Bulacan State University
COLLEGE OF NURSING City of Malolos, Bulacan
A Case Study of
A 22 YEAR OLD MALE, DIAGNOSED WITH CALCULOUS CHOLECYSTITIS
In Partial Fulfillment of the Requirements in RLE (103-A) at the
Bulacan Medical Center
(
Medical Ward)BSN 3-E (GROUP 2)
Castro, Mary Joyce Dela Cruz, Carllae Lucille
De Guzman, Liberty C. Delloro, Ephraim Fabian, Shiela Marie GABRIEL , ANER M. (Leader) Ilag, Caress S. Macaranas, Carmona Jane
Miranda, Marife Pangan, Mary Grace S. Roque, Lyra Cariza Vidon, Jill Irish Kae
TABLE OF CONTENTS
I.
INTORDUCTION
a. Reason why ……….
1
b. Objectives ………..
3
II.
NURSING HEALTH HISTORY
a. Demographic Data ……….
5
b. History of illness (present, fast and family illness ) ………
6
c. Genogram ………...
7
d. Functional Health Pattern (Prior and during hospitalization) ……….
8-14
e. Growth and Development ……….
15-16
III. ANATOMY AND PHYSIOLOGY ………..
17-21
IV.
PATHOPHYSIOLOGY
a. Schematic Diagram ………
22-24
b. Definition of the disease ……….
25
c. Signs and symptoms ………..
26
d. Precipitating factors ………..
27-28
e. Predisposing factors ………..
29
V.
PHYSICAL ASSESSMENT ……….
31-43
VI.
LABORATORY AND DIAGNOSTIC PROCEDURES ………
44-49
VII. PATIENT AND HIS CARE
a. Medical Management ……….
50-51
b. Drugs ………..
52-57
c. Diet ………
58-59
d. Exercise ……….
60
VIII. SURGICAL MANAGEMENT
a. Nursing Responsibilities (postoperative) and Client’s
Response……… 61
IX.
NURSING CARE PLAN……….
62-69
X.
HEALTH TEACHING ………...
70
XI.
DISCHARGE PLANNING ………
71-72
XII. CONCLUSION ………
73
I.
INTRODUCTIONThis is a case study of a 22 year old male nursing graduate of Our Lady of Fatima University who was rushed at Bulacan Medical Center complaining of severe pain on the right upper quadrant of the abdomen. He was admitted last August 01, 2010 at 6:45 a.m. The patient was initially diagnosed with abdominal mass to confirm calculous cholecystitis after performing laboratory and diagnostic tests, because the results shows that the patient is suffering from an inflamed gallbladder due to calculi or stones. The physician then decided to perform an emergency procedure an open cholecystectomy at 11:15 am.
Calculous cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted or ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur.
The most common cause of cholecystitis is gallstones. The bile becomes concentrated in the gallbladder. This later causes irritation and is probably the leading cause of inflammation. Cholecystitis affects women more often than men and is more likely to occur after age 60. People who have a history of gallstones are at increased risk for cholecystitis. In the international level, cholecystitis has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. It affects 20.5 million people (1988-1994) with a mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies. In the Philippines alone, 24,913 people are affected by the disease and 139 number of reported deaths last 2007. (http://digestive.niddk.nih.gov/statistics)
Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur, and the blood vessels in the gallbladder are compressed, compromising its
vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile with Escherichia coli, klebsiella species, or streptococcus is identified with cultures obtained during surgery in a small percentage of surgical treated patients.
SIGNIFICANCE OF THE STUDY
We, the student nurses have chosen this case as we see it fit for the peri-operative concept as the patient, who is a nursing graduate had to undergone open cholecystectomy. Moreover, despite the cholecystitis’ low incidence, we would like to give credit and to know more of the nature and function of the gallbladder. Much often this small organ is not given importance. Thus we are in a pursuit for knowledge to be able to impart it to others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the symptoms presented.
