TABLE OF CONTENTS

I. Introduction 3
II. Objectives 4
III. Nursing Assessment
1. Personal History
1.1. Patients profile 5
1.2. Family and individual information 5
1.3. Level of growth and development
1.3.1. Normal development at particular stage 5-7
1.3.2. The ill person at particular stage of patient 8
2. Diagnostic Results 8-9
3. Present profile of Functional Health Patterns 9-11
4. Pathophysiology and Rationale
4.1. Normal anatomy and physiology 12
4.2. Schematic diagram 13
4.3. Disease process and its effect on different organ/system14-15
4.4. Comparative chart 15-16
IV. Nursing Intervention
1. Care guide of patient 16-18
2. Actual patient care:
2.1. Nursing care plans 19-22
2.2. Brunswick lens model 23
2.3. SOAPIE charting 24-25
2.4. Drug therapeutic record 26-30
2.5. Health teaching plan 31-32
V. Evaluation and recommendation 33
VI. Evaluation and implication of this case study to: 33
1. Nursing practice
2. Nursing education
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3. Nursing research
VII. Bibliography 34

I. INTRODUCTION
They say that along with old age comes a different perspective of
health. As many of us know the older we get the more prone we are to certain health
problems and diseases. Such is the case of Ms. Lagura, Lourdes.

In Open Cholecystectomy, the patient is placed under general

anesthesia and then a surgical incision is made at the right upper quadrant of the
abdomen. The gallbladder is then surgically removed and assessment of other organs
are also done. The specimen may then be taken for biopsy. The post operative
period lasts usually a week but can sometimes take months depending on the patients
health condition and if any other complications occurred. During this time nursing
interventions are centered not only on reestablishment of physiologic balance and
pain relief but also on preventing complications and promoting independence by
teaching the patient self-care.

Open Cholecystectomy is definitely not a rare procedure. In line with this, the
student decided to take the opportunity to make a case study on the said topic not only
to gain further knowledge on the said surgical procedure but also to learn more about
the post-operative care given to such patients. The hopes are that this paper would
also be able to guide other students on the care rendered should they encounter a post-
open cholecystectomy client.
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II. OBJECTIVES
GENERAL OBJECTIVE:
After 3 days of holistic nursing care, the patient will be able to attain
maximum level of functioning and manifest positive response to medical and nursing
interventions.

SPECIFIC OBJECTIVES:
A. Student-Nurse Centered:
After 8 hours of holistic nursing care, the student nurse will be able to:
1. establish rapport and a good working relationship with the client
2. update the client's profile based on Gordons Functional Health Pattern
3. present informative data including clients family and health history
4. discuss pathophysiology of the disease
5. formulate a comprehensive nursing care plan for the client
6. impart health teaching to client and significant others to promote
independence
B. Client Centered:
After 1 week of holistic nursing care, the patient will be able to
1. establish rapport and a good relationship with the student nurse
2. gain knowledge regarding the condition and the operative procedure
undergone
3. show positive response to medications
4. function normally and perform activities of daily living
 4

1. PERSONAL HISTORY
1.1 Patients Profile
Ms. Lagura, Lourdes a 68yr. old, single woman was admitted to Cebu
Doctors University on February 19, 2008 and was scheduled surgical
operation of her Cholecystolithiasis last February 20, 2008. Patient was under
the care of Dr. Rosello.
1.2 Family and individual information, social and health history
Ms. Lagura, a 68yr. old, single woman, a Roman Catholic and Filipino. She is
a retired teacher. She was experiencing discomforts at her right upper quadrant
of her abdomen which turn out to be gall stones. This discovery prompted the
patients admission and surgical operation, Open Cholecystectomy.
1.3. Level of Growth and Development
Physical changes
Most elderly experience declines in hearing, vision, taste, and smell. They also
experience some declines in their ability to detect pain and notice temperature
changes. These declines are typically gradual and become more pronounced in
late old age (70 +). Other health related issues include rising blood pressure,
declining lung capacity, and neural loss. It is important to note that declines in
all these areas can be greatly influenced by one's lifestyle. Some may also
experience changes in their sexuality.

