NURSING CASE STUDY

FINAL DIAGNOSIS:
Chronic Calculous Cholecystitis

I. HEALTH HISTORY
A. DEMOGRAPHIC
1. Client’s Name: R.D.S
2. Gender: Male
3. Age, Birth date and Birthplace: 30 y/o | 10-20-1991 | MASBATE
4. Marital (Civil) Status: MARRIED
5. Race and Nationality: FILIPINO
6. Religion: ROMAN CATHOLIC
7. Address, Telephone Number, E-mail Address: 371 PARROT ST. PALO ALTO
HABAY I, BACOOR, CAVITE | 09675917180
8. Educational Background/Other Significant Framing: COLLEGE GRADUATE
9. Occupation: SERVICE TECHNICIAN
10. Usual Source of Medical Care: COMPANY’S PRIVATE DOCTOR

B. SOURCE AND RELIABILITY OF INFORMATION

The patient himself who was competent to provide information and the
patient’s wife. He was able to speak clearly and was conscious, coherent and
conversant. The patient’s chart was also used as a secondary source of
information
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS
“Sumasakit talaga ‘yung tiyan ko tsaka nagsusuka”
“Nung na-ultrasound ako do’n nalaman na may gallstones ako”
“Nagpa-second opinion ako dito tapos ang nakita nila parang polyps”

D. HISTORY OF PRESENT ILLNESS/OR PRESENT HEALTH

5 months PTA, the patient had a diffuse abdominal pain with a scale of
7 out of 10 with occasional post-prandial vomiting of food contents amounting to
½ cup and feeling of bloatedness. The patient sought consult at their company
doctor and prescribed with Pantoprazole & Gaviscon which offered relief.

Interim – Asymptomatic

1-month PTA, the had an abdominal pain again with a scale of 8-9 out of
10 that lasted for 3 days. He sought consult at Medical Center Imus and had
ultrasound done which revealed gallstones but without indicated size, but was
advised to have surgery.

3 weeks PTA, the patient sought consult with an AP at DLSUMC for 2nd
opinion and had ultrasound done which revealed gallbladder polyps, and was
advised and scheduled for surgical intervention.

Interim- tested positive for COVID in RTPCR, hence procedure was deferred.

1-week PTA, the patient sought consult and had procedure rescheduled.

DOA, patient came in for scheduled Laparoscopic Cholecystectomy procedure

(09/27/2022).

E. PAST MEDICAL HISTORY OR PAST HEALTH

That patient has a complete immunization. He denies any significant
childhood illnesses and but had a minor motorcycle injury before. He also has no
previous record of hospitalization or any surgical operation due to illness. When
 asked about his allergies, the patient has no known drug, food, environmental,
and seasonal allergies. He was taking Vitamin C and Gaviscon as prescribed by
his doctor but eventually stopped after he was diagnosed with gallstones.

F. FAMILY HISTORY

MATERNAL PATERNAL

UA UA
UA UA
A&W UCD
A&W UCD

UA UA 40
A&W A&W POISONED

UA UA UA
30 UA
A&W A&W A&W
A&W A&W

Legend:
UA – Unrecalled Age
UCD – Unrecalled
cause of Death
A & W – Alive and
Well
- Male

- Deceased

- Female

- Deceased

G. SOCIO-ECONOMIC
OCCUPATION/SOURCE MONTHLY
FAMILY MEMBER
OF INCOME INCOME
R.D.S Service Technician Php 40,000
(Patient)
A.S. Teacher Php 20,000
(Wife)

Both the patient and his Wife provide for their needs because both of
them have work. Their major expenses are food, electricity, water, and house
payment; spare money will put on savings for the future since the wife is 3 months
pregnant and preparing for their first child.

H. DEVELOPMENTAL HISTORY
 Age: 30 years old
Developmental Stage: Young Adulthood
Developmental Task: Intimacy vs. Isolation

Relationships are important to person included in the young adults age

group. It is the time where they want to start a family, have lasting friends and a
strong family relationship. Young adults need to form intimate, loving
relationships with other people to make them feel successful and on track.
Success leads to strong relationships, while failure results in loneliness and
isolation.

