Final Chole,,,sa Wakas Tpoz

Republic of the Philippines Tarlac State University College of Nursing Lucinda Campus A.Y.: 2008-2009

Case Study of CHOLEDOCHOLITHIASIS

Submitted by: Castanar, Aimelyn C. Coquia, Benjamin III S. Cortez, Christian Jay B. Dumlao, Jennifer M. Gabriel, Rutzki S. Justo, Jonalyn V. Mamucod, Madel S. Marcos, Shierly Luz D. Natividad, Manuelito A. Pasamba, Janine P. Group B3

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TABLE OF CONTENTS I. Introduction…………………………………………………………………1 II. Nursing Process……………………………………………………………..3 A. Assessment 1. Personal Data……………………………………………………3 2. History of Past Illness…………………………………………...6 3. History of Present Illness………………………………………..6 4. Physical Assessment i. 13 Areas of Assessment……………………………………..6 5. Diagnostic and Laboratory Procedures……………………...….17 6. Anatomy and Physiology……………………………………….22 7. Pathophysiology i. Book Based…………………………………………………24 ii. Client Based………………………………………………...25 B. Planning 1. Nursing Care Plan………………………………………………26 C. Implementation 1. Medical Management…………………………………………...34 2. Drug Study……………………………………………………...38 3. Diet……………………………………………………………...43 4. Activity or Exercise……………………………………………..45 5. Surgical Management…………………………………………...48 6. SOAPIE…………………………………………………………50 D. Evaluation 1. Patient’s Daily Program in the Hospital………………………...57 2. Discharge Planning……………………………………………...58 III. Conclusion…………………………………………………………………..59 IV. Recommendation……………………………………………………………59 V. Bibliography………………………………………………………………...60

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ACKNOWLEDGEMENT The group would like to thank almighty God for giving us strength and courage to fulfill this case study. The group wishes to extend a sincere thank you to the talented Dean of our college, and level coordinators for being the contributors and reviewers of this case study, who provide many valuable and very helpful ideas, and suggestions. To our clinical instructor for this case study Ms. Mylene Romero for her attention to detail that promoted an excellent outcome, and to our fellow 3rd year students, for their questioning minds and motivation for this case study. And also the group would like to thank to our parents that serves as our seeking light and reflections, and for allowing us to pursue this case study and have our overnight for almost a week. And finally, to our panelist for sharing their knowledge, for us to have a beautiful new designs of our selected case. GROUP B3

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I.

INTRODUCTION

Choledocholithiasis is the presence of gallstones in the common bile duct. This condition causes jaundice and liver cell damage, and is a medical emergency, requiring the endoscopic retrograde cholangiopancreatography (ERCP) procedure or surgical treatment. A tendency for this disease can be inherited. Doctors can use a blood test of alkaline phosphatase, bilirubin and cholesterol to diagnose choledocholithiasis. However, ultrasound demonstrating an enlarged common bile duct is the test of choice. Treatment involves removing the stone using ERCP. Typically, the gallbladder is then removed, an operation called cholecystectomy, to prevent a future occurrence of common bile duct obstruction. Gallstones are more common among women after 40 years of age and among certain groups of people, such as Native Americans. They are uncommon in children and young adults. The risk factors for gallstone formation include increased age, obesity, a typical Western diet, and a family history of gallstones. About 15% of people with gallstones will develop stones in the common bile duct, the small tube that carries bile from the gallbladder to the intestine. Risk factors include a previous medical history of gallstones. However, choledocholithiasis can occur in people who have had their gallbladder removed. (http://www.umm.edu/ency/article/000274.htm) In the United States, the incidence rate for gallstones is approximately 40% in individuals older than 60 years. In individuals undergoing cholecystectomy for symptomatic cholelithiasis, 8-15% of patients younger than 60 years have CBD stones, compared to 15-60% of patients older than 60 years. (http://emedicine.medscape.com/article/172216-overview) The incidence of cholelithiasis increases after the age of 40 years, affecting 30% to 40% of the population by the age of 80 years. Four times more women than men develop cholesterol stones and gallbladder disease; the women are usually older than 40, multiparous, and obese. The incidence of stone formation rises in users of oral contraceptives, estrogens and clofibrate; these substances are known to increase biliary cholesterol saturation. The incidence of stone formation increases with age as a result of increase hepatic secretion of cholesterol and decrease bile acid synthesis. In addition, there is an increase risk because of malabsorption of bile salts in patients with gastrointestinal disease or T-tube fistula or in those who have had ileal resection or bypass. The incidence also increases in people with diabetes. (endnote 11th edition by brunners and suddarth’s, volume 2) In the Philippines, there were 131 males (18%) and 609 (82%) females, with a female ratio male 4.6:1. Benign lesions comprised 99% (mean age 36), mostly chronic cholelithiasis (97%) and acute cholelithiasis which constituted 15 cases only (2%), malignant lesions comprised only 7 cases for example 1% of all lesions (mean age 65). 4

(http://www.thedoctorsdoctor.com/diseases/gallbladder_chronic_cholelithiasis.htm#epidemiolog y) Reasons for choosing this case: As the group go on with our weekly duty at the Tarlac Provincial Hospital, the group observed a case of choledocholithiasis. So, as nursing students, the group decided to study this kind of case. The significance of studying this case is to enhance or broaden our knowledge as well as the patient’s who are suffering this disease and also to those people who are in high risk of having this disease for us to share our knowledge for the primary prevention and simple interventions of the disease. Importance of the study: It is of fundamental importance that case studies are to be performed in the nursing profession; it is where understanding of the disease’ description, pathophysiology and etiology that satisfactorily contribute to the formation of proper holistic management to the patient is being learned. Thorough exploration and completion of case studies provide nurses a systematic way of looking events analyzing information regarding a certain. It expands medical knowledge and expertise in the nurses’ part The primary significance of the study is to stimulate the mind and awareness of the patient as well as the family members to properly acquire enough knowledge and correct information in dealing and recognizing such kind of disease. To make also the health team to be more aware about the status of our health care system where they can analyze and apply towards themselves and others in fulfilling good health condition. Through this study, the people will know and be aware about what Choledocholithiasis mean when it comes to our health by educating them the importance of this condition. Case study is specially designed to provide information in which both the patient and the student nurse benefits from it. With this, we, as student nurses will be able to provide appropriate nursing interventions that would help in restoring the wellness of the patient in accordance to his or her condition. This is primarily essential because it enhances the student’ skills, knowledge and attitude in the practice of the nursing process. It provides broader understanding about the condition chosen through research and actual observation as it is a training ground and practice in developing learned skills in the assessment and management of the disease. This can serve as an instrument for the future reference of the next nursing students of the school. To share the book based and actual clinical management of the disease and may be used as a base line for more advance and depth study in accordance to the changing society.

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Objectives: Comprehensive understanding about the condition will formulate a good perception and information to both patients and nurse in dealing and exploring such kind of disease. These objectives will help to attain such benefits in knowledge and skills to identify Choledocholethiasis. General  Enhance understanding regarding Choledocholethiasis and together factual data and current trends in regards to the condition Specific  Establish rapport with the client thus enhancing communication skills and to be able to gather pertinent information to the client and significant others.  Know and apply corresponding intervention regards to post-op Choledocholithotomy surgery.  Evaluate effectiveness of the nursing intervention rendered.  Perform continuous physical assessment in order to gather pertinent information the disease condition.

II. Nursing Process: A. ASSESSMENT 1. Personal Data a. Demographic Data: Name Age Sex Civil Status Occupation Religious Affiliation Role Position in the Family Address Date & Place of Birth Nationality Usual Source of Medical Care Chief Complaint Diagnosis Date of Admission

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: Mr. D : 51 yrs. Old : Male : Married : Farmer, Construction Worker : Roman Catholic : Head of the family : Ramos, Tarlac : Toledo Ramos, Tarlac : Filipino : none : Abdominal Pain : choledocholithiasis secondary to ruptured gall bladder : February 9, 2009

b. Environmental status According to Mr. D, they regularly clean their own house that is bungalow and made of pure concrete. Their house has 3 bedrooms and in the living room they have appliances television, radio and electric fan. Their house is located near in the farm with their relatives. Drainage system is open. Source of water is forced pump. They have pets, dogs and cat that live outside their house. c. Lifestyle Mr. D likes planting vegetables in their backyard during his leisure time. He usually eat foods rich in fats like meats cooked with oil, fried fish, and vegetables. He is fond of drinking alcohol, and verbalizes that they usually eat “chicharon” as their pulutan. In terms of rest pattern Mr. D only sleeps for about 7-8 hours every night. Usually he sleeps at 7:00 p.m. and wakes up at 3:00 a.m. He usually drinks coffee every morning and sometimes in afternoon while having some chat with his friends. At 4:00 AM he’ll eat his breakfast. After his morning routine he go to work and go home at 6:00 p.m. He spend his day doing his work. d. Social Status . The patient spends his time during weekends with his family and friends by doing his favorite routine which is planting. The family lives in their own house along with their relatives. There is no conflict between the family members. Whenever some issues or problem arises, they handle it by talking about it in a calm and respectful manner. According to the patient, he is not anymore active in community activities or project because he doesn’t have any time to join and participate. e. Psychologic Status According to the client he often experience fatigue in some of his work. But concluded that it is just normal because of the type of his work. It was his goal to provide all the necessary things needed by his family. He believes he will only achieve this goal if he will look forward and treat his family as his only treasure. And whenever life doesn’t go well with his plans, he gets a little depressed. He always thinks about his family problems specifically financial accountabilities. Whenever he is anxious, he usually had conversations and seeks some advises with his wife.