Psychosocial development

Late Adulthood: 55 or 65 to Death

Ego Development Outcome: Integrity vs. Despair
Basic Strengths: Wisdom
Erikson felt that much of life is preparing for the middle adulthood stage and
the last stage is recovering from it. Perhaps that is because as older adults we
can often look back on our lives with happiness and are content, feeling
fulfilled with a deep sense that life has meaning and we've made a contribution
to life, a feeling Erikson calls integrity. Our strength h comes from a wisdom
 5

that the world is very large and we now have a detached concern for the whole
of life, accepting death as the completion of life. On the other hand, some
adults may reach this stage and despair at their experiences and perceived
failures. They may fear death as they struggle to find a purpose to their lives,
wondering "Was the trip worth it?" Alternatively, they may feel they have all
the answers (not unlike going back to adolescence) and end with a strong
dogmatism that only their view has been correct. The significant relationship
is with all of mankind"my-kind."

Psychosexual development

The Genital Stage (Sigmund Freud Stages of Psychosexual

Development)

During the final stage of psychosexual development, the individual

develops a strong sexual interest in the opposite sex. Where in earlier
stages the focus was solely on individual needs and, interest in the welfare
of others grows during this stage. If the other stages have been completed
successfully, the individual should now be well-balanced, warm, and
caring. The goal of this stage is to establish a balance between the various
life areas.

Cognitive development:

The mental processes of the late adult become slower, this involves the
working memory of the person, and there is forgetfulness, confusion,
deficits in concentration. Older people also tend to be more reflective and
introspection, they develop a heightened aesthetic, creative, philosophical
and spiritual sensitivity.

Moral development:

The post-conventional level, also known as the principled level, consists of

stages five and six of moral development. Realization that individuals are
separate entities from society now becomes salient. One's own perspective
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should be viewed before the society. It is due to this 'nature of self before
others' that the post-conventional level, especially stage six, is sometimes
mistaken for pre-conventional behaviors.
In Stage five (social contract driven), individuals are viewed as holding
different opinions and values. Along a similar vein, laws are regarded as
social contracts rather than rigid dictums. Those that do not promote the
general welfare should be changed when necessary to meet the greatest
good for the greatest number of people.[8] This is attained through majority
decision, and inevitably compromise. In this way democratic government
is ostensibly based on stage five reasoning.

Spiritual development

Individual-Reflective Period

Individual focuses on reality, constructing ones own explicit system;

high degree of self-consciousness. Young adults who need to answer the
religious questions of their own children may find that the teaching of their
own early childhood is more acceptable to them now than during adolescence.

Developmental tasks:

Later Adulthood (60 to 75)

Promoting intellectual vigor
Redirecting energy to new roles and activities
adopting ones life
developing a point of view about death
 7

1.3.2 THE ILL PERSON AT THE PARTICULAR STAGE

The client at present particular stage is manifesting the normal

physical, emotional and cognitive deterioration that is associated with the
aging process. Due to clients ill status, the client is having difficulty in coping
with her aging process, the slow degenerative manifestations particularly her
physical attributes. The additional trauma received from her surgical operation
also hinders her activities of daily living, altering her diet and additional
discomfort from the pain.

2. DIAGNOSTIC RESULTS

Diagnostic Tests Normal Values Patients Results Significance

CBC as of February 26, 2007
Decreased with anemia or
Hemoglobin 14.0-17.5 d/dL 11.2 g/dL
after blood loss
Hematocrit 41.5-50.4% 33.3% Normal
WBC count 4,400-11,000 18.2 cu/mm Normal
cu/mm
40-70% 60% Normal
Neutrophil
0-5% 3% Normal

Eosinophil 20-40% 33% Normal

Lymphocytes
Monocytes 0-8% 4% Normal

Decreased with anemia or

RBC 4.5-5.9 10^g/uL 4.45 10^g/uL
after blood loss
Mean
80-96 fL 86.6 fL Normal
Corpuscular
 8

Mean
27.5-33.2 pg 29 pg Normal
Corpuscular HgB
(MCH)
Mean
Corpuscular HgB 33.4-35.5% 33.5 pg Normal
Concentration
(MCHC)
Platelets 150-450 10^g/L 314 10^g/L Normal
Source: Medical-Surgical Nursing, 10th Edition, by Smeltzer and Bare, Vol. 2, pg.
2214 2233

3. PRESENT PROFILE OF FUNCTIONAL HEALTH

PATTERNS

1. Health perception
The client has undergone open cholycystectomy and is still in mild discomfort
from the surgical trauma. She is worried about her wound and how long it would
heal considering she has been diagnosed with diabetes mellitus which could slow
down her healing process. However the patient thinks that if she could maintain
her blood sugar level to normal she would heal in a shorter span of time. She does
not remember if she is fully immunized but she takes care of her health following
doctors orders and modified her diet to maintain her blood pressure and glucose
level.