As teen-agers living in a fast-phased world and governed by schedules, just like NJE a nursing graduate, we too are predisposed to lifestyle modification – especially diet and food preferences which can contribute to the disease. With this study, we hope to apply our learning in t aking care not only of our patients but also of ourselves.
As nursing students and future nurses, we would want to understand and appreciate more on what is happening to a patient with calculous cholecystitis. Consequently, we are interested on what will be the necessary management that will be given. Through this, we are hoping that we will be able to find the right plan of care and sound interventions, not forgetting the patient’s rights as a person. All in all, these will help us to become efficient nurses and better persons later on.
OBJECTIVES
General Objective:
Our first main goal is to gain knowledge through the completion of the case study and to impart this learning to those directly and indirectly involve with the completion of this case. In psychomotor aspect, our goal is to apply all what we have learned during the process of completing this case study to improve nursing care that will meet NJE’s need for the improvement of his general welfare. With the knowledge gained and through the application of this knowledge, another goal is that we will be able to empathize with the current situation of the patient and to gain some values like the value of patience and calmness which is important for us to have in order to become better nurses in the future.
Specific Objectives:
To determine functional health status of client with cholecystitis.
Integrate knowledge of nursing care in post cholecystectomy client to formulate a quality nursing care plan. Implement appropriate nursing intervention to satisfy the patient’s needs.
Client-centered:
Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need. To identify intervention that appropriate for patient’s needs.
Integrate psychosocial and spiritual consideration into plan of care for client with gallbladder disorder.
Research and understand the disease process of the patient’s illness and also the possible causes and the symptoms the patient experience that may suggest the current condition of the patient.
Student-centered:
To use knowledge in assessing and understanding the manifestation of gallbladder disease.
To determine the priority nursing intervention and diagnosis that we can contribute by using our knowledge that we have learned in clinical setting. To implement quality nursing care that suited for client undergone cholecystectomy
II.
Nursing Health History PATIENT’S PROFILEBiographic Data Name: NJE
Address: 916 Ibayo, Sto Rosario, Paombong, Bulacan Birthday: December 04, 1987
Birthplace: Paombong, Bulacan Age: 22 years old
Sex: Male Status: Single Occupation: None Nationality: Filipino
Educational attainment: College Graduate (BS Nursing-OLFU) Religious Orientation: Roman Catholic
Health Care Financing and usual source of Medical Care: Philhealth (beneficiary) Date of Admission: August 01, 2010 at 6:45 a.m.
Date of operation: August 01, 2010 11:15 am. Date discharge: August 05, 2010
Chief Complaint: Abdominal pain on the right upper quadrant Initial Diagnosis: Cholelithiasis
History of Present Illness
Three months prior to admission, (May 03, 2010), NJE experienced sudden onset of pain in the right upper quadrant of the abdomen. The pain become mild to moderate and sometimes does not relieve by position. The patient noticed loss of weight, pallor, weak and easy fatigability. The patient was worried about his condition so he seeks medical attention to a private physician. The patient undergone abdominal ultrasound and the results revealed presence of gallstones. A day prior to admission (July 31, 2010 10:40 pm), patient experienced severe epigastric pain radiating to the right upper quadrant of the abdomen (pain scale of 7/10), and associated bloatedness with nausea and vomiting. There is presence of facial grimace and guarding behavior. A decrease in appetite was also experienced on that day. According to the patient, he noticed a yellowish discoloration of his skin and a clay-colored stool. By August 01, he was rushed at Bulacan Medical Center due to intolerable pain (pain scale of 9/10) accompanied by fever. Diagnostic exams were done such as Abdominal Ultrasound, Complete Blood Count, Platelet Count, Prothrombin Time and Partial Thromboplastin Time. He received IVF of D5LRS 1L regulated @ 30 gtts/min. Ultrasound revealed Calculous Cholecystitis, so the patient was advised for admission and operation.
