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College of Nursing

A Grandcase Presentation


In partial fulfillment of Requirement for:


Submitted by:

Alvarez, Jennifer N.
Aquino, Joanna Rose P.
Aquino, Karla mae
Banez, Ivy Z.
Camemo, Jinky G.
Cabero, Elaine Lourdes F.
Mercader, Juan Miguel F.
Neri, Martin Jaren
Reyes, Farida Paula S.
Reynoso, Sean Rupert
Samson, Rona Angelika
Togonon, Phillippe

Group 14

A. General Data
Patient’s Initials: RVH
Address: Paranaque City Informant: RVH (client herself)
Age: 33Y1M Date of Admission: Jan. 5, 2010
Sex: Female No. of days in hospital: 4
Date of Birth:November 19, 1976
Civil Status: Married
Occupation: N/A

B. Chief Complaints

The patient experienced abdominal pain in the right upper quadrant with the pain scale of 8/10,
as 10 being the highest. She describes it as a stabbing, intermittent pain that occurs for almost 3
to 4 hours with an interval of 5 minutes. The pain radiates to the subscapular region and to the
right shoulder. The onset of pain is often after a meal or in the evening. Associated symptoms are
nausea and vomiting.

C. History of Present Illness

December 22, 2009 patient RVH felt pain on the right upper quadrant of the abdomen
with the pain scale of 8/10 as 10 being the highest. The pain was still tolerable that time so she
didn’t take any medication. The same amount of pain re-occur last December 25-27, 2009 , she
self medicate and took Buscopan 5mg for relief. December 28, 2009 the pain is progressively
increasing and it already radiated on her shoulder and most often on her scapular area so she
decided to have a check-up at Medical Center Paranaque. Ultrasound was done and it revealed
Sludge filled gall bladder with lithiasis and diffused wall thickening, rule out acute cholecystitis.
She was then scheduled for Laparoscopic Cholecystectomy on January 6, 2010 because the
gallstone is already in the neck of the gallbladder. December 30, 2010 the stabbing pain worsens
especially after eating. She was advised to take Etoricoxib 12 mg/tab every time the pain will
occur. January 3-4 she already experienced nausea and vomiting. January 5, 2009 when she was
admitted to her room, the pain became severe with pain scale of 8/10.

D. Past History
Childhood Illnesses
Chickenpox (9 years old)
Asthma (birth – 6 years old)
Mumps (10 years old)
Adult Illnesses
Previous Immunization
Cervical Cancer Vaccine (2009)
Cesarean birth on second child (2005)
Cesarean birth on third child (2009)
Medications prior to confinement
Vitamin C –OD 500 mg
Clusivol -OD 500mg
E. Systems Review

1. Health Perception-Health Management Pattern

According to the client, her general health these past few months has been fair even
though she has had coughs and colds. The client also mentioned, “Pag may sipon ako o ubo,
calamansi juice lang muna iniinom ko pero pag grabe na yung sipon, pag hindi ko na kaya
umiinom na ko ng gamot.” She takes over-the-counter drugs such as Robitussin or Solmux and
takes it twice a day and her colds/coughs will usually be relieved after five to seven days.

She performs monthly breast self examination and mentioned that there were no
tenderness and masses felt. She is now regularly taking Vitamin C(500mg) and Clusivol Multi-
Vitamins (500 mg ) for her supplements 1 tablet per day.

During her confinement, the client’s perception about her health has changed. She also
said, “Feeling ko hindi na ako ganun kahealthy gaya ng dati kase ang laki na ng tinaba ko
pagkatapos ko ipanganak yun last baby ko” She also mentioned that she is always bothered
because of the pain she feels due to the incision. The client looks tired and not well rested.
During the interview, the client feels pain. “Masakit pa rin dito sa may opera sakin.” as
verbalized by the client. When she was asked to rank her pain from 0 -10, as 10 being the
highest. She rates it as 8. She said that her movement is limited because of the pain.

2. Nutrition Metabolic Pattern


January 2, 2010 January 3, 2010 January 4, 2010
BREAKFAST 2 slices of loaf bread 1 bowl of cereal 1 cup of coffee
2 boiled egg 1 glass of orange juice 1 bowl of oatmeal
1 cup of coffee
DINNER 1 plate of Caesar salad 1 plate of chicken ½ cup of mushed
1 glass of water macaroni salad potato
1 glass of water 2-3 cubes of steamed
1 glass of water

The table above is the client’s daily food intake prior to confinement. As told by the
client, she eats twice a day which consumes breakfast and dinner. She does not eat in between.
She does not eat rice either. She also mentioned that she usually drinks six to eight glasses of
210 cc of water every day and about a glass of soda once a week. She also mentioned that she
does not have any dental problems and does not wear dentures.