2. Perceptual pattern
The patient wears glasses for reading and writing. She sometimes complains
about her hearing but she does not wear hearing aids. She expresses that she has
less sensitivity to pain or sometimes touch but she easily gets cold but has no
sensitivity to heat. Most of the time she feels dizzy and light headed when she
moves suddenly or stands up after sitting or lying down in prolonged periods of
time.

3. Self concept
 9

Ms. Lagura jokes that she is old and that she is sickly. She says that she does her
best to keep herself fit and keep her diagnosed problems in check to avoid any
complications. She says she knows how to take care of herself and know how to
modify her lifestyle accordingly.

4. Sleep and rest

Ms. Lagura usually sleeps at around 9 10pm in the evening and wakes up as
early as 5:00 in the morning she also takes naps in the afternoon. However,
during her hospital stay she says she frequently wakes up in the evening as there
are medications and vital signs to be taken. But she is not very disturbed as she
manages to sleep again.

5. Nutritional and metabolic pattern

The patients usual intake is vegetables, fish and not so much on pork. She has
also been avoiding too salty and too sweet foods as she is a hypertensive diabetic.
Though she admits to have eaten food that should be avoided she says she is
compliant of her maintenance medications. She drinks 8 glasses or more of water
and states that she has maintained her weight to keep herself as healthy as she
could be.

6. Elimination pattern
The patient is on foley bag catheter. She usually defecates early morning
everyday. But since her operation she has not defecated for 4 days. Her skin is
warm, but a little bit yellow, non-pruritic and there is slight edema.

7. Activity and Exercise pattern

Ms. Lagura said that she tries some exercises while sitting down whenever she
can. However she complains that she easily gets tired and becomes dyspneic
sometimes after much exertion. After surgery she guards her movements as it is
still a bit painful to move around and she says she is scared the stitches might
come off.

8. role and relationship pattern

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Ms, Lagura lives with her sister. She has no children and is retired and is living
off on her pension and some money given by friends and relatives. Decision
making is mainly made by her and her sister depending on the situation or matter
to be discussed.

9. Sexuality and sexual functioning

Patient had her menarche at the age of 15 yrs then she had menopause at 50yrs
old. She is in her genital stage. She is not sexually active.

10. values belief system

The patient is a Roman catholic. She prays the rosary everyday and goes to mass
every Sunday with her family. She is not very active in church activities as she
says she is old and easily gets tired so she opts to pray every night and go to mass
as often as she can.
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4.PATHOPHYSIOLOGY AND RATIONALE

4.1 NORMAL ANATOMY AND PHYSIOLOGY OF ORGAN

AFFECTED:

The gallbladder is a small pear-shaped organ that stores and concentrates bile.
The gallbladder is connected to the liver by the hepatic duct. It is
approximately 3 to 4 inches (7.6 to 10.2 cm) long and about 1 inch (2.5 cm)
wide.

The function of the gallbladder is to store bile and concentrate. Bile is a

digestive liquid continually secreted by the liver. The bile emulsifies fats and
neutralizes acids in partly digested food. A muscular valve in the common bile
duct opens, and the bile flows from the gallbladder into the cystic duct, along
the common bile duct, and into the duodenum (part of the small intestine).
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4.2 SCHEMATIC DIAGRAM OF THE PATHOLOGY OF THE

DISEASE

Factors:
More in women than in High calorie diet
men. Cirrhosis
Above 40 years of age. Bile stasis
Obesity Diabetes
High cholesterol levels Cystic Fibrosis

Pathophysiology:
Decrease bile acid synthesis and increased cholesterol synthesis in the
liver, resulting in bile supersaturated with cholesterol, which precipitates
out of the bile to form stones. The cholesterol saturated bile
predisposes to the formation of gall stones and acts as an irritant,
producing inflammatory changes in the gall bladder.

