Calculous Cholecystitis Case Study Sample

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Calculous Cholecystitis

A Case Study

Presented to the Faculty, Ateneo de Davao Universi ty

College of Nursing

Submitted to:

Daphny Grace Peneza, R.N., R.M., M.N.

Clinical Instructor – Panelist for the Case Study Submitted by:

Gino Gregor Palaca Marvin Rey Andrew Pepino

Rio Remonde Kevin Melvin Roa

Krystle Rustia

BSN-3H-4a

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To their respected clinical instructor for this rotation, Daphny Grace Peneza, R.N., R.M., M.N., for her support and guidance to the group. She has imparted knowledge that would furthermore enhance the student’s understanding of their patient’s case, thus making them ready to present this case presentation.

To their client, Meg, and her family, for being open and generous enough to disclose personal information that would be helpful for this study. The group would also like to thank them for their patience throughout the duration of the study and for giving the group the opportunity to care for Selecta and apply what they have learned.

To the proponents’ respective family and friends for their prayers as well as their financial support. They have also been a source of inspiration of the students.

To the members of this group for working hard and giving their efforts, time and resources in conducting the study and for the completion of the written output.

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INTRODUCTION

One of the body organs that we can live without is the gallbladder. However, does this mean it is of no use to the body? The gallbladder is a pear-shaped organ situated underneath the liver. Its function is to store bile and release it as needed for digestion. Bile emulsifies the fats in food, breaking them to small fragments so they can be further digested and absorbed in the small intestine. If the gallbladder is not working as it should, the digestion of fats can be seriously impaired.

One of the common gallbladder diseases is calculous cholecystitis. Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading to poor drainage of bile. Trapped bile can irritate and inflame the walls of the bladder, thus leading to inflammation. Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman & Brandt, 2006). It affects women more often than men and is more likely to occur at the age of 20-50 or over 60. Asians are also more prone to develop pigment stones. Moreover, people who are obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. In the United States, it is estimated that 6.3 million men and 14.2 million women aged 20 to74 had gallbladder disease (Everhart, Khare, Hill, Maurer, 1999). In the Philippines, an extrapolated prevalence of 5, 073, 040 people are affected by the disease (http://digestive.niddk.nih.gov/statistics). Gallstones that do not cause symptoms do not require treatment. However, if gallstones cause, disruptive, recurring episodes of pain, surgical removal of the gallbladder is recommended.

Recently, the Group 3H-4a had a patient who was diagnosed with

symptomatic calculous cholecystitis and underwent laparoscopic

cholecystectomy. The group chose this case for they see it fit for their perioperative concept. Rarely do they interact with patients who had minimally invasive surgery. The proponents are hoping that through this case study, they will be more knowledgeable and aware about such gallbladder disorder and the surgical procedure done for the said disease. They are also interested to know

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the proper and necessary nursing management that will be given to a patient affected by the disease. Moreover, they would also like to impart their learning to their families and their community regarding the prevention and care if ever such condition will arise in the scenario.

As nursing students, they are hoping that this study will help them become more efficient and better nurses in the future. The student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well.

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OBJECTIVES

General objective: Within 2 weeks exposure to various clinical areas, the group should have been able to present a comprehensive case study which explains the pathology, the treatment and the appropriate medical and nursing management regarding the condition of their chosen client. The group also aims to perform the necessary nursing interventions to help alleviate the patient’s condition and improve her health.

Specific Objectives: The proponents also created certain aims that will help them in achieving their general objectives. Within 2 weeks of exposure, the proponents aim to:

Cognitive:

 Gather pertinent data regarding the past and present health history of the patient through interview and assessment;

 Draw the family genogram of the patient;

 Define the complete diagnosis of the patient by directly citing it from three different sources;

 Ascertain the patient’s developmental status using the theories of Robert Havighurst, Erik Erikson and Lawrence Kohlberg;

 Conduct a thorough cephalocaudal assessment obtained from the client;

 Review the anatomy and physiology of the organs affected in the patient’s disease;

 Present the etiology and symptomatology of the disease;

 Trace the pathophysiology of the patient’s disease;

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 Obtain, analyze and interpret laboratory and diagnostic procedures done on the patient and include the normal and abnormal values and findings for comparison, and the specific nursing responsibilities associated with each diagnostic procedure;

 Make drug studies on each drug given to the client, correlate them with the disease process, explain why such drugs were ordered, and present important interventions in administering the drug;

 Identify three nursing theories that can be applied to the patient’s condition;

 Present specific, measurable, attainable, realistic, and time-bounded nursing care plans for the patient;

 Correlate the different nursing theories with the nursing care plans that are presented in this case study;

 Make a discharge plan for the patient with the use of M.E.T.H.O.D.;

 Validate patient’s prognosis according to the following categories: onset of illness, duration of illness, precipitating factors, willingness to take medications and treatment, age, environmental factors and family support;

 Broaden our scope of knowledge about the disease and the appropriate Nursing Care for the patient with the disease;

Psychomotor:

 Find a patient who will be the subject of their case presentation;

 Render health teachings to the patient and her significant others to promote health;

 Provide care based on the various nursing care plans formulated by the researchers and the patient herself;

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 Share information about calculous cholecystitis and the factors that cause the development of such disease and its complications;

 Share how the disease affects those affected by it and the systems involved in its occurrence;

Affective:

 Establish rapport with the patient and significant others;

 Show genuine concern and willingness in serving the client;

 Be aware of the client’s progress on the succeeding interactions;

 Appropriately state the bibliography of all resources used in order to prevent plagiarism and promote honesty.

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PATIENT’S DATA

Client’s Code Name: Meg

Age: 38 years old

Gender: Female

Birth date: November 6, 1971

Address: Upper Sirib, Calinan Davao City

Nationality: Filipino

Religion (Denomination): Christian (Roman Catholic)

Civil Status: Married

Spouse: Bobong

Educational Attainment: 4th year high School

Occupation: House keeper

Height: 5ft 2inches

Weight: 62 kgs.