As for the patient’s case, the patient has a healthy and happy relationship
with his wife. When asked about how he manage and cope up with negative
feelings, he said that he always talk with his wife and spend some time together.
He also said that his wife is his rest. Now, the patient and his wife are about to
have their first child and they are happy and contented with their life.

I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

1. ROS AND PE
Date of Examination: 9/27/22
Systems ROS PE
A. General/Overall Health “Okay naman na ako, wala na Vital Signs:
Status nararamdaman masyado bukod BP: 120/80
dun sa opera ko” PULSE: 83
RR: 20
TEMP: 37.1 °C
• Feels and looks relaxed;
cooperative and purposeful
• Speech is in moderate tone
• Client appears to be her
stated chronological age
• With ongoing D5LR 1L to
run for 8° inserted at left
metacarpal vein, infusing
well
B. Integument “Meron akong syringoma napa- SKIN
laser ko ‘to kaso ‘di ko na Inspection:
natapos ‘yung session...”
• Skin is tan in complexion
“Madali naman gumaling mga • (-) rashes on all skin area
sugat ko..” • (-) flushing
“Do’n kasi sa work ko ‘di • (-) edema
maiiwasan masugatan • (+) lesions/scars in both
paminsan-minsan..” arms and hands
• (+) syringoma
Palpation:
• Skin is warm to touch
• Good skin turgor
• Hair is smooth and silky to
touch
• Good capillary refill
HAIR
Inspection:
 • Shiny and evenly
distributed hair along the
scalp
• Good hair distribution
Palpation
• Smooth and silky to touch
NAILS
Inspection:
• Fingernails and toe nails
are clean and trimmed
• Pinkish nails
Palpation:
• Nails form 160° angle at
base, hard, smooth and
immobile
• (+) smooth cuticles
• With good capillary refill of
2 seconds
C. Head “Wala naman po…” Inspection:
• Head is round and
symmetrical
• (-) lacerations
• Face is oval and symmetric
• Normocephalic
Palpation:
• Smooth and hard skull
• Good ROM of TMJ
• (-) Lumps, masses
• (-) head depressions or
elevations
D. Eyes “Hindi naman po malabo mata Inspection:
ko…”
• Visual fields intact
• No discharges
• Symmetrical blinking
• (+) PERRLA
Palpation
• No drainage noted when
nasolacrimal duct is
palpated
E. Ears “Wala naman po…” Inspection:
• Equal in size bilaterally
• No discharges
Palpation:
• Firm cartilages
• (-) Tenderness
F. Nose and Sinuses “Wala naman po…” Inspection:
• (-) nasal discharge
• Nose is smooth and
symmetric
• (-) Nasal flaring
Palpation:
• (-) nasal tenderness
G. Mouth and Throat “Wala naman…” Inspection:
• (-) lesions, swelling
• Tongue is pink and moist
• Gums are pinkish
• (-) tonsillitis

H. Neck “’Yung dito sa may bandang Inspection

likod parang may something
s’ya na tumutusok, baka siguro • (-) lesions
sa paghiga… wala naman pong • (-) swelling of lymph nodes
bukol..” • Full ROM
Palpation
• Palpable thyroid gland
when swallowing
• (-) swelling, tenderness
I. Breast and Axillary “Wala naman po…” Inspection
• Hyperpigmented areola
• Nipples everted bilaterally
• (+) hair
Palpation
• No masses/tenderness
palpated
• (-) pain

J. Respiratory “Hindi naman po normal Inspection

naman…”
• Chest expansion symmetric
• Sternum in midline
Palpation
• (-) tenderness
• (-) masses
Percussion
• Resonant
Auscultation
• No adventitious sounds
present
• Lung sound clear on both
lung fields
K. Cardiovascular “Parang wala naman…” Inspection
• (-) Jugular vein distention
and non-visible
 • (-) Varicose veins on both
legs
Palpation
• Carotid pulse equal
bilaterally
• Good capillary refill, <2
seconds
Auscultation
• Heart sound are rhythmic,
regular beating
• (-) extra heart sound
L. Urinary “Wala naman, pero ngayon ‘di Inspection
pa ako ulit nakaka-ihi”
• (-) hematuria
• (-) dysuria
• (-) polyuria
M. Genitalia “Wala namang problema…” • Patient refused