Signs and Symptoms:

Epigastric distress such as fullness
Abdominal distention
Biliary colic
Jaundice
Changes in urine and stool color
Vitamin deficiency

Surgical Management: Nursing Management:

Open cholecystectomy Encourage ambulation
Laparoscopic Encourage deep breathing
exercises and use of
cholecystectomy incentive spirometry
Lithotripsy Monitor intake and output
Medical Management: Monitor vital signs
Medications: Give patient health
- Antibiotics teaching for home care
- Analgesics
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4.3 DISEASE PROCESS AND ITS EFFECTS ON THE ORGAN OR SYSTEM:

Cholelithiasis
Also known as gallstones, these hard masses are formed in the
gallbladder or passages, and can cause severe upper right abdominal
pain radiating to the right shoulder, as a result of blocked bile flow.

4.3.1 THE SURGICAL OPERATION

A cholycystectomy is the surgical removal of the gallbladder. The two basic types of
this procedure are open cholycystectomy and the laparoscopic approach. It is
estimated that the laparoscopic procedure is currently used for approximately 80% of
cases.
A cholycystectomy is performed to treat cholelithiasis and cholecystitis. In
cholelithiasis, gallstones of varying shapes and sizes form from the solid components
of bile. The presence of stones, often referred to as gallbladder disease, may produce
symptoms of excruciating right upper abdominal pain radiating to the right shoulder.
The gallbladder may become the site of acute infection and inflammation, resulting in
symptoms of upper right abdominal pain, nausea and vomiting. This condition is
referred to as cholecystitis. The surgical removal of the gallbladder can provide relief
of these symptoms.
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In a conventional or open cholycystectomy, the gallbladder is removed through a

surgical incision high in the right abdomen, just beneath the ribs. A drain may be
inserted to prevent accumulation of fluid at the surgical site.
As with any surgical procedure, the patient will be required to sign a consent form
after the procedure is explained thoroughly. Food and fluids will be prohibited after
midnight before the procedure. Enemas may be ordered to clean out the bowel. If
nausea or vomiting is present, a suction tube to empty the stomach may be used, and
for laparoscopic procedures, a urinary drainage catheter will also be used to decrease
the risk of accidental puncture of the stomach or bladder with insertion of the trocar (a
sharp-pointed instrument).

4.4 COMPARATIVE CHART

Classical symptoms Clinical symptoms Rationale
POSTOPERATIVE
Surgical incision Manifested -a necessary part of the
-a 10-15cm incision was surgical procedure
made through the abdomen
to remove gallbladder
Postoperative pain Manifested -due to tissue trauma from
-patient is reluctant to procedure
breathe deeply due to the
pain caused by the
proximity of the incision to
the muscles used for
respiration. The patient was
shown how to support the
operative site when
breathing deeply and
coughing, and given pain
medication as necessary.
Hypotension Not Manifested -result from blood loss
Hemorrhage -may occur due trauma of
Not manifested the surgical procedure
 15

Nausea and vomiting Not Manifested -side effect of anesthesia

Malignant hyperthermia
Respiratory complication
Constipation
Urinary retention
Anxiety
Not manifested -chemically induced by
anesthetic agents
Not Manifested -anesthetic agents can cause
respiratory depression or
aspiration of respiratory tract
secretion or vomitus
Manifested -from decrease in mobility
- patient has not been able and oral intake and due to
to defecate since the the opioid analgesics used
procedure was done
Not Manifested -anesthetics and opioids may
interfere with the perception
of bladder fullness and the
urge to void
Not manifested -may be from pain, new
environment, lack of control,
fatigue
Source: MS by Brunner and
Suddarth, 19th ed.

IV. NURSING INTERVENTION

1. Care Guide of Patient who has undergone Open Cholecystectomy
Postoperative care begins in the operating room immediately after surgery and
continues in the postanesthesia care unit (PACU) as well as during the days
after the procedure. Factors affecting the extent of care required are: the
original health status of the patient, type of surgery, and whether the surgery
was performed in a day-surgery setting or in the hospital. Day-surgery centers
operate on an out patient basis and intensive monitoring is done in the few
hours postoperatively that the patient remains in the center. Should any
complications occur, then the patient is sent to the hospital. Patients admitted
in the hospital may require anything between a day to weeks of postoperative
care before they are discharged. Postoperative care includes:
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Preventing respiratory complications - The patient is encouraged to turn