Health Insurance: Phil Care

Hospital: Davao Medical School Foundation (DMSF)

Vital Signs on Admission: BP: 130/80 mmHg PR: 79 bpm RR: 19 cpm T: 37 ºC

Unit: 3C- 324-5

Chief Complaint: Pain at right upper quadrant

Admitting Physician: Dr. Walter Batucan

Admitting Diagnosis: Acute Cholelithiasis

Final diagnosis Calculous Cholecystitis

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FAMILY BACKGROUND AND HEALTH HISTORY

A. Family Background

Meg is the second child among Mamang and Papang’s four children. All children of Mamang were born through Normal Spontaneous Vaginal Delivery without any complications. She delivered all her children at their house with the help of ―mananabang‖. The family has been residing in Sirib, Calinan Davao City since the marriage of Papang and Mamang. Their home is near their farm.

The client, Meg has 3 siblings namely: Kenny (Male, deceased), Luigi (Male, 30, married), and Dora (Female, 28, married). Meg graduated high school and didn’t to proceed to college because she helped her family tend their farm.

According to the patient, her father and mother are still alive and they suffer from hypertension and diabetes. She said that the family lineage of her mother also suffers from heart problems as well as kidney problems. Two of her uncles on father’s side underwent surgery, cholecystectomy, and had the same condition as Meg. Her older brother died due to motorcycle accident. Luigi was diagnosed with hypertension and Dora had a history of UTI. There was no one else in her immediate family that suffered cholecystitis aside from Meg herself.

Meg got married to Bobong in the 1998. They were blessed with 3 children. Her 3 children were delivered through Normal Spontaneous Vaginal Delivery, all were born in the Maternity clinic in Calinan. Her eldest child is now studying in 4th grade. So far, none of her children suffer a serious illness.

In terms of their expenses, Bobong is the one that provides money for their daily expenses. Bobong is a Supervisor at DABCO and has a wage of approximately 10,000 a month. Meg said that they budget the

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money well for them to have food and to provide the necessary daily needs and expenses. By helping tend to the 2 hectare farm of the patient’s parents, they also get their share. They plant coconut trees, bananas, and pineapples in their farm.

Lifestyle

The patient has sedentary lifestyle. When Meg stopped going to school, she helped her mother with household chores. Right now, she is busy taking care of Bobong and their 3 children. She is the one who cooks, cleans the house, and does the laundry of the whole family. Sometimes, she does gardening in their backyard. According to her, she only works in the house, but still, she experiences fatigue from doing household chores especially since she is the only one who does the laundry.

She reported that she doesn’t smoke, but her husband does; he smokes almost one pack a day. Meg said that she drinks liquor very seldom; she only consumes a half of glass or a glass of liquor occasionally.

The family has good relationship. At night, they watch television together and this serves as their bonding time. Occasionally, they gather together with her relatives when there are fiestas, birthday celebrations and other special occasions.

She is not so active in terms of social organizations such as GKK (Gagmay’ng Kristohanong Katilingban), but she sometimes joins in the events in their community like the fiesta. She sometimes goes to church on Sundays together with her children.

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Meg sleeps around 9:00 o’clock at night and wakes up around 5:00 o’clock in the morning to prepare things needed of her husband. She is the one who cooks the ―baon‖ of her husband for work.

Meg said that she eats at least two times a day in small meals. She said “naga-diet diet man ko kay tabaan nako sa akoang lawas, nagsugod ko katong 36 years old pako, pero karong tuiga giundangan na nako ang pagdiet-diet”. For breakfast she usually eats, ―bulad‖, ―bagoong‖, ―ginamos‖ and bread. Every morning, she always drinks coffee. In a day, she can consume at least 3 cups of coffee. Her lunch and supper are sometimes vegetables that are found in their backyard such as ―kamunggay‖, ―upo‖, ―okra‖, ―talong‖ and ―tinangkong‖. She is not fond of eating pork and beef. She said that before, she limits herself from eating fatty foods since she aimed to lose weight because she was afraid of becoming obese. Also, she is so fond of drinking soft drinks. In a day she can consume 4 glasses of coke. But she also drinks approximately 5-6 glasses of water. She also loves to eat salty foods, especially junk foods. According to her, she has no allergy from any form of food.

B. Past Health History

Meg and her husband preferred to have artificial family planning than natural family planning. She started using birth control pills since she was 36 years old.

She said that she is not sure if she completed her immunizations. Her mother forgot already and the records were lost. They only avail of the services of the health center very seldom. She said that their house was far from the health center so they weren’t able to avail of all of the services. She also experienced common illnesses such as cough, colds, fever, measles and even chickenpox. They only treated it at home, since her mother knows how to make use of different herbal medicines such as

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kalabo, mayana, buyo, gabon, and tawa-tawa. Also, they sometimes bought over-the-counter drugs such as paracetamol, Neozep, and Medicol. With regards to how long she experienced those usual illnesses, she said “dili man jud ko maabtan ug simana sa akoang kalintura ug bisan ubo”.

She experienced measles when she was a 1-year old and had chickenpox when she was 10-year old. Meg had her menarche when she was 11 years old.

Meg reported that she got pregnant with her 1st child at the age of 28; unfortunately, she had miscarriage on the 1st week of pregnancy. She was hospitalized at Robillo Hospital, Calinan Davao City. Completion curettage was performed to her. Again, on her 3rd pregnancy, she had a miscarriage and was hospitalized on the maternity clinic and underwent completion curettage. She reported that in almost all her pregnancies, she experienced an increased blood pressure, usually 140/90. After delivering her third child at the age of 36, Bobong and Meg decided to make use of family planning. Meg started to take birth control pills until now to prevent unexpected pregnancy.