Past history of illness:
NJE experienced common illness such as colds, cough, chicken fox and fever during his childhood. However, he could not recall at what age he got the disease. Her mother used “cilantro” for the management of his chicken pox. He had no food and drug allergy and he does not experience any injuries and accidents in the past. He received oral polio vaccine (OPV), diphtheria, pertusis and tetanus (DPT) for his immunizations.
Family history of illness:
The grandparents of our patient are both deceased and he can’t recall the cause and the age of death. His father died on 1998 due to kidney disease and his mother was 41 yrs old and still alive. He has three siblings, he was the eldest, second to him is 19 years old, the third was 15 years old and the youngest is a 12 yr. old male. No one in his family has the same condition with him.
GENOGRAM:
LEGEND:
MALE CALCULOUS CHOLECYSTITIS
FEMALE DECEASED UNKNOWN
CAUSE OF DEATH
PATIENT KIDNEY DSE UNKOWN AGE
55 y/o TME 45 y/o RME 44 y/o PME 41 y/o YMJ 59 y/o PMJ 55 y/o CMJ 55 y/o SMJ 22 y/o NJE 16 y/o KJE 13 y/o
CJE 19 y/o HJE
Functional Health Pattern Prior Hospitalization During Hospitalization Health perception and Health management
He told us that the most important factors for a healthy life is just eating nutritious foods, having a balance diet and having enough hours of sleep. He does not smoke but drinks alcohol frequently (2 bottles. of BAR every Saturday. He does not believe in faith healer. When he is in pain he will take OTC drugs, when we asked him what drugs is that he told us it was mefenamic acid 500mg.
According to him, during his hospitalization, he feels weak but he is eager to get well so, he tries to follow the doctor’s order for fast recovery. He takes his medicine on time. The following medicines are administered to the client as part of his regimen.
Metronidazole- 500 mg TIV q8 Ranitidine – 50 mg TIV q8 Celecoxib – 200 mg OD Cefuroxime -750 mg TIV q8 IV Fluids D5LRS 1,000 mL regulated @ 30-31 gtts/min. Nutritional and metabolic pattern
He likes to eat fried foods and he doesn’t have any eating difficulty. Whenever the patient is suffering abdominal pain, his appetite decreases. He doesn’t take any vitamin supplements. According to him when he has wound it heals well. He doesn’t have any dentures.
During his first day of hospitalization (August 01, 2010) he was ordered NPO in preparation for operation and change it to General liquid diet on August 02, 2010 post operation and on August 03, 2010 at 12:15pm he was instructed on a DAT diet with fat restriction to provide nutrition after the operation..
Date Breakfast Lunch Dinner
July 29, 2010 1/2 cup of rice 1 fried egg 220 ml of water(1 glass) AM SNACK: 1 order of Jollihotdog with 300 mL of coke. 1 cup of rice 1 piece fried pork chop 440 ml of water AFTERNOON SNACK: 240 ml of soft drink(RC cola) 21 grams of Garlic Adobo Peanut (Sugo) 1/2 cup of rice 2 pcs of fried chicken 220 ml of coffee with milk(1 cup) EVENING SNACK: Kita Cheese biscuit (2 packs)
Date Breakfast Lunch Dinner
August 01, 2010 Nothing Per Orem AM SNACK: None Nothing Per Orem AFTERNOON SNACK: None Nothing Per Orem EVENING SNACK: None August 02, 2010 30 ml of water AM SNACK: None 30 ml of water AFTERNOON SNACK: None 30 ml of water EVENING SNACK: None
July 30, 2010 1 cup of rice 3 pieces of fried hotdog 340 ml of water (1 ½ glasses) AM SNACK: 350 ml Coke 1 pc hamburger w/ cheese 1 cup of rice 2 pcs fried chicken 220 ml of water (1 glass) AFTERNOON SNACK: 1 cup coffee 1 sliced of chicken sandwich 1 cup of rice 2 pieces of 2x4 inches of fried beef tapa 440 ml of water (2 glasses) EVENING SNACK: 1 pack (3 pcs) of Sky flakes 150 ml of water
July 31, 2010 1 cup of rice 1 slice pritong bangus 220 ml of water(1glass) AM SNACK: 1 cup coffee w/ milk 1 ½ cups of rice 1 pc fired pork chop 440 ml of water(2 glasses) AFTERNOON SNACK: 1 pc hamburger w/cheese EVENING SNACK: NONE August 03, 2010
Soft diet with SAP 3 tbsp of Lugaw 3o ml of water AM SNACK: None 3 tbsp of Lugaw 3o ml of water AFTERNOON SNACK: None 1 piece Boiled egg 30 ml of water EVENING SNACK: None
Elimination Pattern
July 28- 31, 2010
He doesn’t have excessive perspiration or body odor.