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FAMILY HISTORY OF HEALTH AND ILLNESS N / A

N/ A

LEGEND:

N / A

N/ A

= Male = Female 7 5

8 0

= deceased male

A&W

7 4

HPN

A&W

8 2

7 9

7 7

N/A

DM

A&W

7 5 A&W

= deceased female = the patient As = Asthma A&W = Alive and well

N B

C = Choledocholithiasis

N/A

5 6

N / A

5 1

A&W

N/A

C

DM = Diabetes Mellitus HPN = Hypertension NB = Newborn N/A = not applicable

8

4 9

4 8

A&W DM

4 6 HPN

4 5

4 4

4 3

4 0

A&W A&W HPN A&W

3 8 A

2. History of Past Illness Mr. D had experienced childhood illnesses such as cough and cold, mumps at the age of 9 years old, chicken pox when he was 12 years of age. The patient verbalized that he cannot remember if he completed his immunization during his childhood. It was in the month of December when he experienced the first onset of pain in his right upper quadrant while he was eating and concluded that it was just an ulcer. He said that the pain lasted for five minutes and reoccur after a minute with the same area, he said he never prompted to seek medical help. And he said he never take any over the counter drugs to relieve pain. But instead he only sat or lied until the pain relieves. 3. History of Present Illness During the two months duration before his hospitalization, the pain still occur once week, but still the patient can tolerate it until the time when he was eating the pain again arises in his right upper quadrant and he said that the pain was continues without any interval that makes him decided to take consultation at Tarlac Provincial Hospital. But when he arrived, his gallbladder was already ruptured according to his physician. So he was directly brought to operating room and Cholecystectomy was done. 4. Physical Assessment 13 AREAS OF ASSESSMENT SOCIAL STATUS Mr. D is 51 years of age, and was married. They make decision for the family together; they are a type of nuclear family. According to him, he never experiences any intimate family violence. They located in a compound area and most of his neighbors are his relatives. He originally lives at Ramos Tarlac City. He proudly said that he has no conflict with people around him, although some misunderstanding happened to him, but he tries to solve it in a good manner like talking to them calmly. When he feels stress, he just takes rest and sleep. His hobbies are planting vegetables on their backyard, listening to music and sometimes chatting with his friends and neighbors. He denies any membership of any social organization; he doesn’t attend any barangay assembly. He is a Roman Catholic, but he rarely attends holy Mass due to lack of time, he mentioned that he only attends mass twice a year. He denied drug abuse. He was fond of smoking and drinking alcohol. Standard and Norms Social status is the determinant of patient’s response to the things he encounters and how he treats or how he deals with other person. Social status of the patient is also a determinant of many factors that can affect the patient’s health. Getting social history is included if the patient is an alcoholic or drug and tobacco user. Alcohol can interfere with normal body metabolism and normal body function, drugs can affects the clients normal body function (Health Assessment by Zator, Estes 2006) 9

Interpretation He has a good relationship with family and relatives and also with his neighbors which is an indication of good social stability. He does his responsibility as a good husband for his wife and responsible father to his childrens. He is able to cope or handle social conflicts. He has a good spiritual status. He has lack of interest with regards to the social organization. Body function can affect by drugs and tobacco because he is fond of using it. MENTAL STATUS • Posture and Movements Post-operative Mr. D is comfortably positioned flat on bed. He is restless due to pain on his right upper quadrant abdomen. He can do his activity of daily living but sometimes needs assistance. His facial expressions are inappropriate with his feelings and mood of conversation. The patient is sometimes stiff due to pain episodes he experience because of the operation done to him. He usually moves slowly and carefully with minimal assistance. She wears loose and light clothing appropriate for his condition. He is not well groomed with uncombed hair and has clean and trimmed nails and pale in appearance. • Level of consciousness Post-operative After the said operation, Mr. D were able to respond with the questions given to him, with an appropriate answer, and was able to do eye contact while answering. • Mood Post-operative Upon assessing Mr. D, he cooperates attentively with appropriate mood. He talks with us calmly with low voice. But he also verbalizes that after he had the operation he was at times moody and was selective with the topic, and questions to be discussed. The patient also mentioned that after his operation he easily gets tired and so he was not able to answer some of our questions at that time. • Thought Process and Perception Post-operative Mr. D was able to expresses his thoughts and feelings. He is willing to answer our questions appropriately and sometimes he also asked related questions related on the topics being discussed to him and share his ideas and experiences in life to the group.

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• Cognitive Abilities Post-operative Mr. D shown awareness to about his present condition, about the treatment and surgical procedure he undergone. He is aware regarding the people around him and the time and place where he is. He is also able to recall significant events in his life. Standard and Norms The patient should appear relaxed with the appropriate amount of concern for the assessment. He should exhibit erect posture, a smooth gait symmetrical body movement. The patient should be clean and well groomed and should wear appropriate clothing for age, weather and socioeconomic status. Facial expression should be appropriate to the content of the conversation and should be symmetrical. The patient should b able to produce spontaneous, coherent speech. The patient should have an effortless flow with normal inflections, volume, pitch, articulation, rate and rhythm. The patient should be able to respond or answer questions appropriately. (Health Assessment by Mary Elle Zator Estes,2006) Interpretation Mr. D responds well and can answer appropriately. He is also aware about the time and the place where he was. Based on the data gathered he possesses the appearance; thought processes, mood and was conscious at the time of monitoring. He also interacts upon assessment and interview with appropriate mood. But due to his condition as he undergoes surgical procedure, his movements were sometimes limited and thus he needs assistance to attain his needs. EMOTIONAL STATUS Post-operative Mr. D expresses and verbalizes his emotions and feelings during the interview; he seems uncomfortable because of the pain episodes he feels after the operation. He said that his stress though he was resting and sleeping. Despite of his condition he still possesses a brave, relaxed attitude. He approached us in a kind attitude. He is fully supported by his family as we see that he is cared by his siblings and children. And he also verbalize that he was able to accept his present condition. Standard and Norms Emotional wellness involves the ability to recognize, accept and express feelings and to accept one’s limitation. It is also the ability to manage stress and to express emotions appropriately. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman)

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Interpretation Mr. D has the ability to manage stress by means of expressing his thoughts and feelings of willingness to participate in our group. He has positive coping mechanism because he approached our group in a kind manner. He possess ability to recognized an accept condition. Therefore his emotional status is in normal state. SENSORY PERCEPTION Post-operative •

Sense of Sight The patient is able to read with the use of his reading glass with a visual acuity of 30/30. His external eyes were symmetrical in shape and size, have no lesion and no bleeding found. His sclera is yellowish in color whole his conjunction in pinkish. The patient can raise both eyelids asymmetrically. His pupils are black and round. Standard and Norms The normal visual acuity is 20/20. There should be no presence of lesions or any perforation in the eye of the patient. •

Sense of Smell The patient’s nose is on the midline, it is symmetrically in shape and the nostrils are intact. He is able to distinguish different color like alcohol, perfume or cologne and different scent of fruits provided like orange. Standard and Norms Patient must be able to identify different smell; nose should be at the midline position, free from lesions and intact nostrils. (Health Assessment by Mary Elle Zator Estes,2006) •

Sense of Hearing Our group performed a hearing test in order to check if the patient had a good sense of hearing by whispering words about 3 inches away from the ear and asked him to repeat the words that were spoken to him to check if he really hear the words. The patient is able to answer questions correctly that means his hearing ability is good. No bleeding, wounds, or lesions are found on his external ear. Standard and Norms Patient should hear whispered words or watch tick test and ear must free from lesions and masses. (Health Assessment by Mary Elle Zator Estes,2006). •

Sense of Taste Tongue and oral cavities are symmetrical and no lesions or abnormalities were found. The patient was able to determine taste of salty, sweet, sour, and bitter taste.

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Standard and Norms Patient should be able to sense the different kind of tastes like sweet, bitter, sour, and salty. (Health Assessment by Mary Elle Zator Estes,2006) • Pain Sensation The patient is able to response with the pain sensation when we pinched his skin. And he was able to determine if the object is sharp or not and can able to determine if the object is smooth or rough. Standard and Norms Identifies correct object, identifies correct number and identifies correct direction of body part is move. (Nurse Handbook of Heath Assessment by J.R Weber,2004) Interpretation Regarding the patient’s sense of perception, before and after his operation, there is no problem found except with his sense of sight because he is using reading glasses whenever he read. It only means that his visual acuity is not in normal. Other than that’s he already possesses normal perception in other areas. MOTOR STABILITY Post-operative Mr. D cannot tolerate heavy movement. He was moderately weak. He needs assistance when ambulating and eating. He moves slowly in changing his position when he sleeps and rest. Standard and Norms Over-all Appearance: The patient should be able to stand on the bedside via independent ambulation. Structural effects should be absent. There should be no outward indications of discomfort during rest, weight bearing, or joint movement. Posture: In standing position the torso and head are upright. The arms hang freely from the shoulders. The feet are aligned and the toes point forward. In sitting position both feet should be placed firmly on the floor surface, with toes pointing forward. Gait and Mobility: Walking is initiated in one smooth, rhythmic fashion. The patient should remain erect and balanced during all stages of gait. (Estes, Mary Elen Zator. (2006),Health Assessment and Physical Examination (3rd Edition Interpretation The patient’s motor stability is not normal because he cannot stand on the bedside, and independently ambulate himself and needs assistance in doing his ADL.