After pregnancy the client noticed that she gained a lot of weight (from 120 lbs she became 160
lbs), but she didn’t bother to decrease her food intake because she is still breastfeeding. After 4
months she was alarmed when she realized that she is still overweight (140 lbs). She abruptly
shifted her diet to salads, bread, steamed beef and white meats. “iniiwasan ko na yung matataba
at maalat, dati kasi mahilig talaga ako sa mga pagkain tulad ng barbecue at porkchop madalas
mga apat na beses sa isang linggo ” as verbalized by the client

During the confinement, the client is on NPO. Upon waking up after the surgery, she felt
hungry and thirsty but did not drink or eat anything due to physician’s order.

3. Elimination Pattern

Prior to hospitalization, the client mentioned that she urinates four to five times daily
which is usually yellow in color. She defecates once a day which is semi-solid formed and brown
in color. “Hindi naman masakit pag umiihi ako.” As verbalized by the client. She does not take
any laxatives either. She also mentioned that she does not perspire excessively except when she
is exercising. The client feels ease and comfort during urinating and defecating

During hospitalization the client usually urinates 11 times a day with a total of 1400 cc
output which is dark yellow in color. On the first day of post operation, the client still does not
defecate. On the second day, her bowel movement has returned, she defecates semi solid in
characteristic and brownish in color.

4. Activity – Exercise Pattern

Before confinement, the client said that she exercises regularly which is done everyday.
She said, “Every day nanonood ako ng instructional dvd tapos ginagaya ko din.” She also said
that playing with her children is also part of her exercise regimen. She does not do any
household chores because they already have a helper to do the cooking, cleaning, laundry and
everything else. Whenever her children are at school, she takes her youngest child to the mall
and strolls around. She also watches television most of the time. Her whole family goes to
church and attends mass every Sunday and they will have their dinner afterwards.

During confinement, the client’s movement is limited due to the pain at the incision site.
“Nahihirapan ako gumalaw ngayon kase kumikirot yun tahi ko” as verbalized by the client.
When asked to rate the pain that she feels, ten being the highest, “mga 8 out of 10 ganun” as
verbalized by the client.

5. Cognitive – Perceptual Pattern

Prior to hospitalization, the client had her last eye check up last year and make known by
the ophthalmologist that her vision is 20/20. She does her eye check-up once a year. She does
not have any hearing difficulties either. She also said that she is a fast learner. “Pag may ituro o
basahin lang ako, naiintindihan ko naman agad. Yun nga yung exercise videos, kagaya nun
madali ko naman masundan. She does not find it hard to make important decisions in her life
because she and her husband talks about it; and most of the time, her husband is the one who
decides. She also said that she has a good memory because she can easily remember things and
recall past events.

According to the client, her vision and hearing did not change during hospitalization.
The only difference that she mentioned is that she is not able to concentrate on other things
anymore. “Mas iniintindi ko kasi itong sakit na nararamdaman ko” as verbalized by the client.

6. Sleep Rest Pattern

Before confinement, the client sleeps for about four to eight hours every day. She sleeps
at around 10:00 pm – 2:00 am and wakes up at around 6:00 – 8:00 am. She does not take
afternoon naps. She does not experience any nightmares but she does wake up at night to drink
water or urinate. She also said that she does not have snoring problems. She always feels well-
rested upon waking up.

During confinement, the client said that she’s having difficulty in sleeping due to the pain
at the incision site. “Nagigising gising ako kasi nga masakit yung tahi. Hindi ako makatulog ng
maayos kaya madalas nangihihina ako.” the client verbalized. She also mentioned that she was
disturbed by the monitoring procedures of the health care provider.

7. Self-Perception Pattern

Before hospitalization, the client describes herself as a jolly, friendly and relaxed person.
“Sobrang masaya ko at kami ng asawa ko kasi may bago kaming baby.” She also said that she is
conscious about her physical appearance because she gained weight. “Feeling ko ang taba taba
ko ang taba taba ko na” The client also mentioned that as much as possible, she does not want
to get mad. “Naiinis lang ako kapag pinagchichismisan ako ng mga taong nakapaligid sa kin.
Syempre sino bang hindi mainis di ba?” She also said that she does not lose hope because her
husband is always there for her and she believes that God will never let her down.

During hospitalization, the client said that even though she is worried about her situation,
her children inspires her and makes her happy. “Pag naiisip ko mga anak ko, naiisip ko I am a
good mother and confident ako sa pagpapalaki ko sa kanila kahit na malaking responsibility
super saya ko talaga”.But then she still worries about her physical appearance “Sobrang tumaba
ako nung nagbuntis ako ayoko ng ganto”.