N. Musculoskeletal “Wala naman pero before kasi Inspection

nagkasakit ako kasi ‘di ako
makalakad kasi nawawalan ng • Full ROM of extremities
lakas ‘yung tuhod ko…sabi ng • Full ROM of TMJ with no
doctor kulang daw ako sa pain, tenderness, clicking
sodium… Uminom lang ako ng • (-) clubfoot
Vitamin B Complex tapos puro • No edema present
saging..”
O. Neurologic “Hindi naman po…” Inspection
• (+) Good eye contact
• Pt is relaxed, cooperative
and purposeful; oriented to
time, place and person

P. Hematologic “Hindi naman po…” Inspection

• No presence of hematomas

Q. Endocrine “Wala naman normal lang Inspection

po….”
• (-) diaphoresis
• (-) tremors
 2. LABORATORY STUDIES/DIAGNOSTICS
Nursing
Normal Responsibilities/
Procedure/Date Indication Actual Findings
Values/Findings Implications

8/5/22 1. The liver is -CHOLELITHIASES PRE:

within normal in AND
Whole Indicated to • Verify Patient
size with GALLBLADDER
Abdomen evaluate the • Explain
homogenous POLYPS AND/OR
Ultrasound cause of procedure to
parenchymal CHOLESTEROLSIS
stomach pain or the patient
echopattern.
bloating. It can - UNREMARKABLE • NPO 8 hours
The intrahepatic
help check for ULTRASOUND OF before the
ducts are not
kidney stones, THE LIVER, procedure
dilated. No focal
liver disease, SPLEEN, KIDNEYS,
mass seen. INTRA:
tumors and AORTA, URINARY
2. The gallbladder
many other BLADDER AND • Position the
is within normal
conditions. PROSTATE GLAND client
in size with
multiple • Explain
subcentimeter findings to
hyperreflectivee patient
choes and non-
POST:
shadowing
echogenic foci • Instruct client
seen attached to resume
to its luminal usual diet
wall. Its wall is • Submit
not thickened. results to the
The common doctor
bile duct is not
dilated.
3. The pancreas is
not visualized
due to overlying
bowel gases.
4. The spleen is
within normal in
size with
homogenous
echopattem. No
focal mass
seen.
5. Both kidneys
are wilhin
normal in size
wilh
homogenous
parenchymal
echogenicities.
The cortico-
medullary
demarcations
 are distinct.
Both central
echo complexes
are intact. No
evidence of
lithiasis seen.
6. The aorta is
normal in
course and
caliber. No
evidence of
enlarged
paraaortic
lymph nodes
seen.
7. The urinary
bladder is
adequately filled
with no
intraluminal
echo seen. Its
wall is not
thickened.
8. The prostate
gland is within
normal in size
with
homogenous
echopattern.
9/8/22 PRE:
Investigation of
HBT & The liver is not - GALLBLADDER • Ensure
the gallbladder
Pancreas enlarged with POLYPS Consent form
and for
Ultrasound homogenous • Verify Patient
indicating -UNREMARKABLE
parenchymal • Explain
diagnoses and ULTRASOUND
echogenicity. procedure to
defining levels STUDY OF THE
Intrahepatic ducts the patient and
of extrahepatic LIVER AND
are not dilated. No its importance
biliary PANCREAS
focal masses seen. • Instruct NPO
obstruction and
screening for The gallbladder to patient for
liver metastases measures 6.2 x 1.6 12 hrs before
cm, with multiple ultrasound
non-shadowing • Remove any
medium level metals or
echoes seen jewelries
attached to its non- INTRA
thickened wall, the
largest of which • Assist client
measures 0.5 cm. in positioning
• Explain every
The common bile
procedure to
duct measures 0.3
the client to
cm.
reduce
The pancreas is anxiety
homogeneous and
POST
not enlarged. It
measures 1.2 cm
 (head), 0.9 cm • Instruct client
(body), and 0.7 cm to resume
(tail). regular diet
• Inform client
.
about the
findings