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BODY TEMPERATURE DATE 02-19-2009

02-20-2009

02-21-2009 02-22-2009 02-23-2009

TIME 5 am 10 am 2 pm 4pm 6pm 10 pm 10 am 2 pm 4pm 6pm 10 pm 6 am 10 am 2 pm 5 am 5 am

ROUTE

Axillary

TEMPERATURE INTERPRETATION 36.5 °C Normal 37.2 °C Normal 37.5 °C Normal 37.5 °C Normal 37.4 °C Normal 36.5 °C Normal 37 °C Normal 37 °C Normal 37.4 °C Normal 37.2 °C Normal 37.4 °C Normal 36 °C Normal 36.5 °C Normal 37 °C Normal 36.7 °C Normal 37 °C Normal

Standard and Norms Route for Body Temp. Measurement Oral Rectal Axillary Tympanic

Average 37.0˚C / 38.6˚F 0.4˚C / 0.7˚F higher than oral 0.6˚C / 1.0˚F lower than oral Calibrated to oral/rectal scale

Normal Range 36.0˚ - 38.0˚C / 96.8˚ – 100.4˚F 36.7˚ – 38.0˚C / 98.0˚ - 100˚F 35.4˚ - 37.4˚C / 95.8 – 99.4˚F See oral / rectal

Reference: Estes, Mary Elen Zator. (2006) Health Assessment and Physical Examination (3rd Edition RESPIRATORY STATUS DATE 02-19-2009

TIME 5 am 10 am 2 pm 4pm 6pm 10 pm

RESPIRATORY RATE INTERPRETATION 26 cpm Tachypneic 18 cpm Normal 21 cpm Tachypneic 30 cpm Tachypneic 28 cpm Tachypneic 24 cpm Tachypneic 14

02-20-2009

02-21-2009 02-22-2009 02-23-2009

10 am 2 pm 4pm 6pm 10 pm 6 am 10 am 2 pm 5 am 5 am

26 cpm 30 cpm 29 cpm 24 cpm 28 cpm 24 cpm 30 cpm 33 cpm 26 cpm 25 cpm

Tachypneic Tachypneic Tachypneic Tachypneic Tachypneic Tachypneic Tachypneic Tachypneic Tachypneic Tachypneic

Standard and Norms In a resting adult, the normal respiratory rate is12- 20 bpm, normal respirations are regular. The normal depth of inspiration is non-exaggerated and effortless. The healthy adults’ thorax rises and falls in unison in the respiratory cycle. The patient’s respiratory cycle can be heard by the unaided ear a few centimeters away from the patient’s nose and mouth. A healthy adult breathes comfortably in a supine position, prone or upright position and most patient inhale and exhale through the nose. No pulsation of masses, thoracic tenderness and crepitus should be present. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman). Analysis: Patient was tachypneic, as a result of his compensatory mechanism of his heart (post op). CIRCULATORY STATUS DATE 02-19-2009

02-20-2009

02-21-2009 02-22-2009 02-23-2009

TIME 5 am 10 am 2 pm 4pm 6pm 10 pm 10 am 2 pm 4pm 6pm 10 pm 6 am 10 am 2 pm 5 am 5 am

BLOOD PRESSURE 120/90 mmHg 120/80 mmHg 120/80 mmHg 110/70 mmHg 110/80 mmHg 110/70 mmHg 100/80 mmHg 110/70 mmHg 110/70 mmHg 110/70 mmHg 100/80 mmHg 110/80 mmHg 100/80 mmHg 100/70 mmHg 110/70 mmHg 100/80 mmHg

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INTERPRETATION Normal Normal Normal Hypotensive Normal Hypotensive Hypotensive Hypotensive Hypotensive Hypotensive Hypotensive Normal Hypotensive Hypotensive Hypotensive Hypotensive

Standard and Norms Normal blood pressure varies with age. As a person ages, blood pressure generally increases. The normal blood pressure of an adult is 120/80 mmHg. Normally baroreceptors (Receptors that are located in the walls of most of the great arteries that sense hypotension and initiate reflex vasoconstriction and tachycardia to bring the blood pressure back to normal) help a patient to maintain a normal blood pressure when changing from supine from a sitting or standing position. Processes increasing cardiac output, such as exercise, will normally increase blood pressure. Pulse pressure is normally 30 – 40 mmHg. Normal pulse rate also varies with age. The normal pulse rate of an adult is 60 – 100 BPM. The heart rate normally increases during periods of exertion. Normal pulse rhythm is regular with equal intervals between each beat. The pulse volume is normally the same with each pulse beat. A normal pulse volume can be felt with a moderate amount of pressure of the fingers and obliterated with greater pressure. Capillary refill is an indicator of peripheral circulation. Normal capillary refill may also vary with age, but the color should not return to normal within 2 -3 seconds. (Health Assessment by Mary Elle Zator Estes) Analysis: Based on the standard and norms the patient is hypotensive but he is able to tolerate his condition as evidenced by not experiencing dizziness and body weakness. NUTRITIONAL STATUS The patient weighs 60 kg and 5’7” in height. The patient was on high protein diet. He was given an IV fluid of D5LRS to maintain fluid and electrolytes balance in his body. He eats three times a day and take some snacks between the periods of eating hours. And was fond of eating foods rich in fats such as fried fish, meats cooked with oil. BMI=weight in kg Height in m2 =60 kg (1.7018)2 = __60__ 2.89612324 = 20.75 Standard and Norms Normal human being usually eats 3 times per day and a fluid intake of 8 - 10 glasses of water. Nutrients must be taken equally according to their standards. There should be no problem regarding food and drug allergies and anything associated with nutrition. Nutritional of patient is a good determinant of a possible heart condition. Nutrition can be a prevention and treatment for some diseases. Normal body mass index is 20 – 25, less than 20 is associated with heart problem, and in some people more than 27 indicates higher risk for developing heart problems. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman) 16

BMI <16 malnourished 16-19 underweight 20-25 normal 26-30 overweight 31-40 moderately to severely obese >40 morbidly obese Interpretation With regards to Mr. D’s nutritional status, it appears that he is able to meet her nutritional needs and can tolerate all type of foods. There are no known problems associated with his nutrition and any drug or food allergies. He’s weight is suited with the height. ELIMINATION STATUS Post-operative Mr. D verbalizes that he usually urinates 3 times within the shift and it is characterized by dark yellow in color. He reported absence of defecation for 2 days, but was able to defecate once daily with clay color stool for the next three days. Also, he verbalizes that he never felt any pain during urination and defecation. He was also inserted with T-tube, with 250 cc in the first duty and 230 cc for the next day characterized by coffee ground in color and slimy, without any stain of blood. Standard and Norms Elimination of the waste products of digestion from the body is essential to healthy people who have had a bowel movement once a day for 75 years can view as a missing 1 day as a serious problem. Normal feces are made of about 75% of water and 25% solid materials. They are soft but formed. Feces were normally brown, chiefly due to the presence of stercobilin and urobilin, which are derived from bilirubin. An adult usually forms 7 – 10 liters of flatus in the large intestines every 24 hours. Urine elimination should be at least 30 – 50ml per hour when a normal person was urinated and the normal bowel movement is 1 – 2 times per day. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman and Nutrition 2005 by 2nd Edition by Alex B. Abalos) Interpretation With regards to the patient’s elimination status, it appears that his urine output is in normal ranges. He experienced constipation in two days and was normally defecated for the next three days of our monitoring.

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REPRODUCTIVE STATUS Mr. D has three children. He is happily married to his wife and still enjoying his life with his family. Standard and Norms Sex has been defined as one of the basic physiologic need according to Maslow’s Hierarchy of needs. It is therefore, sex is an essential part for the well being of a person. An average normal individual should have a nature reproductive status in order to meet or attain sexual satisfaction. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman) Interpretation The patient is sexually healthy but not as active like on her early age. It because of his condition and age, his reproductive activities was decreased. STATE OF PHYSICAL REST AND COMFORT Post-operative After the said operation, Mr. D was complaining of difficulty in getting sleep. He usually sleeps for only 5-6 hours and it was not continuous because of the doctor and nurses rounds, including the onset of pain in his right upper quadrant which has an interval of 10-15 minutes. Observable signs of inadequate sleep are still seen on the patient such as eyebags, frequent yawning and sometimes irritable. Standard and Norms The sleep wake cycle is very important to young adults they usually have an active lifestyle, and are thought to have required 7-8 hours of sleep each night but may do well on less. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman and Nutrition 2005 by 2nd Edition by Alex B. Abalos) Interpretation In terms of rest and sleep pattern of the patient, it appears that he has a disturbed sleeping pattern and inadequate sleep before and after the operation due to pain he experienced and unfamiliarity of the environment. He only have 5-6 hours of sleep at night, this is indicate that Mr. D sleep pattern is not normal. STATE OF SKIN APPENDAGES The color of his skin is brown. No rashes found in the incision site and reddish in color.There is no bed sores found. Hairs are well distributed in black color. Nail plate is clear, firm and the tissue surrounding the nails are intact with no lesion. The skin of the patient is slightly dry and when you pinched, it takes 2 seconds to turns back to its original state.Some skin damage is found due to IV insertion, Lab test such as CBC and operation that was done (cholecystectomy).

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Standard and Norms Normally, the skin is uniform whitish pink or brown color, defending on the patient race. Exposure to sunlight results increased pigmentation of an exposed area. Normally, there are no areas of bleeding. No skin lesions should be present except for freckles, birthmarks or moles, which may be flat or elevated. The skin is dry with minimum of perspiration. Moisture also varies with changes in environment, muscular activity, and body temp. stress and activity levels. Skin surface temp. should be warm and equal bilaterally. Skin surface should be non tender. It should be smooth, even and firm except where there is significant hair growth. When the skin is released, it should returns to its original contour rapidly. Edema should no be present. Terminal hair is found in the eyebrows, eyelashes and scalp, and in the axilla and pubic areas after puberty. Males may experience a certain degree of normal balding and may also develop terminal facial and chest hair. The scalp should be pale white to pink in light skinned individuals and light brown in dark skinned individuals. There should be no signs of infestations or lesions. Dandruff may be present. Hair may feel thin, straight course, thick or curly. It should be shiny and resilient when traction is applied and should no come out in clumps in your hands. Normally, the nails have a pink cast in light skinned individuals and are dark brown in dark skinned individuals. It should be smooth and slightly rounded or flat. Curve nails are normal variant. Nail thickness should be uniform throughout, with no brittle edges. The angle of the nail bed should be approximately 160 degrees. It should be firm on palpation. (Health Assessment by Mary Elle Zator Estes) Interpretation The patient has a poor skin turgor. Dryness of the skin was observed and it can be a sign of dehydration also it may reflects on his age.

