NAME: Mrs.

A AGE: 27 years old SEX: Female ADDRESS: Binondo, Manila BIRTHDATE: 06/14/1986 BIRTH PLACE: Manila RELIGION: Catholic NATIONALITY: Filipino CIVIL STATUS: Married OCCUPATION: Barista

ADMISSION NUMBER: 10*** ADMISSION DATE AND TIME: 08/06/2013 2000H WARD/ROOM/BED: 5A/510 ADMITTING PHYSICIAN: Dr. Kendrick Go Sia ADMITTING DIAGNOSIS: Cholelithiasis possible Open Cholecystectomy CHIEF COMPLAINT: The patient verbalized Pabalik-balik kasi yung sakit matagal na, kaya pina-schedule na ako ni doctor for operation

Family Health History According to the patient no her parent does not experience having cholelithiasis but her siblings does. Her father has hypertension and diabetes mellitus, her mother doesnt have any diseases that can be passed on from generation to generation. The patient verbalized sa side ni papa may high blood tsaka diabetes pero sa side naman ni mama wala, lima kaming magkakapatid pangalawa ako sa pinakamatanda, yung panganay nagkaroon na rin ng ganito, yung iba maayos naman wala namang mga sakit

Social History and Lifestyle The patient said that she likes to eat salty and fatty foods before she was hospitalized, she also eats vegetables and fruits. She verbalized naku mahilig ako dati sa maaalat na pagkain tsaka sa taba, pag kumakain ako gustong gusto ko yung taba sa ulam, kumakain din naman ako ng gulay tsaka prutas pero hindi naman to the point na kada meal dapat may gulay. She said that she drinks about 1 liter to 1.5 liter of water a day, she urinates for about 3-4 times a day and defecates everyday or sometimes every other day as she verbalized nakaka isa hangang isat kalahating litro lng ako ng tubig sa isang araw kaya yung ihi ko 3 times lang minsan 4 times, yung pagdumi ko naman regular minsan kada isang araw. The patient plays volleyball as a form of exercise. She said that she sleeps for about 8 hours a day she verbalized Maayos naman yung tulog ko abot naman ng mga 8 hours a day pero minsan umaabot ng 12 hours tapos minsan naman 3 hours lang. Mrs. A drinks alcohol occasionally and smokes 3 sticks of cigarettes per day she verbalized umiinom ako pero kapag may okasyon lang tsaka hindi ko naman inaabuso yung tamang amount lang, yung sigarilyo naman pinakamadami ko na yung tatlong sticks kada araw.

Past Health History The patient Mrs. A has not been hospitalized before, she did not have any operation. She verbalized Hindi pa naman ako na confine tsaka na operahan dati, ngayon pa lang. Kapag pumupunta ako ng hospital dati para sa mga check-up lng yun, tulad nung February chineck-up lng ako tapos niresetahan ng gamot mga one week ko din yon ininom, Omeprazole ata yun tsaka Buscopan. Mrs. A has a completed vaccination in her childhood she verbalized Sabi naman ng mother ko kumpleto naman daw ako ng bakuna noon meron daw ako nung mga BCG na yan.

Present Health History The patient Mrs. A had an operation Open Cholecystectomy one day ago. She has been experiencing pain on the right upper quadrant of her abdomen. She verbalized kanina lang ako na-operahan pero matagal na akong naka-schedule for operation. February ko pa unang na-experience yung sakit then nagpunta ako dito sa metro sa emergency room, binigyan lang ako ng gamot ng doctor para pampawala ng sakit, kaso nung March sumakit ulit kaya nag-pa check-up ulit ako tapos niresetahan ulit ako ng gamot then 3rd time nung May 2013 yun yung pinaka masakit pag balik ko dito sabi ng doctor mag pa ultrasound daw ako, tapos yun nakita na may mga bato nga daw, tapos nagpa-schedule na ng operation kahapon lng nagawa

IN TEGUMENTARY SYSTEM Q: Meron po bang problema sa balat? Mga pangangati or sugat? A: Wala naman akong ibang problema bukod ditto sa nasa tiyan ko, pag nakakain lang ng seafood namamantal ako