8. Roles - Relationships Pattern

The client has a nuclear type of family which is composed of her husband, two daughters
and a son. Her husband works as a businessman, and as the breadwinner of the family, he
provides everything especially the financial aspect. She said that her husband’s salary is enough
to provide for them. The client is a housewife and takes care of their children. “Minsan kapag
hindi ako nagsshoshopping or nasa mood ako, pupunta ako sa business namin. Kapag hindi
naman, after ko asikasuhin mga anak ko, nanonood lang ako tv sa bahay. Hintayin ko lang sila
makauwi.” The client mentioned that she and her husband always talk especially when it comes
to major decisions in life. “Lagi naming pinaguusapan lahat before kami magdesisyon
syempre.” She also said that she and her husband have a good relationship with each other and
with everybody else in the house. The client also mentioned that she has a lot of friends and they
meet occasionally.

During confinement “madalas nandito ang asawa at anak ko pagkatapos sa trabaho ng

asawa ko dinadala nya mga anak naming sa ospital, makita ko lang sila para bang nagiginhawaan
na ako” as verbalized by the informant.

9. Sexuality – Reproductive Pattern

According to the client, she had her menarche when she was 12 years old. She also said
that her period lasts for about four to five days. She consumes three to four sanitary pads a day
which were fully soaked and bright to dark red in color. She does not experience dysmenorrhea
or headache during her period. The client also said that she and her husband are both sexually
active. She also mentioned that they do not use any family planning method.

10. Coping-Stress Tolerance Pattern

Prior to hospitalization, the client said that a major change in her life this past year is
giving birth to her new baby. “Having a new, healthy baby is really a blessing to me and to the
family” as verbalized by the client. She also said that there is no crisis going on within her
family. Whenever they have problems concerning with their children they fix it right away. “
hindi namin tinatapos ang araw na may problema kami” She also believes that her husband is
the most helpful person in talking things over. “He’s not just my husband, but also my best
friend. I really think na importante yung ganun.” The client also mentioned that she is relaxed
most of the time. “Lagi din ako nagsisimba at nagpepray kaya alam ko na hindi rin ako
mahihirapan sa buhay dahil kay God.”

During hospitalization, that client said that she is not stressed out about her surgery
because she believes that everything will be fine. “Hindi naman ako takot dito or natatakot sa
opera, nabobother lang talaga ko sa sakit ng tahi yun lang.” She also said that she also follow
her physician’s orders because she wants to get well immediately. The client said that her
husband and her chidren helps her in getting well. “makita ko lang sila ayos na ko” as verbalized
by the patient.

11. Values-Belief Pattern

The client believes that she generally gets the things she wants in life. “Not just
materially, pero like yung gusto ko pa ng another baby, yun binigay din Nya. Sa ngayon kasi
bata pa naman mga anak ko, syempre gusto ko makapagtapos sila ng pagaaral at syempre
magandang buhay. Gusto din naming magvacation as a family siguro magbeach sa summer.”
The client is a Roman Catholic and her whole family attends mass every Sunday night. She
believes that religion and her relationship in God is very important. “Hindi pwedeng hindi ako
magdasal bago matulog sa gabi,” the client verbalized.
F. Family Assessment
RH Husband 42 M Businessman, PhD College Graduate
MH Daughter 11 F none Grade 5
JMH Son 4 M none Preschool
HH Daughter 10mos F none -

G. Heredo – Familial Illness

• Maternal – Diabetes Mellitus, Hypertension
• Paternal – Hypertension

H. Developmental History


Psychosocial 33 years old GENERATIVITY V. The client has
Theory STAGNATION established her own
by Erik Erikson family and is
financially stable to
raise her kids. She
also talks with her
husband especially
when major decisions
have to be made.
“Lagi naming
pinaguusapan lahat
before kami

Psychosexual 33 years old GENITAL STAGE The client has a

Theory husband and her own
by Sigmund Freud family. She can
freely express her
feelings as a woman
and is happily
married. She and her
husband are both
sexually active and do
not use any family
planning method.
“Pareho kasi kami ng
husband ko na
mahilig sa bata kaya
okay lang madaming

Cognitive Theory 33 years old FORMAL The client does not

by Jean Piaget OPERATIONAL have a hard time in
making decisions.
She has a good
memory and can
easily recall things.
She is a fast- learner.
“Pag may ituro sa kin
or basahin naalala ko
kaagad, especially
pag nagcoconcentrate
Moral Theory 33 years old LEVEL 3- The client is aware
by Lawrence POSTCONVENTIONA that people have
Kohlberg L MORALITY different opinions and
that respect should
STAGE 6- SOCIAL still be given to them.
CONTRACT AND “Kahit na madami tao
INDIVIDUAL RIGHTS pinagchichismisan
ako, nakakainis pero I
try not to mind them.”
Spiritual Theory 33 years old STAGE 5- The client is a Roman
by James Fowler CONJUNCTIVE Catholic and has her
own point of view
when it comes to
religion. She goes to
church every
Saturday night with
her family. “Hindi
ako makatulog kapag
hindi nagdadasal.”