frequently and take deep breaths at least every 2 hours to clear secretions and
prevent pneumonia. Coughing is also encouraged to dislodge mucus plugs.
This is done with a pillow as a splint to lessen pain on incision site &
overcome fear of undoing the stitches. Analgesics may also help as oxygen
may be given via cannula to prevent or relieve hypoxia.
Encouraging activity - Surgical patients are encouraged to be out of bed as
soon as possible. Early ambulation reduces the incidence of postoperative
complications, increases ventilation, reduces the stasis of bronchial secretions
in the lungs, and reduces postoperative abdominal distention by increasing the
muscle tone of the abdominal wall tone and stimulating peristalsis.
Promoting wound healing - Periodic assessment of surgical site is done.
The wound edges, integrity of sutures or staples are inspected for infection,
redness, warmth, swelling, unusual tenderness or drainage. It should also be
inspected for reactions to tape or trauma from tight bandages.
Dressing Changes - The first postoperative dressing is usually changed by
a member of the surgical team. Subsequent dressing changes, however, are at
times done by the nurse. A dressing is applied to provide a proper environment
for wound healing, absorb drainage, splint or immobilize the wound, protect
the wound and new epithelial tissue from mechanical injury, protect the wound
from bacterial contamination and from soiling, promote homeostasis, and to
provide mental and physical comfort to the patient
Maintaining normal body temperature - The patient is at risk for
malignant hyperthermia and hypothermia in the postoperative period. The
room is maintained at a comfortable temperature, and blankets are provided.
Treatment includes oxygen administration, adequate hydration and proper
nutrition. The patient is also monitored for cardiac dysrhythmias. The risk for
hypothermia is greater in the elderly and in patients who were in the cool
operating room for a long time.
Maintaining gastrointestinal function and resuming nutrition
The patient may not be allowed to eat post op as the effects of the anesthesia
causes reduced bowel movement. So the patient is placed on temporary NPO.
The patient may only start liquid diet when she is able to produce gas and on
 17

full diet when she is able to remove her bowel contents which is a sign of
bowel movement.
Promoting bowel function - Early ambulation, improved dietary intake,
and a stool softener promote bowel elimination. Until the patient reports return
of normal bowel function, the nurse should assess the abdomen for distention
and the presence and frequency of bowel sounds.
Managing voiding - Bladder distention and the urge to void should be
assessed on the patients arrival on the unit and frequently thereafter. The
patient is expected to void within 8 hours after surgery. If the patient has an
urge to void but cannot void, catheterization may be done.
Managing a safe environment - Because the patient remains groggy
during the immediate postoperative period, the siderails should be up, and the
bed should be in the low position to prevent falls. Other immediate
postoperative orders involve special positioning, equipment, or intervention.
The patient is instructed to ask for assistance with any activity.
Providing emotional support to the patient and family - The nurse helps
the patient and the family work through their anxieties by providing
reassurance and information and by spending time listening to and addressing
their concerns. The family should be pre-oriented to the patients postoperative
look such as presence of tubes and the size of incisions to prepare them and
keep them calm in front of the patient.
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 19

CEBU DOCTORS' UNIVERSITY

COLLEGE OF NURSING
Name of patient: Lagura, Lourdes CEBU CITY
Hospital no: 207631
Age: 68 yrs old
Impression/diagnosis: Acute Cholelithiasis
Gender: female
Attending physician: Dr. D. Rosello
Chief complaints: pain in the right upper quadrant of abdomen
NURSING CARE PLAN
Problems Cues/ Needs Nursing Scientific Basis Objective Nursing Actions
Diagnosis of Care

