the cases). The bile becomes concentrated

in the gallbladder. This later causes irritation and is probably the leading

cause of inflammation. Cholecystitis affects women more often than men and

is more likely to occur after age 40. People who have a history of gallstones

are at increased risk for cholecystitis. In the international level, cholecystitis

has an increased prevalence among people of Scandinavian descent, Pima

Indians, and Hispanic populations, whereas cholelithiasis is less common

among individuals from sub-Saharan Africa and Asia. It affected 20.5 million

people (1988-1994) with a mortality record of 1,077 deaths in 2002.

Hospitalizations total up to 636,000 in the same year and over 500,000 have

undergone cholecystectomies. In the Philippines alone, an extrapolated

prevalence of 5,073,040 people are affected by the disease last 2007.


The student nurses have chosen this case as they see it fit for the peri-

operative concept as the patient has had undergone open cholecystectomy.

Moreover, despite the cholecystitis’ low incidence, they would like to give

credit and to know more of the nature and function of the gallbladder. Much

often this small organ is not given importance. Thus they are in a pursuit for

knowledge to be able to impart it to others. Furthermore, this case is quite

interesting since it does not always affect only females and elderly. It can

affect everyone. It can be alarming since many people are confused and

unaware of the symptoms presented.

As teen-agers living in a fast-phased world and governed by schedules,

they too are predisposed to lifestyle modification – especially diet and food

preferences which can contribute to the disease. With this study, the student

nurses hope to apply their learning in taking care not only of their patients

but also of themselves.

As nursing students and future nurses, they would want to understand

and appreciate more on what is happening to a patient with cholecystitis.

Consequently, they are interested on what will be the necessary

management that will be given. Through this, they are hoping that they will

be able to find the right plan of care and sound interventions, not forgetting

the patient’s rights as a person. All in all, these will help them to become

efficient nurses and better persons later on.


After 5 days of data gathering, research and analysis, the student

nurses shall have devised objectives that will guide them for the proper

understanding and fair interpretation of the case of their chosen patient.



The student nurses’ first main goal is to gain knowledge through the

completion of the case study and to impart this learning to Mr. Police and to

those directly and indirectly involve with the completion of this case.

Specific Objectives under Cognitive aspect

Within the 5 days span of duty, the student nurses will be able to:

• Gather significant data from the patient’s chart which includes the

doctor’s order, laboratory exams and etc. to have complete

information about the patient’s current condition.

• Research on the anatomy and physiology of the clients affected


• Research on the possible causes and also the symptoms the patient

experienced that may suggest the current condition of the patient.

• Research and understand the disease process of the patient’s illness.

• Determine and interpret the medical management employed including

laboratory and diagnostic procedures.

• Identify and study the drugs prescribed to the patient which affects the

patient’s current situation.


In this aspect, the student nurse’s goal is to apply all what they have

learned during the process of completing this case study to improve nursing

care that will meet Mr. Police’s need for the improvement of his general


Specific Objectives under Psychomotor aspect

Within the 5 days span of duty, the student nurses will be able to:

• Conduct a thorough physical assessment and to interpret the

assessment in order to give the care the patient need.

• Formulate nursing care plans and apply them to satisfy the patient’s

needs and give appropriate nursing interventions.

• Make a discharge plan for the patient using M.E.T.H.O.D and validate

the patient’s prognosis according to categories.


With the knowledge gained and through the application of this

knowledge, another goal is that the student nurses will be able to empathize

with the current situation of the patient and to gain some values like the

value of patience and calmness which is important for a them to have in

order to become better nurses in the future.

Specific Objectives under Affective aspect

Within the 5 days span of duty, the student nurses will be able to:

• Establish rapport and therapeutic communication in order to gain

information about the patient which includes the medical and family

health history, expectations of his condition to him gather significant

data from the patient’s chart and to his family and etc.; and for the

betterment of nursing care.

• Assume the role of being the patient’s advocate.


Personal Data

Name: Mr. Police

Age: 46 years old

Sex: Male

Nationality: Filipino

Date of Birth: August 28, 1962

Place of Birth: General Santos City

Civil Status: Married

Address: Cabantian, Country Homes, Davao City

Religion: Christianity (Roman Catholic)

Educational attainment: College Graduate

Occupation: PNP

Clinical Data

Admitting Date and Time: April 27, 2009 at 10:40 am

Case Number: 01-36-90

Ward: St. Joseph (3C)

Room/ Bed: 325-5

Attending Physician: Dr. Batucan, Wolter

Chief Complaint: right upper quadrant pain

Diagnosis: Cholecystitis T/C Cholelithiasis

VS upon admission:
BP –120/90 mmHg R – 28 cpm P – 109 bpm Temp

– 36.5˚C

Sources of info: Chart, Mr. Police himself, and his wife


Lolo Lola Lolo B Lola

A± †ħ

Dad A B Mo 3 4 5 6
1 ħ

A Mr. Step- Step-

Police Sis brod Ø

BB 1 BB 2

ħ: Hypertensive
±: Unknown cause of death
Ø: Suicide
Δ: Died of childhood illness
†: Deceased

A. Family Background

Mr. Police is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children.

But his younger sister died of a childhood illness at the age of three

years old, he could not recall. He grew up at General Santos City where

the relatives of his mother live. When Mr. Police was a first year high

school, his parents got separated because of third party. He lived with

his mother and Mrs. Mom’s live-in partner at Davao City, while his

father returned to Leyte where his other relatives live. With his

mother’s second family, he had another two siblings, Step-brod and

Step-sis. Step-brod died at the age of 18 because of suicide. He had

suicide because of altered mental status due to shabu use. Today,

Step-sis has her own family at Leyte.

Because Mr. Police had been away from the relatives of his father, he

does not know any significant disease they have or had. He doesn’t

also know the causes of deaths of his grandmother and grandfather on

the paternal side. On the other hand, what he only knows is that the

eldest sister of her mother has hypertension, and that his grandfather

on the maternal side died of hypertension.

Currently, Mr. Police has been married to Anna for 15 years. They met

at Mandug, Davao City, where Mr. Police had been assigned at work

before. The couple had difficulty conceiving a child because Anna has

an obstetrical problem. She verbalized, “ingon sa doctor naa man gud

daw gas-gas akoang matres.” Fortunately, nine years after their

marriage, they were blessed with BB 1 who is now a kindergarten

student, aged six years old. Two years after, BB 2 followed.

B. Personal Background

Mr. Police graduated at MATS with a 4-year degree of BS-MT. But

because he couldn’t find a job with the course he had, he had six-

month training to become a policeman. Currently, he had been

assigned to San Pedro Police Station for a year already. He works 24

hours straight, then have a two-day rest.

On his rest day, he stays in their house and on the evening, goes with

his friends and has a drinking session. He enjoys watching TV, and

sometimes does the cooking as he likes to. He is not as close as the

children are to Anna. But he enjoys playing with them sometimes and

taking them out on weekends. He is a “barkadista” as his wife, Anna,

describes him. He has a set of close friends who are also policemen like

him. He is a Roman Catholic, who does not always goes to Church

every Sundays but is a Sto. Niño devotee. Every January, he goes back

to General Santos City, to attend certain activities in celebrating Sto.

Niño fiesta.

Mr. Police has been a smoker since he was 20 years old. His wife said

he smokes three boxes of cigarettes everyday. He has also been an

alcoholic drinker since he was 13 years old. He drinks three glasses of

alcoholic drink everyday. Furthermore, he doesn’t have a regular

exercise. But he enjoyed boxing with his friends, as an exercise, which

only lasted for six months (September 2008- February 2009). He

stopped because his friends also decided to stop. With regards to his

diet, he is a “meat-addict,” as Anna verbalized. Everyday, he eats

meat, and could not sleep without eating such. He also eats lots of

pulutan during their drinking sessions such as laman-loob, chicaron,

and other pica-pica. Moreover, he does not eat vegetables but eats all

kinds of fruits. Moreover, he has no known drug and food allergy.

C. Effects/ Expectations of Illness to Self/ Family

Because of his condition, he had to undergo an operation which means

he had to have a sick leave from his work. Moreover, Anna also has to

watch over him and she has to leave the children under the care of her

elder sister for a while. Moreover, Anna is worried of the effect of the

operation to the health of her husband. But she is hoping that because

of this hospitalization, he would realize that he should have a healthy

control over his health, that he would cease drinking and smoking.

Furthermore, Anna is also expecting that her husband would regain his

strength back soon.

D. History of Past Illness

Mr. Police experienced common illness such as colds, cough, and fever

during his childhood. He also had chicken pox during his childhood.

However, he could not recall at what age he got the disease and as

well as the management of his chicken pox.

Five years prior to admission (2004), he was diagnosed with diabetes

with an FBS result of 7.8 mmol/dL. They were having an annual check

up when he discovered that he has elevated blood sugar. He was then

advised to control his diet and have a regular exercise but he was not

given any maintenance drug. Moreover, he was not compliant with the

doctor’s advice.
Two years ago (2007), he was admitted to Davao Medical Center due to

loss of consciousness. Prior to that, he was experiencing palpitations,

and pain on the suboccipital area (nape) associated with headache. He

had elevated blood pressure of 180/100 as he could remember during

the VS taking at the emergency room. He was admitted for one day

and was diagnosed with hypertension. He was then given Lopicard

5mg tab OD, as a maintenance anti-hypertensive medication. The

doctor advised him to cease smoking and drinking alcohol, and as well

as to avoid over fatigue. He stopped smoking, but only for two months.

E. History of Present Illness

A month prior to admission, Mr. Police experienced right upper

quadrant pain associated with a sense of bloatedness, without nausea

and vomiting. The pain was tolerable so he did not seek medical

attention yet. He said he also had an increased level of pain tolerance

so he also didn’t mind to take any pain relievers. Until three days prior

to admission, patient had severe right upper quadrant pain, which was

said to be intolerable. Moreover, when pressure is applied on the RUQ

of the abdomen, pain is elicited. He had also lost his appetite because

of the pain. His scleras were also slightly icteric during admission and

he was positive with Murphy’s sign. So he sought consultation at Out-

Patient Department- Emergency Room at Davao Medical School

Foundation Hospital. Ultrasound revealed cholecystitis, so patient was

advised admission and operation.

Theories Stages Justification
Mr. Police and Anna have a
Freud’s A good sexual relationship.
Psychosexual C Though Mr. Police has an
Theory H erection-related problem,
Energy is directed
I the couple are able to
toward attaining a
Genital (13 E maintain a healthy sexual
mature sexual
years and V relation with each other.
relationship. This
older) E Anna said that she
stage involves a
D understands that this
reactivation of the
might be due to Mr.
pregenital impulses.
Police’s diabetes, though
These impulses are
they sometimes do not
usually displaced, and
achieve sexual
the individual passes
satisfaction. The erection-
to the genital stage of
related problem of Mr.
maturity. An inability
Police does not damage
to resolve conflicts
the couple’s relationship. It
can result in sexual
even made the couple
problems, such as
more mature and
frigidity, impotence,
understanding of each
and the inability to
other’s sexual needs.
have a satisfactory
Furthermore, Mr. Police
sexual relationship.
compensates by wooing
his wife through romantic
dinners and being sweet
with her, even in public.
Moreover, energy is
directed towards his work
as a policeman, being
committed to his work and
as well as to his
colleagues, who are also
the recipient of Mr. Police’s
energy towards his social
relationships to other
Stage 7: Generativity
Erikson’s A vs. Stagnation Mr. Police is able to send
Psychosocial C The middle adult his child to a private
Theory H years are a time of school, to ensure a high
I concern for the next standard of his educational
Stage 7: E generation as well as needs. Moreover, he works
Generativity vs. V involvement with alone to provide the
Stagnation E family, friends, and family’s financial needs.
(Middle D community. Socially- He doesn’t allow his wife
Adulthood valued work and to work to make sure that
40-65 yrs.) disciplines are the children receive a
expressions of direct parental guidance in
generativity. Simply their growing years.
having or wanting Moreover, as he works as a
children does not in policeman, he is satisfied
and of itself achieve with his service to the
generativity. There is public through their
a desire to make a protection and crime
contribution to the control activities. He
world. If this task is yearns for the
not met, stagnation community’s peace and
results, and the order and is achieved
person becomes self- through his public service
absorbed and as a policeman.
obsessed with his or
her own needs or
regresses to an
earlier level of
Mr. Police said that it is
Middle Adulthood normal that in his age,
Havighurst’s A Developmental tasks people get disease
Development C for middle adulthood because they are aging.
al Theory H include: Moreover, he is able to
I • Accepting and obtain a satisfactory
Middle E adjusting to occupational performance,
Adulthood V physical changes as he stayed on his job for
(40-65 yrs. old) E • Attaining and already more than 20
D maintaining a years already. Though his

satisfactory children are still four and

occupational six years old, he teaches

performance them values such as

• Assisting children honour, respect, and

to become honesty, for them to

responsible adults become like him, a

• Relating to one’s responsible citizen of our

country. In addition, Mr.
spouse as a person
Police said that he is
• Adjusting to aging
blessed with their
relationship because Anna
• Achieving adult
is not just a wife to her,
social and civic
but also a friend, whom he
could confide his problems.
As his parents are also
getting old, he said that he
visits them at least once or
twice a year. He even said
that wants them to live
their remaining life happy
and satisfied with it.
Moreover, he has achieved
social and civic
responsibility through his
public service as a


At 4 pm on April 30, 2009, physical assessment was done. Mr. Police, a

46 year old Filipino male, was lying in bed, asleep; with an IVF # 3

D5NSS 1L at the level of 80 cc, regulated at 120 cc/hr, infusing well at

right metacarpal vein; with epidural catheter; with Jackson Pratt drain;

with slightly soaked, intact dressing at right upper quadrant of the

abdomen, status post open cholecystectomy. Patient is responsive and

coherent when awaken; with complain of pain at the incision site, with

a pain scale of 6 out of 10. Patient was on NPO. He appeared

endomorphic. Patient was in good grooming, wearing clean patients

gown. Respiratory distress was not noted. Aside from that, he weighs

85 kg and stands 5’5” and has a body mass index of 31.18 which

denotes that he belong to the obese type I which ranges from 30 –



BP= 120/180 mm Hg PR= 85 bpm RR= 15 cpm

T= 36 °C


Skin was warm to touch, slightly dry, rough, and with good skin turgot.