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5. Diagnostic and Laboratory Procedures Diagnostic/ Laboratory Procedures Hematology • WBC •

Gran

•

RBC

•

Hgb

•

Hct

•

MCHC

•

Plt

Date Ordered

Indications/ Purposes

February 13, 2009

The CBC is used for the following purposes: •as a preoperative test to ensure both adequate oxygen carrying capacity and homeostasis. •to identify persons who may have an infection. •to diagnose anemia. •to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia. •to monitor treatment for anemia and other blood diseases.

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Results

Normal Values

Analysis and Interpretation

7.36

4.1-10.9

• Within normal values.

5.4

2.0-7.8

• Within normal values.

3.84

4.20-6.30

• Decreased level of RBC indicated hemorrhage.

121g/L

120-180 g/L

• Within normal values.

326g/L

370-510g/L

• Decreased level of Hct indicated hemorrhage

371g/L

310-360g/L

• Increased MCHC value indicates hemorrhage

272g/L

140-440g/L

• Within normal values.

Diagnostic/ Laboratory Procedures Hematology • WBC

•

Gran

•

RBC

•

Hgb

•

Hct

Date Ordered

Indications/ Purposes

February 17, 2009

The CBC is used for the following purposes: •as a preoperative test to ensure both adequate oxygen carrying capacity and hemeostasis •to identify persons who may have an infection •to diagnose anemia •to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia •to monitor treatment for anemia and other blood diseases.

21

Results

Normal Values

Analysis and Interpretation

12.0

4.1-10.9

•

Increased WBC indicates inflammatory and infectious processes

9.0

2.0-7.8

•

Increased gran (neutrophil) indicates acute infection or inflammatory processes.

3.62

4.20-6.30

•

Decreased level of RBC indicated hemorrhage.

115g/L

120-180 g/L

•

Decreased Hgb indicates hemolytic reactions, hemorrhage.

309g/L

370-510g/L

•

Decreased Hct indicates hemolytic reactions, hemorrhage.

•

MCHC

372g/L

310-360g/L

•

Increased MCHC indicates hemorrhage

•

Plt

499g/L

140-440g/L

•

Increased platelet indicates acute infection, anemia, or leukemia.

Nursing Responsibilities Before: 1. Check for the doctor’s order. 2. Discuss the importance of the procedure. 3. Explain to the client how to participate to the procedure. After: 1. Apply pressure on the site for 5-10 minutes after the procedure. 2. Have the patient take a rest after the procedure. 3. Encourage patient to eat foods rich in iron such as beans, green leafy vegetables and meats.

22

Diagnostic/ Laboratory Procedures Blood Chemistry • CHON •

Albumin

•

Globulin

Date Ordered February 20. 2009

Indications/ Purposes •

Measurement of the blood levels of other elements regulated in part by the kidneys can also be useful in evaluating kidney function.

Results

Analysis and Interpretation

50g/L

60-78 g/L

20g/L

32-45g/L

•

Decreased albumin indicates malabsorption.

30g/L

23-35g/L

•

Within normal values.

Nursing Responsibilities Before: 1. Check for the doctor’s order. 2. Discuss the importance of the procedure. 3. Explain to the client how to participate to the procedure. After: 1. Apply pressure on the site for 5-10 minutes after the procedure. 2. Have the patient take a rest after the procedure.

23

Normal Values

Diagnostic/ Laboratory Procedures Serum Electrolytes >Sodium

Date Ordered

Indications/ Purposes

February 13, 2009

• To determine electrolyte and acidbase imbalances.

Results

Normal Values

Analysis and Interpretation

145.5mmol/L

136-142mmol/L • Increased sodium indicates dehydration, excessive IV sodium, insufficient water intake or impaired renal function.

>Potassium

4.01mmol/L

3.8-5.0mmol/L

• Within normal values

>Chloride

117.2mmol/L

95-103mmol/L

• Increased chloride indicates dehydration, metabolic acidosis or respiratory alkalosis.

Nursing Responsibilities Before: 1. Check for the doctor’s order. 2. Discuss the importance of the procedure. 3. Explain to the client how to participate to the procedure. After: 1. Apply pressure on the site for 5-10 minutes after the procedure. 2. Have the patient take a rest after the procedure. 3. Instruct patient to increase fluid intake.

6. Anatomy and Physiology

The common hepatic duct is the duct formed by the convergence of the right hepatic duct (which drains bile from the right functional lobe of the liver) and the left hepatic duct (which drains bile from the left functional lobe of the liver). The common hepatic duct then joins the cystic duct coming from the gallbladder to form the common bile duct. The liver is also the largest gland in the human body. It lies below the diaphragm in the thoracic region of the abdomen. It produces bile, an alkaline compound which aids in digestion, via the emulsification of lipids. It also performs and regulates a wide variety of high-volume biochemical reactions requiring very specialized tissues. The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the body is to store bile and aid in the digestive process. The cystic duct is the short duct that joins the gall bladder to the common bile duct. It usually lies next to the cystic artery. It is of variable length. It contains a 'spiral valve', which does not provide much resistance to the flow of bile. Bile can flow in both directions between the gallbladder and the common hepatic duct and the (common) bile duct. In this way, bile is stored in the gallbladder in between meal times and released after a fatty meal. Bile, which is synthesized in the liver, is carried to the right and left hepatic ducts, which converge along with the Cystic duct to form the common hepatic duct. There it enters the superior end of the common bile duct and either empties into the second (and retroperitoneal) part of the duodenum, or enters the cystic duct to be stored in the gallbladder. The duodenum is largely responsible for the breakdown of food in the small intestine. Brunner's glands, which secrete mucus, are found in the duodenum. The duodenum wall is composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely

retroperitoneal. The duodenum also regulates the rate of emptying of the stomach via hormonal pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in response to acidic and fatty stimuli present there when the pyloris opens and releases gastric chyme into the duodenum for further digestion. These cause the liver and gall bladder to release bile, and the pancreas to release bicarbonate and digestive enzymes such as trypsin, lipase and amylase into the duodenum as they are needed. The pancreatic duct, or duct of Wirsung, is a duct joining the pancreas to the common bile duct to supply pancreatic juices which aid in digestion provided by the "exocrine pancreas". The pancreatic duct joins the common bile duct just prior to the ampulla of Vater, after which both ducts perforate the medial side of the second portion of the duodenum at the major duodenal papilla. The stomach is a highly acidic environment due to hydrochloric acid production and secretion which produces a luminal pH range usually between 1 and 2 depending on the species, food intake, time of the day, drug use, and other factors. Combined with digestive enzymes, such an environment is able to break down large molecules (such as from food) to smaller ones so that they can eventually be absorbed from the small intestine. A zymogen called pepsinogen is secreted by chief cells and turns into pepsin under low pH conditions and is a necessity in protein digestion. The pancreas is a dual-function gland, having features of both endocrine and exocrine glands. •

Endocrine

The part of the pancreas with endocrine function is made up of a million cell clusters called islets of Langerhans. There are four main cell types in the islets. They are relatively difficult to distinguish using standard staining techniques, but they can be classified by their secretion: α cells secrete glucagon, β cells secrete insulin, cells secrete somatostatin, and PP cells secrete pancreatic polypeptide. The islets are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes or by direct apposition. According to the volume The Body, by Alan E. Nourse, the islets are "busily manufacturing their hormone and generally disregarding the pancreatic cells all around them, as though they were located in some completely different part of the body." •

Exocrine

In contrast to the endocrine pancreas, which secretes hormones into the blood, the exocrine pancreas produces digestive enzymes and an alkaline fluid, and secretes them into the small intestine through a system of exocrine ducts. Digestive enzymes include trypsin, chymotrypsin, pancreatic lipase, and pancreatic amylase, and are produced and secreted by acinar cells of the exocrine pancreas. Specific cells that line the pancreatic ducts, called centroacinar cells, secrete a bicarbonate- and salt-rich solution into the small intestine.

PATHOPHYSIOLOGY BOOK BASED RISK FACTORS

Non-modifiable: • FEMALE • FERTILITY • FORTY YEARS OLD and ABOVE

Modifiable: • ↑FAT Intake

GALLSTONE IN BILE DUCTS

IN LIVER

BILE STASIS

BILE ACCUMULATES IN LIVER

CHOLESTATIC JAUNDICE

BILLIARY CIRRHOSIS

BACTERTIAL PROLIFERATION

ABNORMAL FAT DIGESTION

GALLBLADDER AND DUCT INFECTION

DIARRHEA

RUPTURE OF GALLBLADDER BLOOD FLOW AND LYMPHATIC DRAINAGE AS COMPROMISED

CHOLECYSTITIS

S/SX • Pain in right upper quadrant • Anorexia, nausea and vomiting • Pain radiate to the back

MUCOSAL SCHEMIA AND NECROSIS

PATHOPHYSIOLOGY CLIENT BASED Modifiable: HIGH FAT DIET

Non-modifiable: 51 YEARS OLD

↑ BILIARY CHOLESTEROL SATURATION

CRYSTALLIZATION OF BILE CHOLESTEROL GALLSTONE IN BILE DUCTS

BILE STASIS

BACTERIAL PROLIFERATION

OBSTRUCTION IN THE CYSTIC DUCT

CHOLECYSTITIS

S/SX >Pain in right hypochondriac region >feeling of fullness >nausea and flatulence CHOLEDOCHOLETHIASIS RUPTURED GALL BLADDER CHOLECYSTECTOMY

• • • • •

Complications: PAIN ON INCISION SITE ↑RESPIRATORY RATE ↓BLOOD PRESSURE CLAY COLORED STOOL DISTURBED SLEEP PATTERN

GALLBLADDER AND DUCT INFECTION

Nursing Care Plan # 1 POST-OPERATIVE ASSESSMENT S>“Masakit yung inopera sa akin”, as verbalized by the patient. > pain scale of 7/10 O >weak in appearance >guarding behavior/selfprotective behavior >limited movement >grimace upon movement > irritable and restless Nursing Diagnosis: Acute pain and discomfort related to surgical incision.

