ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING
ANGELES CITY

CASE STUDY – CHOLECYSTITIS

JBL – MS WARD

Submitted by:
Diyco, Kevin Cesar
Pelayo, Roan Rae
Santos, Alvin Ronn
BSN 4-2, Group 6

Submitted to:
Luciano O. Coral III, RN, MN
INTRODUCTION
Cholecystitis, which has long been considered an adult disease, is quickly
gaining recognition in medical practice because of the significant documented
increase in nonhemolytic cases over the last 20 years. Gallbladder disease is
common throughout the adult population, affecting as many as 25 million
Americans and resulting in 500,000-700,000 cholecystectomies per year.

Although gallbladder disease is much rarer in children, with 1.3 pediatric

cases occurring per every 1000 adult cases, pediatric patients undergo 4% of all
cholecystectomies. In addition, acalculous cholecystitis, uncommon in adults, is
not that unusual in children with cholecystitis. Because of the increasing
incidence of gallstones and the disproportionate need for surgery in the pediatric
population, consider cholecystitis and other gallbladder diseases in the
differential diagnosis in any pediatric patient with jaundice or abdominal pain in
the right upper quadrant, particularly if the child has a history of hemolysis.

Cholecystitis is defined as inflammation of the gallbladder and is

traditionally divided into acute and chronic subtypes. These subtypes are
considered to be 2 separate disease states; however, evidence suggests that the
2 conditions are closely related, especially in the pediatric population. Most
gallbladders that are removed for acute cholecystitis show evidence of chronic
inflammation, supporting the concept that acute cholecystitis may actually be an
exacerbation of chronic distension and tissue damage. Cholecystitis may also be
considered calculous or acalculous, but the inflammatory process remains the
same.

Most information related to morbidity and mortality in gallstone disease is

related to the adult population, although some trends can be extracted and
applied to the pediatric population. In general, the mortality rate of
cholecystectomy in acute cholecystitis has dropped from 6.6% in 1930 to 1.8% in
1950 to nearly 0% in recent studies. In one study, the overall mortality rate in
42,000 patients receiving open cholecystectomy (OC) was 0.17%; the mortality
rate in patients younger than 65 years was 0.03%. Children can be expected to
do well, although comorbid conditions are common and may cause
complications. Risk factors for morbidity and mortality in the pediatric population
include associated conditions, such as cystic fibrosis (CF), obesity, hepatic
disease, diabetes mellitus, sickle cell disease, and immunocompromise.

General complications, such as pulmonary, cardiac, thromboembolic,

hepatic, and renal insufficiency, account for most deaths. Procedure-related
complications mainly contribute to morbidity and occur with higher frequency in
acute cholecystitis in which symptoms of gallstone disease have been present
longer than 1 year. The most common procedure-related complications are
wound infections, abscess, cholangitis or pancreatitis, ileus, hemorrhage, and
bile duct complications.

Laparoscopic cholecystectomy (LC) is associated with risks as well. Major

complications include bleeding, pancreatitis, leakage from the duct stump, and
major bile duct injury. The risk of ductal injury increases from 0.1-0.2% in OC to
0.5-1% in LC; however, Holcomb et al reported no iatrogenic injuries with LC in
their first 100 patients. They believe that with conscientious surgical care,
morbidity related to the laparoscopic approach can be minimized.

Racial and genetic influences in the adolescent age group are similar to
those of adults. African Americans without hemolytic disease and the African
Masai are less prone to cholelithiasis, whereas Chilean women, Pimas, and
whites are more predisposed to this disease. Two contributing diseases in
particular have a genetic component and racial distribution. Hemolytic diseases,
including sickle cell disease and hemoglobin C disease, occur almost exclusively
in the black population, although thalassemia also has a Mediterranean
distribution. CF, which occurs mainly in whites, may also contribute to the
formation of biliary sludge and, possibly, acalculous cholecystitis.
 The physical examination in acute cholecystitis usually reveals right upper
quadrant tenderness. The classic triad is right upper quadrant pain, fever, and
leukocytosis. The patient may have abdominal guarding and a positive Murphy
sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right
upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder
combined with distension may create a palpable mass between the 9th and 10th
costal cartilages.

In rural Asia, infections with Opisthorchis sinensis or Ascaris

lumbricoides are predisposing conditions. In the United States, these gallstones
are more rare, although they have been found after cholecystectomy in which the
bile was infected (most often by E coli) and in infants and children infected
with Staphylococcus, Enterobacter, Citrobacter, and Salmonella species. In
addition, chronic urinary tract infections may predispose individuals to the
formation of these gallstones, and isolated gallstones associated
with Ascaris have been recorded in the United States.

Many disease processes can precipitate or foster these events. Infection

induces the deconjugation of bilirubin glucuronide, thereby increasing the
concentration of unconjugated bilirubin in the bile. Hemolysis overwhelms the
conjugation abilities of the liver, increasing the amount of unconjugated bilirubin
in the bile. Hemolytic diseases include hereditary spherocytosis, sickle cell
disease, thalassemia major, hemoglobin C disease, and possible uncontrolled
glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. Multiple blood
transfusions also increase the pigment load, which predisposes the bile to the
formation of biliary sludge.
A. . Objectives

a. Nurse Centered

Short Term:
After the initial student nurse-patient interaction, the student nurses
will:
o Establish rapport with the patient.
o Introduce themselves and state their purpose to the patient.
o Use therapeutic communication during nurse-patient interactions.
o Obtain necessary data such as personal information, family history,
and history of past and present illness.
o Perform physical assessment in a cephalocaudal and IPPA
approach.
o Review and monitor diagnostic and laboratory results.
o Provide due care to the patient which includes medical,
pharmacological, and nursing interventions.

Long Term:
After the completion of this case study, the student nurse will:
o Review the medical condition of the patient.
o Identify precipitating and predisposing factors to the occurrence of
the disease condition.
o Review the book-based and patient-based manifestations of the
disease.
o Correlate other factors such as relevant data, laboratory results,
and abnormal findings in the physical assessment.
o Formulate nursing diagnoses and subsequent planning to aid the
patient’s prognosis.
 o Implement what has been planned and provide health teachings as
appropriate.
o Evaluate patient’s response to over-all interventions through the
patient’s daily progress chart.
o Provide health teachings upon discharge of the patient such as the
maintenance of medical managements and measures to prevent
reoccurrences or to alleviate aggravating conditions.

b. Patient Centered
Short-Term:
After the initial student nurse-patient interaction, the student nurse
will:
o Acknowledge the presence of student nurse as part of the heal care
team responsible in taking care of her conditions.
o Build up a therapeutic relationship with the student nurse.
o Cooperate in different activities and management done.
o Provide pertinent data and cooperate in physical assessment
procedures.
o Understand the disease process and its complications.
o Comply with the treatment and management at hand.