Neither jaundice nor cyanosis observed. Papules on the face observed,

with nevi noted on the right side of the nose. Patient was not cyanotic.

No bruises or discolorations observed. No edema noted.


Skull size was normocephalic. Skull and face were symmetrical with an

equal distribution of hair. Hair was black in color with fair amount of

white and gray strands, short, dry, and fine. There was no dandruff or

infestation present. No lesions, lacerations, tenderness, masses and

depressions noted.

The forehead was furrowed with wrinkles. Face portrayed emotions

with symmetrical movements. No masses or involuntary movement.

The face was round, with no edema, lesions, discolorations present.


Mr. Police did not use any corrective aids such as glasses or contact

lenses. Eyebrows were evenly distributed and symmetrically aligned

with no of flakes, scars and lesions noted. Eyelashes were evenly

distributed and slightly curled outward. Lid margins were clear,

lacrimal duct openings were evident at the nasal side of the upper and

lower lids. Blinking reflex was present. Skin around the eyes was intact

with equal movement, with no discharges and no discolorations

observed. Eyelids close symmetrically. No edema seen in the

periorbital region. Shiny smooth and pink palpebral conjunctiva noted.

No edema or tenderness over lacrimal gland observed. Eye color was

dark brown. His pupils were equal within 1-2 mm diameter in size and

both have a brisk reaction to light and uniform reaction to

accommodation. Small anterior polar opacification was observed on

both eyes. Nystagmus, strabismus and lid lag were not evident.


Ears were symmetrical with same size bilaterally and color consistent

with face. Pinnas were free from lesions, masses, swelling, redness,

tenderness, and discharges and were in line with the eyes. External
canals were clear with no cerumen seen. No inflammation, masses,

discharges and foreign bodies noted. Gross hearing acuity was good.

No pain on the mastoid process was reported upon palpation.


The nose was symmetrical with no deformities, skin lesions, masses

present. Nasal septum is intact and in midline. No nasal flaring was

observed. No discharges were present. No tenderness in his sinuses

upon palpation.


Mouth was proportional and symmetrical. Lips were rust colored and

were dry with no presence of ulcerations, sores or lesions. Teeth were

yellowish in color with some dental caries noted. Right upper first

premolar tooth was absent. Tongue was in central position and moves

freely with no swelling or ulcerations observed. Gag reflex was present

as evidenced by patient swallowing. Tonsils were not inflamed.

Halitosis was also noted.


Neck was symmetrical with no masses or swelling noted. No jugular

vein distention was noted. Range of motion was normal and moves

easily without discomfort upon rotation, flexion, extension and

hyperextension. Thyroid was not enlarged has no nodules, masses, and

irregularities upon palpation. Trachea is symmetrical and in midline

without deviation.

Nipples were dark brown in color, inverted and in the midline. No

crusting and masses noted. Breasts were symmetrical with no edema

noted. Both axilla were free of lesions rashes, and infections. Lymph

nodes were not palpable.


No thorax deformity observed. Respiratory rate was 15 cycles per

minute with regular breathing pattern. Symmetrical chest expansion

was observed during respiration. No use of accessory muscles during

breathing observed. Chest wall was intact; no tenderness and masses

noted. Uniform temperature also noted. No adventitious breath sounds

heard upon auscultation. No cough present. No dyspnea, hemoptysis,

hiccups noted.


Apical heart beat was present upon auscultation with a point of

maximal impulse at the 5th intercostal space left midclavicular line;

with cardiac rate of 85 beats per minute with a regular rhythm. No

abnormal beats, palpitations, thrills or murmurs present upon



Abdomen was slighty enlarged and globular when patient was in

supine position; with slightly soaked, intact dressing on the right upper

quadrant with Jackson Pratt drain. Pulsations were not visible. The
abdomen had hypoactive bowel sounds of two bowel sounds per

minute. Tenderness noted on the right upper quadrant near the incision



Unable to perform inspection in the genitourinary region. However,

patient verbalized that he had not noted any discharges from his

genitalia nor presence of papules or ulcerations. Patient had not yet

voided since he had arrived from the OR.


Symmetrical shoulder movement observed during respiration. Spine

was located at the midline with no discrepancies noted. Shoulders,

arms, elbows and forearms were free from nodules, deformities and

atrophy. Range of motion was not limited. Neither pallor nor bone

enlargements were noted upon inspection of the upper extremities. A

permanent tattoo was present on his right deltoid area, anchor-

designed. Upper extremities were not edematous. Radial and brachial

pulses were present. Hip joint and thighs were symmetrical with no

deformities present. No edema noted at both legs. No inflammation

noted in the lower extremities. Range of motion was active and not



- Cholecystitis is the inflammation of the galbladder

Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of

Mecial-Surgical Nursing 11th Edition.

- Cholecystitis refers to inflammation of the gallbladder and cystic


Source: Barbara Gould, Pathophysiology for the Health Professions,

Third Edition, Saunders Elsivier

- Cholecystitis refers to inflammation of the gallbladder.

Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered

Health Sciences


- The presence of calculi in the gallbladder

Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of

Mecial-Surgical Nursing !0th Edition.

- Cholelithiasis refers to formation of gallstones, which are masses

of solid material or calculi that forms in the bile.

Source: Barbara Gould, Pathophysiology for the Health Professions,

Third Edition, Saunders Elsivier

- Cholelithiasis, or gallstones, is caused by precipitation of

substances contained in bile, mainly cholesterol and bilirubin.

Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered

Health Sciences



A. Location and size of the liver- largest gland in the body, weighs

approximately 1.5 kg; lies under the diaphragm; occupies most

of the right hypochondrium and part of the epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform


1. Left lobe- forms about one sixth of the liver

2. Right lobe- forms about five sixths of the liver; divides into

right lobe proper, caudate lobe, and quadrate lobe

3. Hepatic lobules- anatomical units of the liver; small branch

of hepatic vein extends through the center of each lobule

C. Bile ducts
1. Small bile ducts form right and left hepatic ducts

2. Right and left hepatic ducts immediately join to form one

hepatic duct

3. Hepatic duct merges with cystic duct to form the common

bile duct, which opens into the duodenum

D. Functions of the liver

1. Glucose Metabolism

-after a meal, glucose is taken up from the portal venous

blood by the liver and converted into glycogen

(glycogenesis), which is stored in the hepatocytes.

Glycogen is converted back to glucose (glycogenolysis)

and release as needed into the blood stream to maintain

normal level of the blood glucose.

-glucose can be synthesized by the liver through the

process gluconeogenesis

2. Ammonia Conversion

-use of amino acids from protein for gluconeogenesis result

in the formation of ammonia as a by product. Liver

converts ammonia to urea

3. Protein Metabolism

-Liver synthesizes almost all of the plasma protein

including albumin, alpha and beta globulins, blood clotting

factors plasma lipoproteins

4. Fat Metabolism

-Fatty acid can be broken down for the production of

energy and production of ketone bodies

5. Vitamin and Iron Storage

-stores vitamin A, D, E, K

6. Drug Metabolism

7. Bile Formation

-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium,

potassium, calcium, chloride, bicarbonate, lecithin, fatty

acids, cholesterol, bile salts

-collected and stored in the gallbladder and emptied in the

intestine when needed for digestion

a. Lecithin and bile salts emulsify fats by encasing them in

shells to form tiny spheres called micelles

b. Sodium bicarbonate increases pH for optimum enzyme


c. Cholesterol, products of detoxification, and bile pigments

(e.g. bilirubin) are wastes products excreted by the liver

and eventually eliminated in the feces

The gallbladder (or cholecyst, sometimes gall bladder) is a small
organ whose function in the body is to harbor bile and aid in the
digestive process.
• The cystic duct connects the gall bladder to the common hepatic

duct to form the common bile duct.

• The common bile romero duct then joins the pancreatic duct, and

enters through the hepatopancreatic ampulla at the major

duodenal papilla.

• The fundus of the gallbladder is the part farthest from the duct,

located by the lower border of the liver. It is at the same level as

the transpyloric plane.

Microscopic anatomy
The different layers of the gallbladder are as follows:
• The gallbladder has a simple columnar epithelial lining

characterized by recesses called Aschoff's recesses, which are

pouches inside the lining.

• Under the epithelium there is a layer of connective tissue

(lamina propria).

• Beneath the connective tissue is a wall of smooth muscle

(muscularis externa) that contracts in response to

cholecystokinin, a peptide hormone secreted by the duodenum.

• There is essentially no submucosa separating the connective

tissue from serosa and adventitia.

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4

inches) long and 3 cm broad at its widest point. It consists of a fundus,

body and neck. It can hold 30 to 50 ml of bile. It lies on the

undersurface of the liver’s right lobe and is attached there by areolar

connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the

gallbladder. The mucosal lining is arranged in folds called rugae,

similar in structure to those of the stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic

and cystic ducts. During this time the gallbladder concentrates bile

fivefold to tenfold. Then later, when digestion occurs in the stomach

and intestines, the gallbladder contracts, ejecting the concentrated bile

into the duodenum. Jaundice a yellow discoloration of the skin and

mucosa, results when obstruction of bile flow into the duodenum

occurs. Bile is thereby denied its normal exit from the body in the

feces. Instead, it is absorbed into the blood, and an excess of bile

pigments with a yellow hue enters the blood and is deposited in the


The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8

Imperial fluid ounces) of bile, which is released when food containing

fat enters the digestive tract, stimulating the secretion of

cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats

and neutralizes acids in partly digested food.

After being stored in the gallbladder the bile becomes more

concentrated than when it left the liver, increasing its potency and

intensifying its effect on fats. Most digestion occurs in the duodenum.


Bilirubin is the substance that gives bile its color. It is formed

from senescent red blood cells. In the process of degradation, the

hemoglobin from the red blood cell is broken down from biliverdin,

which is rapidly converted to free bilirubin thru biliverdin reductase.

Free bilirubin, which is not soluble in plasma, is transported in the

blood attached to plasma albumin. Even when it is bound to albumin,

this bilirubin is still called free bilirubin. As it passes through the liver,

free bilirubin is released from its albumin carrier molecule and moved

into the hepatocytes. Inside the hepatocytes, free bilirubin is converted

to conjugated bilrubin thru glucoronyl transferase, making it soluble to

bile. Conjugated bilirubin is secreted as a constituents of bile, and in

this form, it passes through the bile ducts into the small intestine. In

the intestine, approximately one half of the bilirubin is converted into a

higly soluble substance called urobilinogen by the intestinal flora.

Urobilinogen is either absorbed into the portal circulation or excreted in

the feces. Most of the urobilinogen that is absorbed is returned to the

liver to be re-excreted into the bile. A small amount of urobilinogen,

approximately 5% is absorbed into the general circulation and then

excreted by the kidneys.

Usually, only a small amount of bilirubin is found in the blood;

the normal level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory

measurements of bilirubin usually measure the free and the

conjugated bilirubin as well as the total bilirubin. These are reported as

the direct (conjugated) bilirubin and the indirect (unconjugated or free)

Precipitating Factors:

Factors Present Rationale

Diet (high Present Increased intake of calories, refined
cholesterol, carbohydrate, cholesterol, and
high calorie, saturated fats has all been postulated
high sodium) to cause cholesterol gallstones.
Patients with cholesterol gallstones
secrete a greater fraction of dietary
cholesterol into bile than do normal

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Medications and Absent Hypolipidemic agents (clofibrate,
Oral gemfibrozil) that lower serum
Contraceptives cholesterol by increasing biliary
cholesterol secretion increase the risk
of cholesterol gallstones by twofold to
Competitive inhibitors of 3-hydroxy-3-
methylglutaryl coenzyme A (HMGCoA)
reductase (lovastatin, simvastatin,
pravastatin) decrease biliary
cholesterol saturation.
Estrogen therapy is associated with an
increased risk of developing
cholesterol gallstones.
Oral contraceptive steroids increase
biliary cholesterol secretion and
saturation but do not affect
gallbladder motility.

Source: Barbara Gould,

Pathophysiology for the Health
Professions, Third Edition, Saunders
Total Parenteral Absent TPN is a powerful risk factor for
Nutrition gallstone formation. Gallstones from
during TPN because of decreased
gallbladder motility from lack of meal-
stimulated cholesystokinin (CKK)
release, resulting in increased fasting
and residual volumes.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Spinal Cord Absent Patients with spinal cord injury have
Injury 10% incidence of forming gallstones
within the first year after injury. This
high risk, which is 20 times normal, is
believed to be secondary to abnormal
gallbladder motility and probably
biliary hypersecretion of cholesterol
from the progressive reduction in body

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Primary Biliary Absent Patients with primary biliary cirrhosis
Cirrhosis have an increased prevalence of
gallstones. Stone analysis has not
been performed, but the elevated
cholesterol saturation of bile in these
patients suggest that they form
cholesterol stones.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Diabetes Present Despite obesity and increased total
Mellitus body cholesterol synthesis and
decreased gallbladder motility seen in
patients with diabetes, diabetes
mellitus itself does not appear to be an
independent risk factor for cholesterol
gallstone disease.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Hemolytic Absent Inherited hemolytic anemia, sickle cell
Syndromes disease, sphericytosis, thalassemia,
chronic hemolysis associated with
artificial heart vavles, and malaria
dramatically increase the risk of
pigment stone formation because of
increased biliary secretion of total
bilirubin conjugates, especially
bilirubin monoglucoronide, at the
expense of the bilirubin diglucuronide,
the predominant conjugate in healthy

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Ileal Disease, Absent Patients with ileal dysfunction have a
Resection, and strikingly increased risk for developing
Bypass gallstones. Gallstones develop in 30-
50% of patients with ileal Chron’s
disease; the risk correlates positively
with the extent and duration of ileal
dysfunction, Although ilieal disease or
resection leads to cholesterol
supersaturation and cholesterol stone
formation in some patients , careful
studies now show that most patients
with ilieal dysfuncyion form black
pigment, not cholesterol stones.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Biliary Infection Absent Brown pigment stones are frequently
found in the intrahepatic bile ducts
and are always associated with
infection by colonic organisms usually
E.coli, or parasitic infestation (Ascaris
lumbricoides, or other helminthes).
Intraductal stones developing after
cholecystectomy are invariable
associated with bile stasis, biliary tree
infection, and/or retained suture

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Obesity Present Obesity is strongly associated with
increased gallstone prevalence. The
risk is proportional to the increase in
total body fat. Obese people
synthesize more cholesterol in both
hepatic and nonhepatic tissues,
transport it to the liver, and secrete
more of it into the bile, leading to bile
that is often greatly supersaturated
with cholesterol.