9/26/22 PRE:
COMPLETE Help diagnose Hemoglobin • Inform the
BLOOD the cause of 130 – 180 159 client about
COUNT these signs and the procedure
Hematocrit
symptoms • Advise client
0.40 – 0.50 0.46
to be relaxed
WBC as possible
4.0 – 10.0 8.4 during blood
extract
RBC
• Disinfect site
4.5 – 6.2
5.3IF of Injection
COUNT INTRA
• Assist client
Neutrophils throughout
a blood test to
DIFFERENTIAL 0.55 – 0.65 the
check your 0.63
COUNT procedure
white blood cell Lymphocyte
levels, which 0.25 – 0.35 • Monitor
0.28 client’s
can indicate the
Eosinophil condition
presence of
0.02 – 0.04 • Provide
infection, 0.03
disease, or an Monocyte comfort
allergic reaction 0.03 – 0.06 measures or
0.06 diversion
Basophil from pain
0.00 – 0.01
0.00 POST
RED CELL I • Apply
pressure
dressing to
RED MCVELL
the puncture
80 – 96
site
used to help
MCH 87.6 • Observe the
RED CELL diagnose the
27 – 31 vein
INDICES cause of
anemia, a punctured
 condition in MCHC 30.1 site for
which there are 320 – 360 bleeding
too few red • Inform the
RDW 344.0
blood cells client about
11 – 17
the findings
Platelet Count 12.3
150 – 400
252
a test to P PROT
evaluate blood I
PROTHROMBI PT Patient
clotting
N TIME 12 – 14.5 ME
PT Control 12.7
12 – 14.5
INR 13.6
0.8 – 1.3
% Activity 1.03
70 – 100
95
a blood test that
APTT
looks at how
PARTIAL 24 – 36
long it takes for
THROMBOPLA blood to clot. It APTT Control 33.8
STIN TIME can help tell if 24 – 36
you have a
APTT Ratio 39.8
bleeding
0 – 1.2
problem or if
your blood does 1.09
not clot
properly.

3. OTHER ASSESSMENT TOOLS

Date(s) Taken Comprehensive Actual Content/Legend Actual Result

9/26/22 Class I – Self Care Patient The patient was classified

as Class I as he can take
Patient Class II – Partial Care Patient
care of herself fully prior
Classification
Class III – Complete Care Patient to hospitalization.

Class IV – Critical Care Patient

9/26/22 History of Falling – 25 The patient was graded
with a score of 5 since he
Fall Risk Secondary Diagnosis – 15
is in bedrest which
Level
Medications – 15 indicates that he is in Low
level for Fall risk.
Ambulatory Aid – 30
Uses crutches/crane/walker – 15
IV / Saline Lock – 20
Gait / Transferring
Impaired – 20
 Weak – 10
Normal – 5
Mental Status - 15

FALL RISK LEVEL:

Low (0-24)
Moderate (25-50)
High (>51)
9/27/22 Able to move 4 extremities voluntary or on command The patient has a score
-2 of 9 out of 10 which
Aldrete Score
shows readiness for
Card Able to move 2 extremities voluntary or on command
discharge in PACU.
-1
Able to move 0 extremities voluntary or on command
-0
Able to deep breath and cough freely - 2
Dyspnea or limited breathing - 1
Apneic - 0
BP 20% of Preanesthetic level. - 2
BP 20% -50% of Preanesthetic level. - 1
BP 50% of Preanesthetic level. - 0
Fully Awake - 2
Arousable on calling - 1
Not Responding - 0
Pink - 2
Pale, Dusky Blotchy, Jaundiced, Others. - 1
Cyanotic - 0
9/27/22 CRITERIA: The patient was in level 2
with the following
Ramsay Patient anxious and agitated or restless or both
comments/endorsements:
Sedation
Patient cooperative, oriented, and tranquil
Scale - (-) PONV
Patient responds to commands only - (+) Post-op PS:
5/10
Brisk response to light glabellar tap or loud auditory - (-) DOB
stimulus - (-) headache
Sluggish response to light glabellar tap or loud
auditory stimulus
No response to light glabellar tap or loud auditory
stimulus
LEVEL:
1, 2, 3, 4, 5, 6