Long-Term:
After the completion of this case study, the patient will be able to:
o Have a more stable health condition.
o Gain strong compliance and attain optimum level of functioning.
o Gain empowerment and responsibility of maintaining health.
o Apply the health teachings given regarding health promotion,
preventive measures, curative and rehabilitative means in her
everyday life.
 A. Personal History

1. Demographic Data

Mrs. Chole is a twenty-seven years old female, and was born on October
17, 1983. Mrs. Chole parents are both Filipino, thus making her a Filipino citizen.
She was baptized under the Roman Catholic Church. She speaks Tagalog and
Pampango but her primary language is Pampango. She is married to Mr.Systitis
they have one child who is 3 years of age. She is living with her mother in law in
Fatima Calutlut City of San Fernando, Pampanga. She was admitted at a tertiary
hospital located at San Fernando City on December 05, 2010 at 3:25 PM.

2. Socio – economic and Cultural Factors

Mrs. Chole belongs to an extended type of family where she lives with her
mother in law. Mrs. Chole is a housewife and sometimes sells viand in their
neighborhood and earns around Php 500 – 800 depending on what kind of viand
she cooked, her husband works as a janitor at PCSO in pampanga and earns
around Php 7,000 – 8,000 per month. Mrs.Chole is a Roman Catholic and
usually go to church every Sunday. She do believe with herbolarios, and she
usually go to the Health Center for checkups. Mrs. Chole does utilize herbal
medicines such as pandan as diuretic and guava leaves as disinfectant. Mrs.
Chole practices self-medication when it comes to OTCs like paracetamol and
mefenamic acid.
B. Family Health-Illness History

+ +
Unknown Hypertension Stroke Hypertension

Hypertensio + Hypertensio

Hypertensio
Hypertensio
Legend:
• - Male - Female

- Deceased - Mrs. Chole

Family History:
Mrs. Chole told the researcher that her grandparents have Hypertension
and are still alive. She said that she does not know any persisting disease in her
parents except for hypertension. She is the 4th child among the six children, with
two males and four females. She said that no one in her siblings is already dead
and all are in normal conditions except for 2 nd sister and 3rd brother who have
hypertension. She shares that there is no history diabetes mellitus, asthma, CRF
in their family.

C. History of Past Illnesses

 Mrs.Chole had history of fever and coryza, but still, these disappeared
early and have been managed properly. She had German Measles at three years
old, and did not take medications at all. At seven Mrs.Chole, had mumps, and is
not given any medications. She declared that her mother had put “tina” or the
blue powder on Mrs.Chole’ s face, however, did not know what it is for.
Mrs.Chole had her menarche on her twelfth year of life. Aside from the
abovementioned diseases, Mrs.Chole had no other diseases.

D. History of Present Illness

One week Prior to admission Mrs. Chole have an right upper quadrant
pain it is characterized as continous, non-radiating pain, no consultation done
she has a positive edema and facial swelling. Three days prior to admission she
still have that right upper quadrant pain, Mrs. Chole vomited and still no
consultation was done, one day prior to admission they consulted local district
hospital and ultrasound was requested and done results revealed cholecystitis,
they referred Mrs. Chole to the tertiary hospital in San fernado.
A. Physical Examination (Cephalocaudal Approach)

December 05, 2010, Sunday (Chart PA)

HEENT: Anicteric sclera, pale palpebral conjunctiva
CHEST AND LUNGS: SCE, (-) murmurs
ABDOMEN: with right upper quadrant painflat, soft, an positive murphy’s sign
EXTREMITIES: with positve edema, full and equal pulses, pallor

December 06 2010, Monday

General Appearance:
The patient shows signs of weakness. The patient is quiet and is non-responsive.
Vital signs taken and recorded as follows: T= 36.8°C (axilla); PR= 82 bpm;
RR=27 bpm; BP= 100/70 mmHg

SKULL and FACE: Mrs. Chole has round normo-cephalic shaped skull with
absence of nodules or masses. She has symmetric facial features and facial
movements as she was able to smile, frown raise eyebrows and puff cheeks.
She does experience headache at a minimum.

HAIR and SCALP: Mrs. Chole has short, scarcely distributed hair, without
presence of lice or other infestations.

SKIN and NAILS: Mrs. Chole has pale complexion, with good skin turgor. She
has warm and moist skin with absence of nodules. She has smooth, convexly
curved, newly trimmed fingernails and toenails, but of pale color and with
capillary refill of more than 3 seconds upon Blanch test.

EYES and VISION: Eyebrows are evenly distributed and symmetrically aligned
with equal movements. Eyelashes are equally distributed and curled slightly
outward and upward. Eyelids close symmetrically with skin intact and no
discharges or discoloration noted. Bulbar conjunctiva is transparent and sclera
appears white. Palpebral conjunctiva is shiny, smooth but is pale. Lacrimal
ducts have no edema or tearing upon palpation. Pupils are equally rounded,
reactive to light and accommodation. She can see objects in the periphery when
looking straight ahead and is able to read a letter at a given distance.

EARS AND HEARING: Auricles are same as color of facial skin, symmetric and
aligned with canthus of eye. Ears are not tender and recoil after being folded.
She has slight amount of cerumen that is yellowish in color. She can hear
normal voice tone.

NOSE AND SINUSES: Nose is symmetric and straight. It has uniform color and
not tender. Nasal septum is intact and in midline. Air moves freely on both nares
as client breathes. Facial sinuses are not tender.

MOUTH AND OROPHARYNX: Lips are pale, soft and symmetrical. She was
able to purse her lips when she was asked to. She has an incomplete set of
teeth. Gums are pale, though there are no signs of bleeding. Tongue is at
the center and pinkish in color with no lesions, no tenderness and moves freely.

NECK: Neck muscles are equal in size and head is centered. She can move her
head freely with no discomfort. Lymph nodes are not palpable and trachea is in
the midline of neck. Thyroid gland is not palpable. Carotid and jugular veins are
not distended and visible, with no bruit sounds.

THORAX AND LUNGS: Chests are symmetrical in size and expansion. Spine is
vertically aligned. Skin is intact, with no palpable masses or nodules. She has no
rales and crackles heard on the both lung field.
ABDOMEN: Patient has no striae, scars, or visible veins, upon inspection. She
has a positive murphy’s sign, right upper quadrant pain. Normal bowel
sounds.

HEART: Heart rate is regular in rhythm upon auscultation without any murmurs.
Peripheral pulses are symmetrical with that of the apical pulse.