Date and time of history taking: January 7, 2010 (0900H)

Height: 5’3” Weight: 64kgs

Actual Height:5’3”

Body Mass Index:

Weight in kg.
BMI = ___________________

(Height in meters) ²

64 kgs.
BMI = ___________________

(1. 60 m) ²

BMI = 24.8 kgs/m²= indication of within the normal range

Desirable Body Weight

(Tannhauser’s Method of DBW Computation)

DBW = Height in cm – 100cm; get 10% of remainder; subtract the

answer from the remainder

DBW = 160 cm – 100cm = 60

60x 10% = 60
64 – 6
DBW = 58kg
Vital Signs

BP: 130/90 mmHg PR: 87 bpm

RR: 25cpm T: 37 oC

General appearance:
- Endomorph
- Client is clean in her overall hygiene
- No breath or body odor
- Cooperative and able to respond
- Understandable and clear tone of speech
- Client’s organization of thought makes sense
- Able to maintain attention span
- Restless appearance
-Jackson Pratt Drain was attached to the RUQ incision site (5mm)

A. Skin
I: - Light to deep brown in color
- Dark pigmentation on areas of skin folds (neck, elbow, inguinal, armpit)

- Hair is evenly distributed on the patient’s skin

- Free from lesions

- No edema

P: - Good skin turgor

- Smooth and moist skin

- Warm to touch

- Uniform temperature on all areas

- No palpable nodules or masses

B. Nails
I: - Well rounded, convex curvature
- Pinkish in color
- Short and clean nails
- Nail bed approximately 160 degrees
- Intact epidermis
P: - Smooth texture
- Good capillary refill (2 seconds)

C. Skull and Face

I: - Normocephalic
- Symmetric facial features and movements
- Upright and still
- Hair is black in color
- Head has no masses and deformities
- Absence of nodules and masses
- No pain upon palpation

D. Eyes
I: - Eyebrow is evenly distributed and skin is intact
- Eyebrows are symmetrically aligned
- Eyelashes are equally distributed and curled slightly outward
- Eyelids are intact, no discharges, no discoloration, or excessive tearing
- Pupils: equal in size, round, black in color, and clearly visible
- Eyelids close symmetrically
- Sclera is white in color
P: - No tenderness felt in her eyes
- No edema in lacrimal and nasolacrimal duct

E. Ears
I: - Color is same with the facial skin, symmetrical
- Aligned with the outer canthus of eye
- Ear canal is pinkish, clean, with scanty amount of cerumen
- No discharges
- No swelling on both ears
P: - Pinna recoils after it is folded
- No tenderness

F. Nose
I: - Symmetric and straight
- No discharge or flaring
- Uniform in color
- Nasal septum intact in midline
- Pink mucosa
P: - No areas of tenderness, inflammation and lumps upon palpation.
- Non-tender and absence of masses on frontal and maxillary sinuses.

G. Mouth and Oropharynx

I: - Light pink and smooth lips

- Able to purse lips
- No dentures
- Symmetry of contour
- Moist, pinkish mucosa
- No bleeding, swelling and inflammation of gums
- Uvula positioned midline of soft palate
- Tongue midline without deviation, moves freely, no tenderness
- Light pink in color, no swelling, symmetrical tonsils

H. Neck
I: - Head is centered
- Able to move with no difficulty
- Able to slightly resist force
- Proportion to body structure
- Coordinated smooth movements
- Thyroid gland not visible
- No discomforts
- No swelling
P: - No vein engorgement and scars
- Lymph nodes not palpable

I. Spine
I: - Spine lies straight without lateral deviation.
P: - No presence of tenderness masses and lumps.

J. Thorax / Lungs
I: - Symmetrical chest expansion
- Quiet, rhythmic and effortless respirations
- Respirations of 22 cycles per minute.
-Spontaneous, non-labored breathing.

Pa: - Skin is intact and uniform in temperature

- No tenderness
- No masses
Per: - Not performed
A: - Absence of adventitious sounds

K. Cardiovascular / Heart
I: - No visible pulsations
- Jugular veins not distended
P: - No lifts or heaves
- Carotid artery has symmetrical pulse volume
- No pulsations on aortic and pulmonic areas

L. Breast
-The patient refused to have a physical examination in her breast but according to the
patient “she doesn’t notice any mass or nodules when doing breast self examination.

M. Abdomen
I: - Contour was round and bilaterally symmetrical Position of umbilicus was midline
and inverted
- Incisions found on in the RUQ, one just right of the midline, slightly below the
xiphoid and coastal margin, and the other midway to umbilicus, one laterally in the
anterior axillary line above the iliac crest at the coastal margin, in midclavicular line
slightly above the level of umbilicus and 2 cm below the rib.
A: - bowel sound heard in 8 times per minute.
Pe: - Not performed
Pa: - Not performed

N. Extremities:
I: - Uniform in color
- Equal size of muscle on both sides of the body
- IV is attached on right metacarpal; intact with no signs of infection
- Lower extremities are flaccid
- Able to move upper extremities
- No tremors or contractures

P: - Absence of tenderness on the upper and lower extremities

N. Genitals
- The patient refused to have a physical examination in her genital area on the day of
interview, but according to the patient, she has no rashes or skin lesions in the area. The
patient doesn’t have difficulty in urinating and no tenderness felt in the area.