C. History of Present Illness

On the second week of December 2009, Meg felt mild pain at the right upper quadrant of her abdomen. She neglected it thinking that it’s nothing serious and might be just an episode of indigestion. After three days, the pain went away. But after two weeks, pain recurred at a higher scale (5/10). Because of this, she was forced to seek medical advice. She went to Isaac T. Robillo Memorial Hospital Calinan, Davao City and was asked to have ultrasound of the whole abdomen. After 2 days, the result was released and they found out that there were stones in her gallbladder. She was advised by the doctor to undergo surgery, cholecystectomy. However,

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the patient resisted the doctor’s advice due to fear of surgery. She was given medications as an alternative (the patient already forgot the name of medications prescribed). She was instructed by the doctor to increase water intake and have a low fat diet, unfortunately, she wasn’t able to follow the doctor’s order and still continued with her usual lifestyle.

Meg said that she still felt the pain after the check-up but she could still tolerate it. She just took medications that were prescribed by the doctors to alleviate the pain she felt.

Last May 5 this year, three days prior to admission, the patient again experienced right upper quadrant pain which lasted until the present condition. This was characterized to be progressive pain with a pain scale of 8 out of 10. There was no radiation noted and no associated symptoms. Two days prior to admission, pain recurred with a pain scale of 10 out of 10. This prompted Meg to seek consultation, hence, admission.

On May 8, 2010, the patient was admitted at Davao Medical School Foundation at Surgical Ward, room 324 bed 5 under the service of Dr. Batucan, with admitting diagnosis of Acute Cholelithiasis.

D. Effects/Expectations of Illness to Self/Family

Biological:

When Meg knew about her condition that she needs to undergo surgery, she didn’t know what to do. She was very worried about herself because she has fear of not waking up after surgery. She feared having complications of not having a gall bladder anymore.

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Psychosocial:

Also, she is worried about her 3 children, who still need care and guidance from their mother. This made her decide not to go through with the surgery before.

Meg wants to overcome her illness so that she can still spend time with her family and friends. Furthermore, she said that she wants to be in good condition as much as possible so that she can do her daily task in everyday life for her family. The client is worried about her condition because she has many plans in life together with her family.

Spiritual:

Still, Meg is still hopeful to overcome her challenges in life. The client still has faith in the Creator, and she continues to pray to Him. She believes that everything will be alright with the help of the creator.

Also, her children were worried about their mother, who’s suffering from such condition. Her husband, Bobong is trying his best to support his wife. Bobong was worried about Meg because for him, it makes him suffer seeing his wife suffering. In addition, their relatives are also extending their care and prayers for Meg because they are worried and concerned for her.

The client is also very thankful because her family, relatives and friends are still there giving support to her for her fast recovery. They are always there and look after her in the hospital and to aid her physically, mentally, emotionally, and spiritually.

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Genogram

Maternal Side

Paternal Side

Ana,, 70 Lala, K, 67 Lolo, K ,† Jose, c, , D, 64 Mamita, †,  Lola, †, o Papito, † Papang, 62 Po, c, 67 Mamang,60, D Sis, , 64 Dora, 28, K Kenny, a, † - Female -Male #- age - Heart problems †-deceased D- diabetic K- Kidney problem o- old age c- cholelithiasis a- accident Meg, , c, 38 Bobong, 45,  Luigi, 30,  Bebe two, 7 Bebe three, 2 Bebe one, 10

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DEFINITION OF COMPLETE DIAGNOSIS

Complete Diagnosis: Calculous Cholecystitis

Calculous

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape and composition.

Source: Boyer, M. (2006). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 11th ed., p. 1347. Lippincott Williams & Wilkins.

Calculus (pl. calculi) is also called stone; an abnormal stone formed in body tissues by accumulation of mineral salts. Calculi are usually found in the biliary and urinary tracts.

Source: http://medical-dictionary.thefreedictionary.com/calculi. Retrieved May 15, 2010.

Calculi (stones) can be divided into two groups—renal calculi and gallstones. The majority of gallstones are composed principally of cholesterol and other calcium salts.

Source: Iyengar, V. Elemental Analysis of Biological Systems: Biomedical, Environmental, Compositional and Methodological Aspects of Trace Elements, Vol. 1, p. 49.

Cholecystitis

Cholecystitis is the inflammation of the gallbladder. In more than 90% of the cases, gallstones are present.

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Source: White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.

Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation)

Source: Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers.

Inflammation of the bladder which may be either acute or chronic. In an acute cholecystitis, the blood flow to the gallbladder may become compromised which in turn will cause problems with the filling and emptying of the gallbladder. A stone may block the cystic duct which will result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. Chronic cholecystitis occurs when there have been recurrent episodes of blockage of cystic duct.

Source: Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill.

Calculous Cholecystitis

Acute cholecystitis is inflammation of the gallbladder. There are two major types of acute cholecystitis— calculous and acalculous. In calculous cholecystitis, gallstones obstruct the gallbladder outlet leading to poor drainage of bile. In physical exam, patients may exhibit Murphy’s sign— right upper quadrant pain elicited by palpation under the right costal margin when the patient inspires.

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Source: Ginsber, G. & Ahmad, N. (2006) The Clinician’s Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.

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DEVELOPMENTAL DATA

According to Taylor, Lillis, LeMone and Lynn (2008), growth and development are orderly and sequential as well as continuous and complex. All humans experience the same growth patterns and developmental levels, but, because these patterns and levels are individualized, a wide variation in biologic and behavioral changes is considered normal. Within each developmental level, certain milestones can be identified; for example, the time the infant rolls over, crawls, walks, or says his or her first words. Although growth and development occur in individual ways for different people, certain generalizations can be made about the nature of human development for everyone.

Robert Havighurst’s Developmental Task Theory

Robert Havighurst believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing societal conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Successful achievement leads to happiness and success in late tasks, whereas unsuccessful achievement leads to unhappiness, societal disapproval, and difficulty in later tasks. The developmental tasks arise from maturation, personal motives, and values that determine occupational and family choices, and civic responsibility. (Taylor, et al. 2008)

Stage Description Result Justification

Middle Age(30-40)

In the middle years, men and women reach the peak of their influence upon society, and

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at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it.