UPPER EXTREMITIES: Skin is uniformly fair in color, with good skin turgor.
Temperature of the skin is uniform in both extremities. Muscles are generally
equal in size on both sides with no tremors or contractures. There are no bone
deformities but there is presence of edema. She was able to adduct and abduct
her arm, supine and prone her hands, shrug her shoulders against resistance,
and flex and extend her arms. She also has good handgrip and was able to
perform the finger-nose test. Muscle strength is graded as five.

LOWER EXTREMITIES: Negative result of Romberg’s test She has bipedal

edema, with shiny, flaky skin. She can extend her legs and flex it.

December 07 2010, Tuesday

General Appearance:
The patient shows signs of weakness. The patient is quiet and is responsive.
Vital signs taken and recorded as follows: T= 37.1°C (axilla); PR= 86 bpm;
RR=20 bpm; BP= 110/80 mmHg

SKULL and FACE: Mrs. Chole has round normo-cephalic shaped skull with
absence of nodules or masses. She has symmetric facial features and facial
movements as she was able to smile, frown raise eyebrows and puff cheeks.

HAIR and SCALP: Mrs. Chole has short, scarcely distributed hair, without
presence of lice or other infestations.
SKIN and NAILS: Mrs. Chole has pale complexion, with good skin turgor. She
has warm and moist skin with absence of nodules. She has smooth, convexly
curved, newly trimmed fingernails and toenails, but of pale color and with
capillary refill of more than 3 seconds upon Blanch test.

EYES and VISION: Eyebrows are evenly distributed and symmetrically aligned
with equal movements. Eyelashes are equally distributed and curled slightly
outward and upward. Eyelids close symmetrically with skin intact and no
discharges or discoloration noted. Bulbar conjunctiva is transparent and sclera
appears white. Palpebral conjunctiva is shiny, smooth but is pale. Lacrimal
ducts have no edema or tearing upon palpation. Pupils are equally rounded,
reactive to light and accommodation. She can see objects in the periphery when
looking straight ahead and is able to read a letter at a given distance.

EARS AND HEARING: Auricles are same as color of facial skin, symmetric and
aligned with canthus of eye. Ears are not tender and recoil after being folded.
She has slight amount of cerumen that is yellowish in color. She can hear
normal voice tone.

NOSE AND SINUSES: Nose is symmetric and straight. It has uniform color and
not tender. Nasal septum is intact and in midline. Air moves freely on both nares
as client breathes. Facial sinuses are not tender.

MOUTH AND OROPHARYNX: Lips are pale, soft and symmetrical. She was
able to purse her lips when she was asked to. She has an incomplete set of
teeth. Gums are pale, though there are no signs of bleeding. Tongue is at
the center and pinkish in color with no lesions, no tenderness and moves freely.

NECK: Neck muscles are equal in size and head is centered. She can move her
head freely with no discomfort. Lymph nodes are not palpable and trachea is in
the midline of neck. Thyroid gland is not palpable. Carotid and jugular veins are
not distended and visible, with no bruit sounds.

THORAX AND LUNGS: Chests are symmetrical in size and expansion. Spine is
vertically aligned. Skin is intact, with no palpable masses or nodules. She has no
rales and crackles heard on the both lung field.

ABDOMEN: Patient has no striae, scars, or visible veins, upon inspection. She
has a positive murphy’s sign, right upper quadrant pain. Normal bowel
sounds.

HEART: Heart rate is regular in rhythm upon auscultation without any murmurs.
Peripheral pulses are symmetrical with that of the apical pulse.

UPPER EXTREMITIES: Skin is uniformly fair in color, with good skin turgor.
Temperature of the skin is uniform in both extremities. Muscles are generally
equal in size on both sides with no tremors or contractures. There are no bone
deformities but there is presence of edema. She was able to adduct and abduct
her arm, supine and prone her hands, shrug her shoulders against resistance,
and flex and extend her arms. She also has good handgrip and was able to
perform the finger-nose test. Muscle strength is graded as five.

LOWER EXTREMITIES: Negative result of Romberg’s test She has bipedal

edema, with shiny, flaky skin. She can extend her legs and flex it.
F. Diagnostic and Lab Procedures

Diagnostic or Date ordered Analysis

Indication(s) or
Laboratory Date Results Normal Values and Interpretation of
Purposes
Procedures result(s) in Results
CBC
> Hemoglobin 12-05-10 It evaluates the 125 g/L 120-160 g/L The client’s result of
12-05-10 hemoglobin contents of Hemoglobin is within
erythrocytes. It measures normal range.
the oxygen carrying
capacity of the blood
since hemoglobin is the
primary component of
the blood which carries
oxygen.

> Hematocrit 12-05-10 It is used to measure the 0.37 0.38-0.40 The client’s result of
12-05-10 volume of RBC in whole hematocrit is slightly
blood expressed as below range which
percentage. The indicates that the patient’s
hematocrit value is RBC is low in proportion
roughly three times the to whole blood.
hemoglobin
concentration.
> Platelet 12-05-10 It is done to examine the 275 150-400x10^9/L The result is within normal
count 12-05-10 capability of the blood to range.
clot
> WBC 12-05-10 A white blood cell count 12.2 5.0-10.0 The result is above normal
12-05-10 is a determination of which indicates infection.
number of WBC or
leukocytes/unit volume in
a sample of venous
blood. The test is used to
detect infection or
inflammation and
leukemia, also used to
help monitor the body’s
response to various
treatments and to
monitor bone marrow
function, and to
determine the need for
further tests, such as
differential count.

The result is above normal

> Neutrophils 12-05-10 0.78 0.18-0.70 limits. Neutrophils is
12-05-10 greater in amount as
compared to other WBC
component because in a
normal inflammatory
response, the neutrophils
are the first ones to be
release and act on the
injured site. Hence, they
are greater in number.

The result is within normal

> Lymphocytes 12-05-10 0.22 0.10-0.48 range.
> Creatinine 12-05-10 More specific to assess 77.6 umol/L 60-120 umol/L The result is within normal
12-05-10 renal function because it range.
is not affected by dietary
consumption & hydration
status.

> Potassium 12-05-10 To monitor serum K+ 4.32 mmol/L 3.5-5 mmol/L The result is within normal
12-05-10 level, a determinant of range.
water balance and
essential for myocardial
contraction.

> Sodium 12-05-10 To monitor serum Na 132.4 mmol/L 136-145 mmol/L The result is below normal
12-05-10 level, a determinant of range which may indicate
water balance. that the patient is
dehydrated or has lost
fluids due to the disease
condition.