SCIENTIFIC EXPLANATION Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and duration of less than 6 months.

PLANNING

INTERVENTION

RATIONALE

> Within one hour of appropriate nursing intervention, the patient’s pain scale will alleviate from 7/10 to 3/10.

Independent: > Offer divertional activities such as reading newspaper or magazines, socialization with others or listening radio.

> Heighten one’s concentration upon nonpainful stimuli to decrease one’s awareness and experience of pain.

> Monitor vital signs: (RR and BP) > Instruct deep breathing exercises.

> vital signs usually altered in acute pain > to improve pulmonary gas exchange or to maintain respiratory function

> Provide comfort measures such as backrub and changing position every 2 hours.

> to provide nonpharmacological pain management and to prevent pressure ulcer

> Provide quiet environment and

> to provide comfort and prevent fatigue

EXPECTED OUTCOMES >After one hour of appropriate nursing intervention, the patient’s pain scale will alleviate from 7/10 to 3/10 as evidenced by: a. can move freely b. verbalized increase level of comfort

calm activities. > Encourage adequate rest periods. Dependent: > Administer analgesics as indicated to maximal dosage as needed.

> to prevent fatigue

> to maintain “acceptable” level of pain or to alleviate or totally eliminate pain

Nursing Care Plan # 2 POST-OPERATIVE ASSESSMENT

SCIENTIFIC EXPLANATION S> “Nanghihina >Introduction of ako” as verbalized spinal anesthesia by the patient into the subarachnoid space O >grimace at the lumbar area >pale and weak in usually L4 and L5 appearance which causes >mostly confined on anesthetic effect or bed the absence of >restless sensation in the >limited lower extremities movements and lower abdomen >inability to perform resulting traumatic ADL or pathophysiologic damage to their NURSING tissue causing body DIAGNOSIS: weakness >Activity intolerance r/t generalize weakness

PLANNING

INTERVENTION

> Within 2 to 3 hours of appropriate nursing intervention the patient will be able to demonstrate increase activity tolerance.

Independent: > Plan care with rest periods between activities >Assist in self care activities, before ambulation >Promote comfort measures and provide for relief of pain. >Perform ROM exercise (active assistive).

>Encourage participation in self care and divertional or recreational activities. >Observe and document skin integrity at least 3

RATIONALE

EXPECTED OUTCOMES > After 2 to 3 hours >To reduce or of appropriate prevent fatigue. nursing >To increase mobility interventions the and to protect or patient will prevent patient from demonstrate activity injury. tolerance as >To enhance ability evidence by: to participate in a. verbalization of activities. patients mobility progression. >Inability rapidly b.demonstration of contributes to muscle patients positive shortening and attitudes towards changes in activities. periarticular and c. patients wide cartilaginous joint understanding about structure which the importance of contribute to the activity tolerance. limitation of motion. >To enhance self concept and sense of independence. >Activity intolerance may lead to pressure ulcer.

times within the shift. >Emphasize adequate intake of fluids at least 15002000 ml and nutritious foods such as fruits and vegetables >Encourage to maintain positive attitude; suggest use of relaxation techniques such as deep breathing exercise. >Pr> Provide emotional sup support and encouragement to the client to gradually increase activity

>Promotes well being and maximizes energy production.

>To enhance sense of well being.

>Fear of breathlessness, pain or falling may decrease willingness to increase activity.

Nursing Care Plan # 3 POST-OPERATIVE ASSESSMENT S> O: > with incision at the right upperquadrant, characterized by reddish color > body weakness noted > blood results: - WBC: 12.0(4.110.9) -Gran: 9.0 (2.0-7.8) - RBC: 3.84 (4.26.3) - Hct: 326g/L (370510g/L) -MCHC: 371g/L (310-360g/L) -Hgb: 115g/L (120180g/L) - Plt:499 (140440g/L) Nursing Diagnosis: Risk for infection r/t broken skin.

SCIENTIFIC EXPLANATION Infection indicates a host interaction with an organism or an infection agent. Colonization of this agent may damage a human cell and the body’s major defense to fight these agents is the increased in the body’s temperature.

PLANNING

INTERVENTION

RATIONALE

> Within 8 hours of appropriate nursing intervention, the patient will be free from manifesting signs and symptoms of infection.

Independent: >Inspect the skin for pre-existing irritation, redness, swelling or burning sensation.

> Presence of these symptoms may be an indicative sign of infection.

>Provide sterile wound care and exercise proper hand washing.

>To prevent cross contamination and possibility of infection.

>Instruct patient not to touch the incision site.

>Minimize opportunity for contamination.

>Monitor VS: Note for signs of fever as necessary.

>Fever may reflect developing infection.

>Assist in self care activities.

>To prevent further injury.

EXPECTED OUTCOMES After 8 hours of appropriate nursing intervention, the patient is free from signs and symptoms of infection as evidenced by: a. afebrile b. (-) redness, swelling, burning sensation on the incision site

Nursing Care Plan # 4 POST-OPERATIVE ASSESMENT

SCIENTIFIC EXPLANATION S> Ø > Vague, uneasy feeling of O>Expressed discomfort or concerns due to dread change in life accompanied by events autonomic > restlessness response. > worried about his condition > unpleasant thoughts about any event related to death or dying > feelings of hopelessness Nursing Diagnosis: Anxiety r/t change in health status.

PLANNING

INTERVENTION

> Within the Independent: shift, the patient >Facilitate development will as a trusting relationship acknowledge with patient and family feelings and identify healthy ways to deal with them. >Provide open, nonjudgmental environment. Use therapeutic communication skills.

RATIONALE

EVALUATION

> Trust is necessary before patient and family can feel free the open personal lines and communication with hospice team and address sensitive issues.

> After the shift, the patient acknowledged feelings and identify healthy ways to deal with them.

>Promotes and encourage dialogue about feelings and concerns.

>Encourage verbalization of thoughts and concerns and accept expressions of sadness and anger.

>Patient may feel supported expression of feelings by understanding that deep and often conflicting emotions are normal in this situation.

>Reinforce teaching regarding disease process and treatments and provide information as requested. Be honest; do not give false hope while providing emotional support.

> Patient/SO’s benefit from factual information. Honest answer promotes trust.

Nursing Care Plan # 5 POST-OPERATIVE ASSESSMENT S>“Hindi ko alam ang gagawin sa sugat ko” as verbalized by the patient. O> uncooperative > irritable > inability to understand procedures > lack of interest > unfamiliarity with information Nursing Diagnosis: > Knowledge deficit r/t disease condition

SCIENTIFIC EXPLANATION Lack of information regarding his condition.

PLANNING >After 3 hours of nursing interventions the patient will verbalize understanding about the disease process

INTERVENTION Independent: > Review disease process, surgical procedure or prognosis.

RATIONALE >Provides knowledge base on which patient can make informed choices.

> Demonstrate care of incisions or dressing or drains.

> Promotes independence in care and reduces risk of complications.

>Emphasize importance of maintaining low fat diet, eating small frequent meals, gradual reintroduction of foods or fluids containing fats over 4 to 6 month period.

>During initial 6 months after surgery, low fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats.

> Discuss avoiding or limiting use of

>Minimizes the risk of

EXPECTED OUTCOMES > After 3 hours of nursing intervention the patient was able to verbalize understanding of the disease process.

alcoholic beverages. > Inform patient that loose stools may occur for several months.

pancreatic involvement. > Intestines require time to adjust to stimulus of continuous output of bile.

>Identify signs and symptoms requiring notification of healthcare provider like dark urine, jaundiced color of eyes or skin, clay colored stools.

> Indicators of obstruction of bile flow or altered digestion, requiring further evaluation and intervention.

> Review activity limitations depending on individual situation

> Resumption of usual activities is normally accomplished within 4-5 weeks.

C. Implementation i. Medical Management I. IVF, BT, NGT, Nebu, TPN, Oxygen Medical Management/ Date Ordered/ Treatment Performed Date Changed/ Date Continued PLRS 1L regulated @ Date ordered: 10-15 gtts/min. February 19, 2009 Date performed: February 19, 2009 Date Changed: February 20, 2009 Date replaced: February 20, 2009

General Description

Indication/ Purposes

Client Reaction to Treatment

An Isotonic solution that contains multiple electrolytes in roughly the same concentration as found in plasma; provides 9 cal/L.

Used in treatment of hypovolemia, burns, fluid loss as bile or diarrhea, and for acute blood loss replacement.

None

NURSING RESPONSIBILITIES Before: 1. Inspect each container. Read the label. Ensure solution is the one ordered and is with in the expiration date. 2. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter. Any container which is suspect should not be used. 3. Use only if solution is clear and container and seal are intact. After: 1. Watch for infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia. 2. Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent monitoring of electrolytes levels is essential. 3. Monitor the regulation of the IVF.

4. Check for any signs of any infiltration complication in the IV site.

Medical Management/ Treatment D5LR 1L regulated @ 30 gtts/min.

D5LR 1L regulated @ 10-15 gtts/min.