Source: Barbara Gould,

Pathophysiology for the Health
Professions, Third Edition, Saunders
Rapid Weight Absent Obese patients undergoing rapid
Loss/ Fasting weight loss (1-2% of body weight or
diets approximately 1-2 kg/week), either by
very low caloric dieting or gastric
stapling, have a 25-40% chance of
developing gallstones within 4 months.
During rapid weight loss, biliary
cholesterol saturation increases
acutely as cholesterol is mobilized
from adipose tissue and skin and
secreted into bile.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Predisposing Factors:

Factors Present Rationale

Gender Absent Women have twice the risk as men of
developing cholesterol gallstones
because estrogen increases biliary
cholesterol secretion. Before puberty
this risk is negligible, and beyond
menopause the increased risk

Source: Barbara Gould,

Pathophysiology for the Health
Professions, Third Edition, Saunders
Advancing Age Present The incidence increases with age.
Less than 5-6% of the population
under age 40 have stones, in contrast
to 25-30% of those over 80.

Source: Carol Mattson Porth,

Pathophysiology, Concepts of Altered
Health Sciences
Race Absent Prevalence highest in North American
Indians, Chilean Indians, and Chilean
Hispanics, greater in Northern Europe
and North America than in Asia,
lowest in Japan; familial disposition;
hereditary aspects

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Heredity Absent Family history alone imparts increased
risk, as do a variety of inborn errors of
metabolism that lead to impaired bile
salt synthesis and secretion or
generate increased serum and biliary
levels of cholesterol, such as defects
in lipoprotein receptors
(hyperlipidemia syndromes), which
engender marked increases in
cholesterol biosynthesis.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Parity/ Absent Pregnancy is an independent risk
Pregnancy factor for cholesterol gallstones. The
risk increases with increasing parity,
especially with more than two
children. During pregnancy, elevated
estrogen and progesterone levels
increase biliary cholesterol secretion.
Elevated progesterone also inhibits
gallbladder contractility. 40% of
women develop biliary sludge in their
gallbladder and 12% of women form
their first stones during pregnancy.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition

Symptoms Present Rationale

Biliary Colic/ Present The most common symptom is in
Moderate to pain the right upper part of the
Severe Pain abdomen or epigastrium. This can
cause an attack of abdominal pain,
called biliary colic, which: develops
quickly, is severe, lasts about one to
three hours before fading gradually,
isn't helped by over-the-counter and
isn't helped by passing wind. The
pain may radiate to the back, right
scapula or shoulder. The pain often
begins suddenly following a meal.
The pain of biliary colic is caused by
the functional spasm of the cystic
duct when obstructed by stones,
whereas pain in acute cholecystitis
is caused by inflammation of the
gallbladder wall.

Source: Carol Mattson Porth,

Pathophysiology, Concepts of
Altered Health Sciences
Tenderness Present Palpation of the abdomen frequently
elicits localized tenderness in the
right upper quadrant which is
associated with guarding and
rebound tenderness.

Source: Carol Mattson Porth,

Pathophysiology, Concepts of
Altered Health Sciences
Murphy’s Sign Present The patient with acute inflammation
of the gallbladder might have a
positive Murphy’s sign, which is
inspiratory arrest during deep
palpation in the right upper

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Nausea and Absent These signs and symptoms may
Vomiting accompany a gallbladder attack.
Pain is usually accompanied by
nausea and vomiting.

Source: Barbara Gould,

Pathophysiology for the Health
Professions, Third Edition, Saunders
Fever and chills Absent Gallstones sometimes get trapped in
the neck of the gallbladder and can
cause persistent pain that lasts
more than several hours and is
accompanied by fever, also due to
the irritation and inflammation of
the gallbladder wall.
Fever occurs in about one third of
people with acute cholecystitis. The
fever tends to rise gradually to
above 100.4° F (38° C) and may be
accompanied by chills
SOURCE: Harrison’s Principle of
Internal Medicine, 16th Edition
fLoss of appetite Present The pain often begins suddenly
and Anorexia following a large or rich meal.
People tend not to eat, especially
fatty or oily foods, in order not to
experience that pain. Fat absorption
is also impaired for the lack of bile
salts, As a result, rapid loss of
weight and anorexia can occur.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th Edition
Predisposing Factors: Precipitating Factors:
Gender Diet
Age PATHOPHYSIOLOGY Medications and Oral Contraceptives
Race Obesity
Heredity Rapid Weight Loss
Pregnancy Spinal Cord Injury
Primary Biliary Cirrhosis
Diabetes Mellitus
Hemolytic Syndromes
Ileal Disease, Resection and Bypass
Biliary Infection
Total Parenteral Nutrition

Liver cells secrete Liver cells Liver excrete Liver excrete Invasion Calcium enters Liver excrete
cholesterol into bile also secrete relatively high conjugated of bile passively some
along with bile salts proportion of bilirubin into bacteria along with other unconjugated
phospholipid in the cholesterol in the bile electrolytes bilirubin into
form of unilamellar bile bile

Residual vesicles Some of the The bacteria Bilirubin tends to
unilamellar hydrolyze form insoluble
vesicles dissolve conjugated precipitates with
of lecithin
bilirubin calcium

Formation of Release of
mixed micelles fatty acids Formation of
Increase in Calcium
unconjugated Bilirubinate
The cholesterol A fatty acids forms Black Pigment
carrying capacity of complex with calcium Gallstones
the micelles and
residual vesicles is
Attraction Bacteria
of release
Leukocytes lytic Formation of
Bile is enzyme
supersaturated with Calcium
cholesterol Bilirubinate
Formation of bilirubin Brown Pigment
Crystals conjugates Gallstones
and fatty
Nucleation of
cholesterol crystals


Mixed Stones

Gallstone tries to go
out of the gallbladder

Obstruction of the Obstruction of the

common bile duct by cystic duct by
gallstones gallstones

Release of phospholipase Disruption of mucous
from the epithelium of the coat of the gallbladder
gallbladder epithelium

Prolong Cholestasis Absence of Bile in ↑ levels of Hydrolization of lecithin Damages mucosal cells
the duodenum bilirubin/bile into lysolecithin due to detergent action of
pigments in the
bile salts
S/S Indigestion,
deficiency, gray
Fibrosis Irritation of the
S/S jaundice, gallbladder wall
ecteric sclera,
Liver Cirrhosis pruritus, dark
Release of prostaglandins
within the gallbladder wall
Fibrous nodules distorts the S/S Biliary Colic,
architecture of the liver Tenderness, Murphy’s
sign, nausea and
vomiting, fever, ACUTE M
Resistance to K elevated wbc, anorexia CHOLECYSTITIS
portal blood flow

Increase pressure
in hepatic portal
Portal Hypertension Open Cholecystectomy
Z Ursodeoxycholicacid Bacteria invade the External surface
injured gallbladder of the
through the blood, gallbladder is
lymphatic or bile ducts scarred and
form adjacent organs layered by
(Empyema of the fibrinous
gallbladder) exudates and

Edema, hemorrhage and

suppuration of the
gallbladder wall
Compression of blood

Increased Intraluminal

Compromised blood flow

to the mucosa and
lymphatic stasis


Ulcerations of the


Free Perforation Localized Perforation

Adhesion to an Pericholecystic abcess

adjacent hollow
viscus (duodenum)

fistula formation

Gall stone induced

intestinal obstruction
(gallstone ileus);
drainage of bile into
adjacent organs; entry
of air and bacteria into
the biliary tree

As the intestine Cut off the blood

becomes supply to the
congested, its affected portion of
ability to absorb your intestine
food and fluids

Dehydration Necrosis

Hypovolemia Perforation in the

intestinal wall

Hypovolemic shock

Generalized Peritonitis


S/S fever,
Septic Shock chills,


Liver failure Shunting of blood into

the splenic vein Blockage or increase pressure in Increase pressure in
the portal vein causes blood to peritoneal capillaries
backflow to the different vessels
Liver is unable to located near the esophagus and
convert the protein GIT
Spleen enlarges to Fluid shifting from the
byproduct ammonia compensate
into urea portal vein to the
decreased liver peritoneal cavity
Splenomegaly Gastroesophageal Varices
Ammonia enters Ascites
general circulation

Increase in size Rupture Invasion of

decreases the spleen’s
bacteria from the
ability to function
Morphologic changes blood, or lymph or
properly or loss of
in astrocytes Hypovolemia through the bowel
Asterixis Increases in blood Hypovolemic shock
Astrocytes may Spontaneous Bacterial
waste product since
undergo Alzheimer Peritonitis
spleen is not able to
type II astrocytosis properly destroy Death
S/S Fever,
Death diarrhea,
Astrocytes become abdominal pain
swollen Septic Shock
enia, anemia, Death
Development of a leukopenia
large pale nucleus, a
prominent nucleolus,
and margination of

S/S Anorexia, Nausea,

HEPATIC Liver tenderness, Jaundice
Cerebral edema

intracranial pressure

Brain Hernation

Hepatic Coma


Chronic Cholecystitis

Increased subepithelial and

subserosal fibrosis and
proliferation of lymphocytes
and other chemical mediators

calcification of the
gallbladder wall
(Porcelain bladder)