Nursing Responsibilities:
Before:
 Explain the procedure to the patient.
 Tell the patient that no fasting is required.
  Inform the patient that this test requires a blood sample and he/she may experience transient discomfort from the
needle puncture and the pressure of the tourniquet.
During:
 Collect approximately 5 to 7 ml of venous blood in a lavender-top tube.
 Avoid hemolysis.
 List on the laboratory slip any drugs that may affect test results.
After:
 Apply pressure to the puncture site.
 If hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal
to the venipuncture site.
 Ensure that subdermal bleeding has stopped before removing pressure.

Diagnostic or Date ordered Indication(s) or Results Normal Values Analysis

Laboratory Date Purposes and Interpretation of Results
Procedures result(s) in
> Urinalysis 12-06-10 To monitor fluid Color: yellow Yellow or Amber Urine color is normal
12-06-10 imbalances or factor
 for fluid imbalances.
Transparency: Clear Turbid urine may contain RBC,
Slightly turbid WBC, bacteria or fat and may
reflect renal infection

Specific Gravity: 1.010-1.035 Urine specific gravity is normal

1.015

Sugar: (-) Negative There is no sugar present in

the urine

Reaction: acidic Acidic The result is normal

RBC: 8-12 / HPF 0-3 RBC in urine is slightly

elevated which means there is
an infection

Pus cells:
8-10 / HPF 0-3 This further proves that there
is infection.

Nursing Responsibilities:
Before:
 Check doctor’s order
  Inform the patient about the procedure and explain the importance of the procedure to be done.
 Inform the patient that there are no restrictions in food and fluid before the test.
 Explain to the patient that this procedure is non invasive; no pain will be felt.
During:
 Assist patient by giving him a bed pan.
 Advise patient to clean the genitalia first.
 Describe the procedure for collecting a clean- catch or midstream specimen.
After:
 Chart time of collection of urine specimen.
 Attach results to the chart as soon as they are available.
 ANATOMY AND PHYSIOLOGY

HEPATOBILLARY TREE

LIVER
A. Location and size of the liver- largest gland in the body, weighs
approximately 1.5 kg; lies under the diaphragm; occupies most of the right
hypochondrium and part of the epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform ligament
1. Left lobe- forms about one sixth of the liver
2. Right lobe- forms about five sixths of the liver; divides into right lobe
proper, caudate lobe, and quadrate lobe
3. Hepatic lobules- anatomical units of the liver; small branch of
hepatic vein extends through the center of each lobule

C. Bile ducts
1. Small bile ducts form right and left hepatic ducts
2. Right and left hepatic ducts immediately join to form one hepatic
duct
 3. Hepatic duct merges with cystic duct to form the common bile duct,
which opens into the duodenum

D. Functions of the liver

1. Glucose Metabolism
-after a meal, glucose is taken up from the portal venous blood by
the liver and converted into glycogen (glycogenesis), which is
stored in the hepatocytes. Glycogen is converted back to glucose
(glycogenolysis) and release as needed into the blood stream to
maintain normal level of the blood glucose.
-glucose can be synthesized by the liver through the process
gluconeogenesis
2. Ammonia Conversion
-use of amino acids from protein for gluconeogenesis result in the
formation of ammonia as a by product. Liver converts ammonia to
urea
3. Protein Metabolism
-Liver synthesizes almost all of the plasma protein including
albumin, alpha and beta globulins, blood clotting factors plasma
lipoproteins
4. Fat Metabolism
-Fatty acid can be broken down for the production of energy and
production of ketone bodies
5. Vitamin and Iron Storage
-stores vitamin A, D, E, K
6. Drug Metabolism
7. Bile Formation
-bile is formed by the hepatocytes
-composed of water, electrolytes such as sodium, potassium,
calcium, chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile
salts
 -collected and stored in the gallbladder and emptied in the intestine
when needed for digestion
a. Lecithin and bile salts emulsify fats by encasing them in shells to
form tiny spheres called micelles
b. Sodium bicarbonate increases pH for optimum enzyme function
c. Cholesterol, products of detoxification, and bile pigments (e.g.
bilirubin) are wastes products excreted by the liver and
eventually eliminated in the feces

GALLBLADDER
The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose
function in the body is to harbor bile and aid in the digestive process.

Anatomy
• The cystic duct connects the gall bladder to the common hepatic duct to
form the common bile duct.
• The common bile romero duct then joins the pancreatic duct, and enters
through the hepatopancreatic ampulla at the major duodenal papilla.
• The fundus of the gallbladder is the part farthest from the duct, located by
the lower border of the liver. It is at the same level as the transpyloric
plane.

Microscopic anatomy
The different layers of the gallbladder are as follows:
• The gallbladder has a simple columnar epithelial lining characterized by
recesses called Aschoff's recesses, which are pouches inside the lining.
• Under the epithelium there is a layer of connective tissue (lamina propria).
• Beneath the connective tissue is a wall of smooth muscle (muscularis
externa) that contracts in response to cholecystokinin, a peptide hormone
secreted by the duodenum.
 • There is essentially no submucosa separating the connective tissue from
serosa and adventitia.

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches)
long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It
can hold 30 to 50 ml of bile. It lies on the undersurface of the liver’s right lobe and
is attached there by areolar connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the gallbladder.
The mucosal lining is arranged in folds called rugae, similar in structure to those
of the stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic and cystic
ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then
later, when digestion occurs in the stomach and intestines, the gallbladder
contracts, ejecting the concentrated bile into the duodenum. Jaundice a yellow
discoloration of the skin and mucosa, results when obstruction of bile flow into
the duodenum occurs. Bile is thereby denied its normal exit from the body in the
feces. Instead, it is absorbed into the blood, and an excess of bile pigments with
a yellow hue enters the blood and is deposited in the tissues.

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

fluid ounces) of bile, which is released when food containing fat enters the
digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile,
produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
 After being stored in the gallbladder the bile becomes more concentrated
than when it left the liver, increasing its potency and intensifying its effect on fats.
Most digestion occurs in the duodenum.

BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is formed from
senescent red blood cells. In the process of degradation, the hemoglobin from
the red blood cell is broken down from biliverdin, which is rapidly converted to
free bilirubin thru biliverdin reductase. Free bilirubin, which is not soluble in
plasma, is transported in the blood attached to plasma albumin. Even when it is
bound to albumin, this bilirubin is still called free bilirubin. As it passes through
the liver, free bilirubin is released from its albumin carrier molecule and moved
into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to
conjugated bilrubin thru glucoronyl transferase, making it soluble to bile.
Conjugated bilirubin is secreted as a constituents of bile, and in this form, it
passes through the bile ducts into the small intestine. In the intestine,
approximately one half of the bilirubin is converted into a higly soluble substance
called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the
portal circulation or excreted in the feces. Most of the urobilinogen that is
absorbed is returned to the liver to be re-excreted into the bile. A small amount of
urobilinogen, approximately 5% is absorbed into the general circulation and then
excreted by the kidneys.

