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Admission date:

Risk factors Pathophysiology


Admitting diagnosis:
A family history of gallstones on Cholecystitis, an acute complication of cholelithiasis, is an acute infection of the gallbladder. Most patients
Cholesistitis the mother's side of the with cholecystitis have gallstones (calculous cholecystitis). A gallstone obstructs bile outflow and bile in
family. the gallbladder initiates a chemical reaction, resulting in edema, compromise of the vascular supply, and
Surgical procedure: N/A Crohn's disease. gangrene. In the absence of gallstones, cholecystitis (acalculous) may occur after surgery, severe trauma,
Diabetes. or burns, or with torsion, cystic duct obstruction, multiple blood transfusions, and primary bacterial
Pertinent PMH/PSH: infections of the gallbladder. Infection causes pain, tenderness, and rigidity of the upper right abdomen and
Hyperlipidemia.
is associated with nausea and vomiting and the usual signs of inflammation. Purulent fluid inside the gall-
Obesity, HTN, Asthma, CKD, Sepsis, Losing weight rapidly. bladder indicates an empyema of the gallbladder.
Drug rash, A-fib Obesity.
Older age.
Last V/S, including O2 sat and pain
scale Diagnostic tests with discussion of
BP-141/76, HR-74, RR-12, expected/unexpected findings
Patient S/S Lab values with discussion of
SpO2-97%, Temp 36.7C expected/unexpected findings CT scan Abd-pelvic with contrast
Dark urine, distended
Current treatments (IV, medications, gallbladder; fever and palpable Na- 134, K-3.7 , Cr- 1.29, BUN- 21, CT scan of abdomen with contrast
catheters, tubes, drains. O2, abdominal mass; biliary colic
ostomies) with excruciating upper right Hgb- 11.0 , Hct- 33.5, Albumin- 2.7,
abdominal pain, radiating to
O2- NC- 2L RBC- 3.54, WBC- 6.0
back or right shoulder
Biliary drain- Right outer quadrant restlessness and colicky pain

Foley Catheter-

PICC-single lumen-left upper bacillic

IV- left forearm, NS locked


Priority Nursing Diagnoses Priority Assessments
Recommended consults: N/A
1. Anxiety related to present medical condition as evidenced by being Assess health history: Note history of smoking or prior
less cooperative with the staff members and refusing to participate respiratory problems. Assess respiratory status: Note
Nutrition Regular diet shallow respirations, persistent cough, or ineffective or
in activities
adventitious breath sounds. Evaluate nutritional status
PT/OT/Speech: PT, OT (dietary history, general examination, and laboratory
2. Disturbed body image related to being overweight and having not study results). Connect tubes to drainage receptacle and
Mental Health intact skin as a result of hypersensitivity reaction as evidenced by secure tubing to avoid kinking (elevate above abdomen).
low self esteem and anger. Place drainage bag in patients pocket when ambulating.
History of depression Observe for indications of infection, leakage of bile, and
obstruction of bile drainage. Observe for jaundice
Other: Allergies 3. Imbalanced nutrition: less than body requirements related to having (check the sclera). Note and report right upper quadrant
decreased appetite as evidenced by low albumin levels. abdominal pain, nausea and vomiting, bile drainage
around any drainage tube, clay-colored stools, and a
4. Risk for impaired skin integrity related to altered nutritional state change in vital signs. Change dressing frequently, using
ointment to protect skin from irritation.
1. Anxiety related to present medical condition as evidenced by being less cooperative with the staff members and
refusing to participate in activities

Interventions with rationale and citation


Expected Outcomes (2)

1. Patient will discuss realistic 1. Assess the clients level of anxiety and physical reactions to anxiety. Symptoms evaluated are mood, tension,
fear, insomnia, concentration, worry, depressed mood, somatic complaints, and cardiovascular, respiratory,
goals related to medical
gastrointestinal, genitourinary, autonomic, and behavioral symptoms. Anxiety is the risk factor for major
condition within 24 hours adverse cardiac risk events in persons with stable coronary artery disease. (Akley, 2013, p.138
2. Patient will seek help in 2. Use empathy to encourage the client to interpret the anxiety symptoms as normal. The way a nurse
dealing with feelings by interacts with a client influences his/her quality of life. Providing psychological and social support can reduce
the symptoms and problems associated with anxiety. (Akley, 2013, p.138)
verbalizing his need in
3. If irrational thoughts or fears are present, offer the client accurate information and encourage him or her to
support within 24 hours talk about the meaning of the events contributing to the anxiety. Avoid and suppress painful emotions,
thoughts and sensations, and limit their involvement in meaningful activities. (Akley, 2013, p.138)
4. Encourage the client to use meaningful self-talk. Reducing negative self-talk and increasing positive self-talk
can be beneficial for all types of anxiety. (Akley, 2013, p.138)
5. Intervene when possible to remove sources of anxiety. Removing or reducing sources of stress and anxiety
among patients has been shown to decrease hypertension and comorbid conditions. (Akley, 2013, p.138)
6. Explain all activities, procedures and issues that involve the client; use nonmedical terms and calm, slow
speech Do this in advance of procedures when possible and validate the clients understanding. Effective
nurse-client communication is critical to efficient care provision. (Akley, 2013, p.138)
7. Provide backrubs/massage for the client to decrease anxiety. Massage was shown to be an excellent method
for reducing anxiety. (Akley, 2013, p.138)
Evaluation
8. Use therapeutic touch and healing touch techniques. Healing touch may be one of the most useful nursing
interventions available to reduce anxiety. (Akley, 2013, p.138)
9. Guided imagery can be used to decrease anxiety. Anxiety was decreased with the use of guided imagery
Goal partially met: during an intervention for post-operative pain. (Akley, 2013, p.141)
Patient demonstrated some 10. Assess client for pain and provide pain relief measures. (Akley, 2013, p.141)
control of anxiety by using 11. Assist clients with life review and reminiscence. When challenges emerged, the participants implemented
the search to find an acceptable and satisfying completion to this life, engaging family members, friends
recommended techniques by 8
and hospice team in an effort to relieve discomfort and regain a degree of control. (Akley, 2013, p.142)
hours.
12. Encourage clients to pray. Prayer, scripture reading and clergy visits were found to comfort some clients, but
sometimes-specific religious tenets may be troubling and need to be resolved before the client can find
peace. (Akley, 2013, p.142)