G. Rectum and Anus

- The patient refused to have a physical examination in her rectum and anus on the
day of interview, but according to the patient, she has no rashes or skin lesions in the
area. The patient doesn’t have difficulty in defecating and no tenderness felt in the


Habits: Swimming, Billiard, Tennis Rank in the family: Mother

Vices: None Travel: None
Lifestyle: Active Educational attainment: College Graduate
Social affiliation: None

Client’s usual day like:

According to the client, she wakes up at around 6-8 in the morning. She eats her breakfast and
prepares her children to go to school. When her husband is at work, and her children are at
school, she exercises. She watches instructional dvds . Afterwards, she watches television or
goes shopping if she feels like it. She stays at home most of the time. She goes to church with her
family every Sunday evening. After dinner, she helps her children do their home works. She
sleeps at around 10 in the evening to 2 in the morning after watching tv.


The patient lives in an exclusive village. Their lot measures about 810 square meters and
they have a 3-storey house with seven rooms, nine bathrooms, one pool, and one garden.
They have 5 maids in their house who works for them.
They also have one dirty kitchen and two dining area. The windows are adequate for ventilation
because they feel the air every evening. They buy Distilled drinking water to a store near them.
They use Nawasa for cooking, washing clothes bathing and other water activities. They have
electricity and they are a subscriber of Meralco. In terms of storage of food, they have a
refrigerator. If there are any left over every lunch, they just place the food on the table covered.
For their garbage disposal, they have two big drums enough to occupy and cover their trash. Four
times a week, the garbage is being collected. They don’t practice recycling but practices
segregation of biodegradables and non biodegradables.


Menarche: 12 years old When: Grade 6

Amount and Characteristics: 2-3 pads of napkin per day
Duration: 4-5 days
Associated Symptoms: None
Deliveries: G: 3 P: 3
OB Score: T: 3 P: 0 A: 0 L: 3

-Not applicable

December 28, 2009

HDT/ Pancreas

Ultrasound Findings:
The liver is normal in size and echopattern. No focal lesions seen. The intrahepatic duct
and common bile duct are not dilated, the latter measuring 3.96 mm.
The gall bladder measures 3.3 cm in widest transverse diameter. An echogenic,
shadowing focus measuring 1.4 cm is noted in the gallbladder neck. The rest of the lumen is then
filled with medium to high level echoes. Wall is diffusely thickened.
Pancreas is normal in size and echogenecity with no discrete lesion seen in it.

Sludge filled gall bladder with lithiasis and diffuse wall
Thickening, rule out cholecystitis
Normal sonogram of the liver and pancreas


January 5, 2010
COLOR Light straw to Light - Urine is diluted. There is no
dark amber Yellow indication of lack of body fluids,
no excess body fluid or presence
of blood, drugs and food.
CHARACTERISTIC Clear Clear - Normal,
REACTION/Ph 4.8 – 7.8 6.8 - Within the normal range, no
indication of acidity and alkalotic.
SPECIFIC 1.005 – 1.030 1.009 - Within the normal range, no
GRAVITY indication of dehydration and high
fluid intake, diabetes insipidus or
SUGAR (-) (-) - Absence of diabetes
PROTEIN (-) (-) - Does not indicate presence of
glomerulonephritis and

PUS CELLS 0.2 hpf 0-8 - Above the normal range,
indication of urinary tract infection
RBC 0-1 hpf 0–5 - Above the normal range,
indication of cystitis, trauma to the
kidney, renal disease, renal calculi,
lupus nephritis, excess aspirin,
anticoagulant, sulfonamides,
menstrual contamination.
AMORP. URATES Occasional
BACTERIA Occasional