Growth of

Metastasize to the

Secondary Liver


Date & Order Rationale Remarks

04-27-09 Pls. admit under Dr. For proper evaluation Done
10:40am Walter G. Batucan and management and
care under
Dr. Batucan who is an
expert on General
Surgery, Liver,
Gallbladder, Billiary
and Pancreatic Surgery.
Low fat diet Bile contains large Done
amount of cholesterol
that usually remains
dissolved in the bile
but when there is
oversaturation with
cholesterol, cholesterol
becomes insoluble and
crystallizes. Low fat
diet serves as a
prevention and
treatment for gallstone
CompleteBloodCount, Complete blood count Done
PlateletCount is the determination of Hemoglobin –
the quantity of each 172g/dL
quantity of each type RBC – 5.46
of each blood cell in a X10^12/L
given specimen of Hematocrit –
blood, often including 0.53
the amount of WBC – 15.2 X
hemoglobin, 10^9/L
hematocrit, and the Segmenters-
proportion of various 0.72
white cells. Lymphocyte-
Platelet count and 0.28
other blood Platelet – 222
components that will X10^9/L
help determine the
underlying diagnosis.
Blood Typing Patient is to undergo Done
an invasive surgery Blood type –
which could lead to O+
blood loss therefore
blood typing is done
before blood can be
transfused on him to
replace the loss blood.
Urinalysis An indicator of health Done
and disease, it is Yellow;
helpful in the detection cloudy
of renal or metabolic Rxn:6
disorders. It is an aid in Spec. gravity-
diagnosing and 1.030
following the course of Glucose (-)
treatment in diseases Albumin
of the kidney and (+++)
urinary system and in Pus cells 2-
detecting disorders in 4/hpf
other parts of the body RBC 1-2/hpf
such as metabolic or Mucus
endocrinic threads (+)
abnormalities in which
the kidneys function
Chest X-ray Chest X-ray provide a Done
good outline of the > Suggestive
heart nad major blood of an
vessels and ussualy inflammatory
can reveal a serious lung disease
disease in the lungs, compatible
the adjacent spaces, with bibasal
and the chest wall, pneumonia.
including the ribs. Please
Ordered so as to check correlate
patient’s cadio- clinically.
pulmonary condition
before undergoing an
invasive surgery.
ECG ECG is a recording of Done
the electrical impulses Normal Sinus
of the heart. Such test Rhythm
is an important
indicator of how well
the heart is
functioning. Prior to
surgery, the heart must
first be checked to
determine whether or
not it can handle the
Fasting Blood Sugar Prior to surgery, blood Done
glucose is to be 6.84mmol/L
checked to determine if
the patient has a
disorder in glucose
metabolism mainly
diabetes for healing
tends to be longer if
one has diabetes.
Creatinine Creatinine is a DONE
breakdown product of 148umol/L
creatine phosphate in
muscle, and is usually
produced at a fairly
constant rate by the
body. It is mainly
filtered by the kidney,
though a small amount
is actively secreted.
Measuring serum
creatinine is used to
indicate renal function.
Uric Acid Measurement of uric Done
acid is most commonly 0.497mmol/L
in evaluation of renal
failure, gout and
Total Bilirubin Evaluates impairment Done
of the liver or 33.3umol/L
hemolytic anemia.
Direct Bilirubin Direct and Indirect Done
Indirect Bilirubin bilirubin are 7.6umol/L
differentiation on why Done
there is an increased 25.7umol/L
bilirubin. Direct
bilirubin is associated
with liver dysfunction
or blockage while
Indirect bilirubin is
related to destruction
of red blood cells.
Alkaline Phosphatase This enzyme test is Done
used chiefly as an 228U/L
index of liver and bone
disease when
correlated with other
clinical findings.
Albumin The test helps in Done
determining if a patient 55.4
has liver disease or
kidney disease, or if
not enough protein is
being absorbed by the
Attach ultrasound Prior to admission Done
result patient had undergone Cholecystitis
UTZ, attaching the with bile
result in the chart sludge
allows better diagnosis formation
and analysis for the and
rest of the medical suggestive
team involved in his hydrophoric
upcoming surgery. change.
entirely rule
out calculus
in the cystic
Refer accordingly Call doctor’s attention Done
immediately once any
unusuality occurs.
11:20am Meds:
Lopicard 5mg tab OD – Patient is hypertensive, Done
c/o patient’s stock and was ordered to
continue his
04-28-09 Please refer to Dr. Torno Prior to surgery Cadio- Done
7am for Cardio-Pulmonary Pulmonary system
clearance – co must first be diagnosed
management whether or not the
patient’s circulatory
and respiratory system
can handle the surgery.
Dr. Torno is an Intenist
whose specialty is
cardio and pulmo.
Pls. schedule for lap Surgical removal of the Done
cholecystectomy gallbladder using a
laparascope is
indicated for acute
Secure consent Securing consent Done
ensures the safety of
both the medical team
and the patient. It is
the permission
obtained from the
patient that he is to
undergo a surgical
Anesthesiologist: Dr. Dr. Barinaga may be
Eugene Barinaga the partner
anesthesiologist of Dr.
Start vitamin K 10g IV Pre-operative standard Done
OD operating procedure so
as to prevent excessive
bleeding during the
actual surgical
Follow up all lab results Lab results are not yet Done
and attach to chart available, thus a follow
up must be made in
order for the doctors to
correlate the findings.
10am Start PLR iL @ KVO rate PLR an isotonic solution Done
that resembles blood
serum used as passage
for the Vit. K IVTT that
was ordered
beforehand and for
future medications. It is
also used for hydration
and electrolyte
04-28-09 Anesthesiologist: Pre-op The referral was made
12:20pm Evaluation so as to ensure a safe
Thanks for this referral and successful surgical
Patient seen and Anesthesiologist made Done
evaluated, chart review rounds to the patient
done so as to establish a
relationship prior to the
scheduled operation
and to evaluate the
Anesthesia plans Explaining the pros and Done
explained consequences cons of the anesthesia Accepted by
and benefits explained allows the patient to patient
contemplate and to
have a mutual
understanding with the
anesthesiologist by
agreeing with what
anesthesia to use.
Nothing per orem To clear the digestive Done
temporary at 5am after tract in preparation for
breakfast the operation to avoid
GI disturbances and
reduce the possibility
of vomiting and
aspiration and the risk
of possible bowel
Midiazolan 15mg 1tab ½ An anti-anxiety drug, Done
tab @ 12nn tomorrow given so as to relieve
with 30cc of water. patient’s anxiety
regarding his upcoming
Resume consent for Consent is a written Done
anesthesia understanding and a
permission from the
patient that allows the
use of certain
anesthesia in the
surgical procedure that
he’ll undergo.
04 -28-09 Reschedule OR tomorrow OR schedule was not Done
3pm at 7am indicated on prior
orders. 7am was
ordered for it was the
most convenient time
for patient, his medical
team and the OR
Inform OR, Dr. Barinaga Informing Dr. Barinaga Done
regarding the
scheduled surgery
allows him time to
prepare and ready
himself for the
upcoming surgical
04-28-09 IM: thank you for refer
No history of cough but Patient showed signs
with rales at L>R and symptoms of
CXR – pneumonia pneumonia.
 CAP low risk Patient was diagnosed
 HPN with CAP low risk due
 T/C DM2 to the findings above,
HPN due to history of
hypertension and T/C
due to high serum
glucose as shown in his
Start Sulperazone 1.5g Given to treat Done
IV q8 respiratory infection
and also serves as pre-
operative prophylaxis.
Continue Lopicard Patient may continue Done
with his maintenance
04-28-09 Pls. reschedule surgery After being seen by his Done
5pm on Thursday internist, his surgeon
then rescheduled the
operation maybe due
to patient having
Anesthesiologist: Dr Change of
Tozon anesthesiologist
instead of Dr. Barinaga
due to the rescheduling
of the surgery.
10pm Schedule at 7am After rescheduling the Done
day, OR finally gave
the time for the
patient’s surgery.
Anesthesiologist aware The new Done
anesthesiologist was
made aware of the
upcoming surgery for
him to be prepared.
04-29-09 For Surgery tomorrow at The scheduled Done
10:40am 7am once cleared procedure will be
carried out once the
Internist cleared the
patient for surgery.
Cefoxitin (Monowell) Serves as pre- Done
1amp IVTT ANST now operative prophylaxis.
prior to OR
04-29-09 Kindly inform Dr. Although Sulperazone Done
1:40pm Batucan – Sulperazone and Cefoxitin can serve
will serve as pre-op as pre-operative
antibiotic management prophyaxis, the
discontinue Cefoxitin if internist chose
ok with Dr. Batucan Sulperazone over
Cefoxitin maybe
because the former is
more potent than the
latter but still it’s the
attending physician’s
decision on what drug
to give.
No absolute Surgery can now be
contraindication to done after CP
planned surgery CP ok clearance was done.
5pm Plan carry out above For abrupt Done
orders implementation.
For open Patient has gangrenous
cholecystectomy instead gallbladder and open
of lap chole cholecystectomy is
indicated for such.
04-30-09 IntraOp
12mn NPO now Patient was put on NPO Done
for he is to undergo
surgery the following
Metoclopramide 1amp Promotes gastric Done
IVTT at 6am emptying prior to
Ranitidine 1amp IVTT at Patient was on NPO so Done
6am ranitidine, an H2
antagonist, was
ordered because it
inhibits the action of
histamine at the H2
receptors of the
parietal cells inhibiting
gastric acid secretion.
04-30-09 PostOp
To PACU For intensive Done
monitoring after the
surgery and for
NPO Nothing per orem until Done
patient passes out
flatus for he still has no
peristalsis and so as to
avoid aspiration.
VS q15 until stable, then Monitoring the vital Done
q1° X 4hrs then q4° signs determines
patient’s body’s
reaction after he had
undergone the surgery
and so as for prompt
intervention for any
deviations in vital
IVF D5NSS iL at 120cc/hr To replenish fluids, Done
nutrients and
1. Tramadol 50mg q6 Relief of moderate to Done
IVTT moderately severe
pain, serves also as a
post operative
2. Ketorolac 30mg q8 Short-term Done
IVTT management (up to 5
days) of moderately
severe acute pain and
reduces signs and
symptoms of
inflammation - redness,
swelling, fever, and
3. Ranitidine 50mg q8 Ranitidine serves as Done
IVTT post surgery antacid
and to prevent ulcer of
which is ketorolac’s
adverse effect.
4. Sulperazone 1.5g q8 Post operative Done
IVTT prophylaxis
Epidural anesthesia: Bupivacaine serves as Done
Bupivacaine 0.25% 10cc analgesia for surgery
+ 0.25 MSO4 OD c/o Dr. added with magnesium
Tozon sulfate so as to prevent
seizue, convulsion and
to lower the blood
Morphine precaution Ordered because Done
morphine increases
biliary spasm.
I & O q shift Anesthetics and Done
surgery affect the
hormones regulating
fluid and electrolyte
balance (Aldosterone
and ADH), placing the
client at risk for
decreased urine output
and fluid and
electrolyte imbalances.
Monitoring I & O help
assess fluid balance.
Accurate measurement
of a patient's fluid
intake and output will
identify those patients
at risk of becoming
dehydrated or
Postoperative patients
are at risk of these.
Refer accordingly Call doctor’s attention Done
immediately once any
unusuality occur
04-30-09 IVFTF: D5NSS iL at To continue IVTT Done
5pm 120cc/hr medication
administration and to
replenish electrolyte
and fluid loss due to
the surgical procedure.

Reference Clinical Interpretatio Nursing

Exam Result
Range Indication n Responsibility
Hematology (April 27, 2009)
Hemoglobi 172 M: 140- Hemoglobin is Above
n 170 an important normal
F: 120 – component of range.
150 red blood cells
g/dL that carries
oxygen and
carbon dioxide
to and from
tissues. The
test is used to
screen for
with anemia
and in
balance. The
capacity of the
blood is also
determined by
Erythrocyt 5.46 4.0-6.0 This test is Within
e X10^9/L used to normal
evaluate any range.
type of
Blood O+ This blood test Type O Inform the
Typing is performed people have patient about
to match red blood the purpose or
donor blood cells with significance of
with recipient neither the test.
who requires antigen, but
blood produce Follow up
transfusion. antibodies results in the
Blood typing against both laboratory.
identifies the types of
inherited antigens. Inform the
antigens that Because of patient the
compromise this result of the
one of four arrangement, test.
possible blood type O can
types: A, B, be safely
AB, O. given to any
person with
any ABO
blood type.
Hence, a
person with
type O blood
is said to be
a "universal
donor" but
receive blood
except from
g O type
Referenc Clinical Interpretatio Nsg
Exam Result
e Range Indication n Responsibility
Urinalysis (April 27, 2009)
Physical Exam
Color Amber Yellow Urine specimens Amber
may vary in colored urine
color from pale is normal but
yellow to dark it indicates
amber. The color high specific
of urine changes gravity and a
in many disease small amount
states due to the of urine.
presence of Specific
abnormal gravity is
pigment. above 1.020
and output
less than 1L
per day
Appearance Cloudy Clear Urine specimen However,
may appear excretion of
clear to cloudy. cloudy urine
This helps to may not be
indicate abnormal
presence of since the
WBC, RBC, change on
bacteria, pus, urine pH may
phosphates, cause
urates and uric precipitation
acid in the urine within the
composition. bladder of
Prepare client:
Alkaline urine
-Explain that
may appear
this test is to
X-ray Report
(April 27, 2009)

Chest PA
Clinical Indication: Chest X-ray is done to diagnose pulmonary disease
and diseases of the mediastinum and bony thorax. This test also gives
valuable information on the condition of the heart, lungs,
gastrointestinal tract and thyroid gland.

Findings: Heart is within normal limit in size. There are infiltrates on

both lung bases. Rest of the lung fields is clear. Lateral CP sinuses are

Impression: Suggestive of an inflammatory lung disease compatible

with bibasal pneumonia. Please correlate clinically.

Interpretation: Chest X-ray was ordered so as to assess the patient’s

cadio and pulmonary system prior to surgery and it was found out that
aside from having cholecystitis, patient also has pneumonia which then
needs an Internist to determine whether he can proceed with the
scheduled surgery.

Nursing Responsibilities:

- Explain to the patient that the chest x-ray will be used for
screening, diagnosis and evaluation of change in his
respiratory system.
- Explain the nature of the procedure to the patient
- Instruct the patient to remove all metal objects between
his neck and chest and change to hospital gown.
- Instruct the patient to take a deep breath and exhale; then
he is required to take another deep breath but hold it while
the picture is taken.
- Tell patient that the procedure takes only a few minutes.
- Inform the patient regarding the result of the test.
ECG Result
(April 27, 2009)

Rate: 25 min
PR interval: 0.10second
Rhythm: Sinus
QRS: 0.08second
Axis: +15°
QTc: 0.44seconds Position Intermediate

Interpretation: Normal Sinus Rhythm

>The electrical impulse is formed in the SA node and conducted

>This is the normal rhythm of the heart.

Nursing Responsibilities:
 Inform patient on why and how the test is done. Tell him that
this is not an invasive procedure, painless and a safe test.
 Place patient in a supine position in the bed or table.
 Prepare the skin (shave if there is excess hair) by applying
contact paste or prejelled discs.
 Place the electrodes accurately.
 Inform the patient regarding the result.
Reference Clinical Nsg
Exam Result Interpretation
Range Indication Responsibility
Blood Chemistry (April 27, 2009)
FBS 6.84 4.20 – Fasting blood Above normal - Explain that
6.40 sugar test level, indicates a blood
mmol/L measure the diabetes. sample will
amount of be taken from
glucose in the the hand or
blood and to arm and that
detect any the sample
disorder of will be
glucose evaluating
metabolism. the amount
of sugar
present in the
blood that
may indicate
diabetes and
evaluate if
has resulted
by the

-Instruct the
client not to
eat or drink
anything, 12
hours prior to
taking the
test. He can
just drink

400 mg tab,
1 tab OD to
gastric acid
since the
patient will
be on NPO for
12 hours.

Creatinine 148 53 – 97 Creatinine is a Above normal 1. Explain

umol/L nitrogenous range, which that this test
waste product indicates a is important
produced decreasing to help
during protein kidney understand
metabolism in function, or how well the
muscle tissue. muscle kidneys are
The test is disease. working.
used to
determine 2. Assess fluid
kidney and
function nutritional
and/or status of
damage. client for
clues or renal
and other
changes in

monitor fluid
through daily
weights and
intake and

4. Evaluate
for increased
fluid volume
manifested by
urine out put,
neck vein
dyspnea and
Total 33.3 2.0 – 21.0 The Above normal Explain the
Bilirubin umol/L measurement range, may purpose and
Direct 7.6 0.0 – 3.4 of bilirubin is indicate the
Bilirubin umol/L important in obstructive procedure of
Indirect 25.7 2.0 – 17 evaluating jaundice of the test.
Bilirubin umol/L liver function, which is a
and hemolytic result of Tell patient
anemia. A obstruction of that 10ml
NORMAL level the common venous blood
of total bile duct or is to be
bilirubin reules hepatic ducts collected
out any due to stones before he
significant or neoplasm. eats his
Above normal
impairment in breakfast.
range, may
the excretory
function of the Inform
liver or patient
excessive regarding the
Above normal
hemolysis of test result.
range, may
red blood
of bilirubin is
done to
which of the
above is the
cause of the
elevation of
total bilirubin.
An in crease in
Uric Acid 0.497 0.2 – 0.4 Uric acid is Above normal Explain the
umol/L formed from range, could be purpose and
the breakdown associated with the
of nucleonic nitrogen procedure of
acids and is an retention and the test.
end product of with increase in
purine urea, creatinine Inform the
metabolism. and other non- patient
Measurement protein regarding the
of uric acid is nitrogenous result.
most substances in
commonly in the blood. May Monitor
evaluation of indicate a patient’s
renal failure, decreased intake and
gout and renal function. output so as
leukemia. to determine
if he has a
Alkaline 228 64 – 306 This enzyme Within normal Explain the
Phosphatas U/L test is used range purpose and
e chiefly as an the
index of liver procedure of
and bone the test.
disease when
correlated with Inform the
other clinical patient
findings. In regarding the
liver disease, result.
the blood level
rises when
excretion of
this enzyme is
impaired as a
result of
obstruction in
the biliary
Albumin 55.4 38 – 51 This test can Above normal Explain the
g/L help range, may purpose and
determine if a indicate renal the
patient has disease. procedure of
liver disease the test.
or kidney
disease, or if Inform the
the body is not patient
absorbing regarding the
enough result.
Ultrasound Report

Ultrasound Report
(This report is based on sonographic findings and must be correlated

The liver is normal in size and tissue attenuation with smooth

external outline. No cystic or solid parenchymal lesions demonstrated
here. The intrahepatic ducts are not dilated. The width AP diameter of
the common bile duct is 0.4cm. no focal lesions noted intraluminally.