Color Frequency Consistency Odor Difficulty
Stool
Clay-colored/
gray Once a day Formed Foul None
Urine
Amber/s traw
6X a day Clear Aromatic None
vomit Whitish Once(July 31, 2010) (+) food fragments “sour smell” With difficulty
He doesn’t have excessive perspiration or body odor.
August 01-03, 2010
Color Frequency Consistency Odor Difficulty
Stool None Urine Amber / straw 4x a day (August 02-03,2010)
clear Aromatic None
vomit
Activity-Exercise Pattern
He has sufficient energy to finish his daily activities. Walking for 15 minutes in the morning every day, except rainy days, is his form of exercise, and he doesn’t easily get tired. When he has free time he chats with his friends or watch television
Activity Level Feeding 0 Bathing 0 Bed mobility 0 Dressing 0 Grooming 0 Toileting 0
Level 0 – full self care
Level I-requires use of equipment
Level II-requires assistance or supervision from another person
Level III- requires assistance or supervision from another person or device Level IV- dependent or does not participate.
During his hospitalization he is often lying on his bed. He just listen to radio or chats with his relatives and some of the patient in the ward. As of august 03, 2010. Activity Level Feeding 0 Bathing 2 Bed mobility 0 Dressing 2 Grooming 0 Toileting 2
Level 0 – full self care
Level I-requires use of equipment
Level II-requires assistance or supervision from another person Level III- requires assistance or supervision from another person or device
Sleep and rest pattern
The patient sleeps for about 7 hours and 30 minutes continuously from 11 p.m. – 6:30 a.m. and he does not have any difficulty falling asleep and does not take any sleeping medications. He takes nap for 2 hours in the afternoon.
The patient sleeps for about 4 to 5 hours at night. His sleep is disrupted due to pain felt on his incision site. He takes nap 1 hour in the afternoon.
Cognitive and Perceptual Pattern
He does not have problems in vision and hearing. According to NJE, he had a sharp memory. He does not have any learning difficulty.
He does not have problems in vision and hearing as well as any learning difficulties.
Self perception and self concept
According to NJE he sees himself as a friendly person. The things that can make him frustrated are when things got out of his control. Sometimes chats with his friend to lessen his frustration.
The patient sees himself as a friendly person. When we asked him what he feels about being hospitalized he told us that he feels fine and he added that he wants to go home already.
Role and Relationship
pattern
The patient has a nuclear family according to members, matriarchal according to authority and neolocal according to location. He is living with his parents. When problem arises he and the rest of the family talk to each other to solve it. He does not belong in any social group but he has a lot of friends in their neighborhood.
His mother is the one who decides about financial matters in their family and according to him their budget is enough for his hospitalization.
Sexual-reproductive
pattern
According to the patient his sex life is complicated and admitted that he is a gay.
The patient sexual life is inactive.
Coping Stress tolerance
When the patient feels tense he chats with his friends and when he has problem he usually share it with his friends to ask for their opinion to solve the problem and according to him it lessen his burdens.