Usually, only a small amount of bilirubin is found in the blood; the normal
level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory measurements of
bilirubin usually measure the free and the conjugated bilirubin as well as the total
bilirubin. These are reported as the direct (conjugated) bilirubin and the indirect
(unconjugated or free) bilirubin.
IV. The Patient’s Illness

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

Medications and Oral Hypolipidemic agents (clofibrate, gemfibrozil) that

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

Total Parenteral TPN is a powerful risk factor for gallstone formation.

Nutrition Gallstones from during TPN because of decreased
gallbladder motility from lack of meal-stimulated
cholesystokinin (CKK) release, resulting in
increased fasting and residual volumes.
Spinal Cord Injury Patients with spinal cord injury have 10% incidence
of forming gallstones within the first year after injury.
 This high risk, which is 20 times normal, is believed
to be secondary to abnormal gallbladder motility
and probably biliary hypersecretion of cholesterol
from the progressive reduction in body mass.

Primary Biliary Patients with primary biliary cirrhosis have an

Cirrhosis increased prevalence of gallstones. Stone analysis
has not been performed, but the elevated
cholesterol saturation of bile in these patients
suggest that they form cholesterol stones.

Diabetes Mellitus Despite obesity and increased total body cholesterol

synthesis and decreased gallbladder motility seen in
patients with diabetes, diabetes mellitus itself does
not appear to be an independent risk factor for
cholesterol gallstone disease.

Hemolytic Syndromes Inherited hemolytic anemia, sickle cell disease,

sphericytosis, thalassemia, chronic hemolysis
associated with artificial heart vavles, and malaria
dramatically increase the risk of pigment stone
formation because of increased biliary secretion of
total bilirubin conjugates, especially bilirubin
monoglucoronide, at the expense of the bilirubin
diglucuronide, the predominant conjugate in healthy
individuals.

Ileal Disease, Patients with ileal dysfunction have a strikingly

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

Biliary Infection Brown pigment stones are frequently found in the

intrahepatic bile ducts and are always associated
with infection by colonic organisms usually E.coli, or
parasitic infestation (Ascaris lumbricoides, or other
helminthes). Intraductal stones developing after
cholecystectomy are invariable associated with bile
stasis, biliary tree infection, and/or retained suture
material.

Obesity Obesity is strongly associated with increased

gallstone prevalence. The risk is proportional to the
increase in total body fat. Obese people synthesize
more cholesterol in both hepatic and nonhepatic
tissues, transport it to the liver, and secrete more of
it into the bile, leading to bile that is often greatly
supersaturated with cholesterol.

Rapid Weight Loss/ Obese patients undergoing rapid weight loss (1-2%
Fasting diets of body weight or approximately 1-2 kg/week),
either by very low caloric dieting or gastric stapling,
have a 25-40% chance of developing gallstones
within 4 months. During rapid weight loss, biliary
cholesterol saturation increases acutely as
cholesterol is mobilized from adipose tissue and
skin and secreted into bile.
Predisposing Factors:
Factors Rationale
Gender Women have twice the risk as men of developing
cholesterol gallstones because estrogen
increases biliary cholesterol secretion. Before
puberty this risk is negligible, and beyond
menopause the increased risk disappears.

Advancing Age The incidence increases with age. Less than 5-6%
of the population under age 40 have stones, in
contrast to 25-30% of those over 80.

Race Prevalence highest in North American Indians,

Chilean Indians, and Chilean Hispanics, greater in
Northern Europe and North America than in Asia,
lowest in Japan; familial disposition; hereditary
aspects

Heredity Family history alone imparts increased risk, as do

a variety of inborn errors of metabolism that lead
to impaired bile salt synthesis and secretion or
generate increased serum and biliary levels of
cholesterol, such as defects in lipoprotein
receptors (hyperlipidemia syndromes), which
engender marked increases in cholesterol
biosynthesis.

Parity/ Pregnancy Pregnancy is an independent risk factor for

cholesterol gallstones. The risk increases with
increasing parity, especially with more than two
children. During pregnancy, elevated estrogen
and progesterone levels increase biliary
 cholesterol secretion. Elevated progesterone also
inhibits gallbladder contractility. 40% of women
develop biliary sludge in their gallbladder and 12%
of women form their first stones during pregnancy.

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

Tenderness Palpation of the abdomen frequently elicits

localized tenderness in the right upper
quadrant which is associated with guarding
and rebound tenderness.

Murphy’s Sign The patient with acute inflammation of the

gallbladder might have a positive Murphy’s
sign, which is inspiratory arrest during deep
palpation in the right upper quadrant.
Nausea and Vomiting These signs and symptoms may accompany a
gallbladder attack. Pain is usually
accompanied by nausea and vomiting.

Fever and chills Gallstones sometimes get trapped in the neck

of the gallbladder and can cause persistent
pain that lasts more than several hours and is
accompanied by fever, also due to the irritation
and inflammation of the gallbladder wall.
Fever occurs in about one third of people with
acute cholecystitis. The fever tends to rise
gradually to above 100.4° F (38° C) and may
be accompanied by chills

Loss of appetite and The pain often begins suddenly following a

Anorexia large or rich meal. People tend not to eat,
especially fatty or oily foods, in order not to
experience that pain. Fat absorption is also
impaired for the lack of bile salts, As a result,
rapid loss of weight and anorexia can occur.

Pathophysiology

Risk factor

• Heredity
• Obesity
• Rapid Weight Loss, through diet or surgery
• Age Over 60
• Female Gender
• Diet-Very low calorie diets, prolonged fasting,
and low-fiber/high-cholesterol/high-starch diets.
 The solute precipitate Crystals must
Bile must become
from solution as solid come together
supersaturated with
and fuse to form
cholesterol and calcium crystals
stones

Gallstone
s

Obstruction of the cystic duct and common bile duct

Sharp pain in
Jaundice
the right part of
abdomen

Distention of the gall Cause of fever

bladder

Localized Areas of
Venous and ischemia
Proliferation cellular irritation
lymphatic drainage may
of bacteria or infiltration or
is impaired occur
both take place

Inflammation of gall bladder

Cholecystitis
The operation of making an
opening in the gall bladder, as Cholecystotomy
for the removal of a gallstone.