Squamous Few
Fasting Blood 71 – 116 mg/dl 111.27 -Within normal range, no
Glucose indication of pre diabetes and
Urea Nitrogen 7.98 – 20 11.93 - Within normal range, no
mg/dl indication of malnutrition, kidney
problems, too much protein intake
and increased protein breakdown
in the body.
Creatinine 0.60 – 1.30 0.89 - Within the normal range, the
mg/dl body has adequate metabolism of
muscle mass
Total Cholesterol 0.00 – 200.00 182.69 - Within the normal range, there is
mg/dl no indication atherosclerosis and
coronary artery disease.
Triglycerides 50 – 150 mg/dl 53.64 - Within the normal range,
adequate energy to the heart and
skeletal muscle.
HDL 32.69 – 75 29.63 - below the normal range,
mg/dl the cholesterol is not properly
removed in the body and
transported to the liver.
LDL 65.38 – 173.85 178.92 - above the normal range,
mg/dl the cholesterol is not properly
transported to various cells.
Uric Acid 2.86 – 6.10 3.98 -Within the normal range, there is
mg/dl no indication of gout or kidney
ALT/SGPT 0.00 – 41.00 13.00 - Within the normal range, there is
U/L no indication of liver disease.
AST/SGOT 0.00 – 37.00 16.90 - Within the normal range, there is
U/L no indication of acute MI and liver
Alkaline Phosphate 42.00 – 98.00 92.00 - Within the normal range, there is
U/L no indication of liver and bone
Total Bilirubin 0.00 – 1.30 0.46 - Within the normal range, there is
mg/dl no indication of liver damage and
or abnormal breakdown of red
blood cells.
Conjugated Bilirubin 0.00 - 0.50 0.14 - Within normal range, there is no
mg/dl indication of liver disease.
Unconjugated 0.00 – 0.80 0.32 - Within the normal range, there is
Bilirubin mg/dl no indication of liver disease.
Amylase 25 – 125 U/L 83.50 -Within the normal range, there is
no indication of pancreatitis

January 5, 2010
Hemoglobin 120 – 150 125 - Within the normal range,
gm/L adequate oxygen-carrying protein
and deliver it to the body tissue
Hematocrit 0.37 - 0.47 0.38 - Within the normal range,
adequate proportion of total blood
volume made up of red blood cell.
RBC Count 4 – 5.4 4.45 -Within the normal range,
adequate oxygen transport in
blood to all cells in the body.
WBC Count 4.5 – 11 12.9 - Above the normal range, may
indicate presence of infection,
leukemia, or tissue necrosis
Platelet Count 200.00 – Adequate -Within the normal range, has a
400.00 good clotting process.

MCV 83 – 101 fL 85.6 - Within the normal range, the size
of the RBC is normocytic.
MCH 27 -31 pg 28.1 - Within the normal range, average
weight of the hemoglobin in RBC.
MCHC 315 – 345 g/L 328 - Within the normal range, average
hemoglobin concentration per unit
volume of RBC,s
RDW 39 – 46 fL 43.1 - Within the normal range, average
width differences of RBC’s.

Lymphocytes 0.20 – 0.35 0.20 - Within the normal range, there is
no indication of chronic and viral

Patient 12.00 – 15.00 13.0 - Within the normal range,
secs adequate oral anti coagulant

Patient 20-30 secs. 26.0 Within the normal range, adequate
clotting factor and platelet.

January 6, 2010

Hazed densities observed in both lung zones (due to breast shadow vs. pneumonic
The cardiac shadow is not enlarged.
Other chest structures are unremarkable
Drugs Indication Action Side effect/ adverse Nursing Considerations Patient Teaching

Date Ordered: - Relief of acute pain. - NSAIDs work by blocking Immune system disorders, - Assess for pain of - Teach patient that the drug must be
1/7/10 the action of a substance in nervous system disorders, osteoarthritis, rheumatoid continued for prescribed time to be
Generic Name: the body called cyclo- cardiac disorders, arthritis; gouty arthritis; effective.
Etoricoxib oxygenase. Cyclo-oxygenase respiratory, thoracic and check ROM, inflammation,
is involved in producing mediastinal disorders, GI characteristics of pain. - Inform patient to avoid NSAIDs,
Brand Name: prostaglandins, in response to disorders, hepatobiliary sulfonamides.
Arcoxia injury or certain diseases. disorders, skin and - Monitor blood counts
These prostaglandins cause subcutaneous tissue before and during therapy; - Advise patient to rehydrate prior to
Classification: pain, swelling and disorders, renal and urinary uric acid. therapy; take with a full glass of water to
Analgesics / anti inflammation. Because disorders. enhance absorption.
inflammatory NSAIDs block the production - Assess for hypersensitivity
of these prostaglandins, they to medication. - Caution patient to report bleeding,
Dosage: are effective at relieving pain bruising, fatigue, malaise; report GI
120 mg/tab OD prn and inflammation. - Monitor kidney and liver symptoms: black tarry stools, cramping.
*POST OP function tests
- Teach patient to check with physician
to determine when the drug should be
discontinued before surgery.

- Advise patient to notify physician of

pregnancy is planned pr suspected

- Advise patient to inform physician if

using drugs such as aspirin, fluconazole,
furosemide, lithium, warfarin, ACE
inhibitors, anticoagulants,
antineoplastics, glucocorticoids, and
thiazide diuretics.