J. FUNCTIONAL ASSESSMENT
1. Health Perception/Health Management Pattern
 As of the moment, the patient feels fine and everything seems bearable. Last
week, the patient and his wife tested positive for COVID-19. Though asymptomatic,
the two isolated and took measures to remove the virus from their body. The patient
does not work out and take his work as his daily exercise. The doctors advised the
patient before to avoid eating fatty foods which the patient follows. The patient and
his wife thinks that eating too much “lechon” from his previous trip to cebu caused
the illness.

2. Self-esteem, Self-concept/Self-perception Pattern

The patient self-esteem depends on the context, but at his work, the patient is
confident with doing his tasks and being with his workmates. Being the youngest
among his colleagues, the patient is able to excel and keep up with them.

3. Activity/Exercise Pattern
The patient’s energy for work or other daily activities is sufficient. As mentioned,
the patient does not exercise but he plans to do basketball one he’s completely
healed. During his free time, the patient spends his time playing mobile legend.

4. Sleep/Rest Pattern
During his day-off, he sleeps for about 10 hours but when he has work, he only
sleeps for about 6-7 hours. When the patient wakes up, his mood is normal, not
irritated. He doesn’t drink any sleeping aids. His sleep pattern is 12-6 but it’s also
depends on his work schedule. No consistent sleep pattern. He also takes daytime
naps when possible.

5. Nutrition/Elimination
The patient takes B-complex. He also said that he has lost weight as he weighs
70 kg before but only weighs 67 kg now. He also has a normal appetite; he does
not eat in big amounts. No diet restrictions or intolerance. But ever since his illness
occurred, he cannot take soft drinks anymore and vomits it after intake. He also
had acid reflux. He was prescribed with Gaviscon. The patient defecates once a
day, and urinates for about 7 times a day.

6. Sexuality/Reproductive
No changes in the sexual relations in the patient given that his wife is pregnant.
The patient and his wife never took contraceptives as they really planned to build
a family together.

7. Interpersonal Relationships/Resources
The patient describes himself as a good and faithful husband to his wife. He gets
along with everyone in his work but has a little misunderstanding with some of his
relatives.

8. Coping and Stress management/Tolerance Pattern

The patient’s support system is his wife. Whenever he gets stressed or has a
problem, he always come to his wife even though he is not that open with his
problems. The patient’s stressors are mostly from work, financial, and their home
relocation. The patient also worries considering that his wife is pregnant, the money
they’re saving for their child as used for his operation instead. To cope up with
problems, the patient sometimes cries to release his emotions.

9. Personal Habits
The patient does not smoke and only drinks alcohol rarely. He also never tried
street drugs or any of its kind.

10. Environmental
The patient and his wife are currently living in an apartment where they described
as clean, safe, and quiet. They have never heard any incident near them as they
 are near the barangay hall. The patient has a motorcycle and uses it as his mode
of transportation while his wife only commutes. The patient’s workplace has a lot
of hazard as they handle huge machines every day.

II. PROBLEM LIST

A. ACTUAL or Active
Problem No. Problem Date Identified Date Resolved/Remarks

1 Chronic Calculous 9/6/22 9/27/22

Cholecystitis Surgery was done.
2 Impaired Comfort 9/6/22 9/27/22
Patient’s pain was addressed.
Pain killers were administered.