I. Physiologic Altered Most patients After 8 hrs. Measures to:

A. Overload comfort: experience some pain of SN- 1. alleviate pain
1. Altered comfort: pain pain, after a surgical patient 1.1 encourage adequate rest
- status 1 day post- open related to procedure. Many interaction,
cholecystectomy. tissue factors influence the the patient 1.2 provide comfort measures
- with surgical wound at trauma pain experience. The will be able (backrub, position change,
midline from lower rib down seconda- degree and severity of to: environmental control)
past umbilical level ry to postoperative pain and 1. verbalize 1.3 encourage deep breathing
- with a surgical wound at the surgical the patients tolerance relief of exercises
right upper quadrant of operation for pain depend on the pain as 1.4 position patient on
abdomen incision site, the evidenced optimum comfort
- reports pain on movement nature of the surgical by a pain 1.5 monitor vital signs
that is 7 out of 10 on pain scale procedure, the extent scale of 4 1.6 observe non verbal cues
-client describes piercing pain of surgical trauma, the out of 10 (i.e. facial grimace)
felt at incision site upon type of anesthetic 1.7 administer pain
movement of abdomen and agent, and how the medication per doctors order
anterior chest lasting for 2-5 agent was prior to exercise or activities
minutes; aggravated by sudden administered. of daily living
movts & coughing; relieved
by analgesics and shallow Source: Fundamentals
breathing of Nursing by Potter &
- guarded movements and Perry p. 446
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facial grimace noted

B. Deficit
1. Risk for infection Risk for Transmission of 2. identify 2. prevent infection
- status 1 day post-Ex. Lap. infection: infective agent from a interven- 2.1 use aseptic technique
- with surgical wound at presence source by a tions to when changing dressing
midline from lower rib down of opera- susceptible host occurs prevent 2.2 inspect the incision site
past umbilical level & stab tive with the environment. infection & for inflammation
wound at left anterior chest wound, Organisms live and reduce risk 2.3 keep area clean and dry
without foul odor or discharges related to multiply in reservoir for acqui-
- reports intermittent tingling at inade- which can be a person, ring it.
itchiness at incision site quate animal, or plant or 2.4 note and record
- seen manipulating incision primary combination of characteristics of drainage on
site with unwashed hands defenses substances. Wound dressing
- Katol ang ako tahi seconda- sepsis is common 2.5 apply heat and cold
usahay, normal ra ry to occurrence after 2.6 clean the wound regularly

na? surgical surgery. It is usually 2.7 administer antibiotics as

incision heralded by increased prescribed
site pain and fluctuating
temperature. The
wound should be
inspected daily for
swelling and local
tenderness.
Source: MS by Black,
6th ed.

2. Impaired physical mobility Impaired In the first few days 3.verbalize 3.increase physical mobility

- reports piercing pain upon physical after surgery, energy & demon- 3.1 position patient to

movement that is rated 7 out of mobility: reserve is limited and strate optimum comfort

10 on pain scale, aggravated by limited transitory. When willingness 3.2 promote medical

sudden movements, relieved move- patient is also to partici- management for pain

by analgesics ments, grieving, lack of pate in 3.3 provide safety measures

- guarded movements and related to energy reserve is even activities as indicated

pain more apparent. During 3.4 implement ROM

facial grimace with movements
noted
- unable to transfer and
ambulate painlessly
- decreased muscle strength
- needs help with activities
- complains of fatigue & pain
- reports inability to move
bowel for 2 days/
- Di nalang gani ko mulihok
kai kutasan ko nya sakit man.
21
seconda- this days of fatigue, exercises
ry to more ambulation is 3.5 encourage participation
surgical required and of self-care activities
operation increasing exercise 3.6 promote progressive
expected. mobilization to maximum
Source: MS by Phipps within limits of patients
and Long tolerance to pain
3.7 encourage repositioning
while in bed
 22

2.3 SOAPIE CHARTING

SOAPIE 1 ( February 27, 2008 )
S- Sakit sakit pa jud tawn ilihok day as verbalized by the patient
O- Seen patient lying down, awake, conscious, communicative, coherent, with IV
5 D5LR 1 liter infusing well at left forearm; status 1 day post-open
cholecystectectomy with surgical wound at right upper quadrant of abdomen, no
discharges on dressing, no foul odor; pain upon movement is rated 7 out of 10 on
pain scale, piercing pain felt at incision site upon movement of abdomen and
anterior chest lasting for 2-5 minutes, aggravated by sudden movements and
coughing, relieved by analgesics and shallow breathing, guarded movements and
facial grimace noted; with vital signs of BP: 130/60 mmHg, T: 36.8 oC, P: 68 bpm,
R: 24 bpm
A- Altered comfort: pain, related to tissue trauma secondary to operative
procedure
P- To reduce pain to a scale of 4 out of 10
I- monitored vital signs, encouraged adequate rest, provided comfort measures,
encouraged deep breathing and incentive spirometry exercises, positioned patient
for optimum comfort, observed non verbal cues, administered analgesics as
prescribed