The gallbladder is significantly distended to 11.6cm to 4.1cm

(length X AP dm) with diffusely thickened walls that measures up to
1.1cm low level echoes are seen in the dependent portion of the
gallbladder. Quetionable echoes are seen in the partly obscured cystic

The pancreas is obscured by overlying bowel gas preluding

adequate assessment.

> Cholecystitis with bile sludge formation and suggestive
hydrophoric change. Cannot entirely rule out calculus in the
cystic duct
> Sonographically normal liver and biliar ducts

Interprertation: Based on the above findings (patient has gangrenous

gallbladder), he then needs to undergo open cholecystectomy instead
of lap cholecystectomy.
Nursing Responsibilities:
 Explain the purpose and the procedure of the test.
 Inform patient that ultrasound is a noninvasive procedure.
 Instruct him not to eat solid food for the 12 hours prior to
exam to allow greatest dilation of the gallbladder.
 Inform him that water is permitted.
 Inform patient regarding the result.

Generic Name: Amlodipine besylate

Brand Name: Lopicard

Classification: Calcium channel blocker;

Antianginal; Antihypertensive

Mode of Action: Blocks the transport of calcium into the smooth muscle
cells lining the coronary arteries and other arteries of the body. Since
calcium is important in muscle contraction, blocking calcium transport
relaxes artery muscles and dilates coronary arteries and other arteries
of the body. By relaxing coronary arteries, amlodipine is useful in
preventing chest pain (angina) resulting from coronary artery spasm.
Relaxing the muscles lining the arteries of the rest of the body lowers
the blood pressure, which reduces the burden on the heart as it pumps
blood to the body. Reducing heart burden lessens the heart muscle's
demand for oxygen, and further helps to prevent angina in patients
with coronary artery disease.

Dosage: Lopicard 5mg tab OD

Indication: Hypertension

Contraindication: Hypersensitivity to amlodipine, impaired hepatic or

renal function, sick sinus syndrome, heart block (second or third
degree), lactation

Side Effects: dizziness, light-headedness, headache, fatigue, edema of

the lower extremities, flushing, nausea, vomiting, palpitations,
stomach pain, drowsiness, muscle cramps, abdominal discomforts

Adverse Effects: asthenia, arrhythmias, chest pain, yellowing of the

eyes or skin, difficulty breathing

Drug - Drug Interaction: Risk of congestive heart failure with beta-

adrenergic blockers.
Increased antihypertensive effects with other
Possible increased serum levels and toxicity of
cyclosporine if taken

Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Administer drug without regard to meals.
4. Monitor patient’s vital signs carefully while adjusting drug to
therapeutic dose.
5. Instruct patient to take drug with meals if stomach upset
6. Instruct him to take drug exactly as prescribed by his
7. Tell patient that he may experience some side effects brought
upon by the drug.
8. Instruct him to report intolerable side effects so management
can be done.
9. Instruct him to eat frequent small meals if vomiting occurs.
10.Oral care if patient vomits.
11.Instruct him to adjust lighting, noise and temperature if he
experiences headache and report if it is intolerable so that
medication may be given.
12.Instruct him to report any adverse effects that he may
Generic Name: Vitamin K

BRAND NAME: Aqua-Mephyton

CLASSIFICATION: Fat soluble vitamin

MECHANISM OF ACTION: Vitamin K is essential for the hepatic

synthesis of factors II, VII, IX, and X, all of which are essential for blood
clotting. Vitamin K deficiency causes an increase in bleeding tendency,
demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding.

DOSAGE: Vitamin K 10g IV OD

INDICATION: Prevention of bleeding, Vitamin K malabsoption,


CONTRAINDICATION: Hypersensitivity, severe hepatic disease, last few

wk of pregnancy

SIDE EFFECTS: Dizziness, flushing, transient hypotension after IV

administration, rapid and weak pulse, diaphoresis, erythema, pain
swelling and hematoma at injection site

ADVERSE REACTION: Anaphylaxis or anaphylactoid reactions, usually

after rapid IV administration

 Cholestyramine, mineral oil: may inhibit Gi absorption of vitamin
 Oral anticoagulants: decreased anticoagulant effect
 Antibiotics: may inhibit vitamin K production leading to bleeding

1. Assess for contraindication.
2. Assess for baseline data.
3. Monitor protime during treatment; monitor for bleeding,
pulse and BP.
4. Teach patient not to take other supplements, unless
directed by prescriber, to take this medication as directed.
5. Tell patient that he may experience side effects brought
about by the drug and to report intolerable ones so as
prompt interventions be done.
6. Instruct patient to report symptoms of bleeding: bruising,
nosebleeds, bleack tarry stools, hematuria.
7. Stress the need for periodic lab tests to monitor
coagulation level.
8. Instruct patient to report adverse effect that he may
Generic Name: Midazolam HCl

Brand Name: Dormicum

Classification: Benzodiazepine (short-acting);Anxiolytic; CNS

depressant; Anticonvulsant

Mode of Action: Acts mainly at the limbic system and reticular

formation; potentiates the effects of gamma amino butyric acid
(GABA), an inhibitory neurotransmitter; anxiolytic and amnesia effects
occur at doses below those needed to cause sedation, ataxia; has little
effect on cortical function.

Dosage: Midazolam 15mg 1tab ½tab at 12nn with 30cc of water

Indication: Sedation, anxiolysis, and amnesia prior to surgery

Contraindication: Hypersensitivity to benzodiazepines;psychoses,

acute marrow-angle glaucoma, shock, coma, acute alcoholic
intoxication, pregnancy (cleft lip or palate, inguinal hernia, cardiac
defects, microencephaly, pyloric stenosis have been reported when
used in the first trimester; neonatal withdrawal syndrome reported in
infants); neonates

Side Effects: Drowsiness, dizziness, GI upset, difficulty concentrating,

fatigue, nervousness, crying, dreams, hiccups, diaphoresis,
incontinence, nausea, vomiting, diarrhea, constipation, dry mouth,
salivation, headache, light-headedness

Adverse Effects: Lethargy, apathy, disorientation, delirium, stupor,

dysarthria, dystonia, tremor, rigidity, vertigo, euphoria, vivid dreams,
psychomotor retardartion, extrapyramidal symptoms, nystagmus,
bradycardia, tachycardia, urticaria, gastric disorder, jaundice, hepatic
dysfunction, paresthesias, gynecomastia, bronchospam, laryngospam,
drug dependence, respiratory depression, respiratory arrest
Drug – Drug Interaction:
 Increased CNS depression with alcohol, opioids, barbiturates,
other sedatives and anaesthetics.
 Increased respiratory depression with opiates, phenobarbital,
other benzodiazepines.
 Plasma concentrations increased by CYP3A4 inhibitors such as
cimetidine, erythromycin, clarithromycin, diltiazem, verapamil,
ketoconazole and itraconazole, antiretroviral agents, quinupristin
with dalfopristin.
 Midazolam concentration decreased by phenytoin,
carbamazepine, phenobarbital, rifampicin.
 Halothane, thiopental requirements may be reduced during
concurrent use.

Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Monitor level of consciousness before, during and for at least
2 – 6hours after administration.
4. Carefully monitor VS during administration.
5. Keep patient on bed for 3hours, not to permit ambulation
upon administration.
6. Teach him that the drug helps him to relax and will make him
sleep, and the drug is a potent amnesiac and he will not
remember what has happened on him.
7. Instruct him to take the drug exactly as prescribed.
8. Instruct him to avoid alcohol, or sleep – inducing, or OTC
drugs before receiving the drug.
9. Tell patient that he may experience side effects brought upon
by the drug.
10.Instruct patient to report adverse effects that he may
Generic Name: Cefoperazone Na 1 g, Sulbactam Na 0.5 g

Brand Name: Sulperazone® [vial]

Classification: Cephalosporin, antibiotic

Mode of Action: Inhibits bacterial cell wall synthesis causing cellular


Dosage: Sulperazone 1.5g q8 IVTT

Indication: Treatment of respiratory infection caused by S. pneumoniae,

H. parainfluenzae, S. aureus, E. coli, Klebsiella, H. influenzae, S.
pyrogenes; Perioperative prophylaxis; Post operative prophylaxis

Contraindication: Hypersensitivity to cephalosporin or penicillin, or

renal failure

Side Effects: diarrhea, nausea, vomiting, headache, dizziness,

hypotension, abdominal pain, pain at injectionsite, inflammation at IV
site, rash

Adverse Effects: paresthesia, seizure, liver toxicity, nephrotoxicity,

bone marrow depression, leukopenia, anaphylaxis, hematuria,
vasculitis, shock

Drug – Drug Interaction:

 Increased nephrotoxicity with aminoglycosides
 Increased bleeding effects with anticoagulant
 Disulfiram-like reaction may occur if alcohol is taken 72hrs
after drug administration
Nursing Responsibilities:
1. Assess for contraindication.
2. Assess for baseline data.
3. Inject slowly over 3-5 minutes.
4. Have vitamin K injection readily available in case of
5. Tell patient that he may experience side effects that are
brought about by the drug.
6. Instruct him to report intolerable side effects so management
can be done.
7. Instruct him to eat frequent small meals if vomiting occurs.
8. Oral care if patient vomits.
9. Minimize stimuli (adjust temperature, lighting and avoid
noise) if headache occurs and if intolerable pain medication
may be given as ordered.
10.Instruct patient to avoid alcohol because severe reactions
could occur.
11.Tell patient to report any adverse effects that he may
Generic Name: Cefoxitin Sodium

Brand Name: Monowell

Classification: Antibiotic; Cephalosporin (second generation)

Mode of Action: Bactericidal: inhibits synthesis of bacterial cell wall,

causing cell death.

Dosage: Cefoxitin 1 amp IVTT ANST now prior to OR

Indication: Surgical prophylaxis

Contraindication: Hypersensitivity to cephalosporins or penicillins.

Side Effects: Nausea, vomiting, diarrhea, flatulence, anorexia,

headache, phlebitis, rash, fever, pain on injection site, dizziness,
stomach upset

Adverse Effects: Lethargy, pseudomembranous colitis, paresthesias,

liver toxicity, nephrotoxicity, convulsion, leukopenia, decreased
hematocrit, decreased platelet, anaphylaxis, superinfection,

Drug –Drug Interaction:

 Enhanced nephrotoxicity with aminoglycosides and loop diuretics
e.g. furosemide.
 Renal excretion inhibited by probenecid.
 Increase bleeding with oral anticoagulants.
 Disulfiram-like reaction may occur if alcohol is taken within
72hours after drug administration.
Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Have vitamin K readily available in case of
hypoprothrombinemia occurs.
4. Instruct patient to avoid alcohol for 3days after drug
administration because serious reactions often occur.
5. Tell patient that he may experience some side effects brought
upon by the drug.
6. Instruct him to report intolerable side effects so management
can be done.
7. Instruct him to eat frequent small meals if vomiting occurs.
8. Oral care if patient vomits.
9. Instruct him to report any adverse effects that he may
Generic Name: Metoclopramide

Brand Name: Octamide PFS, Reglan

Classification: GI stimulant, antiemetic, dopaminergic blocker

Mode of Action: Stimulates the muscles of the gastrointestinal tract

including the muscles of the lower esophageal sphincter, stomach, and
small intestine by interacting with receptors for acetylcholine and
dopamine on gastrointestinal muscles and nerves; decreases the reflux
of stomach acid by strengthening the muscle of the lower esophageal
sphincter; stimulates the muscles of the stomach and thereby hastens
emptying of solid and liquid meals from the stomach and into the
intestines; interacts with the dopamine receptors in the brain and can
be effective in treating nausea.

Dosage: Metoclopramide 1amp IVTT @ 6am

Indication: Stimulation of gastric emptying prior to surgery

Contraindication: Hypersensitivity to metoclopramide, GI hemorrhage,

mechanical obstruction or perforation; pheochromocytoma (may cause
hypertensive crisis); epilepsy

Side Effects: drowsiness, restlessness, fatigue, anxiety, insomnia,

depression, sedation, nausea, diarrhea, urinary frequency

Adverse Effects: parkinsonm-like reactions, involuntary muscle

movements, facial grimacing, dystonic reactions resembling tetanus,
transient hypertension, tardive dyskinesia, myoclonus
Drug – Drug Interaction
 Decreased absorption of Cefprozil, cimetidine, digoxin from the
 Increased oral bioavailability or absorption of acetaminophen,
cyclosporine, ethanol, levodopa, tetracycline
 Decreased effect on gastric emptying with anticholinergic, opioid
analgesics, levodopa
 Increased risk of serious adverse effects due to excess release of
neurotransmitters with MAOIs for example, isocarboxazid
(Marplan), phenelzine (Nardil), tranylcypromine (Parnate),
selegiline (Eldepryl), and procarbazine (Matulane)

Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Give direct IV dose slowly (over 1 to 2 minutes).
4. Monitor BP carefully during IV administration.
5. Monitor for extrapyramidal reactions, and consult physician if
they occur.
6. Keep diphenhydramine injection readily available incase of
extrapyramidal reactions.
7. Have phentolamine readily available in case of hypertensive
crisis (most likely to occur with undiagnosed
8. Tell patient that he may experience side effects brought upon
by the drug.
9. Instruct patient to report involuntary movement of the face,
eyes or limbs, severe depression, severe diarrhea.
10.Provide a safe environment if restlessness, involuntary muscle
movement occur.
Generic Name: Ranitidine

Brand Name: Zantac

Classification: Histamine 2 antagonist

Mode of Action: 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.