 Selecting a mate

 Learning to live with a partner  Starting family

 Rearing children

Achieved

The patient married and started a family last 1998. She is happy with her husband since she receives care and unconditional love from him. She works together with her husband in taking care of and rearing their children by

providing their physiological,

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 Managing home

 Getting started in occupation

 Taking on civic responsibility

Achieved

The patient has no job, however, she is the one managing the house, by cleaning, washing clothes, doing other

household chores and being a

peacemaker when trouble happens among her children. She is the one managing the house to have a peaceful and organized home. Meg is also responsible for budgeting their money needed to sustain them in their everyday living. She sees to it that her husband’s salary is well budgeted and not put into waste.

The patient is doing her responsibilities as a Filipino citizen by following laws in our country such as not throwing garbage anywhere, and following traffic rules. She is also a registered voter.

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Patient verbalized that if she were not admitted in the hospital, she would really vote in the 2010 Presidential elections. She also pays taxes (property tax and cedula) as part of her responsibility as a citizen.

Erik Erikson’s Psychosocial Development Theory

Erikson emphasized developmental change throughout the human life span. In Erikson’s theory, eight stages of development unfold as we go through the life span. Each stage consists of a crisis that must be faced. According to Erikson, this crisis is not a catastrophe but a turning point of increased vulnerability and enhanced potential. The more an individual resolves the crises successfully, the healthier development will be. It is patterned to the Psychosexual Development of Sigmund Freud but more concentrated on what task and conflict should a person be able to manage in a certain age group. That is termed psychosocial development. He described eight stage of development:

1. Infancy 2. Early childhood 3. Late childhood 4. School age 5. Adolescence 6. Young adulthood 7. Adulthood 8. Maturity

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Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or unsuccessful.

Middle Adulthood: 25-65 years Ego Development Outcome: Generativity vs. Self absorption or Stagnation Basic Strengths:

The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when a person is in this stage, she often fear inactivity and meaninglessness.

As the children leave home, or the person’s relationships or goals

Working towards achieving

goal

As a wife and a mother of three children, she is the one who inculcates values in the family whom she acquired from her parents. She makes sure that her children will be raised with good attitude and as good Filipino Citizens.

As of now, her children are dependent and still with them, she still doesn’t know what her feelings will be when her children will leave home someday. Today, she is busy taking care of her children and her husband as those are the responsibilities of a mother and wife.

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Production and Care

changes, she may be faced with major life changes—the mid-life crisis—and struggle with finding new meanings and purposes. If a person doesn't get through this stage successfully, she

can becomes self-absorbed and

stagnate.

Significant relationships are within the workplace, the community and the family.

Creativity, productivity, concern for others or self-indulgence, self-concern, lack of interests and commitments

Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352

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ages/organize/Erikson.htm

Lawrence Kohlberg’s Levels of Moral Development

Lawrence Kohlberg outlined the different planes of moral adequacy, based on his continued interest in how children would react to varying moral dilemmas. Kohlberg stated that ethical behavior was based on moral reasoning, which in turn could be broken down into six specific developmental stages. The stages are progressive, in that it is highly improbable for someone to regress backwards. Once a person acquires the functionalities of higher stages of moral development, it will be difficult for him to lose these abilities and revert to lower levels of growth. Every stage follows another, making it difficult for a person to jump forward and virtually skip an entire stage.

The levels and stages are as follows:

Level 1: Preconventional

Stage1: Punishment/obedience

Stage2: Instrumental/relativist

Level 2: Conventional

Stage3: Approval Seeking

Stage4: Law and order

Level 3: Postconventional

Stage5: Social Contract

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Post-conventional Level Stage 5: Social Contract Stage6: Universal-ethical

At stage 5 social contract and utilitarian orientation, correct behavior is defined in terms of society’s law. Laws can be changed, however, to meet

society’s needs, while

maintaining respect for self and others.

Stage 6, universal ethical principle orientation, represents the person’s concern for equality for all human beings, guided by personal values and standards regardless of those

Achieved

Working towards achieving

goal

She sees that most of the laws are correct and worth to be followed. She said that she follows the rules of the country and the city she lives in. She doesn’t want nuisance in the society because she believes that to be able to live in a serene place, people must maintain and establish respect with themselves and then to others.

She knows about universal laws, specifically about justice. She is concerning about justice, “malooy gyud ko sa mga tao nga dili matagaan ug hustisya, labaw na ng mga kabus” , as verbalized by the patient.

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set by society or laws. Justice might be internalized at an even higher level than society. Few adults ever reach this stage of development.

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PHYSICAL ASSESSMENT Patient’s Name: Meg

Age: 38 yrs. old

Sex: Female

Admitting Diagnosis: Acute Cholelithiasis

Final Diagnosis: Calculous Cholecystitis

Chief Complaint: right upper quadrant pain

Date of Assessment: May 12, 2010

Time of Assessment: 4:00 pm

Location of Assessment: DMSF Hospital, 3C, Room 324-5

Vital Signs upon physical assessment:

I. General Survey

The patient was received lying on bed, awake, conscious, coherent, afebrile and without IVF. She has three 0.5-cm long incisions at her epigastric and right lower rib cage areas and a 1-cm incision under her umbilicus. Incision site is dry and intact. Each incision is covered with dry and intact dressing. Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale. She is oriented to time (verbalized it was late in the afternoon), person (identified watcher correctly), place (verbalized she’s in the hospital) and

Temperature : 36.6 °C

Pulse Rate: 82 bpm

Respiratory Rate: 18 cpm

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reason for admission (stated that she was admitted due to right upper quadrant abdominal pain). Patient is not in respiratory distress.