Surgical
Incision
Disruption of skin, tissue
Destruction of
and muscle integrity skin layers

Destruction of Broken skin and

Skin Layers traumatized tissue
Stimulation of sensory
nerve endings
Impaired Skin
integrity
Broken Skin and
traumatized tissue
Pain

Increased risk for

environmental exposure
to pathogens

Risk for
Infection
V. The Patient’s Care

IVF:
INTRAVENOUS DATE ORDERED/ GENERAL INDICATION CLIENT’S RESPONSE TO
FLUID DISCONTINUED DESCRIPTION TREATMENT
D5W x KVO via Date ordered: D5W is an isotonic It is used in repairing The patient tolerated the
microset 12-05-10 solution which neither electrolyte and IVF well.
causes cells to swell nor acid/base
shrink. However, the imbalances, and also
Date discontinued: dextrose component is includes total and
12-06-10 easily metabolized by the partial, parenteral
body making the solution nutrition solutions.
hypotonic later on
causing cells to swell.

Nursing Responsibilities:
 Before starting IV therapy, consider duration of therapy, type of infusion, condition of veins and medical condition
of the patient to assist in choosing IV site.
 Explain the procedure and its purpose to the patient.
 After initiation of IV therapy, monitor patient frequently for signs of infiltration, phlebitis, sins of fluid overload or
dehydration.
 OXYGEN DATE ORDERED/ GENERAL INDICATION CLIENT’S
THERAPY DISCONTINUED DESCRIPTION RESPONSE TO
TREATMENT
O2 inhalation at Date ordered: Oxygen is an odorless, To treat the harmful Relief in discomfort
2-3LPM via 12-05-10 tasteless, colorless, transparent and possible lethal brought by difficulty
nasal cannula gas that is slightly heavier than effects of hypoxemia, of breathing.
air. It can be dispensed from a and to decrease
Date discontinued: cylinder, piped-in system, liquid myocardial workload.
12-05-10 O2 reservoir or O2 concentration.
It is generally prescribed when
the amount of O2 in the blood
and tissues are not sufficient to
meet the body’s need.
The most common intervention
to improve gas exchange
between the alveoli and the
blood by increasing the
concentration of oxygen in the
inspired air and to assist the
patient to meet cellular oxygen
demand.

Nursing Responsibilities:
 Inform the patient that the oxygen therapy may be done to reduce risk of complications.
 Be sure that you are giving the right amount and regulation to the right patient.
 Instruct the client and the visitors about the hazard of smoking with oxygen use.
 Make sure that the electrical devices are in good working condition to prevent the occurrence of short-circuit
sparks.
Drugs:
GENERIC/ DATE ORDERED/ DOSAGE, ROUTE GENERAL MECHANISM OF INDICATION/ CLIENT’S
BRAND NAME DISCONTINUED AND ACTION ACTION PURPOSE RESPONSE
FREQUENCY
Meperidine HCl / Dates given: 25 mg IV PRN for Opioid agonist Acts as agonist at Relief of moderate The patient was
Demerol 12-05-10 pain analgesic specific opioid to severe acute relieved of pain.
12-06-10 receptors in the pain.
CNS to produce
analgesia,
euphoria,
sedation; the
receptors
mediating these
effects are thought
to be the same as
those mediating
the effects of
endogenous
opioids.

Ampicillin + Dates given: 750mg + 50cc Antibiotic, Bactericidal action Treatment of Signs of
Sulbactam 12-05-10 D5W to run in Penicillin against sensitive infections cause infection such as
12-06-10 soluset BID organisms; inhibits by susceptible fever were
synthesis of strains of Shigella, prevented.
bacterial cell wall, Salmonella, E.
causing cell death. coli, H. influenzae,
P. mirabilis, N.
gonorrhoeae,
enterococci,
gram-positive
organisms
Nursing Responsibilities:
 Prepare the medication with correct dosage.
 Administer the medication on the right route.
 Clean the IV line where the drug is being administered.
 Observe the patient for any reaction to the drug.
 Advise patient to report fever, diarrhea and allergy.
 To enhance absorption, give drug with meals.
 Protect drug from light.
 Monitor electrolyte levels, fluid intake and output, weight and blood pressure.
 Inform the patient that eggs and milk, coffee and tea consumed with a meal or 1 hour after may significantly inhibit
absorption.
 Do not crush or chew sustained release products.
 Inform that it may cause change in stool color, abdominal cramps, diarrhea, or constipation.
 Inform patient that citrus fruits enhance iron absorption.
Diet:

DIET *DATE ORDERED/ GENERAL SPECIFIC FOODS

INDICATIONS CLIENT’S RESPONSE
REGIMEN **DISCONTINUED DESCRIPTION TAKEN
*12-05-10 The patient is NPO status is Patient followed the diet.
NPO **12-06-10 not allowed to prescribed because
eat or drink the patient’s chief
anything, complaint was
including oral vomiting. NPO status
meds. would prevent
complications with
regards to the
patient’s GI.

Activity and Exercise:

EXERCISE REGIMEN *DATE ORDERED/ GENERAL INDICATIONS CLIENT’S

**DISCONTINUED DESCRIPTION RESPONSE
Complete Bed Rest with *12-05-10 CBR with BRP is This is to reduce the Patient was
Bathroom Privileges **12-06-10 wherein the patient is metabolic demand of the cooperative with the
instructed to stay in bed body, especially the activity.
without any kind of organs when a patient is
strenuous activity except experiencing a disease
for going to the condition that requires
bathroom. rest.
A. Nursing Management
a) NCP (Nursing Care Plan)
a. Acute Pain
b. Risk for Hyperthermia
c. Risk for Impaired skin integrity r/t mechanical process (surgery)
d. Self-care deficit related to pain or discomfort
e. Risk for Infection r/t inadequate primary defenses
 1. Acute Pain
NURSING SCIENTIFIC NURSING EXPECTED
ASSESSMENT PLANNING RATIONALE
DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
S> Patient may Acute pain Fracture itself Short-term: >Monitor and >To obtain Short-term:
report: causes pain, but After 4 hrs. record vital signs baseline data the patient’s
-pain in the in addition to this, of NI, the >Assess pt’s >To determine pain scale
surgical surgical patient’s condition, perform extent of shall have
incision site intervention also pain scale a comprehensive condition, have a decreased
- pain is felt leads to will assessment of basis for future
post stimulation of decrease pain to include comparison, and
operatively pain receptors. location, determine
- dyspnea Pain is one of the characteristics, appropriate
O>Patient may common Long-term: onset/duration, nursing
manifest: symptoms of post After 2 days frequency, quality interventions to be Long-term:
-pain scale operative of NI, the or severity and carried out to The patient
greater than patients. Noxious patient will precipitating or alleviate the pain shall have
5/10 stimuli (bleeding) demonstrate aggravating demonstrated
-altered v/s causes release of techniques factors techniques on
-restlessness biochemical on how to >position in how to
-fatigue mediators manage the comfortable manage the
-elevated PR (prostaglandin, pain, if pain position >to provide non- pain, if pain
-guarding bradykinin, occurs such >Perform pain pharmacological occurs such
behavior serotomin, as assessment each pain as relaxation
-facial mask histamine, relaxation time pain occurs. management. techniques
-sleep substance P) techniques >Encourage pt. to >to know if the (deep
disturbance which then lead (deep take a nap. pain is breathing
-autonomic to sensitization of breathing >plan care with progressing or exercises).
alteration in nociceptors exercises). rest periods not.
muscle tone (receptors >encourage >to divert feeling
responsible for verbalization of of pain
pain). pain > To
Transmission of >Encourage use lessen/prevent
this pain of relaxation fatigue
impulses will techniques like >to assess pain
occur in the deep breathing and involve
peripheral nerve >Instruct pt. to patient in plan of
fibers to spinal increase intake of care
cord through the foods, rich in vit. >To provide
spinothalamic C, CHON and nonpharmacologic
tract to brainstem iron management
and thalamus >Instruct the
then to somatic patient to >To provide
sensory cortex increase oral fluid adequate nutrition
where pain intake as ordered
perception >administer
 occurs. The client analgesics as
becomes ordered >To prevent
conscious to pain dehydration
when it reaches
the cortical
structure. Then >to decrease
for the client to painful sensation
elicit a reaction it
will travel down
from neurons of
brainstem to the
spinal cord which
releases
biochemical
mediators
(opioids,
serotonin, and
norepinephrine).