Drugs Indication Action Side effect/ adverse Nursing Considerations Patient Teaching

Date Ordered: - Relief of moderate to *Binds with opiate receptors Sedation, drowsiness, - Assess patient’s - Discuss in detail all aspects of the drug
1/5/10 severe pain; for pre – in CNS: ascending pain sweating, nausea, dry underlying condition before therapy: reason for taking drug and
Generic Name: operatively analgesia, pathways in limbic system, mouth and dizziness, therapy obtains drug expected result.
Nalbuphine supplement to thalamus, midbrain, headache, vomiting. history. Assess pain
balanced anesthesia, hypothalamus, altering characteristics before - Discuss with patient that dizziness,
Brand Name: surgical anesthesia, perception of and emotional administration and after drowsiness, confusion are common.
Nubain obstetrical anesthesia. response to pain. Relieves treatment. Instruct patient to change position
pain. slowly to prevent orthostatic
Classification: - Monitor vital signs after hypotension and avoid getting up
Drugs Indication Action Side effect/ Nursing Patient Teaching
adverse reaction Considerations

Date Administration Inhibits Palpitations, - Obtain patient’s - Advise patient not to

Ordered: prior to acetylcholine at bradycardia, history of perform strenuous
1/5/10 anesthesia to parasympathetic tachycardia, underlying activity in high
Generic reduce or neuro effector orthostatic condition and temperatures due to
Name: prevent junction, blocking hypotension, reassess regularly. danger of heat stroke.
Atropine secretions of vagal effect on the headache,
respiratory heart (SA node), nervousness, - Monitor cardiac - Instruct patient to take
Brand tract. exocrine glands, drowsiness, rate, rhythm, and as prescribed and not to
Name: smooth muscles, weakness, character. Watch skip doses.
and urinary bladder. dizziness, for tachycardia, it
Drug increases confusions, may cause - Instruct patient to report
Classificatio heart rate, dries insomnia, fever, ventricular blurring of vision, loss of
n: secretions, excitability, fibrillation. sight; troubled breathing,
Antidotes decreases sweating restlessness, sweating, flushing, chest
and salivation in tremor, allergic - Monitor ECG for pain, allergic reactions,
Dosage: low doses. reactions, ectopic ventricular constipation, and urinary
.5 R arm Im Mydriasis urticaria, rash, beats, PVC, retention.
*INTRA-OP (dilatation of the flushing, nasal tachycardia, in
pupil) and congestion, cardiac patients. - Advise patient not to
cycloplegia (failure altered taste, drive, operate machines,
to accommodate for xerostomia, - Monitor or perform other
close vision) occur nausea, vomiting, respiratory status: hazardous activities,
at moderate doses. dyspagia, rate, rhythm, atropine may cause
Motility of GI and constipation, cyanosis, dizziness, drowsiness, or
GU systems are heartburn, bloated wheezing, blurred vision. Alcohol
affected at high feeling; paralytic dyspnea, engorged may also cause dizziness
doses. ileus, urinary neck veins. and drowsiness.
hesitancy and
retention, - Monitor allergic / - Advise patient not to
impotence, hypersensitivity take OTC drugs products
bronchospasm, reaction: rash, without approval of
suppression of urticaria. physician.
decreased - Monitor input-
sweating. output ratio; check
for urinary
retention and daily
output in elderly or

- Monitor for
bowel sounds

- Monitor for
XI. Ongoing Appraisal

On January 5, 2010 a 33 year old female was admitted to the ward at exactly 3:30 AM with chief
complaint of abdominal pain at the right upper quadarant under the service of her attending
physician.. She was conscious and coherent and has prolonged and non labored breathing. Initial
vital signs were taken. The attending physician was informed of the admission. At exactly 3:40
AM IVF of D5NM IL @ 3ogtt/min was started to run for 8 hours. ECG and chest X-ray was
done. Laboratory tests such as FBS, BUN, UREA, LIPID PROFILE, SGOT, SGPT, URIC
ACID, CBC, UA, PTT, ALKALINE PHOSPHATE, and TOTAL BILE were requested by the
attending physician.
At exactly 3:50 am initial dose of HNBB 1 amp IV given. The consent of the patient was
obtained and wheeled to the room of choice. At exactly 4:25 AM Nubain 1 amp IV given.
January 6, 2010 of 4 am IVF #2 D5NMIL at 30 gtt/min was infused. Vital signs were
continuously monitored. The consent was signed for the procedure laparoscopic
cholecystectomy. At exactly 3:30 pm above IVF was consumed and replaced. At exactly 8:10
pm the NOD was inquired by her anesthesiologist to continue the pre op meds. The patient was
advised to be on NPO post midnight. At exactly 9 pm Prevacid 30 mg mg 1 tab was given. At
exactly 1 am the patient complained of stomach pain with pain scale of 9/10. She was then seen
and examined by Dr. Reyes, He administered Nubain 1 amp IV. The patient verbalized relief of