Patient appears appropriate for her stated age. She stands 5 feet and 2 inches tall and weighs 62 kg. Her body mass index (BMI) is 24.9 which is normal. She has an endomorphic body type. Patient is in fair grooming as evidenced by unsoiled t-shirt she is wearing, well-kept hair and clean linens and pillows. However, it was noted that patient has halitosis. Nails were long but clean.

Through the course of the physical assessment, it was observed that the patient is cooperative and has an accommodating attitude towards the student. The patient is calm. Patient’s speech was audible, comprehensible and in moderate pace.

II. Skin

Skin is fair in color, intact and with hairs, except in the palms, soles and dorsa of the distal phalanges. Skin is dry and slightly warm upon palpation. It returns quickly to its normal state when picked up between two fingers and released. Skin texture is soft and fine while extensor surfaces such as the elbows have coarser skin. The palms and the soles are calloused. No skin breaks present aside from the incision sites on her abdomen. No edema present.

III. Hairs and Nails

Upon inspection, hair was noted to be black. It is thick, oily, straight, long and well-kept. Hair is also evenly distributed as evidenced by absence of bald spots. Dandruff or flaking was not present. Other infestations, such as lice, were not noted. The color of scalp is lighter than the color of skin.

Nails on both hands and feet are long but clean. Nail polish was removed. Client has a capillary refill time of 2 seconds. No clubbing of the nailbeds noted.

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IV. Head

Patient’s head is round and normocephalic in configuration with smooth skull contour. There were no palpated masses, nodules, deformities or fractures. Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds. Facial movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions. Patient can move her head up and down and side to side. No lesions noted on the face.

V. Eyes

Hairs of eyebrows are thick and evenly distributed. Eyebrows are symmetrically aligned and there’s equal movement as evidenced by the patient’s ability to elevate and lower the eyebrows. No edema, lesions, puffiness or tenderness noted upon inspection and palpation of the periorbital area. Eyelashes are equally distributed and curled slightly outward with no ectropion or entropion. Eyelids’ surface is intact with no discharges and no discoloration but with noted eye bags on the lower surface. No lid lag noted. Blink reflex is present. Palpebral fissure is equal in both eyes. Bulbar conjunctiva is pale pink. Cornea is transparent and without cloudiness. Sclera is anicteric. Eyeballs are symmetrical with no bulging observed. Pupils were black in color, equally round, 3mm in size and reactive to light and accommodation. Pupils quickly constrict when a penlight is shone towards the pupil from a lateral position. Iris is dark brown in color.

Client has central and peripheral vision. She can see things on the side of her eye, like the adjacent bed, even when looking straight ahead. Moreover, pupils constrict when looking at near objects and dilate when looking at far objects. During ocular motility testing, patient was asked to follow the examiner’s

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finger in the six cardinal fields of gaze. There was smooth, parallel movement of eyes in all direction. Both eyes move in unison. No nystagmus noted. To test her visual acuity, the students asked her to read their nameplates placed about 1 ½ feet away from her. She was able to correctly read the names without any difficulty. Patient verbalized she doesn’t use any corrective aids. She also did not report any vision difficulty or eye pain.

VI. Ears

The color of the patient’s ears is the same as her facial skin. The skin behind the ear in the crevice is smooth and without breaks. The left and right pinna are symmetrical and aligned with the inner canthus of the eye. Pinna recoils after it is folded. Auricle is nontender upon palpation. Mastoid process is smooth and hard and no tenderness or swelling noted. External canals have minimal cerumen. No sanguinous discharges noted on the meatus. Patient was able to hear a soft whisper equally in both ears. She can also hear normal voice tones as evidenced by prompt responses to questions asked.

VII. Nose

It was noted that the nostrils were symmetrical and the nasal septum is midline. There were no observed discharges draining from the client’s nose. Hair is noted on the nares. Nares are patent since patient is able to breathe normally on both nostrils without difficulty when one nose is closed with digital compression and patient inhaled with mouth closed. No lesions on the external nose structure were seen. There was no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges. Client’s gross smell was functional as she could identify the scent of alcohol.

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VIII. Mouth

Mouth is proportional and symmetrical. Lips are cracked, dry, pink in color and with no masses or congenital defect. Buccal mucosa was uniform pale pink in color and moist. The patient’s gum was, moist, firm and pinkish in color. No gum retraction or bleeding was noted. Teeth are of complete set. There are no spaces in between teeth. Dental carries are evident in lower right and left molar. Teeth are yellow in color. Patient has no dentures. Tongue is pink, moist, slightly rough and has thin whitish color on the surface. It is also in central position and moves freely. The base of tongue is smooth with prominent veins. No tenderness, lesions or any unusualness noted. Soft palate is light pink in color. On the other hand, hard palate is much lighter and more irregular in texture. Uvula is positioned in midline of soft palate and rises when the patient says ―ah‖. Tonsils are not inflamed. No ulcerations and exudates present. Patient has no difficulty of masticating and swallowing. Halitosis was noted. Patient has no speech disorders.

IX. Neck

Neck is symmetrical with no masses or unusual swelling upon palpation. No jugular vein distention noted. Pulsation at carotid arteries is strong and regular in rhythm. Range of motion is normal and no pain elicited upon flexion, extension, and rotation of head. Thyroid is not enlarged upon palpation with no nodules, masses or irregularities upon palpation. Thyroid also rises when patient was asked to swallow. Trachea is symmetrical and in midline without deviation. No lymph adenopathies appreciated. No torticollis present.

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X. Breast

Breast is conical, symmetrical and skin color is lighter than exposed areas. No lesions, redness, or edema and texture is even. No dimpling or retraction. Nipples are in midline and everted pointing in the same direction. Areola and nipples are dark brown in color and has no discharges, crusting and masses.

XI. Chest/Lungs

Chest skin integrity is good and intact. Patient has symmetrical chest wall movement. Point of maximal impulse is at 5th intercostal space left midclavicular line. Apical pulse is 84bpm. Patient has distinct heart sounds, with S1 louder than S2; negative for murmurs. There were no noted deformities in the client’s thoracic area. There are no bulges or retraction of the intercostal spaces.