Dosage: Ranitidine 50mg q8 IVTT

Indication: Post surgery antacid to prevent ulcer formation

Contraindication: Hypersensitivity to ranitidine, lactation.

Side Effects: headache, rash, dizziness, vertigo, constipation, diarrhea,

nausea, vomiting, abdominal discomforts, local burning or itching at IV

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

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

Drug – Drug Interaction: Increased effects of warfarin, tricyclic

Nursing Responsibilities:
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.
Generic Name: Tramadol HCl

Brand Name: Ultram

Classification: Analgesic, centrally acting

Mode of Action: 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.

Dosage: Tramadol 50mg q 6° IVTT

Indication: Relief of moderate to moderately severe pain; post surgery


Contraindication: 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

Drug – Drug Interaction:

 Carbamazepine reduces the effect of tramadol by increasing its
inactivation in the body.
 Quinidine (Quinaglute, Quinidex) reduces the inactivation of
tramadol, thereby increasing the concentration of tramadol by
 Combining tramadol with monoamine oxidase inhibitors (for
example, Parnate) or selective serotonin inhibitors [(SSRIs, for
example, fluoxetine (Prozac)] may result in severe side effects
such as seizures or a condition called serotonin syndrome.
 Tramadol may increase central nervous system and respiratory
depression when combined with alcohol, anesthetics, narcotics,
tranquilizers or sedative hypnotics.

Nursing Responsibilities:
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
Generic Name: Ketorolac tromethamine

Brand Name: Toradol

Classification: NSAID, Nonopioid analgesic

Mode of Action: Reduces the production of prostaglandins, chemicals

that cells of the immune system make that cause the redness, fever,
and pain of inflammation and that also are believed to be important in
the production of non-inflammatory pain. It blocks the enzymes that
cells use to make prostaglandins (cyclooxygenase 1 and 2). As a result,
pain as well as inflammation and its signs and symptoms - redness,
swelling, fever, and pain - are reduced.

Dosage: Ketorolac 30mg q8 IVTT

Indication: For short-term management (up to 5 days) of moderately

severe acute pain that otherwise would require narcotics. It most often
is used after surgery.

Contraindication: Hypersensitivity to ketorolac, renal Impariment,

aspirin allergy

Side Effects: rash, ringing in the ears, headaches, dizziness,

drowsiness, abdominal pain, nausea, diarrhea, constipation, heartburn,
fluid retention, somnolence, insomnia, dyspepsia, dry mucous
membrane, sweating, peripheral edema, GI pain

Adverse Effects: gastric or duodenal ulcer, renal impairment, liver

failure, dysuria, bleeding, platelet inhibition, neutropenia, leukopenia,
pancytopenia, thrombocytopenia, bone marrow depression
Drug – Drug Interaction:
 Increased levels of ketorolac in the body and increased
side effects with Probenecid (Benemid).
 Increase risk of lithium toxicity with lithium (Eskalith)
 Reduced kidney function with concominatnt use with
angiotensin converting enzyme (ACE) inhibitors.
 Increase risk of bleeding with anticoagulants (warfarin),
 Increased risk of nephrotoxicity with other nephrotoxins
(aminoglycosides, cyclosporine)

Nursing Responsibilities:
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Infuse slowly as a bolus over no less than 15 seconds.
4. Administer with ranitidine to avoid ulceration.
5. Tell patient that he may experience side effects brought upon
by the drug.
6. Encouraged oral fluid intake to avoid dry mucous membrane.
7. Provide comfort measures if headache occurs.
8. Instruct to report intolerable side effects for prompt
9. Instruct to report signs of bleeding such as black tarry stool,
weakness and dizziness upon standing.
10.Instruct to report if he experiences adverse effects.
Generic Name: Bupivacaine

Brand Name: Bupican

Classification: Anesthesia

Mode of Action: Block the generation and the conduction of nerve

impulses, presumably by increasing the threshold for electrical
excitation in the nerve, by slowing the propagation of the nerve
impulse, and by reducing the rate of rise of the action potential. The
analgesic effects of Bupivacaine are thought to be due to its binding to
the prostaglandin E2 receptors, subtype EP1 (PGE2EP1), which inhibits
the production of prostaglandins, thereby reducing fever,
inflammation, and hyperalgesia

Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD

Indication: Local or regional anesthesia; analgesia for surgery

Contraindication: Hypersensitivity to bupivacaine or other local

anesthesia e.g. lignocaine, blood clotting disorder, low blood pressure,

Side Effects: nervousness, tingling around the mouth, tinnitus, tremor,

dizziness, blurred vision, ringing of the ears, feeling of disorientation,
nausea, vomiting, drowsiness, numbness of tongue, lightheadedness

Adverse Effect: convulsion, seizures, unconsciousness, arrhythmias,

tachycardia, bradycardia, cardiac arrest, hypotensive shock,
respiratory arrest, myocardial depression,
Drug – Drug Interaction: Additive effects when used with
antiarrhythmic drugs
Nursing Responsibilities:
1. Assess for contraindication.
2. Assess for baseline data.
3. Monitor vital signs carefully, drug depresses the pulmonary
and cardiac system.
4. Monitor for side effects.
5. Tell patient that he may experience side effects brought about
by the drug and if such is/are intolerable he must report them
so as prompt interventions be done.
6. Oral care if vomiting occurs.
7. Monitor for occurrence of adverse effects, report to the
anesthesiologist any signs and symptoms of adverse effects.
8. Continue to monitor patient following discontinuation of
Generic Name: Magnesium Sulfate

Brand Name:

Classification: Electrolyte, Antiepilecptic, Antihypertensive, Laxative

Mode of Action: An important cofactor for enzymatic reactions and

plays an important role in neurochemical transmission and muscular
excitability; prevents or controls convulsions by blocking
neuromuscular transmission and decreasing the amount of
acetylcholine liberated at the end plate by the motor nerve impulse;
attracts and retains water in the intestinal lumen and distends the
bowel to promote mass movement and relieve constipation; acts
peripherally to produce vasodilation; larger doses cause lowering of
blood pressure.

Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD

Indication: Parenteral anticonvulsant for the prevention and control of

seizures, lowers BP while in surgery

Contraindication: Hypersensitivity to magnesium sulfate, heart block,

myocardial damage; abdominal pain, appendicitis, fecal impactation,
hepatitis, intestinal and biliary tract obstruction

Side Effects: weakness, dizziness, excessive bowel movement,

sweating, flushing, headache, nausea, vomiting, palpitations

Adverse Effects: fainting, magnesium intoxication, hypotension,

depressed reflexes, flaccid, paralysis, hypothermia, circulatory
collapse, cardiac and CNS depression, hypocalcemia, tetany
Drug – Drug Interaction:
 Potentiation of neurotransmuscular blockade produced by
nondepolarizing neuromuscular relaxants (tubocurarine,
atracurium, pancuronium, vecuronium)
 CNS depression and peripheral transmission defects produced by
magnesium is antagonized by calcium.
 Reduces antibiotic activity of streptomycin, tetracycline and
tobramycin when given together.

Nursing Responsibilities:
1. Assess for contraindication.
2. Assess for baseline data.
3. Do not administer unless solution is clear and container is
undamaged. Discard unused portion.
4. Monitor knee-jer reflex before repeated parenteral
administration. If it is suppressed, do not administer the drug
for it may cause respiratory center failure.
5. Administer with caution if flushing and sweating occurs.
6. Have calcium gluconate readily available if signs and
symptoms of hypermagnesemia occur.
7. Tell patient that he may experience some side effects brought
about by the drug and instruct him to report intolerable side
effects so as prompt intervention be done.
8. Oral care when vomiting occurs.
9. Volume for volume replacement when excessive bowel
movement and vomiting occurs to replace the loss fluid.
10.Instruct patient to report adverse effects immediately.
Procedural Report
on Open Cholecystectomy

Surgeon: Dr. Batucan, Wolter

Operation: Open Cholecystectomy

Anesthesiologists: Dr. Togon

Date of Surgery: 04/30/09 at 7:00 am

Cholecystectomy is the excision (removal) of the gallbladder.


Cholecystectomy may be performed to treat chronic or acute

cholecystitis, with or without cholelithiasis, or to resect a malignancy.


Cholecystectomy, performed laparoscopically, is the preferred

treatment for symptomatic gallstones unless the patient is extremely

obese, there are excessive adhesions, or ductal or vascular anomalies

exist. If unexpected pathology is encountered, if acute inflammation

distorts normal tissue planes, or if there is excessive bleeding or

surgical injury, the laparoscopic procedure is promptly converted to

“open” cholecystectomy.

Type of Anesthesia

• General anesthesia

• Thoracic epidural anesthesia (as an alternative)

Preparation of the Patient

Antiembolitic hose may be put on the legs,

as requested. The patient is supine; both arms

may be extended on padded armboards. A pillow

may be placed under the sacrum and/ or under the

knees to avoid straining back muscles. Pad all

bony prominences and areas vulnerable to skin

and neurovascular pressure of trauma. A

nasogastric tube may be inserted by the anesthesia provider. A foley

catheter is not routinely placed. An electrosurgical dispersive pad is


Skin Preparation

Begin at the intended site of incision, either right subcostal (most

frequently used), right paramedian, or medline, extending from the

axilla to the pubic symphysis and down to the table on the sides.


The incision is right subcostal, right paramedian, or midline. The

abdominal cavity is entered in the usual manner. The gallbladder is

grasped (generally with a Pean clamp). The cystic duct, cystic artery,

and common bile duct are exposed. The surgeon must be aware of

anomalies of these structures. The cystic artery is clamped (using two

right-angle clamps) and ligated with a suture passed on a long

instrument or by clips (e.g., Hemoclips), as is the cystic duct. The

gallbladder is mobilized by incising the overlying peritoneum and after

local dissection is removed. The underlying liver bed may be

reperitonealized. A drain (e.g., Jackson-Pratt ™) may be employed

exiting a stab wound and secured to the skin with a stitch. The wound

is closed in layers. The skin is closed with interrupted stitches, tapes,

or skin staples.

Instruments, Machines and Supplies

• 4 folded towels and a laparotomy sheet


• Folded blanket or pad (for positioning)

• Sequential compression device with disposable leg wraps, if


• Suction

• Ultrasound generator, if requested

• Laser (e.g., Nd: YAG laser fiber or pulsed dye) when requested


• Major procedures tray

• Long Metzenbaum scissors

• Hemoclip or other ligating clip appliers

• Biliary tract tray (for common duct exploration)

• Choledochoscope when requested; if unavailable, a uteroscope

or small cystoscope may be substituted


• Antiembolitic hose

• Basin set

• Blades, (2) #10, (1) #15, or (1) #11

• Suction tubing

• Hemoclips or similar ligating clips

• Electrosurgical pencil and cord with holder and scrape pad

• Needle magnet or counter

• Dissectors (e.g, peanut or Kittner sponges)

• Drains, e.g., Penrose 1” or suction drain (e.g., Jackson-Pratt or

Hemovac™), optional

• Mushroom-tipped (retention) catheters, e.g., Pezzer or Malecot,


• Culture tubes, one aerobic and one anaerobic

• Hemostatic agent e.g., Surgicel™, Helistat™, Thrombostat™,

Avitene™, available

Nursing Responsibilities


• All care that is given and observations made regarding the

patient (e.g., condition of skin preoperatively) must be

documented in the operative record for continuity of care and for

medicolegal reasons.

• The nurse conveys to the patient that he will act as the patient’s

advocate by speaking for him while the patient is in surgery.

• Assess health factors that affects the patient preoperatively:

nutritional status, drug or alcohol use, cardiovascular status,

hepatic and renal function, endocrine function, immune function,

previous medication use, psychosocial factors, as well as the

spiritual and cultural beliefs.

• When the circulator reviews patient allergies with the patient, he

ascertains that the patient has no history of allergy to

radiopaque dye.

• Inform the patient of the scheduled date and time of the surgery

and where to report

• Instruct what to bring (insurance card, list of meds & allergies)

• Check the chart for patient’s sensitivities and allergies e.g.

allergy to iodine. Document allergies noted preprocedure and

document alternative used.

• Instruct what to leave at home such as jewelry, watch,

medications and contact lenses

• Instruct what to wear ( loose fitting, comfortable clothes and flat


• Remind the patient not to eat or drink if directed

• The patient may have fear and anxiety regarding the surgical

procedure and the unfamiliar environment. Explain nursing

procedures before performing them and the sequence of

perioperative events.

• Assess and document patient’s anxiety level and level of

knowledge regarding the intended procedure. Clarify

misconceptions by answering the patient’s questions in a

knowledgeable manner and refer questions to the surgeon as


• Decrease fear

• Teach deep-breathing, coughing or incentive spirometer

• Provide emotional support to the patient regarding feelings of

altered body image by providing the patient an opportunity to

express her feelings.

• Respect cultural, spiritual and religious beliefs


• It is imperative that the patient be positioned over the correct

area on the table to ensure accurate visualization of the biliary


• A protective facial shield is suggested for those scrubbed to

avoid inadvertent splashing of contaminated fluids onto mucous

membranes and eyes.

• All medications, dyes, etc., on the opening field must be labeled.

Scrub person should use a marking pen on labels to identify all

solutions. All medication containers should be kept in the room

until the completion of the procedure.

• Instruments used on the gallbladder are isolated in a basin

(considered contaminated)

• Prevent musculoskeletal injuries to team members by employing

ergodynamic measures when positioning the patient.

• Take appropriate measures to maintain patient’s body

temperature e.g., offer warm blanket or raise room temperature

as necessary.

• Keep the patient adequately covered to maintain patient’s

privacy, expose only the immediate area involved for the


• Strictly follow the principles of surgical asepsis

• Keep surgical conscience

• Count all instruments and sharps with circulating nurse before

and after the procedure

• Know the name and use of the instrument

• Never pile the instruments on top of each other

• Know the name and use of the instrument and handle the

instrument individually

• Hand the surgeon the correct instrument

• Pass the instrument firmly and decisively

• Be careful in handling of sharp instruments at all times

• The scrub person sets up the instruments on the back table for

the surgeon.