E- the pain seems to lessen after I took the medication

SOAPIE 2 (February 28,2008)

S- Katol ang ako tahi usahay, normal ra na? as verbalized by the patient
O- Seen patient lying down, awake, conscious, communicative, coherent; with IV
5 D5LR 1 liter infusing well at left forearm; status 3 days post-exploratory
laparotomy with surgical wound at right upper quadrant of the abdomen, no
discharges on dressing, no foul odor yet patient is noted to regularly manipulate
site with unwashedhands; with vital signs of BP: 130/70 mmHg, T: 37.2 oC, P: 84
bpm, R: 19 bpm
A- Risk for infection: presence of postoperative wound, related to inadequate
primary defenses secondary to surgical operation
P- To promote timely wound healing and reduce risk for infection
I- vital signs monitored, used aseptic technique in dressing wound, inspected site
for inflammation, kept site clean and dry, stressed importance of proper
 23

handwashing, discouraged scratching of wound, noted characteristic of discharges

on dressing

E- Ila ra man ni i.change ako dressing miss sa?

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2.4 HEALTH TEACHING PLAN

OBJECTIVES CONTENT METHODOLOG
Y
General objectives:
After 1 week of holistic care,
the patient and significant
others will be able to acquire
adequate knowledge,
positive attitude, and proper
skills in providing
postoperative care.

Specific objectives:
After 30 minutes of student
nurse-patient or significant
others interaction, the patient
or significant others will be
able to:

1.define deep breathing Definition Informal

exercises in their own level 1.1 deep breathing exercises are Discussion
of understanding exercises done where a large volume
of air is inhaled and exhaled
promoting optimum lung expansion

2. enumerate the importance Importance: Informal

of deep breathing exercises
2.1 promotes adequate oxygenation Discussion
2.2 promotes airway clearance
2.3 improves respiratory response
2.4 promotes relaxation and comfort
2.5 promotes lung expansion

3. properly perform deep Method/Technique used: Informal

breathing exercises 3.1 place hands below the clavicles Discussion,
 25

exerting moderate pressure Demonstration,

3.2 ask the client to inhale for 5 and Return
seconds ask him or her to Demonstration
concentrate on expanding the upper
chest forward and upward while
inhaling to aerate the apical lobes of
the lungs
3.3 ask client to hold breath for 3-4
seconds to promote aeration of the
alveoli
3.4 ask client to exhale passively and
slowly for 8 seconds through the
mouth
3.5 repeat exercises for 15
respirations 4 times per day

4. exhibit positive attitude in Encourage client to ask questions Open Sharing

carrying out the procedure and voice out concerns regarding
learned procedure.

5. verbalize feelings with Encourage client to ask questions Open Sharing

regards the activity and and voice out concerns regarding
interaction with the student procedure.
nurse
 26

DRUG THERAPEUTIC RECORD

Drug/Dose/ Classification/ Indication/ Side-effects/ Contraindication Principles Of Care

Frequency/ Mechanism
Route

1. Co- Antimicrobial; I: upper respiratory infections, sinusitis, Augmentin

Amoxiclav Antiinfectives tonsillitis, bronchitis, bronchopneumonia, solutions should
(Augmentin) cystitis not be mixed with
600 mg IV q 8 Hinders the cell infusions
hours wall synthesis S/E: containing
12pm-8pm- of sensitive Hypersensitivity Reactions: Angioneurotic glucose, dextran
4am bactericidal edema, anaphylaxis, serum sickness-like or bicarbonate.
against many syndrome, hypersensitivity vasculitis. Store at 5C.
gram (+) (-)
bacteria Skin rash pruritis and urticaria have been
reported occasionally. Other reactions
including erythema multiforme, Stevens-
Johnson syndrome, toxic epidermal
necrolysis and bullous exfoliative
dermatitis, and acute generalised
exanthematous pustulosis (AGEP) as in the
case of other -lactam antibiotics, have
been seen rarely.

If any hypersensitivity dermatitis reaction

occurs, treatment should be discontinued.

Interstitial nephritis can occur rarely.

Gastrointestinal Reactions: Effects include

 27

diarrhea, nausea, vomiting and indigestion.

Mucocutaneous candidiasis and antibiotic-
associated colitis (including
pseudomembranous colitis and
haemorrhagic colitis) have been reported
rarely.