2. Risk for Hyperthermia

Assessme Nursing Scientific Objectives Nursing Rationale Evaluation
nt Diagnosis Explanation Intervention
S>Ø Risk for It is caused by the Short term: >Establish rapport >To gain Short term:
O>The Hyperthermia fever producing After 4 hours of patient’s trust Patient’s
patient substance known as Nursing >Assess patient’s >To monitor body
may “pyrogens.” These Interventions, condition physiologic temperature
manifest: pyrogens are the patient’s condition shall have
secreted by toxic temperature >Monitor vital signs >To have a decreased
• increased bacteria or released will decrease baseline data from 38 to
body by degenerating from 38 to the > Perform TSB >To facilitate 37.5
temp. tissue of the body. It normal range loss of heat
above is believed that this (36.5 C- 37.5 through the
normal substance stimulate C) process of
range the release of the conduction and
(38) second substance >Loosen the evaporation
• flushed known as leukocyte constrictive clothing > To improve Long term:
skin which have been Long term: ventilation Patient shall

• increased drawn. This Patient will >Place cold have

RR leukocyre pyrogens maintain a compress in the >Heat is lost maintained

(tachypn goes to the normal forehead. through a normal

ea) bloodstream and temperature >Keep patient’s conduction temperature

• seizures stimulates the heat back dry >To prevent .

regulating center, the further
thermostat which is >Provide adequate complication
the hypothalamus ventilation >To promote
and set it to a febrile heat loss by
state, Febrile level of means of
the hypothalamus in >Encourage convection
which there will be an adequate fluid
increase in intake >To prevent
epinephrine >Encourage dehydration
vasoconstriction. adequate rest. >To reduce
oxygen demand
>Provide and
comfortable consumption.
beddings/ linens >To promote
comfort and
prevent skin
> Administer drugs irritations
such as anti- >To aid in re-
pyretics as ordered setting core
>Provide temperature.
supplementary >To offset
oxygen as needed increased
and ordered oxygen demands
 and consumption

3. Risk for Impaired skin integrity r/t mechanical process (surgery)

SCIENTIFIC
ASSESSMEN NURSING NURSING EXPECTED
EXPLANATIO PLANNING RATIONALE
T DIAGNOSIS INTERVENTIONS OUTCOME
N
S> Patient Impaired skin Because of the Short term: > Assess pt’s > to gather Short term:
may report: integrity r/t surgery, the After 4hrs, of condition. Monitor baseline data The patient
-itching mechanical patient is NI, the and record VS shall have
-numbness of process expected to patient will >Assess for dry > Uremic skin participated in
surrounding (surgery). have an be able to scaling skin does not have the preventive
area incision site. participate in usual amount of oil measures to
Thus impairing preventive because of improved skin
O>pt may the integrity of measures to >Assess for pruritus decreased sweat integrity
manifest: the skin, improve skin and oil glands
-edema or making it more integrity >Pruritus can be
inflammation prone to caused by dry skin Long term:
of the invasion of Long term: >Note changes in or accumulation of A The patient
surrounding microorganism After 2 days skin color, texture nitrogenous waste shall have
area s. of NI, the and turgor. in the blood displayed
-poor skin patient will >restrictive timely healing
turgor display clothing can of skin
-dry, scaly timely >Periodically increase risk of lesions/woun
skin healing of measure affected skin breakdown ds without
-erythema skin lesions/ area. >To determine complications
-disruption of wounds severity of the
skin surface without >Keep area clean, condition.
(epidermis) complication dry and stimulate >To monitor
-destruction s circulation. progress of
of skin layers healing.
(dermis) >To decrease
-invasion of >Use appropriate potential skin
body padding devices. breakdown.
structures >To reduce
>Encourage early pressure and
ambulation or enhance
mobilization. circulation to
compromised
>Instruct the patient area.
to wear loose fitting >To promote
clothing when circulation and
edema is present reduce risk
>Stress the associated with
importance of not immobility.
 scratching skin and >Scratching can
keeping fingernails cause lesions and
short open sores
>Instruct patient to
perform proper hand > To prevent
washing transmission of
>Suggest use of micro organism
TSB for bathing >Increased
warmth can
increase the
itching

4. Self-care deficit related to pain or discomfort

Assessmen Diagnosis Scientific Objectives Interventions Rationale Desired
t Explanation Outcomes
S=Ø Self care Due to the SHORT > establish > to gain the trust SHORT
deficit different factors TERM: rapport and compliance of TERM:
O = Patient related to namely pain, After 5 hours the client The patient
may pain or discomfort and of nursing >to establish will have
manifest: discomfort musculoskeletal interventions, > monitor vital baseline data been able
> inability to impairment that the patient will signs >to help in the to identify
prepare the surgical be able to >identify degree determination of individual
food for procedures can identify of individual the measures to be areas of
ingestion produce, the individual impairment implemented weakness
>inability to ability of the areas of >to capitalize on
wash body patient to move weakness. >assess skills and this strenght when LONG
or body and perform strengths of the formulating plan of TERM:
parts activities will be LONG TERM: client care The patient
>impaired impaired. Such After a week > enhances will have
ability to impairment to of nursing >Promote commitment to been able
obtain or mobility and interventions, client/SO plan optimizing to
replace activities may the patient will participation in outcomes demonstrat
articles of prevent the client be able to problem e
clothing from performing demonstrate identification and technique/li
>inability to his self care technique/lifes decision making >to enhance festyle
carry out activities hence tyle changes >assist with capabilities changes to
proper toilet deficit on self to meet self- rehabilitation meet self-
function and care can occur. care needs. program >to decrease the care
hygiene >provide privacy anxiety of the needs.
during personal patient
care activities
>assist with >to encourage
necessary client and build on
adaptations to success
 accomplish
ADL’s; begin with
easily
accomplished
tasks >to prevent fatigue
>identify energy
saving behaviors >to prevent injuries
>review safety
concerns and
modify activities
or environment