The big change in his life is when he found out that he has gallstones. When he has problem he usually share it with his friends and
according to him it is effective.
Values belief pattern
According to him he doesn’t get easily the things he wanted, he works hard for it. Religion is important to him and his family. They also go to church every Sunday and ask God for guidance and good health.
III.
GROWTH AND DEVELOPMENTTheories Stages Justification Resolution
Freud’s Stage of
Psychosexual Development
Genital stage: post puberty
During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.
The patient is in the genital stage but he does not developed sexual interest with the opposite sex rather than same sex. According to him he is not attracted with girls but he enjoys hanging out with them as friends.
The patient does not developed sexual interest with opposite sex.
Jean Piaget’s Stage of Cognitive Development
The formal operational stage (20 to Adulthood) During this time, people develop the ability to think about abstract concepts. Skills such as logical thought, deductive reasoning, and systematic planning also emerge during this stage.
The client thinks rationally and logically. He is able to solve the problem with his family by communicating to them and vice versa.
Positive The patient thinks logically and rationally.
Erickson’s Stage of
Psychosocial Development
Young Adulthood (19 to 40 years)
Intimacy vs. Isolation Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.
The patient share more intimately with others. He has a strong bond with his friends and family.
Positive
Kohlberg’s Stage of Moral Development
Level 3. Post conventional Morality Stage 5 - Social Contract and Individual Rights At this stage, people begin to account for the differing values, opinions and beliefs of other people. Rules of law are important for maintaining a society, but members of the society should agree upon these standards.
The patient understands the different roles of the society, and can distinguish what is right or wrong based on internalized rules on
conscience rather than social law. He follows rules according to his willingness. According to him, he will follow all the orders of the doctor that will help to make his condition better. He also said that he does things if he knows that it is good for him and according to his
willingness.
Positive
The patient follows rules according to his knowledge and willingness.
Fowler’s
Faith development pattern
Individuative-Reflective Faith: (early 20 to adulthood)
One begins to move beyond the group identity and adopt individual views; a "de-mythologizing" stage of faith; translates the symbols and images of one's tradition into personal concepts and ideas; beginning of post-conventional morality.
The patient has a religious side of him. He believed in God and go to church every Sunday. To his present illness, he believed in God and to the health care provider that he can overcome his illness.
Positive
The patient develops matured sense of faith
LIVER
Largest organ in the body
Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium. Weighing 1.5 kgs.
LIVER LOBES AND LOBULES
The liver has two lobes, separated by the falciform ligament Left lobe- about one sixth of the liver
Right lobe- about five sixth of the liver.
BILE DUCTS
Right hepatic duct- drains bile from the right functional lobe of the liver Left hepatic duct- drains bile from the left functional lobe of the liver
Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 6–8 cm. Approximate width: 6 mm in adults; merges with cystic duct to form common bile duct, which opens into the duodenum.
Cystic duct- is the short duct that joins the gall bladder to the common bile duct.
FUNCTIONS OF THE LIVER
The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months' supply), vitamin B12, iron, and copper.
Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose
Ammonia conversion- use of amino acid from protein for glycogenesis results in the formation of ammonia as a byproduct. Liver converts ammonia to urea. Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, blood clotting factor plasma lipoproteins. Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies.
Bile formation- bile is formed by the hepatocytes
- Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol, bile salts - Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.
BILE
Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following:
to carry away waste
to break down fats during digestion
Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, bile gives feces its dark brown color.
TRANSPORT OF BILE
1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts.
2. These ducts ultimately drain into the common hepatic duct.
3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine).
4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver.
5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.
GALLBLADDER
The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process.
A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck. Fundus - the lower free and the expanded end of the Gall bladder.
Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of the body is upwards, backwards, and to the left.
Neck-it is the “S” shaped curve present above the body, and extends up to the cystic duct. Direction is upwards, forwards and then takes a turn and becomes downwards and backwards.