B. HIGH RISK or Potential

Problem No. Problem Date Identified

1 Risk for Infection 9/27/22

III. NURSING CARE PLAN

CUES DIAGNOSI LONG TERM SHORT INTERVENTION RATIONALE EVALUATION
S TERM
Subjective Altered At the end of After 8 hrs. of Ind: Goal Met:
• “Masakit lang comfort: hospitalization, pt SN-patient Assessed the To monitor Pt verbalizes
‘yung sa may Pain, will express pain interaction, patient’s vital effectiveness of a pain relief
bandang related to relief as manifested the patient will signs and medical as evidenced
tissue by: 1. verbalized be able to: characteristics of treatment for by improved
opera ko…“
1.verbalize
as verbalized trauma improved mood and pain at least 30 pain relief. baseline
relief of pain
by the patient secondary well-being minutes after data.
as evidenced
• Pain scale: to surgical 2. demonstrates administration of
by a pain
5/10 operation diversional and medication.
scale of 4/10
Objective: relaxation activities
• RR: 20 Elevated the head To increase the
• T: 37.1 of the bed and oxygen level by
• BP: 120/80 position the allowing optimal
patient in semi lung expansion
• Wt: 67 kg
Fowler’s
- Gallbladder Polyps
Dep:
- Unremarkable Administered To alleviate pain
ultrasound study prescribed pain on the surgical
of the liver and medications. site. Following
pancreas physician’s
order is a
Dx: Chronic responsibility of
Calculous a nurse
Cholecystitis

Edx:
To provide
optimal comfort
 Demonstrated the and prevent pt
use of appropriate from focusing
non- on her pain.
pharmacological
approaches to
control pain (e.g.,
relaxation
breathing
distraction
techniques such
as listening to
music or watching
television)
Impaired A month after After 8 hrs. of Ind: Goal Met:
Skin hospitalization, pt SN-patient Evaluated skin for The Client were
Integrity will achieve a timely interaction, itching. Check for appearance of able to
wound healing the patient will color changes in jaundice could demonstrate
without be able to the skin and suggest a ways to
demonstrate blockage in bile
complications. sclerae for promote
behaviors to flow secondary
promote jaundice, and wound
urine to bile stone healing.
healing/preve retention.
nt skin
breakdown

Dressings Clean the

changed as patient’s skin
using soap and
needed.
water. Keeps the
skin around the
incision clean
and acts as a
barrier against
excoriation.

Took note of the When bile isn’t

color and present in the
consistency of the intestines, it
stools causes clay-
colored feces.

Examined Abscess or
complaints of fistula formation
 severe or symptoms that
unrelenting right necessitate
upper quadrant medical
(RUQ) discomfort, attention.
fever,
tachycardia, and
bile drainage
leaking around
the tube or from a
wound

Dep:
Gave Antibiotics Treatment for
as directed. an abscess
and/or infection
is required
Risk for At the end of After 8 hrs. of Ind: Goal Met:
Infection hospitalization, SN-patient Assessed for the Signs and Client did not
client will remain interaction, presence of local symptoms have any
free of infection, as the patient will infectious include complication
evidenced by be able to localized and infection
processes in the
identify swelling,
normal vital signs skin or mucous during
interventions localized
and absence of to prevent membranes. hospitalizatio
signs and symptoms redness, pain or n and
infection &
of infection. tenderness, recovery
reduce risk for
loss of function
acquiring it.
in the affected
area, palpable
heat.

Monitored any Signs and

signs and symptoms of
symptoms of infection vary
infection. according to the
body area
involved

Assessed and Patients with

monitor nutritional inadequate
status, weight, nutrition may be
history of weight anergic or
loss, and serum unable to
albumin. muster a
cellular immune
response to
pathogens,
making them
susceptible to
infection.

Aseptic
 Maintained strict technique
asepsis for dressing decreases the
changes, wound chances of
care, intravenous transmitting or
therapy, and spreading
catheter handling. pathogens to or
between
patients.

This reduces or
Ensured that any eliminates
articles used are germs.
properly disinfected
or sterilized before
use.

Proper nutrition
Encouraged intake of and a balanced
protein-rich and diet support the
calorie-rich foods immune
and encourage a systems’
balanced diet. responsiveness
and enhance
the health of all
the body’s
tissues.

Explain to the
Edx: client how
Instructed client not to infections can
share personal care be transmitted
items from sharing
personal items

Other people
Taught the can spread
importance of infections or
avoiding contact with colds to a
individuals who have susceptible
infections or colds. patient (e.g.,
Teach the importance immunocompro
of physical distancing. mised) through
direct contact,
contaminated
 objects, or air
currents.