Nursing Process Concept Map


1. Disturbed body image related to being overweight and having not intact skin as a result of hypersensitivity reaction
as evidenced by low self esteem and anger.

Expected Outcomes (2)


Interventions with rationale and citation
1. Client will demonstrate
adaptation to changes in 1. Incorporate psychological questions related to body image as part of nursing assessment to identify clients at risk
physical appearance or body for body image disturbance (those with stomas/ostomies/colostomies or other disfiguring conditions). Assessment
of psychological issues can help to identify clients at risk for body image concerns as a result of a disfiguring
function as evidenced by condition. (Akley, 2013, p.162)
adjustment to lifestyle change 2. Assess for history of childhood maltreatment in clients suffering from body dissatisfaction, anorexia, or other eating
disorders and make appropriate psychosocial referrals if indicated. The result from this study indicates specific forms
by 24 hours of childhood maltreatment (emotional or sexual abuse) are significantly associated with body dissatisfaction,
2. The client will Identify and depressive symptoms, and eating disorders. (Akley, 2013, p.162)
3. Assess for the influence of cultural beliefs, regional norms, and values on the clients body image. Each client
change irrational beliefs and should be assessed for body image based on the phenomenon of communication, time space, social organization,
expectations regarding his environmental control, and biological variations. (Akley, 2013, p.164)
4. Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity. (Akley,
medical condition by 24 hours 2013, p.164)
5. Assess clients level of social support, as it is one of the determinants of clients recovery and emotional
health.Males who perceived they have good social support were found to adapt better to changes in body image.
(Akley, 2013, p.164)
6. Encourage client to discuss concerns related to sexuality and provide support or information as indicated. Many
conditions that affect body image also affect sexuality. Brown and Randle found that clients (particularly females)
with stomas often believe they are less sexually attractive after surgery, though their sexual partner may not share
that view. (Akley, 2013, p.164)
7. Use cognitive-behavioral to assist the client to express his emotions and feelings. This study of clients with bulimia
Evaluation used CBT and helped the clients to disentangle themselves regarding body image and weight. (Akley, 2013, p.162)
8. Help client describe ideal self, identity self-criticisms, and give suggestions to support acceptance of self. Job
rehabilitation and body image should be incorporated into daily care of head and neck cancer clients. For example,
participants could learn how to use cosmetic strategies to improve their facial appearance during OPD syndrome
Goal was not met: follow up. Thus, the negative impact might be reduced. (Akley, 2013, p.162)
9. Discuss spirituality as an adjunct to improving bod y satisfaction. (Akley, 2013, p.163)
10. Provide client with list of appropriate community support groups. This study of three different cancer groups
Patient didnt demonstrate showed their perceived benefits were similar; the groups provided information, acceptance, and understanding.
adjustment to the changes in physical (Akley, 2013, p.163)
11. Focus on remaining abilities. Have client make a list of strengths Results from unstructured interviews with women
appearance by verbalizing he didnt aged 61 to 92 years regarding their perceptions and feelings about their aging bodies suggest that women exhibit the
feel comfortable in his skin. internalization of ageist beauty norms, even as they assert that health is more important to them than physical
attractiveness and comment on the naturalness of the aging process. (Akley, 2013, p.163)
12. Refer clients who are having difficulty with personal acceptance, personal and social body image disruption, sexual
concerns, reduced self-care skills, and the management of surgical complications to an interdisciplinary team or
specialist (eg. ostomy nurse) if available. There is sufficient research-based evidence to conclude that intestinal
ostomy surgery exerts a clinically relevant impact on health-related quality of life, and that nursing interventions
can ameliorate this effect. (Akley, 2013, p.164)
References:

1. Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: an evidence-based guide to planning care (9th ed.). Maryland Heights, Mo.:
Mosby.
NursingJ.Process
2. Johnson, Concept
Y. (2010). Map for Brunner & Suddarth's textbook of medical-surgical nursing (12th ed.). Philadelphia: Wolters
Handbook
Kluwer/Lippincott Williams & Wilkins.