It can hold 30 to 50 ml of bile.
It lies on the undersurface of the liver’s right lobe and attached there by areolar connective tissue. The cystic duct connects the gallbladder to the common hepatic duct to form common bile duct.
FUNCTION OF THE GALLBLADDER
Stores bile enters to the gallbladder by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five folds to ten folds. Then later when digestion occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice, a yellow discoloration of the skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.
The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.
Liver excrete relatively high proportion of cholesterol in the bile Bile is supersaturated with cholesterol Formation of solid Liver excrete some unconjugated bilirubin into bile Calcium enters bile
passively along with other electrolytes Unconjugated Bilirubin tends to form insoluble Invasion of bacteria in the gallbladder Liver excrete conjugated bilirubin into bile The bacteria hydrolyze conjugated bilirubin Increase in unconjugated Attraction of Leukocytes Leukocytes hydrolyze bilirubin
Modifiable and Precipitating Factor:
Food preference (high cholesterol/fat) Non Modifiable Factor:
Heredity
V. PATHOPHYSIOLOGY
Obstruction of the bile ducts
Formation of Calcium Bilirubinate Formation of
stones
Gallstones in the bile ducts/gallbladder
(Cholesterol, brown/black pigment) Crystals must come
together and fuse to form stones
Mild to moderate pain/biliary colic in the right part of the abdomen – due to functional spasm
of the cystic duct; irritation of the viscera (July 30, 2010)
27 s/s s/s Nausea and vomiting – may accompany a gallbladder attack (July 31, 2010) Continues irritation of the gallbladder
CALCULOUS
CHOLECYSTITIS
Inflammation of the gallbladder Fever – due to elevated WBC because of bacteria invasion in the injured gallbladder (August 01, 2010) Severe Pain/biliary colic – due to inflammatory process (August 01, 2010) Facial grimace (August 01, 2010) Guarding behavior (August 01, 2010) Jaundice – due to obstruction of bile flow (July 30, 2010) Clay-colored stool – may result from problems in the biliary system; due toabsence of bile in the duodenum; warning signal that’s something wrong with digestion (July 31, 2010)
IF TREATED IF NOT TREATED PHARMACOLOGIC TREATMENT o Antimicrobials o Narcotic Analgesics o Anticholinergics o Antiemetic o Gallstone solubilizer SURGICAL TREATMENT: o Open/Laparoscopic Cholecystectomy o Lithotripsy o Endoscopic papillotomy POSSIBLE COMPLICATIONS: Ischemia Necrosis Rupture of gallbladder Gangrene Peritonitis
CALCUOUS CHOLECYSTITIS - is the inflammation of the gall bladder resulting from an obstruction of bile outflow due to gallstones Signs and Symptoms
Rationale
Biliary Colic The most common symptom is pain in the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic, which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-counter drugs and isn't helped by passing wind. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones, whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall. Nausea and Vomiting These signs and symptoms may accompany a gallbladder attack. Pain is usually accompanied by nausea and vomiting.
Fever and chills Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever, also due to the irritation and inflammation of the gallbladder wall.
Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied by chills
Loss of appetite and Anorexia The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain. Fat absorption is also impaired for the lack of bile salts; As a result, rapid loss of weight and anorexia can occur.
Jaundice Due to obstruction of the bile flow.
Clay-colored stool may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal that’s something wrong with digestion
Nausea and vomiting may accompany a gallbladder attack
Facial grimace and Guarding behavior
Precipitating Factors:
Factors Rationale
Diet (high cholesterol, high fats)
Increased intake of cholesterol and saturated fats has all been postulated to cause cholesterol gallstones.
If there is an increased production of cholesterol, bile is being supersaturated with cholesterol, that leads in formation of crystals/stones.
Medications
Hypolipidemic agents (clofibrate, gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol gallstones by two fold to three fold.