Client’s respiratory rate is 18 cycles per minute. Patient did not complain of chest pain or chest tightness. Guarding of the chest noted upon respiration due to the proximity of the incision site to the diaphragm. Patient is not in respiratory distress. Coughing episodes were also not observed. Vesicular breath sounds are soft and low pitched. Her breathing is deep, regular and slow with a long inspiratory phase and a short expiratory phase. With no adventitious sounds, lungs are clear to auscultation and no crackles, wheezes or rubs. It was observed that vocal fremitus is present both at the back and front of the chest when the patient says ―ninety-nine‖.

XII. Abdomen

Abdomen is round. Color of skin in abdomen is slightly lighter than the rest of the body. A 0.5-cm incision was noted at the subxyphoid area. Another two 0.5-cm incisions are seen at her right lower rib cage. A 1-cm incision is also present just below her umbilicus. All four incisions are covered with dry and intact dressing. Patient complains of pain on the surgical site and verbalized,

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―Nagangulngol tong gioperhan. Pwede makahingi ug tambal para sa sakit?” Patient reported a pain scale of 6 out of 10. Aortic pulsations are not visible. Umbilicus is midline and inverted. Symmetrical movement of abdomen upon respiration was noted. Upon auscultation of the abdomen, it was noted that patient has normal bowel sounds—high-pitched and occurred 16 times per minute. Abdomen is soft and there is no point tenderness. Patient was on DAT as ordered.

XIII. Back and Extremities

Peripheral pulse of the patient was symmetrical and regular in rhythm; radial pulse is 82bpm. Patient has normal capillary refill of 2 seconds. The nails were pinkish in color without cyanosis and clubbing. Patient is able to ambulate freely. She was able to sit up on bed and perform range of motion on both upper and lower extremities. However, it was noted that patient has guarded and slow movement for she feels pain on her abdomen. Client’s grasping ability was moderately strong on both hands. No edema or cyanosis was noted on both upper and lower extremities. There is no swelling, tenderness or nodules palpated on each joint. The shoulders, arms, elbows and forearms are free of nodules, swelling, deformities and atrophy.

The skin at the back of the patient is uniform in color. Symmetrical chest expansion with respirations noted. No spinal tenderness noted. There are no skin breaks present. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks. There were no deformities or abnormalities on the bone such as scoliosis, osteoporosis and alike to be noted.

XIV. Genito-urinary

Pubic hair is present, thick in each strand, curly and equally distributed on the mons pubis. No vaginal bleeding or any other unusual discharges noted.

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Patient voids freely. She has no difficulty urinating and did not report dysuria. She verbalized her urine is amber in color.

XV. Neurological

Patient was received lying on bed, awake, conscious, coherent and afebrile. Reflexes are normal and symmetrical bilaterally in both extremities. Patient is oriented to person, place and time. She has a Glasgow coma scale of 15: 4 from eye opening, 5 for verbal resoponse and 6 for motor response. She is also alert and attentive.

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ANATOMY AND PHYSIOLOGY

GALLBLADDER

The gallbladder is a hollow organ that sits just beneath the liver. In adults, the gallbladder measures approximately

8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct. Its function is to store and release bile, a fluid made by the liver.

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CYSTIC DUCT

The cystic duct is the

short duct that joins the gall bladder to the common bile duct. The cystic duct varies from 2 to 3 cm in length and

terminates in the gallbladder.

Throughout its length, the cystic duct is lined by a spiral mucosal elevation, called the valvula spiralis (valve of

Heister) which is

a series of crescentic folds of mucous

membrane in the upper part of the cystic duct, arranged in a

somewhat spiral manner. Its length is variable and usually ranges from 2 to 4 cm. The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology (stones or passed stones).

The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.

BILE

The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin.

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Bile, is produced by hepatocytes in the liver and and then flows into the common hepatic duct, which joins with the cystic duct from the gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of Oddi, a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum, is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all the original organic molecules.

When food is released by the stomach into the duodenum in the form of chyme, the duodenum releases cholecystokinin, which causes the gallbladder to release the concentrated bile to complete digestion.

Bile helps to emulsify the fats in the food. Besides its digestive function, bile serves also as the route of excretion for bilirubin, a byproduct of red blood cells recycled by the liver.

The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum, the final section of the small intestine. Bile salts also act as bactericides, destroying many of the microbes that may be present in the food.

In the absence of bile, fats become indigestible and are instead excreted in feces, a condition called steatorrhea.

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ETIOLOGY AND SYMPTOMATOLOGY

Etiology

Predisposing Factors

Present/

Absent Rationale Justification

Female PRESENT Women between 20 and 60 years of age are twice as likely to develop

gallstones as men.

Estrogen increases cholesterol levels in bile and decrease gallbladder movement, both of

which can lead to gallstones.

Sources:

Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1822

Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184

http://www.diabetesmonitor.com/learning-center/gallstones.htm The patient is female. Diabetes mellitus

ABSENT People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids increase the risk of gallstones.

Sources:

Harrison’s Principles of Internal Medicine,

The patient is not diabetic.

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Tenth Edition 1983 page 1823

Age

(20-50; over age 60)

PRESENT Many of the body’s systems and

protective mechanisms become less efficient with age. Body systems and

processes become sluggish.

Sources:

Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1823

The patient is 38 years old. Ethnicity (Native American, Mexican American) (Asian)

PRESENT Native Americans have a genetic predisposition to secrete high levels

of cholesterol in bile. In fact, they have the highest rate of gallstones

in the United States. A majority of Native American men have gallstones by age 60. Mexican American men and women of all

ages also have high rates of gallstones.

Asians are more genetically predisposed to having pigment stones as compared to those living

The patient is Filipino. She is predisposed to having pigment stones.