CARDIOVASCULAR SYSTEM Q: May problema po basa puso? Sumasakit po ba ang dibdib? A: Hindi naman

RESPIRATORY SYTEM Q: Nahihirapan po bang huminga or madalas po bang hingalin? A: hindi din,minsan hihingal ako perp pag naglalaro lng ako ng volleyball

DIGETIVE SYSTEM Q: May masakit po ba sa tyan? A: Wala naman, medyo may kakaiba sa tiyan ko kasi may tahi pero hindi naman siya masakit, tsaka natanggal naman na yung mga bato eh Q: May problema po ba sa pagdumi? A: Wala naman

LYMPHATIC SYSTEM Q: Gaano po kayo kadalas magkasakit? A: Bihirang bihira lang, tsaka hindi naman malalala kasi mga sakit lang ng ulo tsaka trangkaso lang

GENITOURINARY SYSTEM Q: May problema po ba sa pag ihi? A: Wala naman Q: May mga unusual discharges po kayong napapansin tulad nd dugo? A: Wala din

MUSCULOSKELETAL SYSTEM Q: May problema po ba sa mga muscles tsaka buto? A: Minsan nagka-cramps yung binti ko pero other than that wala naman na.

General Appearance Patient is on a semi-fowlers position with an IVF of PLR 1L at 360cc level, infusing well at left lower arm. Patient is awake and coherent, wearing the hospitals gown; with foley catheter to urine bag and op-site dressing on the abdomen. Vital Signs: 1600H 8/7/13
Temperature: 36.5 degrees C
Pulse Rate: 65 bpm Cardiac Rate: 69bpm Respiration Rate: 20 cpm BP: 110/80 mmHg

BODY TECHNIQ PARTY UE USED Skin Inspection

NORMAL FINDINGS Whitish pink or brown in color; dark skin tone depending on patients race; no evidence of discoloration No areas of increased vascularity, ecchymosis and bleeding No lesions except for birthmarks or nevi Dry with minimum perspiration; smooth, even and firm; no edema present

ACTUAL FINDINGS Brown color of the skin Presence of incision and op site dressing No edema, bleeding

ANALYSIS Abnormal due to surgical intervention

Hair

Inspection

Color varies from dark black to pale blonde; evenly distributed; no lesions in scalp; thin, coarse, straight, thick or curly hair

Black hair color, evenly distributed, no lesions in scalp

Normal

Nails

Inspection & Palpation

Pink to brown cast; 2-3 seconds capillary refill; smooth and slightly rounded

Pink cast; 2 seconds capillary refill; smooth and slightly rounded

Normal

Head

Inspection & Palpation

Normocephalic and symmetrical, smooth, nontender without masses and depression Facial features should be symmetrical; shape can be round, oval or slightly squared; no involuntary movements; no edema and disproportion

Face

Inspection & Palpation

Normocephalic and symmetrical, smooth, nontender without masses and depression Facial features is symmetrical; roung in shape; no involuntary movements; no edema and disproportion

Normal

Normal

Neck

Inspection & Palpation

Symmetrical neck muscles; head in full ROM without discomfort; no palpable masses or enlargement of lymph nodes and thyroid glands

Symmetrical neck muscles; head in full ROM without discomfort; no palpable masses or enlargement of lymph nodes and thyroid glands
Eyes are aligned; no movement of either eyes Both eyes move smoothly and symmetrically in each 6 cardinal sides No drooping, infections or tumors Pink and moist conjunctiva Pupil - Deep black, round, equal in diameter, constrict briskly to direct light

Normal

Eyes

Inspection

Eyes are aligned; no movement of either eyes Both eyes move smoothly and symmetrically in each 6 cardinal sides No drooping, infections or tumors Pink and moist conjunctiva Pupil - Deep black, round, equal in diameter, constrict briskly to direct light

Normal

Ears

Inspection

The patient has no hearing difficulty Match the flesh color of the entire skin; proportional; no pain or tenderness Symmetrically in the midline of the face; no lesion, swelling, bleeding and masses