• Scrub person needs to have a right angle clamp (Mixter)

available throughout the dissection of the biliary tree.

• Usually a stab wound is made in the cystic duct using a #11

blade. The incision is extended with Pott’s scissors.

• Have T-tubes available following common duct exploration

• One syringe is filled with saline, and a second syringe is filled

with radiopaque dye diluted to half strength (labeled accordingly)

• Scrub person takes care to make certain that the saline or dye

catheters are devoid of air bubbles (which can be confused for


• Use a small basin to accept the specimen

• Aerobic and anaerobic cultures may be taken of the bile or

gallbladder bed.


• The circulator accompanies the anesthesia provider and the

patient to the PACU; he/she gives the PACU perioperative

practioner a detailed intraoperative patient report regarding the

course of events as they apply to the individual.

• Assess the patient: appraise air exchanges status & note skin

color; verify & identify operative status & surgeon performed;

assess neurological status (LOC)

• PACU nurse observes the patient’s breathing, monitors blood

pressure and vital signs, and documents all pertinent


• PACU nurse assumes the role as the patient’s advocate..

• Report for abnormalities especially for signs and symptoms of


• Perform safety checks – good body alignment, side rails and

maintain patent airway and cardiovascular stability

• Relieve pain and anxiety


pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating

Room. 3rd edition

F.A. Davis Company.Philadelphia

Nursing Theories

Ma. Estine Levine’s Conservation Model

Levine’s conservation model provides a thoughtful basis for

making effective wound management choices in order to improve
wound healing and consequently ameliorate individual well being and
quality of life. The relationship between effective wound management
and positive patient outcomes draws on Levine’s four conservation
principles, about which she states:

The conservation principles address the integrity of the individual…

from birth to death. Every activity requires an energy supply because
nothing works without it. Every activity must respect the structural
wholeness of the individual because well-being depends on it. Every
activity is chosen out of the abilities, life experience, and desires of the
“self”’ who makes the choices. Every activity is a product of the
dynamic social systems to which the individual belongs.

The patient last April 30, 2009 was on status post cholecystectomy.
Cholecystectomy was done to remove the gallbladder. Incision was
made. To have an effective wound healing and prevent complications,
vital signs was monitored. Patient was encouraged to take a rest. To
regain structure and function, the body needs to restore structural
integrity through repair and healing. It is very important to take note of
the discharges, its quantity and characteristic. Aseptic technique in
wound dressing was applied to prevent possibility of infection. In
addition, to promote healing, antibiotics was also given.

Jean Watson

Dr Watson believes that a new paradigm is emerging in health

care. She states that conventional medicine has become increasingly
technological, typically centering on treatment to cure disease with
medications and surgery. In contrast, the caring approach of nursing
focuses on conscious compassionate skills that help patients achieve a
healthy state of mind, body, and spirit. Dr Watson relates that caring is
intrinsic to the therapeutic interpersonal relationship between the
nurse and patient. Ten primary carative factors form the structure of Dr
Watson's caring theory

Psychological caring-healing therapies strive to instill hope or

faith. To meet the psychological or spiritual needs of patients, nurses
traditionally incorporate humanistic, altruistic values by using the
power of prayer, spiritual beliefs, or suggestions or through a trusting
therapeutic nurse-patient relationship. The nurse's relationship and
interpersonal teaching enables the patient to provide self-care,
determine personal needs, and provide opportunities for personal
growth. Therapeutic communication is implemented through nonverbal
behavior and listening, facilitating nonpossessive warmth, initiating
self-understanding, and communicating with personalized responses to
develop a helping, trusting relationship

After developing a therapeutic trusting relationship, the nurse

can help the patient relax before surgery with the caring-healing
therapies of holistic nursing. Being available to the patient, listening to
his concerns, and providing silence was practiced to relieve patient’s
anxiety. Medications were also given such as anxiolytic medicines to
decrease anxiety.

Faye Abdellah

According to her, nursing is based on an art and science that

mould the attitudes, intellectual competencies, and technical skills of
the individual nurse into the desire and ability to help people , sick or
well, cope with their health needs.

To view Abdellah’s 21 nursing problems according to Maslow’s

hierarchy of needs, in the physiologic needs, the nurse must facilitate
the maintenance of a supply of oxygen to all body cells, nutrition of all
body cells, fluid and electrolyte balance, elimination, maintain good
body mechanics and prevent and correct deformities, good hygiene
and physical comfort, promote optimal activity: exercise , rest and
sleep and to facilitate the maintenance of regulatory mechanisms and

Patient’s needs was attended such as proper positioning, cough

and deep breathing exercises to prevent post operative complications.
Patient was on NPO, but it is very important to increase fluid intake and
eat high caloric foods to prevent dehydration and weakness due to
increased metabolic demands of the body. It is very important to take
into consideration the diet after NPO because the body is on the
process of repairing.
Nursing Care Plan

Date/ Cues Need Nursing Objectives of Nursing Interventions Evaluation

Time Diagnosis Care
April S: “ Sakit jud C Acute Pain Within my 8 hr 1. Observe and document Goal met.
27, akoa tiyan O related to care, the client location, severity and
2009 karun G inflammation will be able to: character of pain. Although pain
(pointing at N and distortion ® Assists in differentiating was not
3- the right I of tissues 1. Report pain cause of pain and provides totally
11pm upper T is controlled if information about disease relieved, the
quadrant of I ® If gallstone not relieved. progression/ resolution,patient
the V obstruct the development ofverbalized, “
abdomen), E cystic duct, the 2. Demonstrate complications and Na ok ok
mura man ug gallbladder the use of effectiveness oframan ko
gimakumot na - becomes relaxation skills interventions. karun, medyo
dili nako distended, and diversional sakit pero dili
masabtan.”, P inflamed and activities as 2. Administer na pareha
as verbalized E eventually indicated for anticholinergics asganina.” The
by the R infected. individual indicated. patient had
patient. C Inflammation situation ® Anticholinergics relieves identified
E and swelling reflex spasm or smooth relaxing
O: Grimaced P depresses the muscle contraction and techniques
face T free nerve assist in pain management. such as deep
With guarding U endings and breathing
behavior A cause the pain. 3. Administer smooth exercises and
Restlessness L The patient muscle relaxants, freeing the
Rigidity of the may have nitroglycerin as ordered. mind from
abdomen P biliary colic ®Relieves ductal spasm. worry which is
RR= 32cpm A with helpful in
Splinted T excruciating 4. Administer minimizing
respiration T upper right Chenodeoxycholic acid. pain.
with short and E abdominal pain ® Chenodeoxycholic acid is
shallow R that radiates to a natural bile acid that
breathing N the back or decreases cholesterol
right shoulder. synthesis reducing size of
Porth CM. 5. Antibiotics
(2002). ® To treat infectious
Pathophysiolog process reducing
y: Concepts of inflammation.
Altered Health
States. 6. Hyperlipidemic agents.
Philippines: ® Reduces itching or
Lippincott pruritus from bile salts in
Williams & skin
7. Note response to
medication and report if
pain is not being relieved.
® Severe pain not relieved
by routine measures may
indicate developing
complications/ need for
further intervention

8. Promote bedrest,
allowing patient to assume
position of comfort.
® Bedrest in Fowler’s
position reduces
intraabdominal pressures;
however, patient will
naturally assume least
painful position.

9. Use soft, cotton lines,

calamine lotion, cool or
moist compress as
® Reduces irritation/
dryness of skin and itching

10. Control environmental

temperature, maintain a
cool room temperature.
®Cool surroundings aid in
minimizing dermal

11. Encourage use of

relaxation techniques such
as deep breathing
exercises. Provide
diversional activities such
as watching television.
®Promotes rest, redirects
attention, may enhance

12. Make time to listen to

complaints and maintain
frequent contact with the
®Helpful in alleviating
anxiety and refocusing
attention, which can relieve
Date/ Cues Need Nursing Objectives of Nursing Interventions Evaluation
Time Diagnosis Care
April S: “Wala ko S Anxiety related Within my 4 1. Be available to the Goal met.
28, kasabot sa E to gallbladder hour care, the patient. Maintain frequent
2009 ako gibati, L removal client will be contacts with the Patient was
mura ko ug F surgery able to: patient/SO. Be available for able to
3- nahadlok - listening and talking as identify ways
11pm karun sa ako P ® Anticipated 1.Verbalize needed. reducing
operasyon ug E surgery can be awareness of ® Establishes rapport, anxiety such
unsa ang R a source of feelings of promotes expression of as use of deep
mahitabo sa C many threats. anxiety and feelings. breathing
akua E These threats health ways to Demonstrates concern and exercises, and
panhuman P can produce deal with them. willingness to help. Helpful anxiety was
ato.” T vague feelings in discussing sensitive reduced to a
I ranging from 2. Report subjects. manageable
O: O mild uneasiness anxiety is level, “ Kung
Restlessness N to panic. reduced to a 2. Identify patient’s sige ko ug
Reports of Identifying a manageable perception of the threat istorya sa ako
uncertainty S threat as level. represented by the ginabati ug sa
and being E merely surgery situation. ako kaguol
scared L is too simplistic, ®Helps recognition of kay
F personal extent of anxiety and mabwasan
- threats are also identification of measures ang ako
C involved. that may be helpful for the kaguol.
O Moreover, individual. Magwapo ako
N although some ginhawa kung
C uneasiness may 3. Encourage patient to muhinga ko
E be attributed to acknowledge reality of ug lalom.”
P fear, the stress without denial or
T remaining reassurance that
feelings relate everything will be alright.
P to anxiety. Provide information about
A measures being taken to
T Source: correct or alleviate
T Carpenito- condition.
E Moyet. Nursing ®Helps patient to accept
R Diagnosis what is happening and
N Application to reduce level of anxiety.
Clinical False reassurance is not
Practice, 11th helpful, because neither
Ed. Lippincott nurse nor patient knows
Williams and the final outcome.
Wilkins, 2005 Information can provide
Date/ Cues Need Nursing Objectives of Nursing Interventions Evaluation
Time Diagnosis Care
April S: Report of A Impaired Within my 8 1. Administer medication Goal partially
28,20 pain C physical hour care, the prior to activity as needed met.
09 T mobility related client will be for pain relief.
O: Limited I to pain at able to: ®To permit maximal effort Patient
3- range of V incision site. or involvement in activity. refused to
11pm motion I 1.Verbalize perform range
Slowed T ® Pain impairs willingness to 2. Change position of motion
movement Y mobility and and frequently when on exercises for a
Decreased - activity. Full demonstrate bedrest; support affected fear of
posturing E function may participation in body parts or joints with experiencing
change speed X be affected and activities pillows. pain after the
E be delayed. ®Decreases discomfort, activity. On
R 2. Maintains maintains muscle strength/ the other
C Source: optimal position joint mobility, enhances hand, there
I of function as circulation and prevents were no
S Monks. Home evidenced by skin breakdown. contractures
E health nursing: the absence of and
assessment contractures 3. Provide skin massage. complications
P and care and decubitus Keep skin clean and dry observed after
A planning. ulcers. well. Keep linens dry and an 8 hour care
T Elsevier Health wrinkle-free. with the
T Sciences, 2002 ®Stimulates circulation client.
E and prevents skin irritation.
N 4. Encourage deep
breathing and coughing.
Elevate head of bed Turn
side to side.
®Mobilizes secretions,
improves lung expansion
and reduces risk of
respiratory complications.

5. Assist with active and

passive range of motion
®Maintains joint flexibility,
prevents contractures and
aids in reducing muscle

6. Provide safe
environment such as giving
assistance in sitting and
transferring from bed to
chair or chair to bed and
use of wheelchair if
®Avoids accidental injuries
and falls.

7. Encourage early
ambulation. Support
abdomen when
®Early ambulation
prevents postop
complications. Splinting
provides incisional support/
decreases muscle tension
to promote cooperation
with therapeutic regimen.
Provide adequate rest
periods in between
®To prevent fatigue.

