Evaluation Cholelithiasis

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XII. EVALUATION Patient MJV, 36 years old, female patient was admitted at Lorma Medical Center last September 12, 2007 at 9:35 AM, with a chief complaint at her right upper abdomen. Diagnostic procedures of ultrasonography, CBC typing, and chest X-ray were requested to verify the clinical impression of cholelithiasis. Afterwards MJV was diagnosed with cholelithiasis and undergone cholecystectomy by her attending physician and surgeon Dr.EVJ. During her 6 days of confinement, quality nursing procedures were rendered by students as well as our Nursing Instructor and the entire healthcare team of Lorma. This includes administration of Ketomed 30 mg via IV push every 6 hours and Fortum 1 gm via IV push every 12 hours. Nursing interventions include the establishment of good working relationship with the patient in order to gain cooperation and mutual trust. She was equally cooperative which provided us substantial information about her lifestyle and practices. Part of our nursing care to the patient includes the imparting of health teachings to the patient, among which were provided to the patient: 

Assess the location

and intensity of pain, for better and accurate pain

management; 

Continued vital signs monitoring, for the patients safety and comfort.

The above health teachings imparted to the patient will be able to identify the patient problem associated by the disease and gained more information about the

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disease and the proper management for the patient suffering from the specific disease. And this case study developed and enhanced our nursing skills through Nurse-Patient Interaction thereby provided quality nursing care to our patient.