Estrogen therapy is associated with an increased risk of developing cholesterol gallstone; estrogen increases biliary cholesterol secretion. Oral contraceptive steroids increase biliary cholesterol secretion and saturation but do not affect gallbladder motility.
Total Parenteral Nutrition
TPN is a powerful risk factor for gallstone formation. Gallstones form during TPN because of decreased gallbladder motility from lack of meal-stimulated cholecystokinin (CKK) release, resulting in increased fasting and residual volumes.
Spinal Cord Injury
Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. This high risk, which is 20 times normal, is believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass.
Primary Biliary Cirrhosis
Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Stone analysis has not been performed, but the elevated cholesterol saturation of bile in these patients suggests that they form cholesterol stones.
Diabetes Mellitus
Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes, diabetes mellitus itself does not appear to be an independent risk factor for cholesterol gallstone disease.
Hemolytic Syndromes
Inherited hemolytic anemia, sickle cell disease, sphericytosis, thalassemia, chronic hemolysis associated with artificial heart valves, and malaria dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates, especially bilirubin monoglucoronide, at the expense of the bilirubin diglucuronide, the predominant conjugate in healthy individuals.
Ileal Disease, Resection, and Bypass
Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. Gallstones develop in 30-50% of patients with ileal Chron’s
disease; the risk correlates positively with the extent and duration of ileal dysfunction, Although ilieal disease or resection leads to cholesterol supersaturation and cholesterol stone formation in some
Patients, careful studies now show that most patients with ileal dysfuncyion form black pigment, not cholesterol stones.
Biliary Infection (bacterial)
Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually E.coli or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable associated with bile stasis, biliary tree infection, and/or retained suture material.
Obesity
Obesity is strongly associated with increased gallstone prevalence. The risk is proportional to the increase in total body fat. Obese people synthesize more cholesterol in both hepatic and nonhepatic tissues, transport it to the liver, and secrete more of it into the bile, leading to bile that is often greatly
supersaturated with cholesterol.
Rapid Weight Loss/ Fasting diets
Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week), either by very low caloric dieting or gastric stapling, have a 25-40% chance of developing gallstones within 4 months. During rapid weight loss,
Predisposing Factors:
Factors Rationale
Gender
Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. Before puberty this risk is negligible, and beyond menopause the increased risk disappears.
Advancing Age
The incidence increases with age. Less than 5-6% of the population under age 60 has stones, in contrast to 25-30% of those over 80. It usually affects people with age of over 60 but it is more prevalent after 80 years of age.
Race
Prevalence highest in North American Indians, Chilean Indians, and Chilean Hispanics, greater in Northern Europe and North America than in Asia, lowest in Japan; familial disposition; hereditary aspects
Heredity
Family history alone imparts increased risk, as do a variety of inborn errors of metabolism that lead to impaired bile salt synthesis and secretion or generate increased serum and biliary levels of cholesterol, such as defects in lipoprotein receptors (hyperlipidemia syndromes), which engender marked increases in cholesterol biosynthesis.
Parity/ Pregnancy
Pregnancy is an independent risk factor for cholesterol gallstones. The risk increases with increasing parity, especially with more than two children. During pregnancy, elevated estrogen and progesterone levels increase biliary cholesterol secretion. Elevated progesterone also inhibits gallbladder contractility. 40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy.
REVIEW OF SYSTEMS LYMPHATIC
Increase WBC
o There is an attraction of leukocytes due to invasion of bacteria.