Date Ordered/ Performed Date Changed/ Date Continued Date ordered: February 20, 2009 Date performed: February 20, 2009 Date Changed: February 21, 2009 Date replaced: February 21, 2009

General Description

Indication/ Purposes

Client Reaction to Treatment

hypertonic. 5% Dextrose in Lactated Ringer’s Injection is sterile, nonpyrogenic and contains no bacteriostatic or antimicrobial agents. This product is intended for intravenous administration.

This Solution is indicated for use in adults and pesiayric patients as a source of electrolytes, calories and water for hydration.

None

Date ordered: February 21, 2009 Date performed: February 21, 2009 Date Changed: February 22, 2009 Date discontinued: February 22, 2009

NURSING RESPONSIBILITIES Before: 1. Inspect each container. Read the label. Ensure solution is the one ordered and is with in the expiration date. 2. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter. Any container which is suspect should not be used.

3. Use only if solution is clear and container and seal are intact. After: 1. Watch for infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia. 2. Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent monitoring of electrolytes levels is essential. 3. Watch for sings and symptoms of potassium intoxication include paresthesias of the extremeties, are flexia, muscular or respiratory paralysis, mental confusion, weakness, hypotension, cardiac arrhythmias, heart block, electrocardiographic abnormalities and cardiac arrest. 4. Monitor the regulation of the IVF. 5. Check for any signs of any infiltration complication in the IV site. Medical Management/Treatment  T-tube

Date ordered/Date Preformed/Date Change/Date Continued February 9, 2009

General Description

Indication/Purpose

>a narrow flexible tube in the form of a T that is used for drainage especially of the common bile duct

T-tube is inserted to preserve the patency of the common duct and to ensure drainage of bile out of the body until edema in the common bile duct has subsided enough for bile to drain into the duodenum normally.

Client Reaction to the Treatment None

Nursing Responsibility: If the patient is being discharged with the T-tube in place, the following instructions will be given: 1. The patient must have instruction about whether the tube should be connected to continuous drainage, clamped continuously, or drained intermittently.  If it is drained continuously, the patient must know how to empty the bag, the importance of keeping the bag below the level of the T-tube insertion site, and ways to maintain mobility with a continuous drainage system. 2. The patient must be instructed about the self-monitoring that will be necessary.  Assessment for infection (redness, warmth and swelling at insertion site, temperature elevation, or purulent drainage from Ttube site).  Assessment for obstruction (recurrence of pain in right upper quadrant, bile drainage around T-tube, recurrence of nausea and vomiting, clay-colored stools, mahogany urine, or jaundice).  Assessment for tube dislodgement (sudden decrease in drainage or evidence that tube has shifted). 3. The patient will be instructed to report signs and symptoms or complications immediately. Medical Management/Treatment > Cholangiogram

Date ordered/Date Preformed/Date Change/Date Continued February 9, 2009

General Description

Indication/Purpose

> an x-ray film on the bile ducts produced after injection of a radiopaque contrast medium.

To visualize gallbladder and bile duct and to determine the exact location of the stones.

Nursing Responsibility: BEFORE: 1. Ask the patient if he is allergic to sea foods or iodine. 2. Explain to the patient the procedure to prevent or reduce anxiety 3. Monitor VS prior to procedure. AFTER: 1. Patient should remain on bed after the procedure.

Client Reaction to the Treatment None

2. Monitor VS. 3. Assess for any bleeding on the incision site. Medical Date ordered/Date Management/Treatment Preformed/Date Change/Date Continued > Peritoneal lavage February 9,2009

General Description

Indication/Purpose

> involves the instillation of 1 L of warmed LR’s or normal saline solution in to the abdominal cavity.

For the cleaning of excess materials (dye) left during cholandiogram.

Client Reaction to the Treatment None

Nursing Responsibility: BEFORE 1. Explain to the patient the procedure to prevent or reduce anxiety 2. Monitor VS prior to procedure AFTER: 1. Secure tunings of the lavage in a drainage bottle to avoid leak. 2. Monitor the amount and characteristics of the secretions. 3. Monitor VS and signs of infection such as redness in the area of insertion and any purulent discharges. ii. Drugs NAMES OF DRUG

DATE ORDERED/DATE TAKEN/GIVEN, DATE CHANGED/DATE DISCONTINUED

ROUTE ADMIN. & DOSAGE & FREQUENCY OF ADMIN

Generic Name: >Cefuroxime Sodium

Date Ordered: 750 mg IVP every 8  February 9, hours 2009

Brand Name: >Kefurox, Zinacef

Date Taken:

GEN. ACTION, MECH. OF ACTION

INDICATION/S, PURPOSES

CLIENT RESPONSE TO MED W/ ACTUAL S/E

Chemical Effect: >Inhibits cell wall synthesis promoting osmotic instability usually bactericidal.

Perioperative prophylaxis

>No usual allergic response

Therapeutic Effect: > Hinders or kills susceptible bacteria including many gram positive organism and enteric gram negative bacilli.

 February 9, 2009

Pharmacologic Class: >Cephalosporin Therapeutic Class: >Antibiotic

NURSING RESPONSIBILITIES BEFORE:      

Check for doctor’s order. Assess patient’s infection before therapy and regularly thereafter. Before giving first dose, obtain specimen for culture and sensitivity tests. Before giving first dose, ask patient about previous reactions to cephalosporins or penicillin. Assess patient’s and family’s knowledge of drug therapy. Instruct patient to take drug exactly as prescribed, even if he feels better

DURING:  Instruct patient to take oral drug with food to enhance absorption.  Explain that tablets may crushed, but drug has bitter taste that difficult to mask even with food. AFTER:  Tell patient to report any adverse reactions immediately.  Be alert for adverse reactions and drug interactions. NAMES OF DRUG

Generic Name:

DATE ORDERED/DATE TAKEN/GIVEN, DATE CHANGED/DATE DISCONTINUED

Date ordered:

ROUTE ADMIN. & DOSAGE & FREQUENCY OF ADMIN

100mg IVP q 8°

GEN. ACTION, MECH. OF ACTION

Chemical action:

INDICATION/S, PURPOSES

>

Moderate

CLIENT RESPONSE TO MED W/ ACTUAL S/E

to > Patient is free

>Tramadol Hydrochloride Brand Name: > Ultram

Date taken:  February 12, 2009

Pharmacologic class: Opioid agonist Therapeutic Analgesic

>Unknown; moderately centrally acting pain synthetic analgesic compound not chemically related to opioids that is thought to bind to opioid receptors and inhibits reuptake of norepinephrine and serotonin.

 February 12, 2009

class:

severe from pain.

Therapeutic effect: >Relieves pain NURSING RESPONSIBILITIES: BEFORE:  Check for doctor’s order.  Assess patients pain before starting therapy and regularly thereafter to monitor the drugs effectiveness. AFTER:  Monitor patient for drug dependence.  Be alert for adverse reactions and drug interaction.  For better analgesic effect, give drug before onset of intense pain  Monitor CV and respiratory status.  Tell ambulatory patient to be careful when getting out of bed and walking NAMES OF DRUG

Generic Name:

DATE ORDERED/DATE TAKEN/GIVEN, DATE CHANGED/DATE DISCONTINUED

Date ordered:

ROUTE ADMIN. & DOSAGE & FREQUENCY OF ADMIN

> 1 amp IVP q 8°

GEN. ACTION, MECH. OF ACTION

Chemical effect:

INDICATION/S, PURPOSES

>

Duodenal

CLIENT RESPONSE TO MED W/ ACTUAL S/E

or > No response

> Ranitidine HCl  February 9, Brand Name: 2009 > Zantac Pharmacologic Date taken: class:  February 9, >H2-Receptor 2009 Antagonist Therapeutic class: >Antiulcerative

> Competitively gastric ulcer inhibits action of H2 at receptor sites of parietal cells, decreasing gastric acid secretion. Therapeutic effect: > Relieves GI discomfort

NURSING RESPONSIBILITIES BEFORE:    

Check for doctor’s order. Teach patient to avoid alcohol. Instruct patient to take drug with or without food Urge patient not to smoke cigarettes; smoking may increase gastric acid secretion and worsen disease

AFTER:  Be alert for adverse reaction and drug interaction NAMES OF DRUG

Generic Name: > Metronidazole Brand Name: > Flagyl

DATE ORDERED/DATE TAKEN/GIVEN, DATE CHANGED/DATE DISCONTINUED

ROUTE ADMIN. & DOSAGE & FREQUENCY OF ADMIN

Date ordered: > 500 mg IVP q 8°  February 9, 2009

GEN. ACTION, MECH. OF ACTION

INDICATION/S, PURPOSES

CLIENT RESPONSE TO MED W/ ACTUAL S/E

Chemical effect: > Direct-acting trichomonazide and amebicide that

> To prevent postoperative infection

> Patient is free from infection as evidenced by temperature within

Pharmacologic Date taken: Class:  February 9, > Nitroimidazole 2009 Therapeutic Class: > Antibacterial; antiprotozoal, amebicide

works at both intestinal and extraintestinal sites

normal range

Therapeutic effect: > Hinders growth of selected organisms, including most anaerobic bacteria and protozoa

NURSING RESPONSIBILITIES BEFORE:  Check for doctor’s order.  Tell patient not to use alcohol or drugs that contain alcohol during therapy and for at least 48 hours after therapy is completed  Urge patient to complete full course of therapy even if he feels better DURING:  Tell patient that metallic taste and dark or red-brown urine may occur AFTER:  Be alert for adverse reaction and drug interactions

NAMES OF DRUG

Generic Name: > Ketorolac Brand Name: > Acular

DATE ORDERED/DATE TAKEN/GIVEN, DATE CHANGED/DATE DISCONTINUED

ROUTE ADMIN. & DOSAGE & FREQUENCY OF ADMIN

GEN. ACTION, MECH. OF ACTION

INDICATION/S, PURPOSES

Date ordered: > 30 mg 1 amp. IVP Chemical effect: > Short- term q 8 > May inhibit management of pain  February 9, prostaglandin 2009 synthesis Date taken:

CLIENT RESPONSE TO MED W/ ACTUAL S/E

> Patient is free from pain

Pharmacologic Class: > NSAID Therapeutic Class: > Analgesic, antiinflammatory

 February 9, 2009

Therapeutic effect: > Relieves pain and inflammation

NURSING RESPONSIBILITIES BEFORE:  Check for doctor’s order.  Assess patient’s pain before and after drug therapy  Explain that drug is intended for short-term management AFTER:  Advise patient to report persistent or worsening pain.  Teach patient to re4cognize and immediately report signs and symptoms of GI bleeding. iii. Diet TYPE OF DIET

Diet as tolerated

DATE ORDERED, DATE STARTED,DATE CHANGED

Date ordered: February 19, 2009 Date Started: , February 19, 2009 Date Changed:

GENERAL DESCRIPTION

It is a normal diet planned to provide the recommended daily allowance for essential nutrients but designed to meet the caloric needs of a bedridden or ambulatory patients whose condition does

INDICATION/S, PURPOSE/S

It serves as a basis for the modifications of therapeutic diets in the hospital.