IV. ANATOMY

The gallbladder is a small pouch that sits just under the liver. The gallbladder stores bile produced by
the liver. After meals, the gallbladder is empty and flat, like a deflated balloon. Before a meal, the
gallbladder may be full of bile and about the size of a small pear.

In response to signals, the gallbladder squeezes stored bile into the small intestine through a series
of tubes called ducts. Bile helps digest fats, but the gallbladder itself is not essential. Removing the
gallbladder in an otherwise healthy individual typically causes no observable problems with health or
digestion yet there may be a small risk of diarrhea and fat malabsorption.

V. PATHOPHYSIOLOGY
Factors: • High calorie
• More in women diet
than in men. • Cirrhosis
• Above 40 years of
• Bile stasis
age.
• Obesity • Diabetes
• High cholesterol • Cystic
levels 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
 Surgical Management: Nursing Management:
• Open cholecystectomy • Encourage ambulation
• Laparoscopic • Encourage deep breathing
cholecystectomy exercises and use of
• Lithotripsy incentive spirometry
Medical Management: • Monitor intake and output
• Medications: • Monitor vital signs
- Antibiotics • Give patient health
- Analgesics teaching for home care

Gallstones are hard, pebble-like structures that obstruct the cystic duct. The formation of gallstones is often
preceded by the presence of biliary sludge, a viscous mixture of glycoproteins, calcium deposits, and cholesterol
crystals in the gallbladder or biliary ducts. This hypersaturation, which results from the cholesterol concentration being
greater than its solubility percentage, is caused primarily by hypersecretion of cholesterol due to altered hepatic
cholesterol metabolism. A distorted balance between pronucleating (crystallization-promoting) and antinucleating
(crystallization-inhibiting) proteins in the bile also can accelerate crystallization of cholesterol in the bile. Mucin, a
glycoprotein mixture secreted by biliary epithelial cells, has been documented as a pronucleating protein. It is the
decreased degradation of mucin by lysosomal enzymes that is believed to promote the formation of cholesterol
crystals.

The pathogenesis of cholecystitis most commonly involves the impaction of gallstones in the bladder neck,
Hartmann’s pouch, or the cystic duct; gallstones are not always present in cholecystitis, however. Pressure on the
gallbladder increases, the organ becomes enlarged, the walls thicken, the blood supply decreases, and an exudate
may form. Cholecystitis can be either acute or chronic, with repeated episodes of acute inflammation potentially leading
to chronic cholecystitis. The gallbladder can become infected by various microorganisms, including those that are gas
forming. An inflamed gallbladder can undergo necrosis and gangrene and, if left untreated, may progress to
symptomatic sepsis. Failure to properly treat cholecystitis may result in perforation of the gallbladder, a rare but life-
threatening phenomenon. Cholecystitis also can lead to gallstone pancreatitis if stones dislodge down to the sphincter
of Oddi and are not cleared, thus blocking the pancreatic duct.

IV. MEDICAL-SURGICAL MANAGEMENT

1. Procedure
Procedure/Date Indication/Analysis Nursing Responsibilities (PRE,
INTRA, POST)
Laparoscopic Indicated for the treatment of PRE:
Cholecystectomy acute or chronic cholecystitis.
The operation is done to remove • Establish rapport
9/7/22 gallstones or to remove an • Assess the patient’s vital
infected or inflamed gallbladder signs
• Monitor I&O
• Ensure Consent form
INTRA:
 • Maintain strict asepsis
during the procedure
• Document data &
findings
• Assist the surgeon
during the procedure
POST:
• Prevent respiratory
complications
• Promote wound healing
• Change dressings
• Promote bowel function
• Provide emotional
support to client and
family