On her second day, January 6, 2010 at 0630H, the client’s IVF was changed to fast drip
300cc of the present IVF of D5NM for 6 hours. Then, the client was brought to the operating
room for the scheduled laparoscopic cholecystectomy.
Procedural report:
• The patient is asked to void prior entering the OR
• The pulse oximeter was attached with intial BP of 180/50 pr of 62 O2 fo 100%
• The general anesthesia intubation was inducted by Dr. Dizon
• Viewing monitors are then placed at the side of the OR bed.
• The patient is in a supine position in a slight to moderate reverse tredelenburg position
• The skin preparation and drape was done.
• An incision was done through an insertion of needle followed by placement of the
operating trocar into the abdomen
• A trocar is placed at the umbilicus and a laparoscope is introduced
• Three additional trocars are placed in the upper abdomen under direction vision for
insertion of operating instruments.
• Insufflation of carbon dioxide was done

With this technique:

• The hepatocystic triangle is dissected, exposing the cystic duct, cystic artery,
infundibulum of the gallbladder, junction of the gallbladder and the cystic duct
• After careful dissection, the surgeon ligates and divided the cystic duct and artery
with suture loops and clips
• The inflamed gallbladder is then removed through the use of sterile elastic plastic
container and withdrawn through the periumbilical incision
• Dessuflation of the carbon dioxide
• The incision was then sutured
• The site was cleansed with hydrogen peroxide.
• Dressing at the incision sites was done by the surgeon

After the operation, the client was monitored every 15 mins for 2 hours at the recovery room
until her vital signs were stable. The client remained at NPO and was advised to stay flat on bed
because of the anesthesia given to her. The client was advised also to do deep breathing exercise
and ambulate to for faster healing. The client was allowed to wet her lips with ice chips but still
at NPO. The physician ordered to maintain NPO, continue her activities and was encouraged to
do deep breathing exercises. Still, the client was advised to continue her deep breathing exercises
and to ambulate more often to promote healing at the incision site. Tepid sponge bath was done
to keep the client comfortable. At exactly 2 pm the above IVF was consumed and replaced with
the # 1 PNSS IL x 30 gtt/min. the client was advised to have an NPO. At exactly 3 pm Etoricoxib
(arcoxia) 60 mg 1 tab was started. The patient was advised to turn to side to side.
At exactly 8 pm Sullamicillin (Unasyn) 375 mg 1 tab was started. At exactly 10 pm the above
IVF was consumed and replaced with D5NSS 1L x 8 hours and regulated at 30 gtt/min.
The JP was drained with 15 cc of brownish discharge of bile and kept in negative pressure. The
patient still complains of the pain at the post operative site.

On January 7, 2010. The IVF was regulated to KVO @ 700 cc level. The patient was senn and
examined by the physician andshe was then advised to ambulate. At exactly 1 pm change of
dressing was done by the physician . Negative flatus and BM was also noted.
On January 8, 2010 she was seen by her attending physician and ordered MGH. The ordered
meds was still continuously given. The return of bowel movement and positive flatus was also
At exactly 4pm the patient was discharged.


Prior to discharge the nurse should assess the patient’s physical and psychological conditions.
The patient should be assessed for:

- Normal vital signs.

- The knowledge of the patient to perform interventions when needed.
- Encourage client to take her medications. Follow the given schedule and dose of taking
the drugs. Explain to her how the drugs should be taken.
- Encourage patient to exercise regularly. Inform her of what exercise she can perform.
- Encourage patient to follow the treatment plan given to her.
- Educate the patient on what to do when there is no nurse/caregiver around.
- Set a date on when the patient would come back for a checkup as ordered.
- Inform the patient on what diet to follow.

Medications should be taken regularly as prescribed, on exact dosage, time and
frequency, making sure that the purpose of the medications is fully disclosed by the health care
provider and to ensure that medications are taken safely. Client or relatives must need to know
the possible side effects and adverse reactions.

Drugs should be continuously taken at the desired dose and duration

-Unasyn 375 mg 1 tab BID x 7 days
-Arcoxia 120mg 1 tab OD for pain


Ambulation and activity must gradually increase after the procedure to prevent problems such as
bowel and urine incontinence.

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.

Gallbladder disease usually is treated by removing the gallbladder. Now that the patient
had her gallbladder removed, the rest is up to her. It is important to rest and let the body recover
after surgery. Consequently, to prevent other complications, she must have her lifestyle and diet

Explain to patient what to expect afterwards. As the anesthetic wears off, there is likely to
be some pain. The anesthetist 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 her
physician. Remind her 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 recovery.
Encourage her 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 side-effects.
Explain to patient to refer for unusualities immediately.

Follow up check up after one week
Remind patients that regular check-ups are important to ensure that the patient condition
is constantly monitored by the doctor.

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


If any of the following symptoms are noted, he should contact her 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 antibiotics