The patient has no hearing difficulty Match the flesh color of the entire skin; proportional; no pain or tenderness Symmetrically in the midline of the face; no lesion, swelling, bleeding and masses Lips pink and moist with no evidence of lesion or inflammation Tongue midline in the mouth; pink, moist and rough; no lesions and swelling, moves freely No accessory muscles are used in normal breathing Vesicular breath sounds

Normal

Nose

Inspection

Normal

Mouth Inspection

Lips pink and moist with no evidence of lesion or inflammation Tongue midline in the mouth; pink, moist and rough; no lesions and swelling, moves freely

Normal

Thora Inspection x & Auscultati on

No accessory muscles are used in normal breathing Vesicular breath sounds

Normal

Chest

Inspection & Auscultatio n Inspection

Symmetrical; no vibrations, thrills and expansions noted Regular rhythm No murmurs Flat or rounded; symmetrical bilaterally; no discoloration Umbilicus depressed and beneath abdominal surface

Abdome n

Symmetrical; no vibrations, thrills and expansions noted Regular rhythm No murmurs Rounded, presence of incision and op site dressing

Normal

Abnormal due to surgical intervention

Genitals

Inspection

Foley catheter to urine bag

Abnormal

Upper Extremi ties

Inspection

Able to perform full ROM No swelling or inflammation Has 5 fingers on each hand; no numbness or paralysis

Able to perform full ROM No swelling or inflammation Has 5 fingers on each hand; no numbness or paralysis

Normal

The gallbladder is part of the digestive system. It is a small, pear-shaped organ on the right side of the body, under the right lobe of the liver. The body can function without the gallbladder. If doctors need to remove it because of disease, there are no serious long-term effects and the body can still digest food.

Structure:The gallbladder is about 7.510 cm (34 inches) long and about a 2.5 cm (1 inch) wide. The gallbladder is made up of layers of tissue: Mucosa: the inner layer of epithelial cells (epithelium) and lamina propria (loose connective tissue) a muscular layer: a layer of smooth muscle perimuscular layer: connective tissue that covers the muscular layer serosa: outer covering of the gallbladder The gallbladder, liver and small intestine are connected by a series of thin tubes or ducts. The common hepatic duct drains bile from the liver through the left and right hepatic ducts. The cystic duct joins the gallbladder to the common bile duct. The common bile duct is where the hepatic and cystic ducts meet and connect to the small intestine. The gallbladder and bile ducts are also called the biliary system or biliary tract.

Function: The gallbladder stores and concentrates bile, a yellowishgreen fluid made by the liver. Bile helps the body digest fats. Bile is mainly made up of: bile salts bile pigments (such as bilirubin) cholesterol water

The liver releases bile into the hepatic duct. If the bile is not needed for digestion, it flows into the cystic duct and then into the gallbladder, where it is stored. The gallbladder can store about 4070 mL (814 teaspoons) of bile. The gallbladder absorbs water from the bile, making it more concentrated. When bile is needed for digestion after a meal, the gallbladder contracts and releases it into the cystic duct. The bile then flows into the common bile duct and is emptied into the small intestine, where it breaks down fats.

August 7, 2013

Received awake on semi-fowlers position, with an IVF of PLR 1L x 8hours at 360cc level, infusing well at left lower arm; on nothing per orem diet; with op-site dressing at abdominal area and foley catheter draining to urine bag, monitored every hour. IVF was consumed by 1930H and shifted to D5LR x 8hours; diet was shifter to soft diet and start oral medications

GENERIC NAME: BRAND NAME: ROUTE/ FREQUENCY CLASSIFICATION INDICATION

Ketorolac Kortezor IVT Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) For short-term management (2 days) of moderate to severe acute post-op pain

MECHANISM OF ACTION: CONTRAINDICATIO N: ADVERSE REACTION: NURSING RESPONSIBILITIES:

Anti inflammatory and analgesic activity inhibit prostaglandins and leukotriene synthesis recent GI bleeding or perforation. Moderate to severe renal impairment.. Prophylaxis before major surgery w/ high risk of bleeding or incomplete hemostasis, GI ulceration, bleeding & perforation GI pain, diarrhea, constipation, flatulence, fullness, vomiting, stomatitis, With meals

GENERIC NAME: BRAND NAME: ROUTE/ FREQUENCY

Amsulvex Sulbactam IVT/30mg

CLASSIFICATION
INDICATION

Penicillins
Infections due to -lactamase-producing Haemophilus influenzae including intra-abdominal infections & UTI due to susceptible organisms. Hypersensitivity to penicillins.