SPECIFIC FOODS TAKEN

Rice, meat, vegetables and fruits.

CLINT RESPONSE AND/OR REACTION TO THE DIET

The patient accepts the ordered diet and he was able to eat the served foods. It is good to the patient’s appetite and meets the caloric need. He understands and

February 20, 2009 High protein diet

not require any dietary modification for therapeutic purposes.

Date ordered: Diet that prescribes a February 20-23, specific level of protein 2009 fraction or amino acid

appreciates the benefits of the diet. Diet tolerated It is used in post operative patients For rapid tissue repair.

2 egg white, and meat

To prevent aggravation of accumulation of fats in the common bile duct.

Lean or grilled meat The patient tries to and fish. eat the served food and understands the benefits of the diet in his condition. Diet tolerated.

Date Started: , February 20, 2009

The patient accepts the ordered diet and he was able to eat the served foods. He understands and appreciates the benefits of the diet. Diet tolerated

Date Changed: February 24, 2009 Low fat

Date ordered: Diet that prescribes a February 20-23, specific level of fat for 2009 patients whose condition requires a small amount Date Started: , of fat fraction. February 20, 2009 NURSING RESPONSIBILITIES

Before: 1. Emphasize the importance of the diet 2. Discuss the food sources included in the diet. 3. Explain to the client the purpose of the diet. After: 1. Assess the client’s response to the diet.

2. Assess the client’s understanding about the diet.

iv. Activity or Exercise TYPES OF EXERCISE

Deep Breathing Exercises

DATE ORDERED, DATE STARTED, DATE CHANGED.

Date ordered: February 19-23, 2009 Date Started: , February 19, 2009 Date Changed: February 24, 2009

GENERAL DESCRIPTION

Deep breathing is a relaxation technique that can be self-taught. Deep breathing releases tension from the body and clear the mind, improving both physical and mental wellness.

INDICATIO/S, PURPOSE/S

Breathing exercises can be used to optimize gas exchange, promote lung expansion, minimize atelectasis, decrease dyspnea, and promote secretion removal especially after prolonged inactivity.

Date ordered: February 19-23, 2009 Date Started: , February 19, 2009 Date Changed: February 24, 2009

Maximum possible movement for a joint. Normal muscle strength for complete voluntary range of motion.

Participate willingly in the activity. Patient verbalizes alleviated pain sensation and serves as an effective relaxation technique. Understands and appreciates the benefits of the exercise

We tend to breathe shallowly or even hold our hold our breath when we are feeling anxious Range of Motion Exercise

CLIENT’S RESPONSE/REACTION TO THE ACTIVITY/EXERCISE

Strengthens muscle to prevent muscle atrophy or weakness among patients who mostly confined on bed. Promotes blood circulation.

Participate willingly in the activity. Understands and appreciates the benefits of the exercise

Daily walking activity

Date ordered: February 23, 2009

Walking with bilateral Date Started: , equal strengths. Activity February 23, 2009 to maintain balance NURSING RESPONSIBILITIES: DEEP BREATHING EXERCISE BEFORE: 1. Explain the procedure to gain patients cooperation. 2. Discuss the benefits of the exercise

Increases mobilization, strengthens muscle and promotes balance.

DURING: 1. Help the client perform deep breathing exercise. 2. Advise to rest between activities. AFTER: 1. Encourage to perform exercise at last 1 hour before every meal. 2. Encourage verbalization of increased comfort. RANGE OF MOTION EXERCISE BEFORE: 1. Explain the procedure to gain patients cooperation. 2. Discuss the benefits of the exercise DURING: 1. Help the client perform deep breathing exercise. 2. Advise to rest between activities. 3. Ensure the patient’s safety. AFTER: 1. Encourage to perform active ROM exercise at last 1 hour before every meal. 2. Encourage verbalization of any pain after the activity

Participate willingly in the activity. Understands and appreciates the benefits of the exercise

3. Encourage verbalization of increased comfort. DAILY WALKING ACTIVITY: BEFORE: 1. Explain the procedure to gain patients cooperation. 2. Discuss the benefits of the exercise 3. Advise to perform activity with enough energy to prevent fatigue. DURING: 1. Assist the patient or advise the patient to perform daily walking activities with the assistance of SO’s. 2. Advise to rest between activities. 3.Ensure the patient’s safety. AFTER: 1. Encourage daily walking activities. 2. Encourage verbalization of any pain after the activity 3. Encourage verbalization of increased comfort. v. Surgical Management Name of Procedure Choledocholithotomy

Date ordered/Date Preformed February 9,2009

Nursing Responsibility BEFORE: 1. Secure consent 2. Explain to the patient the procedure. 3. Monitor VS. 4. NPO post midnight.

General Description

Indication/Purpose

Operation to make an incision on the common bile duct to remove gallstones.

Removal of stones on the common bile duct.

Client Reaction to the Operation Reduce anxiety

AFTER: 1. Maintain patient flat on bed for 8 hours. 2. Monitor for bleeding on the incision site. 3. Monitor Vs. 4. NPO until positive flatus. Name of Procedure Choledochostomy

Date ordered/Date Preformed February 9, 2009

General Description

Indication/Purpose

Making an incision in the common duct, usually removal of stones. After the stones have been evacuated, a tube is usually inserted into the duct for drainage of bile until edema subsides.

Removal of stones

Client Reaction to the Operation Reduce anxiety

General Description

Indication/Purpose

Client Reaction to the

Nursing Responsibility BEFORE: 1. Secure consent 2. Explain to the patient the procedure. 3. Monitor VS. 4. NPO post midnight. AFTER: 1. Maintain patient flat on bed for 8 hours. 2. Monitor for bleeding on the incision site. 3. Monitor Vs. 4. NPO until positive flatus Name of Procedure

Date ordered/Date

Cholecystectomy

Preformed February 9, 2009

Making an incision for the removal of gallbladder

Removal of gallbladder

Operation Reduce anxiety

SOAPIE # 1 POST-OPERATIVE S: “Masakit yung inopera sa akin”, as verbalized by the patient. O: 8:15pm> received patient flat on bed > with ongoing IVF of D5LRS 1L regulated at 30-31gtts/min at the level of 800cc infusing well > pain scale of 7/10 >weak in appearance >guarding behavior/self- protective behavior >limited movement >grimace upon movement > irritable A: Acute pain and discomfort related to surgical incision. P: Within one hour of appropriate nursing intervention, the patient’s pain scale will alleviate from 7/10 to 3/10. I: > Offered divertional activities such as reading newspaper or magazines, socialization with others > Monitored vital signs specifically RR and BP. > Instructed deep breathing exercises. > Provided comfort measures such as backrub and changing position every 2 hours. > Provided quiet environment and calm activities. > Encouraged adequate rest periods. > Administered analgesics as indicated to maximal dosage as needed. E: >After one hour of appropriate nursing intervention, the patient’s pain scale will alleviated from 7/10 to 3/10 as evidenced by: a. can move freely b. verbalized increase level of comfort

SOAPIE # 2 POST-OPERATIVE S: > “Nanghihina ako” as verbalized by the patient. O: 8:15pm > received patient flat on bed. > with IVF of D5LRS 1L regulated at 30-31 gtts/min at 800 cc level, infusing well >grimace >pale and weak in appearance >mostly confined on bed >restless >limited movements >inability to perform ADL A: >Activity intolerance r/t generalized weakness. P: > Within 2 to 3 hours of appropriate nursing intervention the patient will be able to demonstrate increase activity tolerance I: > Planned care with rest periods between activities >Assisted in self care activities. >Promoted comfort measures and provide for relief of pain. >Performed ROM exercise (active assistive). >Encouraged participation in self care and divertional or recreational activities. >Observed and document skin integrity at least 3x within the shift. >Emphasized adequate intake of fluids at least 1500-2000 ml and nutritious foods such as vegetables and fruits . >Encouraged to maintain positive attitude; suggest use of relaxation techniques such as deep breathing exercise. >Provided emotional support and encouragement to the client to gradually increase activity. E: > After 2 to 3 hours of appropriate nursing interventions the patient had demonstrated activity tolerance as evidence by: a. verbalization of patients mobility progression. b. demonstration of patients positive attitudes towards activities. c. patients wide understanding about the importance of activity tolerance.