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in the Western countries

Sources:

http://www.diabetesmonitor.com/learning-center/gallstones.htm

Precipitating Factors

Present/

Absent Rationale Justification

Pregnancy

ABSENT Excess estrogen from pregnancy,

hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile

and decrease gallbladder movement, both of which can lead

to gallstones. Source: http://www.fbhc.org/Patients/Modul es/gallstns.cfm The patient is not pregnant. Rapid weight

loss ABSENT As the body metabolizes fat during rapid weight loss, it causes the liver

to secrete extra cholesterol into bile, which can cause gallstones.

Sources:

Lippincott Williams and Wilkins Handbook of Diseases Third

Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm No rapid weight loss was noted by the patient.

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Obesity ABSENT

The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases

gallbladder emptying. Sources:

Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page

1823

Edition, page 184

http://www.fbhc.org/Patients/Modul es/gallstns.cfm

The patient is not obese.

Fasting ABSENT Fasting decreases gallbladder movement, causing the bile to become overconcentrated with

cholesterol, which can lead to gallstones. Source: http://www.diabetesmonitor.com/lea rning-center/gallstones.htm The patient doesn’t fast. Hormone replacement therapy, or birth control pills

PRESENT Excess estrogen from pregnancy,

hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile

and decrease gallbladder movement, both of which can lead

to gallstones. The patient has been on birth control pills since she was 36 years old.

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Page | 41

Source:

Edition, page 184

http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

Low Fat Diet PRESENT Before dietary fat can be digested, it has to be emulsified. Bile is used for this purpose. The liver makes bile continuously and stores it in the

gall bladder until such time as it is needed. However, if a low-fat diet is

eaten, that bile remains in the gall bladder.

Gallstones are formed when the gall bladder is not emptied on a

regular basis. In people who continually resort to low-fat diets, bile is stored for long periods in the

gall bladder — and it stagnates. In time — and it is really quite a short time — a 'sludge' begins to form.

Source: http://www.second-opinions.co.uk/gallstones.html The patient avoids fatty foods.

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Page | 42 Symptomatology Signs and Symptoms Present/ Absent Rationale Justification Right upper quadrant pain (may radiate to right scapula, shoulder, or interscapular area) “biliary colic”

PRESENT _Obstruction _of _ducts

connected to the gallbladder will cause inflammation

produced by increased

intraluminal pressure and

distension of the

gallbladder.

Sources:

Harrison’s Principles of Internal Medicine, Tenth

Edition 1983 page 1825 The patient came into DMSF complaining of RUQ pain. Fever (low grade)

ABSENT _Fever _is _a _nonspecific

response that is mediated by endogenous pyrogens released from host cells in response to infectious or non-infections disorders. It may be brought about by prostaglandins released during inflammation.

Source: Carol Mattson

The patient

was not

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Page | 43 Porth (2005. Pathophysiology, Seventh edition page 205) Murphy's sign (abrupt interruption of deep inspiration)

PRESENT _{Classically Murphy's sign is}

tested for during

an abdominal examination; it is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the

mid-clavicular line (the

approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally,

during inspiration,

the abdominal contents are

pushed downward as

the diaphragm moves down (and lungs expand). If the patient stops breathing in

(as the gallbladder

is tender and, in moving

downward, comes in

contact with the examiner's fingers) and winces with a 'catch' in breath, the test is

The patient was positive

for the

Murphy’s Sign.

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considered positive. A positive test also requires no pain on performing the maneuver on the patient's left hand side.

Source: http://www.turner-white.com/pdf/hp_nov00_m urphy.pdf Nausea and vomiting

ABSENT Nausea and vomiting

sometimes occur with biliary colic. The inflammation of the gallbladder causes pain

and spasms of the

abdominal muscles which

may make one feel

nauseated.

Source:

Understanding Medical

Surgical Nursing by

Williams and Hopper page 742 The patient didn’t complain of nausea or vomiting. Mildly elevated

ABSENT Biliary obstruction causes

suppression of bile flow,

The patient’s bilirubin was

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serum bilirubin

and regurgitation of

conjugated bilirubin into the bloodstream.

Sources:

Harrison’s Principles of Internal Medicine, Tenth

Edition 1983 page 1829 not increased. Elevated SGPT and SGOT enzymes

PRESENT SGOT (AST) and (ALT) is

an enzyme found mostly in the liver but also in the heart, the muscles, the kidneys, the pancreas and in red blood cells. High

elevations may be

associated with liver

disease or muscle trauma. Elevations may also be associated with a variety of

conditions including

myocardial infarction (heart attack), pancreatitis, bile duct obstruction and more.

Abnormalities of liver enzymes including The patient’s lab tests reveal an elevated level of SGPT and SGOT enzymes.

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AST/SGOT and ALT/SGPT are indicative of problems such as Mirrizi syndrome, or a stone in the bile duct causing infection/liver inflammation.

Sources

http://my.diabetovalens.com /apollo/sgot.asp

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Page | 47 PATHOPHYSIOLOGY Predisposing Factors:  Female  Age 38  Ethnicity  Diabetes Mellitus Precipitating Factors:  Birth control pills  Low Fat Diet  Pregnancy

 Rapid weight loss

 Obesity

 fasting Bile stagnates in the

gallbladder

Pigment solute precipitate as solid crystals

Crystals clump together and form stones

Gallstones

Upon contraction, a stone is moved and becomes impacted on the cystic duct

Bile stasis

Gallbladder contracts after intake of fat to release bile

CHOLELITHIASIS

Lumen is obstructed by stones

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Page | 48 If treated with:

If not treated

Good prognosis

Chemical reaction inside gallbladder triggers the release of inflammatory

enzymes (Prostaglandins)

ACUTE CHOLECYSTITIS

Increased intraluminal

pressure and distention of the gallbladder Inflammation of the gallbladder Biliary Colic (RUQ pain) Murphy’s Sign Fluids leak into

gallbladder Edema Constriction of blood vessels Continued increase in intraluminal pressure of gallbladder Rupture of gallbladder