8. Provide diversion such as

talking with the patient or
watch television.
®Decreases boredom,
promotes relaxation.
Date/ Cues Need Nursing Objectives of Nursing Interventions Evaluation
Time Diagnosis Care
April S/O: N Impaired tissue Within an 8 1. Check the incisional Goal met.
30, Incision at U integrity related hour care, the drain, make sure that they
2009 right upper T to surgical client will be are free flowing. Within the
quadrant R incision able to: ® Incision site drains are span of care,
with Jackson I used to remove any hemorrhage
Pratt drain T 1. Be free of accumulated fluid and bile. was not
with slightly I ® In complications Correct positioning observed and
soaked, intact O gallbladder such as heavy prevents back up of the patient was
dressing at N removal bleeding at the bile in the operative area. able to
right upper A surgery, a incision site. demonstrate
quadrant of L surgeon makes 2. Observe color and behaviors to
the abdomen, - a large incision 2. Demonstrate character of the drainage. prevent skin
status post M (cut) in your behaviors to ®Initially, may contain breakdown
open E belly to open it prevent skin blood and blood-stained through
cholecystecto T up and see the breakdown fluid, normally changing to participation
my A area. The greenish brown (bile color) in the change
B surgeon then after the first several hours. of dressing
O removes your and change of
L gallbladder by 3. Place patient in low or positions.
I reaching in semi-fowler’s position.
C through the ®Facilitates drainage of
incision and bile.
P gently lifting it
A out.The 4. Change dressings as
T surgeon will often as necessary. Clean
T make a 5 to 7 the skin with soap and
E inch incision in water. Use sterile Vaseline
R the upper right gauze, zinc oxide or karaya
N part of your powder around the incision.
®Keeps the skin around
belly, just the incision clean and
below your ribs. provides a barrier to
The surgeon protect skin from
will cut the bile excoriation.
duct and blood
vessels that 5. Observe skin, sclerae,
lead to the urine for change in color.
gallbladder. ®Developing jaundice may
Then your indicate obstruction of the
gallbladder will bile flow.
be removed.
6. Note color and
Source: consistency of stools.
®Clay colored stools result
http://www.nlm. when bile is not present in the intestines.
e/002930.htm 7. Investigate increased or
consistent RUQ pain;
development of fever,
tachycardia; leakage of bile
drainage from wound.
®Signs of suggestive of
abscess or fistula formation
requiring medical

8. Administer antibiotics.
®Necessary for treatment
or prohylaxis for abscess or
9. Monitor laboratory
studies such as WBC
® Leukocytosis reflects
inflammatory process such
as abscess formation or
development or peritonitis
or pancreatitis.
Date/ Cues Need Nursing Objectives of Nursing Interventions Evaluation
Time Diagnosis Care
April S/O: Surgical H Risk for Within an 8 hr 1. Monitor vital signs. Note Goal met.
30, incision at E infection care, the client onset of fever, chills,
2009 right upper A related to will be able to: diaphoresis, changes in Within the
quadrant L presence of mentation, and complaints span of care,
3- T surgical incision 1. Be free of of increasing abdominal temperature
11pm H purulent pain. remained
®The skin is drainage or ®Suggestive of presence of normal,
P the first line of erythema; be infection/ developing patient was
E defense against afebrile sepsis, abscess or not afebrile.
R infection. Any peritonitis. No purulent
C break in its drainage
E continuity may 2. Practice good hand noted.
P allow washing and aseptic wound
T microorganisms care.
I to enter the ®Reduce risk of spread of
O body which in bacteria.
N turn can cause
- the infection, 3. Inspect incision and
H and since the dressings. Note
E patient had characteristics of drainage
A undergone from wound.
L cholecystectom ®Provides early detection
T y, there is a of developing infectious
H break of process and monitor
continuity of resolution of pre-existing
M the skin, which peritonitis.
A may contribute
N to the 4.Administer antibiotics
A development of ®May be given
G future prophylactically or to
E infections. reduce number of
M multiplying microorganisms
E Source: in the presence of infection
N to decrease spread and
T Mattson Porth, seeding of the abdominal
Essentials of cavity.
P Pathophysiolog
A y Concepts of 5. Use sterile gloves for
T Altered Health wound care. Practice
T Status, aseptic technique.
E Lippincott ®Prevents invasion of
R Williams and bacteria or microorganisms
N Wilkins, 2007 at site and eventually
prevents possible infection.

6. Instructed to maintain
clean dry clothes
preferably cotton fabric
®Skin friction caused by
stiff or rough clothes leads
to irritation of fragile skin
and increases risk for

7. Cleanse incision site with

povidone iodine.
®Disinfects site and
prevents multiplication of
microorganisms which may
cause infection.
8. Instruct client not to wet
incision site.
® Microorganisms thrive at
damp areas and makes it
conducive for replication.

9. Provide a cool
environment. Adjust air
conditioner as preferred by
the client.
® Hot room temperature
induces sweating which
may inhibit the healing of
wound and eventually
cause moisture at the area
delaying the healing
Discharge Planning


• Tramadol

• Ketorolac

• Ranitidine

• Sulperazone

Mr. Police should comply with the medications he has been prescribed

with in order to aid in the recovery state after surgery. With regards to his

medications, he must know and understand the general knowledge of the

drugs, their side effects and their adverse effects. If he experiences any

adverse effects, he needs to refer to his physician immediately.


Cholecystectomy actually requires time to recover. Laparoscopic

cholecystectomy usually requires only one night in the hospital. A major

advantage of the procedure is that it patients can return to work in 1 to 2

weeks. But compared to open cholecystectomy, it is advised to have 4 to 6

weeks duration time for recovery. Once home, it is possible to tire more

easily than usual to begin with, so it is important to take it easy. Strenuous

exercise and lifting should be avoided. Light exercise such as walking is

recommended. Normal activities, including returning to work, can usually be

resumed after about a week. Patient must follow his surgeon's advice about
driving. He shouldn't drive until he is confident that he could perform an

emergency stop without discomfort.


Gallbladder disease usually is treated by removing the gallbladder.

Now that the patient had his gallbladder removed, the rest is up to him. It is

important to rest and let the body recover after surgery. Consequently, to

prevent other complications, he must have his lifestyle and diet modified.

Health Teachings:

• Explain to patient what to expect afterwards. As the anaesthetic wears

off, there is likely to be some pain. The anaesthetist will prescribe

painkillers. Suffering from pain can slow down recovery, so it's

important to discuss any pain with the doctors or nurses.

• On discharge, the nurse must advise about caring for the stitches,

hygiene and bathing, and will arrange an outpatient appointment for

the stitches to be removed, if necessary. Some people will have

dissolvable stitches, which do not need to be removed.

• Instruct patient to comply with the home medications that would be

given by his physician. Remind him to complete the full course of the

antibiotic treatment.

• Encourage patient to do the recommended light exercises such as

walking. Avoid doing strenuous activities which could slow down his


• Encourage him to comply with the dietary modifications; limit the

intake of saturated fat and avoid the consumption of alcoholic

beverages to prevent the occurrence of serious post-cholecystectomy


• Explain to patient to refer for unusualities immediately.

Out-patient Care:

Remind patients that regular check-ups are important to ensure that

the patient condition is constantly monitored by the doctor. If any of the

following symptoms are noted, he should contact his doctor:any of the

wounds start to bleed

• any of the wounds become more

• painful, red, inflamed or swollen

• the abdomen swells

• pain is not relieved by the prescribed painkillers

• a fever develops.

These could be signs of an infection that may need to be treated with



In time, patients who have suffered cholecystectomy are exposed to a

high risk of developing heart disease, diabetes and disorders of the nervous

system. This is due to inappropriate synthesis and assimilation of vital

nutrients, vitamins and minerals. In order to prevent the occurrence of

serious post-cholecystectomy side-effects, operated patients need to make

drastic lifestyle and dietary changes. They should limit the intake of

saturated fat and avoid the consumption of alcoholic beverages. Also, they

should eat smaller amounts of food during a single meal. People who have

had gall bladder removal surgery are advised to eat around 5 or 6 smaller

meals a day instead of 2 or 3 usual meals. Considering the fact that the

organism is unable to completely absorb important nutrients without the

help of the gall bladder, operated patients also need to take vitamin and

mineral supplements and bile salts to aid the process of digestion.


Category Poor Fair Good Rationale

Onset of / A month prior to admission, Mr. Police
illness experienced right upper quadrant
pain associated with a sense of
bloatedness, without nausea and
vomiting. The pain was tolerable so
he did not seek medical attention yet.
He said he also had an increased level
of pain tolerance so he also didn’t
mind to take any pain relievers. Until
three days prior to admission, patient
had severe right upper quadrant pain,
which was said to be intolerable.
Moreover, when pressure is applied on
the RUQ of the abdomen, pain is
elicited. He had also lost his appetite
because of the pain. His scleras were
also slightly icteric during admission
and he was positive with Murphy’s
sign. So he sought consultation at
Out-Patient Department- Emergency
Room at Davao Medical School
Foundation Hospital. Ultrasound
revealed cholecystitis, so patient was
advised admission and operation.
Duration of / Though no complications aroused yet,
illness Mr. Police did not immediately seek
medical attention as he had persistent
RUQ pain a month ago. He waited for
the pain to become intolerable before
seeking medical advice. Moreover, the
obstruction brought about by the
cholecystitis caused his icteric sclera,
which could have been absent if he
sought medical attention earlier.
Precipitating / Only three out of eleven known
factors precipitating factors are present with
Mr. Police’s case which is the
following: diet (high cholesterol, high
calorie, and high sodium), diabetes
mellitus and obesity.
Attitude and / Mr. Police said he would undergo any
willingness treatment regimen he has to as long
to as his condition would get better.
medication Moreover, he let himself be admitted
and to the hospital and to undergo surgery
treatment as he is determined to get well as
soon as possible.
Environment / DMSFH is a hospital with an
environment, very conducive for
healing. Moreover, the personnel in
the institution which includes the
medical team are very responsive to
the needs of the patients.
Age / The client is almost 50 years old. The
wear and tear theory states that as
one grows older, most of our organs
are already used and abused. As one
ages, one also becomes more
susceptible to infections and organ
Family / Anna is always watching over Mr.
support Police during his admission. She said
she will always be with Mr. Police
through his ups and downs, as he
vowed him during their wedding day.
Moreover, relatives come to Davao to
visit Mr. Police, and together with
them are the encouragement and
support they give Mr. Police.
Total 0/7 3/7 4/7


No. of categories rated POOR (1) + No. of categories rated FAIR (2)

No. of categories rated GOOD (3) divided by TOTAL NO. OF


=0(1) + 3(2) + 4(3)

= 6 + 12



Scoring for General Prognosis:

1-1.6 =POOR

1.7-2.3 =FAIR

2.4-3.0 =GOOD

General Prognosis:
The general prognosis of the client is good. This means that the client
has a good chance of recovering from his illness.

Generally, the student nurse’s one week exposure and duty at the

Davao Medical School Foundation Hospital has been a memorable

experience to them. The exposure had been an avenue for further

development and enhancement of their skills and capabilities in rendering

care and promoting holistic wellness to their clients. It reminded them again

that nursing profession entails a deep sense of responsibility and challenging


After five days of exposure at St. Joseph (3C) ward, the student nurses

has identified and understood the causative factors of cholecystitis, its signs

and symptoms, clinical manifestations, diagnostic studies, medical,

pharmacological and nursing interventions through obtaining cues and

health history in conjunction to the disease process. They underwent

extensive research in order to comprehensively understand his condition.

Upon learning his case, it challenged and motivated them to work hard to

provide the appropriate and effective nursing intervention and care.

Moreover, cholecystitis is the most common problem resulting from

gallbladder stones. It occurs when a stone blocks the cystic duct, which

carries bile from the gallbladder. Predisposing factors can include heredity,

age, sex and race. With the presented factors that cannot already be

modified, one has to take action towards preventing the disease to happen.

The only one who can help yourself is you alone. With the proper knowledge

about the nature of the disease as well as its preventive measures along with
responsibility and sense of will, one can surely direct himself away from the


Our gallbladder is not to be taken for granted. There have been reports

that mortality can be as high as 15% for immunocompromised patients.

Furthermore complicated cholecystitis has 25% mortality (eg, gangrene,

empyema of gallbladder).

“No matter how the disease has already reached an alarming incidence rate or not, it is

a duty of every human person to take care of his own body, not just for the sake of other people

that depend on him, but most especially for himself ~ a primary obligation that he must fulfil.”

Every exposure is a learning experience filled with lessons. After

thoroughly studying Mr. Police’s case, the group has come up with the

following recommendations:

To the client:

Recovering after open cholecystectomy surgery doesn’t depend solely

on the healthcare team. More than anything else, there must be willingness

to recover on the part of the patient. With this, he must carry out his

responsibilities in fighting his own condition. He is encouraged to verbalize

his thoughts and feelings to his medical attendants, such as his nurses,

because it would be better for him to express whatever is causing stress on

his part thus, hindering his recovery or yet understand that the things that

his nurses is doing for him is for his own good and betterment in life. He is

encouraged to willingly and actively participate in therapeutic activities that

will render improvement of his condition. Moreover, he should fight his as

much as he can through complying with the treatment being given to him

and through continuing his rehabilitation process so that the chances of his

recovery will be greater.

To the patient’s family

Undeniably, the patient’s family plays a significant part in his battle

against the disease. The family members should be involved with his

treatment as much as possible since their support motivates him to exert

more effort in the recovery process. They should not only be physically

present. More than that, they should give their emotional support to boost

the patient’s morale. In addition, they are encouraged to be oriented and

educated with the basic facts about the patient’s condition so that they will

understand his condition better. Not only that, they should always asked the

student nurses for assistance, advices, or clarifications because they are

always ready to lend a helping hand. Through this, they would be able to

know how to manage and meet his needs when he is discharged from the

institution where he is admitted.

To the group

Maintain practicing teamwork and unity within the group so that better

output will be formulated. Be sensitive and respond to the needs of other

group members. If one is done with the task, try to help the others and

contribute something that would make the work better. Being calm is always

a good move. Fix the problems in a peaceful manner. Be open-minded to

suggestions and prevent intensive discussions so that healthy relationship

within the group will be maintained.

To the fellow student nurses

It is not through a single effort that you learn the entirety of a certain

illness. Rather, it takes continued research and study in order to be more

updated with information that will render an insightful understanding of what

it is all about. As student nurses, you should do your best to be equipped

with the necessary knowledge that will help you in your endeavors especially

when you go on duty in units where intensive care is needed. It is through

this that you can provide the quality and holistic nursing care that patients

need. You should realize that your patients are also humans, though suffering

from a chronic illness. You should always be humane in treating and

approaching them so that you can be of help in the best way you can.

Nursing students of AdDU should be committed to the goal of being men and

women for others. They should not only appreciate the concepts during

lecture session but should also positively digest the experiences they get

from their duties and exposures.

To the Ateneo de Davao University- College of Nursing

The AdDU- College of Nursing has been exerting much effort in

providing the best exposures to its nursing students. The faculty and staff

are encouraged to continue elevating the standard of the Ateneo Nursing

Curriculum through quality training of Clinical Instructors in the advent of

seminar, forums or trainings, quality-level lectures and affiliations with

various medical institutions for the students’ exposures and duties.

To the Professional Medical World

Open cholecystectomy undeniably has its own disadvantages. The scar

alone after surgery is one of the major disadvantages. Furthermore,

Minilaparotomy cholecystectomy presents exposition difficulties, and

laparoscopy requires expensive equipment and additional training.

Laparotomy is more painful, causes trauma to the abdominal wall, and

requires a longer convalescence; it is also less aesthetic. Researches and

studies have been conducted to discover a new technique of minimal

invasive cholecystectomy. Such new technique presented for minilaparotomy

cholecystectomy is transcylindrical. As the medical field advances, the

people’s trend as well as preference also changes. As much as possible, a

cheaper, less invasive and more aesthetic procedure is preferred. The group

would like to comment on the success of the emergence of new studies and

invention. They are to look forward to further studies and improvement.






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