CONTRAINDICATION: ADVERSE REACTION: NURSING RESPONSIBILITIES:

With meals

GENERIC NAME: BRAND NAME: ROUTE/ FREQUENCY CLASSIFICATION INDICATION

Ketorolac Kortezor IVT/1.5mg Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) For short-term management (2 days) of moderate to severe acute post-op pain

MECHANISM OF ACTION: CONTRAINDICATIO N: ADVERSE REACTION: NURSING RESPONSIBILITIES:

Anti inflammatory and analgesic activity inhibit prostaglandins and leukotriene synthesis recent GI bleeding or perforation. Moderate to severe renal impairment.. Prophylaxis before major surgery w/ high risk of bleeding or incomplete hemostasis, GI ulceration, bleeding & perforation GI pain, diarrhea, constipation, flatulence, fullness, vomiting, stomatitis, With meals

GENERIC NAME: BRAND NAME: ROUTE/ FREQUENCY CLASSIFICATION INDICATION MECHANISM OF ACTION:

Metoclopramide PLASIL SIVP/10mg Prokinetic Drug, Antiemetic Drug Gastrointestinal (GI) motility disturbances. Nausea and vomiting of central and peripheral origin associated with surgery. Dopamine antagonist that acts by increasing receptor sensitivity and response of upper GIT tissues to acetylcholine. This cause contraction of gastric smooth muscles, relaxation of the pyloric sphincter and duodenal bulb and increased peristalsis without stimulating gastric, biliary and pancreatic secretions. It also produces sedation and induces release of prolactin Metoclopramide should not be used whenever stimulation of gastrointestinal motility might be dangerous Sedation, restlessness, diarrhea, headache, dizziness, nausea -Assess patients GI complaints: nausea, vomiting, constipation -Frequently monitor blood pressure of patients taking IV form of drug

CONTRAINDICATIO N: ADVERSE REACTION: NURSING RESPONSIBILITIES:

Cholecystectomy is a surgical procedure to remove your gallbladder a pear-shaped organ that sits just below your liver on the upper right side of your abdomen. Your gallbladder collects and stores bile a digestive fluid produced in your liver. Cholecystectomy may be necessary if you experience pain from gallstones that block the flow of bile.

Impaired Skin Integrity Risk for Infection

Pain medicine: You may need medicine to take away or decrease pain. Learn how to take your medicine. Ask what medicine and how much you should take. Be sure you know how, when, and how often to take it. Do not wait until the pain is severe before you take your medicine. Tell caregivers if your pain does not decrease. Pain medicine can make you dizzy or sleepy. Prevent falls by calling someone when you get out of bed or if you need help. Antibiotics: This medicine is given to fight or prevent an infection caused by bacteria. Always take your antibiotics exactly as ordered by your primary healthcare provider. Do not stop taking your medicine unless directed by your primary healthcare provider. Never save antibiotics or take leftover antibiotics that were given to you for another illness.

Take your medicine as directed. Call your primary healthcare provider if you think your medicine is not helping or if you have side effects. Tell him if you are allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the amounts, and when and why you take them. Bring the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an emergency. Eat a variety of healthy foods. This may help you have more energy and heal faster. Healthy foods include fruit, vegetables, whole-grain breads, low-fat dairy products, beans, lean meat, and fish. Ask if you need to be on a special diet Contact your primary healthcare provider if: You have a fever. You have nausea and vomiting. You are constipated or urinate less than usual. You have questions or concerns about your condition, surgery, or care.

Keep dressing dry and intact Proper wound care

Hand washing before and after change of dressing Use appropriate wound dressing Maintain clean and dry skin to provide barrier to infection Pat skin dry instead of rubbing to reduce risk for irritation Apply wound dressing carefully

Use splint or instruct patient to use pillow when coughing or sneezing Improve nutrition and hydration to improve skin condition
Adequate protein intake Adequate fluid intake