5. Risk for Infection r/t inadequate primary defenses

ASSESSMEN NURSING SCIENTIFIC PLANNING NURSING RATIONALE EXPECTE
T DIAGNOSIS EXPLANATIO INTERVENTIONS D
 N OUTCOME
S>Ø Risk for The skin is the Short term: >Monitor vital >To have a baseline Short
infection largest organ After 4 hours signs. data term:
O>The related to in the body, it of nursing >To determine which After 4
patient may inadequate is our physical intervention >Assess patient for areas will be given hours of
manifest: primary barrier against the patient causative factors. more attention to in nursing
>increase in defenses friction and will verbalize preventing interventio
body shearing understandin aggravation of the n the
temperature forces and g of condition. patient
>fatigue protection individual >Wash hands >Effective hand shall
>weakness of against causative/risk thoroughly with washing removes verbalize
muscles infection, factors warm water, soap, pathogenic understand
>restlessness chemicals, and friction before organisms from the ing of
>erythema ultraviolet and after providing hands thus individual
and irradiation, client care. Teach preventing the causative/ri
inflammation particles. Due client to wash her transmission of micro sk factors
of incision site to the surgical Long term: hands before and organisms.
incision, After 3 days after using the Long
pathogens or of nursing bathroom,etc. term:
microorganism intervention >Monitor lab values After 3
s that the patient as obtained. Notify >Allows early days of
contaminates will caregiver of any identification of nursing
in the skin can demonstrate abnormal values. infectious and allows interventio
freely enter the techniques. >Instruct patient to prompt treatment. n the
body cavity Lifestyle maintain dry and >Decreases dark patient
and can cause changes to clean environment. moist environment, shall
harmful effects promote safe which enhances demonstrat
of infection. environment >Teach client of growth of micro- e
infection to report: organisms. techniques.
fever, abdominal >Provides Lifestyle
tenderness, foul information the client changes to
vaginal discharge. needs to identify promote
>Administer infections early. safe
medications as environme
ordered. nt
>To prevent
infection.
 b) Actual SOAPIERs

FIRST STUDENT-NURSE INTERACTION, 2nd Hospital day (December 6,

2010)

S>O

O > Received patient on bed on supine position, conscious and coherent, with an
ongoing IVF of D5W x KVO via microset @ 100 cc level regulated infusing well
on the left hand, with good skin turgor; with an initial VS of the following: T=
36.8°C (axilla); PR= 82 bpm; RR=27 bpm; BP= 100/70 mmHg

A >Acute Pain

P > After 2 hours of nursing interventions, the patient will decrease pain
sensation from 7/10 to 5/10

I > established rapport.

> Assessed general condition/appearance.
> Ascertained knowledge of safety needs and injury prevention.
> Assessed pain sensory
> Monitored and recorded vital signs
> PM care rendered
> Provided regular skin and oral care
> Repositioned client every 2 hours
>Provided safety and comfort measures
> Instructed patient to request assistance as needed.
> identified energy-conserving techniques.
 E > Goal Met; the patient decreased pain sensation

SECOND STUDENT-NURSE INTERACTION, 3rd Hospital day (December

7, 2010)

S>O

O > Received patient on bed on supine position, conscious and coherent, with no
IV fluid attached, with good skin turgor; with an initial VS of the following: T=
37.1°C (axilla); PR= 86 bpm; RR=20 bpm; BP= 110/80 mmHg

A > Acute Pain

P > After 2 hours of nursing intervention, the patient’s pain scale will decrease
from 10/10 to 7/10.

I > Established rapport.

> Assessed general condition/appearance.
> Assessed for referred pain
> Encouraged use of relaxation techniques
> Encouraged diversional activities
> repositioned every 2 hours
> Encouraged adequate rest periods
> encouraged early ambulation
> Maintained adequate hydration

E > Goal Met AEB patient’s pain scale of 7/10.

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1. Client’s daily progress chart (From admission to discharge)

DAYS Admission 2 3
(Specific date) (12/05/10) (12/06/10) (12/07/10)

Nursing problems
a. Acute Pain * * *

b. Risk for Hyperthermia

c. Risk for Impaired skin integrity r/t mechanical
process (surgery) *

d. Self-care deficit related to pain or discomfort

* *

e. Risk for Infection r/t inadequate primary defenses

Vital Signs
1. Temperature No records found T= 36.8°C (axilla) T= 37.1°C (axilla);
; PR= 82 bpm;
2. Pulse Rate PR= 86 bpm;
RR=27 bpm;
3. Respiratory rate RR=20 bpm;
BP= 100/70
4. Blood pressure mmHg BP= 110/80
mmHg
DIAGNOSTICS/ LAB procedures
1. CBC *
2. Urinalysis *

Medical Mgmt.
1 D5W x KVO via microset * *
2. O2 inhalation *

Drugs
1. Meperidine HCl / Demerol * *
2. Ampicillin + Sulbactam * *

Diet
 * *
1. NPO
Activity/ exercise
1. CBR with BRP * *
VII. CONCLUSION

After doing such case, the group have conclude and learned that
Cholecystitis, which has long been considered an adult disease, is quickly
gaining recognition in medical practice because of the significant documented
increase in nonhemolytic cases over the last 20 years. Gallbladder disease is
common throughout the adult population. Most information related to morbidity
and mortality in gallstone disease is related to the adult population, although
some trends can be extracted and applied to the pediatric population.

The physical examination in acute cholecystitis usually reveals right upper

quadrant tenderness. The classic triad is right upper quadrant pain, fever, and
leukocytosis. The patient may have abdominal guarding and a positive Murphy
sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right
upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder
combined with distension may create a palpable mass between the 9th and 10th
costal cartilages.

Surgery is one of the most medical/surgical interventions needed to be

done so as to remove the inflammation. Preventing of it such as low salt low
fat diet or balanced diet is the top priority to prevent the occurrence of the
disease process.