Nausea is more often associated with

higher oral dosages. If gastrointestinal
reactions are evident, they may be reduced
by taking Augmentin at the start of a meal.

Hepatic Effects: A moderate rise in AST

and/or ALT has been noted in patients
treated with -lactam class antibiotics, but
the significance of these findings is
unknown. Hepatitis and cholestatic
jaundice have been reported rarely

C/I: hypersensitivity; history of cholestatic

jaundice/ hepatic dysfunction.

2. Ranitidine Gastrointestinal agents; I:Duodenal and gastric ulcers; Give with or

(Zantac) 50 Anti-secretory (H2-receptor
mg IVTT q 8 antagonist)
hours
6am-6pm Ranitidine is a specific,
rapidly acting histamine H2-
antagonist. It inhibits basal
and stimulated secretion of
gastric acid, reducing both
the volume and the acid and
GERD; erosive esophagitis; without food
heartburn Administer
adjunctive antacid
S/E: treatment 2 hours
CNS: headache, malaise, before or after drug
dizziness, somnolence, insomnia,
vertigo, mental confusion,
agitation, depression, hallucination
CV: bradycardia
 28

pepsin content of the GI: constipation, nausea,

secretion. Ranitidine has a abdominal pain, vomiting, diarrhea
long duration of action and SKIN: rash
so a single 75- or 150-mg HEMATOLOGIC: reversible
dose effectively suppresses decrease in WBC count,
gastric acid secretion for at thrombocytopenia
least 12 hrs.
C/I:
Clinical evidence has shown Pregnancy and lactation
that ranitidine combined
with amoxicillin and
metronidazole eradicates
Helicobacter pylori in
approximately 90% of
patients. This combination
therapy has been shown to
significantly reduce
duodenal ulcer recurrence.
Helicobacter pylori infects
about 95% of patients with
duodenal ulcer and 80% of
patients with gastric ulcer.
 29

V. EVALUATION AND RECOMMENDATION

Prognosis
There was an improvement in patient's condition. By 6 days post operative,
there was improvement in skin color. More improvement towards optimum health can
be expected.

VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO:

Nursing Practice
This case study is geared towards providing adequate knowledge, developing
positive attitude, and proper skills in caring for postoperative patients most
specifically those undergoing Open cholecystectomy.

Nursing Education
This case study aims to help the nursing students become efficient nurses by
providing knowledge about the surgical operation, its procedures, the postoperative
patient and allows him or her to be able to formulate nursing interventions and a
health teaching plan appropriate for the client. Ensuring the student has adequate
knowledge also gives him or her a sense of confidence and readiness to care for the
postoperative client.

Nursing Research
This study of may be used as basis for future researchers of this kind of
surgical operation. It can also provide information needed by other students so they
may understand the procedure and the care needed by postoperative clients.
 30

VIII. BIBLIOGRAPHY

Beers, Mark. The Merck Manual of Medical Information; 2nd edition: Merck & Co.,
Inc., 2003.
Brunner and Suddarth. Textbook of Medical Surgical nursing .9th Edition:
Lippincott Williams and Wilkins, Inc.: 227 East Washington Square,
Philadelphia. PA, 9106, 2000.

Doenges, Martlynn E., Moorhouse, Mary Frances, and Geissler-Murr, Alice C.

Nursing Care Plans, 6th Edition: F.A. Davis Company, 2002.

Doenges and Moorhouse, Nursing Pocket Guide, 8th edition: F.A. Davis Company,
200.

George R. Spratto and Adrienne L. Woods. 2003 PDR Nurses Drug Handbook:
Janssen, 2004

Kozier, Barbara and Erb, Glenora et.al. Fundamentals of Nursing, 5th Edition: Pearson
Education: Asia Pte Ltd., 2002
MIMS
101st Edition 2004

Pilliteri, Adele Maternal & Child Health Nursing, 2nd Edition: Philadelphia: J.B.
Lippincott Company, 1995

Potter, Patricia A. and Perry, Anne Griffin. Fundamentals of Nursing, 5th Edition:
Missouri: Mosby, Inc., 2001.

Robbins, Stanley and Ramzi Cotran. Pathologic Basis of Disease, 2nd Edition:
Philadelphia: W.B. Saunders Company, 1979

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