Spread of bile and indigenous microorganisms into peritoneal cavity Continued lack of blood supply to gallbladder Necrosis

Gangrene and empyema

Perforation of gallbladder Surgery, proper

diet (low fat, high fiber), compliance to medications

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Page | 49 Sepsis

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DOCTOR’S ORDER

Date Order Rationale Remarks

5/8/10 @ 11pm

Admit under the care of Dr. Batucan

Admitted under the care of Dr. Batucan, a surgeon, for his specialties on surgical procedures (Laparoscopic cholecystectomy) Done. Patient was placed in ward 324 bed 5 Secure consent to care Consent is an agreement between client and health care provider to give proper quality care. It is also to protect the client from harmful procedures and the institution from law suits

Done

Low fat diet Doctors were not sure

whether the gallstones are either cholesterol or pigment stones. Thus, this is done to prevent any further damage to the gallbladder.

Done

Monitor VSqShift and record

Monitoring vital signs is important in order to note any unusualities and to refer these as follows.

Done

Labs:

CBC A complete blood count

(CBC) is a series of tests used to evaluate the composition and

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Platelet

Urinalysis

concentration of the cellular components of blood. It

consists of the following tests: red blood cell (RBC) count, white blood cell (WBC) count, and platelet count;

measurement of hemoglobin and mean red cell volume; classification of white blood cells (WBC differential); and calculation of hematocrit and red blood cell

Platelet count is to determine the number of platelets; If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form (thrombosis), which may obstruct blood vessels.

It is done to detect urinary tract infection. It also measures the level of

ketones, sugar, protein, blood components and many other substances Done Done Venoclysis: PNSS 1L @ 100cc/hr PNSS is an isotonic solution to provide hydration since it

Done. IVF infusing well

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was found out that the specific gravity for urine is in the borderline (1.010). It is also to provide electrolytes, and as a medium for IVTT meds at right metacarpal vein. Meds: Demerol 50mg IVTT now then prn for abdominal pain

HNBB (Hyoscine N-Butyl Bromide) 20mg 1amp IVTT now

Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation for relief of moderate to severe pain

It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists causing smooth muscle

relaxation indicated for her abdominal pain

Given

MHBR Moderate high back rest is to

elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. This is also to prevent ascending infection that could be caused by possible rupture of the gallbladder.

Done

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unusualities: severe abdominal pain, vomiting

assessed and evaluated properly and be managed accordingly. 5/9/10 8:10am Start Cefoxitin (Monowel) 1g IVTT q8 ANST

Cefoxitin inhibits synthesis of bacterial cell wall causing cell death which acts as a

perioperative prophylaxis for surgical procedures. ANST or after negative skin test is to check whether the client is not allergic to the antibiotic.

Done. Result for skin test is negative. Cefoxitin may be given to the patient. For ultrasound tomorrow morning

This is done to visualize internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. This is also to know the condition of the gallbladder whether it ruptured or not.

Not able to comply. Patient had her ultrasound on May 11, 2010.

For total bilirubin,

Direct bilirubin,

Indirect bilirubin

Bilirubin is elvated if

hepatocytes are injured and cannot metabolize or excrete bilirubin

Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts

Increase in unconjugated bilirubin may be caused by

Done. Results are normal

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Alkaline phosphatise

hepatic disease, cholestasis, and hemolysis

High levels of alkaline phosphatise indicates liver disease SGPT (Serum glutamic pyruvic transaminase) SGOT (Serum glutamic oxaloacetic transaminase)

SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver function. Elevation of this may possibly mean liver problems

AST (aspartate

aminotransferase) or SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. It is also found in lesser amounts in other tissues. Elevated levels may be caused by liver or heart disease Done. Patients SGPT results are high Done. SGOT results are also high Schedule for laparoscopic cholecystectomy on Tuesday (4/11/10) 2pm

Lap Chole was to surgically remove the gallbladder with only a small incision.

Done.

Surgery was done on 4/11/10 @ 4pm Secure consent/AC Patient has the right to be Done.

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consented in all procedures to be done, and for legal

purposes. Anesthesia

clearance is for the patient to be evaluated whether he/she is fit to undergo the operation. It is also for the

anaesthesiologist to predict the operative risk and the appropriateness of the anaesthesia to be induced during operation.

Inform OR For the OR to know that such

case will be performed and to prepare the necessary

instruments and room. This is also to coordinate availability of staff and surgeon

Done

Refer In order for the patient to be

assessed and evaluated properly and be managed accordingly.

Done

5/9/10 5:00pm

May have ultrasound on Tuesday 5/11/10

This was to visualize internal organs, to capture their size, structure and any pathological lesions with real time

tomographic images. It is also to know whether the

gallbladder has ruptured or not. Done. Ultrasound result retrieved on 5/11/10. Impression: Cholelithiasi s; Sonographic

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Page | 56 ally normal liver and pancreas 5/10/10 1:00pm To reschedule OR tomorrow from 2pm to 4pm

To inform the OR that the procedure will be moved from 2pm to 4pm Done. Patient had her surgery at 4pm of May 11, 2010. IVF TF: PNSS 1L @ KVO PNSS is an isotonic solution for hydration and as a

medium for IVTT meds; KVO was done since patient’s hydration was good.

Done

9:15pm Please facilitate AC AC is to assess patient’s rate of survival and check for what anesthetics is right for the patient, making sure that the patient isn’t allergic to the anesthetic

Done

For Lap Chole tom 4pm

This was to surgically remove the gallbladder with only a small incision. Patient can undergo laparoscopic cholecystectomy since gallbladder has not ruptured yet as seen on the ultrasound result.

Done.

For blood chem. and Ultrasound tom

Blood tests are used to determine physiological and biochemical states, such as

Calculous Cholecystitis Case Study Sample