2. Pharmacotherapeutics/Medicines
GN (BN) Indication Nursing Responsibilities/Implications
Classification Stock Dosage and (PRE, INTRA, POST)
Frequency
D5LR 1 L Indication: PRE:
5% Dextrose in Lactated is useful for daily
Ringer’s maintenance of body • Check Doctor’s order
fluids and nutrition, • Verify patient
Classification: • Assess fluid intake and output
and for rehydration
• Hypertonic • Check for the consistency of
Dosage: the IV fluid, do not administer
• Nonpyrogenic 31 gtts/min to run for unless solution is clear and
• Parenteral fluid 8 hours container is undamaged.
• Electrolyte
• Nutrient Replenisher INTRA:
• Practice 10 rights in
medication
• Observe asepsis
• Properly label IV fluid
POST:
• Discard unused portion
Omeprazole (Prilosec) Indication: PRE:
Proton-pump inhibitor used to treat excess
20 mg stomach acid in • Check Doctor’s order
conditions such as • Verify patient
non-cancerous • Assess for possible
stomach ulcers, contraindications and cautions:
gastroesophageal history of allergy to a proton pump
reflux disease (GERD), inhibitor to reduce the risk of
active duodenal ulcer, hypersensitivity reaction
Zollinger-Ellison • Explain to patient the importance
syndrome and erosive of taking the drug
esophagitis INTRA:
Dosage & Frequency:
• Using aseptic technique, withdraw
40 mg od (IV)
the appropriate dose
 • Infused for over 15 minutes
POST:
• Monitor the effectiveness of the
drug (patient response)
• Assess for drug toxicity
Ketorolac (Ketorobas) Indication: PRE:
NSAID used for the short-
30 mg/ml term treatment of • Check Doctor’s order
moderate to severe • Verify patient
pain in adults. It is • Assess for an allergy
usually used before or • Explain effects/indication of
after medical medications
procedures or after • Assess patients who develop
surgery. severe diarrhea and vomiting for
dehydration and electrolyte
Dosage & Frequency: imbalance.
30 mg Q6° x 4 doses
INTRA:
• Observe 10 rights in giving
medication
• Take with meals to avoid GI
upset
POST:
• Discontinue drug promptly if
diarrhea, dark stools,
hematemesis, ecchymoses,
epistaxis, or rash occur and do
not use again. Contact physician.
• Notify physician if persistent GI
discomfort, sore throat, fever, or
malaise occur
Cefuroxime (Axetil) Indication: PRE:
Antibacterial indicated for the
500 mg treatment of a variety • Check Doctor’s order
of infections • Verify patient
• Assess for an allergy
Dosage & Frequency: • Explain effects/indication of
500 mg Q12° medications
INTRA:
• Give oral drug with food to
decrease GI upset and enhance
absorption
• Have vitamin K available in case
hypoprothrombinemia occurs.
• Discontinue if hypersensitivity
reaction occurs.
POST:
• Report severe diarrhea with
blood, pus, or mucus; rash;
difficulty breathing; unusual
tiredness, fatigue; unusual
 bleeding or bruising; unusual
itching or irritation.
VII. PROGRESS NOTES
Day No. Existing Cues/Problems
Interventions Actually Done (Nursing and Collaborative)
Client’s Response
n/a n/a
VIII. DISCHARGE HEALTH TEACHING PLANS
Content Strategy
1. Compliance The patient will be instructed One-on-one discussion with
Medication regarding his home patient and relatives about
Diet medications and teaching health teaching plans
Exercise him the proper nutritional
Activity/Lifestyle Changes diet, some helpful teachings
on alleviating wound pain.
Also an increase in oral fluid
intake would be part of the
teaching instructions to help
him promote faster wound
healing.
2. Follow up/Check up n/a n/a
IX. SUMMARY OF CLIENT’S STATUS OR CONDITION AS OF LAST DAY OF CONTACT
Date: September 28, 2022
Problems encountered (actual and resolved)

This is the last interaction with the patient. The patient does not experience any pain or discomfort and
was advised to start ambulation. The doctor already ordered the patient that he can go home later that
day.

REFERENCES:
Hoffman, M. (2021). Picture of Gallbladder. WebMD. Retrieved from https://www.webmd.com/digestive-
disorders/picture-of-the-gallbladder

Benson, M. D., & Gandhi, M. R. (2000). Ultrasound of the hepatobiliary-pancreatic system. World Journal
of Surgery. Retrieved from https://pubmed.ncbi.nlm.nih.gov/10633143/