SOAPIE # 3 POST-OPERATIVE S> O: > with incision at the right upperquadrant, characterized by reddish color > body weakness noted > blood results: - WBC: 12.0(4.1-10.9) -Gran: 9.0 (2.0-7.8) - RBC: 3.84 (4.2-6.3) - Hct: 326g/L (370-510g/L) -MCHC: 371g/L (310-360g/L) -Hgb: 115g/L (120-180g/L) - Plt:499 (140-440g/L) A> Risk for infection r/t broken skin. P> Within 8 hours of appropriate nursing intervention, the patient will be free from manifesting signs and symptoms of infection such as swelling, redness.. I >Inspected the skin for pre-existing irritation, redness, swelling or burning sensation. >Provided sterile wound care and exercise meticulous hand washing. >Instructed patient not to touch the insertion site. >Monitored VS: Note for signs of fever as necessary. >Assisted in self care activities. E> After 8 hours of appropriate nursing intervention, the patient is free from signs and symptoms of infection as evidenced by: a. afebrile b. (-) redness, swelling, burning sensation

SOAPIE # 4 POST-OPERATIVE S> Ø O> Expressed concerns due to change in life events > Restlessness > Worried about his condition > Unpleasant thoughts about any event related to death or dying > Feelings of hopelessness A>Anxiety r/t change in health status. P> Within the shift, the patient will acknowledge feelings and identify healthy ways to deal with them I>Facilitated development as a trusting relationship with patient and family > Provided open, nonjudgmental environment. Use therapeutic communication skills. > Encouraged verbalization of thoughts and concerns and accept expressions of sadness and anger. >Reinforced teaching regarding disease process and treatments and provide information as requested. Be honest; do not give false hope while providing emotional support. E> After the shift, the patient acknowledged feelings and identify healthy ways to deal with them.

SOAPIE # 5 POST-OPERATIVE S: >“Hindi ko alam ang gagawin sa sugat ko” as verbalized by the patient. O: 3:00pm > received patient flat on bed > With IFC intact at level of 100cc > With ongoing IVF of D5LRS 1L regulated at 30-31gtts/min at the level of 800cc infusing well > Uncooperative > Irritable > Inability to understand procedures > Lack of interest > Unfamiliarity with the information A: Deficit knowledge regarding disease condition. P: After 3 hours of nursing interventions the patient will verbalize understanding of therapeutic needs. I: · Reviewed disease process, surgical procedure or prognosis. · Demonstrated care of incisions or dressing or drains. · Emphasized importance of maintaining low fat diet, eating small frequent meals, gradual reintroduction of foods or fluids containing fats over 4 to 6monthperiod. · Discussed avoiding or limiting use of alcoholic beverages. · Informed patient that loose stools may occur for several months. · Identified signs and symptoms requiring notification of healthcare provider like dark urine, jaundiced color of eyes or skin, clay colored stools. · Reviewed activity limitations depending on individual situation E: · After 3 hours of nursing interventions the patient was able to verbalize understanding of the disease process.

D. EVALUATION 1. Patient’s daily program in the hospital Daily program

1st Day (Feb 19 2009)

2nd Day (Feb 20 2009)

3rd Day (Feb 21 2009)

4th Day (Feb 22 2009)

5th Day (Feb 23 2009)

Nursing Problems 1. Acute pain and discomfort related to surgical incision. 2. Activity intolerance r/t generalize weakness 3. Risk for infection related to broken skin 4. Anxiety related to change in health status 5. knowledge deficit r/t disease condition

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• Temperature: 5 am-36.5 °C 10 am-37.2 °C 2 pm-37.5 °C 4pm-37.5 °C 6pm-37.4 °C 10 pm-36.5 °C •

• Temperature: • Temperature: • Temperature: • Temperature: 10 am-37.2 °C 6 am-37 °C 5 am-36.7 °C 5 am-37 °C 2 pm-37.5 °C 10 am-37 °C 4pm-37.5 °C 2 pm-37.4 °C 6pm-37.4 °C 10 pm-36.5 °C •

•

•

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Respiratory Rate: 5 am-26 cpm 10 am-18 cpm 2 pm-21 cpm 4pm-30 cpm 6pm-28 cpm 10 pm-24 cpm

Respiratory Rate: 10 am-26 cpm 2 pm-30 cpm 4pm-29 cpm 6pm24 cpm 10 pm-28 cpm

Respiratory Rate: 6 am-24 cpm 10 am-30 cpm 2 pm-33 cpm

Respiratory Rate: 5 am-26 cpm

Respiratory Rate: 5 am-25 cpm

• Pulse Rate: 5 am-70 10 am-65 2 pm-73 4pm-79 6pm-76 10 pm-72

• Pulse Rate: 10 am-71 2 pm-74 4pm-77 6pm-76 10 pm-75

• Pulse Rate: 6am-72 10 am-75 2 pm-69

• Pulse Rate: 5 am-70

• Pulse Rate: 5 am-69

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Blood Pressure: 5 am-120/90 mmHg 10 am-120/80 mmHg 2 pm-120/80 mmHg 4pm-110/70 mmHg

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Blood Pressure: 10 am-100/80 mmHg 2 pm-110/70 mmHg 4pm-110/70 mmHg 6pm-110/70 mmHg

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Blood Pressure: 6 am-110/80 mmHg 10 am-100/80 mmHg 2 pm-100/70 mmHg

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Blood Pressure: 5 am-110/70 mmHg

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Blood Pressure: 5 am-100/80 mmHg

Diagnostic & Lab. Procedures Medical and Surgical Mgt. Drugs

Diet Exercise

6pm-110/80 mmHg 10 pm-110/70 mmHg

10 pm-100/80 mmHg

none

Blood chemistry

none

none

none

Vital signs monitoring PLRS Pro-tab Tramadol Cefuroxime Gentamycin Metronidazole High protein diet DAT

Vital signs monitoring PLRS Pro-tab Tramadol Cefuroxime Gentamycin Metronidazole High protein diet DAT

Vital signs monitoring PLRS Pro-tab Tramadol Cefuroxime Gentamycin Metronidazole High protein diet DAT

Vital signs monitoring PLRS Pro-tab Tramadol Cefuroxime Gentamycin Metronidazole High protein diet DAT

Vital signs monitoring PLRS Pro-tab Tramadol Cefuroxime Gentamycin Metronidazole High protein diet DAT

Range of motion

Range of motion

Range of motion

Range of motion

Range of motion

2. Discharge Planning i. General condition of the patient upon discharge It was February 24, 2009, when the patient was discharge. He was able to sit on bed without assistance. He was able to consume all the food on the tray. He is still with his t-tube intact. The doctor ordered the patient for OPD follow-up after one week, regular cleaning, changing of dressings at the insertion site. The patient was also advised to continue low fat and low sodium diet. ii.

METHOD M: > Ciprofloxacin 500mg twice a day >Mefenamic Acid 500mg 3 times a day > Tramadol 100mg once a day E: > Activities of daily living (ADL) T: > Ø H: > •

Encouraged to continue high protein diet, low fat-low sodium diet.

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Encouraged to continue taking the prescribed medicine.

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Encouraged to resume activities of daily living.

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Emphasized the importance of maintaining proper hygiene, especially cleaning the t-tube insertion site.

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Teach pt. and significance others to report any signs of infection like redness, warmth and swelling at insertion site, temperature elevation, or purulent drainage from T-tube site to avoid further complications.

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Emphasized to significant others the importance of emotional support.

O: > Follow up checkup after one week D: > Low fat low sodium high in protein

III. CONCLUSION Discipline is one of the major factors needed by the patient with choledolithiasis. He must be able to know on how to tolerate his foods particularly the limitations of fats and cholesterol intake which are one of the major factors that lead for the formation of stones in the gallbladder`. Proper balance nutrition is a good practice for the alleviation and minimal occurrence of this kind of disease. With regards to the patients medical and surgical managements, occurrence of problems such as risk for infection prior to surgery may be prevented by means of proper cleaning of the incision site and medications should be taken as prescribed with proper dosages to avoid any of its adverse or side effects. As we work this kind of study, the group gained wide knowledge and understanding about Choledolithiasis, the problems related to this condition and the different management that should be prioritized in order for us to have positive outcomes in nursing problems. Good nursepatient relationship was also established as we conduct this study. This study helps us to identify measures to prevent complications of the disease and also for them to have understanding about this condition and to practice independent implementation for this kind of disease IV. RECOMMENDATION As nursing students, we should have wide knowledge about our patient’s condition in order for us to give appropriate managements. So we group B3 recommend to our patient to maintain proper diet that is high in protein for faster tissue repair and low salt-low fat diet to prevent aggravation of disease. Drinking sufficient water for at least 8 glasses or more, may also be helpful for proper circulation of nutrients that patient’ take. Patient should always be practice proper intake of his medication and must always obtain proper hygiene especially on the insertion site of the t-tube to prevent secondary infections. Any abnormalities or adverse effects should report to the physician immediately. Patient should also practice independence to promote sense of well-being.

V. BIBLIOGRAPHY BOOKS: Ackley, Betty J. and Ladwig, Gail B., Nursing Diagnosis Handbook, 7th Edition, 2006. Estes Zator, Mary Ellen. Health Assessment and Physical Examination, 3rd Edition, 2006. Ignativicius and Workman. Medical- Surgical Nursing, Collaborative and Critical Thinking Vol. 1 and 2, 2004. Kozier, Erb, Berman, Synder. Fundamentals of Nursing, Concepts, Process and Practice, 7th Edition, 2004. Lippicott, Williams and Wilkins. Springhouse Nurse’s Drug Guide, 2007. Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions. Smeltzer, Suzanne C. and Bare, Brenda G., Medical- Surgical Nursing, Vol. 2 10th Edition, 2004.

Website http://www.umm.edu/ency/article/000274.htm http://emedicine.medscape.com/article/172216-overview