GASTROINTESTINAL
Inflammation of the gallbladder
o Due to obstruction of cystic duct and decrease blood flow that can cause invasion of bacteria, bacteria attracts leukocytes, phagocytosis occur that results in inflammation of gallbladder
Improper emulsification of fat (problem with GIT)
o Due to obstruction of bile out flow, there is an insufficient amount of bile that comes in the duodenum
INTEGUMENTARY
Jaundice
o Due to obstruction bile outflow into the duodenum
RESPIRATORY
Short shallow breathing o Due to pain
PHYSICAL ASSESSMENT
Name: NJE T – 37.2 ºC
Age: 22y/o P – 91 bpm
Date of assessment - August 02, 2010 R – 31 cpm
BP – 110/80mmHg
GENERAL APPEARANCE
Method Normal Findings Actual Findings Remarks
1. Body Built Ht. Wt. BMI Inspection and observation
Proportionate, normal BMI in relation to age Proportionate Ht:5’6’’ Wt:54kg BMI:19.1 Normal
2. Posture and Gait Inspection and
observation
Relaxed, erect posture, coordinated movement
Slouched, uncoordinated movement
Deviation from normal due to the pain @ the
incision on the right upper quadrant of the
abdomen
3. Over-all Hygiene and Grooming Inspection and Observation
Clean and neat Clean and neat ; no body and breath odor
4. Signs of Distress Inspection and observation
No signs of distress Present signs of distress such as facial grimace with guarding
behavior
Deviation from normal due to pain at the site of
incision at right upper quadrant of the
abdomen
5. Obvious signs of health or illness Inspection and observation
No signs of illness or disease Appears weak with facial grimace and guarding behavior
Deviation from normal due to present condition; Post cholecystectomy MENTAL STATUS 1. Level of Consciousness/ Orientation
Inspection Conscious and coherent; Oriented to time, place and situation
Oriented to date, place and time situation
Normal
2 Emotional Status Inspection No facial grimace (+) facial grimace
Deviation from normal due to pain at the site of incision at right upper
quadrant of the abdomen
3. Attitude Inspection Cooperative Cooperative during assessment Normal
4. Affect/mood, appropriateness of responses
Inspection Appropriate to the situation Responses are appropriate to the situation; irritated
Deviation from normal due to pain at the site of
incision at right upper quadrant of the
SKIN
1. Color Inspection Uniform in color Yellowish discoloration
Deviation from normal due to the effect of bilirubin that is still present at the blood
streams.
2. Presence of Edema Inspection and
Palpation
Absence of Edema (+) peripheral edema
Deviation from normal due to water retention caused by fluid shifting from intracellular to intravascular.
3. Presence of Lesions Inspection No Lesions With incision at the right upper
quadrant of abdomen
Deviation from normal due to status post cholecystectomy
4. Moisture of the skin Palpation Moist in Axilla and skin folds Moist in Axilla and skinfolds Normal
5. Temperature Palpation Uniform temperature Uniform temperature Normal
6. Skin Turgor Palpation When pinched, it springs back
within 3 seconds
It springs back to previous state <3 seconds
Normal
1. Fingernail plate shape Inspection plate is approx. 160° plate 160° Normal
2. Fingernail and toenail bed color Inspection Highly vascular and pink in light skin clients
Nail beds are highly vascular Normal
3. Fingernail and toenail texture Inspection and Palpation
Smooth texture Smooth texture Normal
4. Tissue surrounding nails Inspection Intact epidermis Intact epidermis Normal
5. Blanch Test of Capillary refill Inspection and Palpation
Prompt return to pink or usual color within 3 seconds
Prompt return within 3 seconds normal capillary refill
Normal
HEAD
SKULL
1. Shape Inspection Rounded, Normocephalic and
symmetrical with frontal, parietal and occipital prominences.
Rounded, Normocephalic and symmetrical with frontal, parietal
and occipital prominences.
Normal
2. Presence of nodules, masses and
depressions Palpation
Smooth uniform consistency, absence of nodules and masses
Smooth uniform consistency,
absence of nodules and masses Normal 3. Evenness of hair growth over the
scalp
Inspection and Palpation
4. Hair thinness or thickness Inspection Thick hair Thick hair Normal
5. Hair texture and oiliness Inspection and Palpation
Silky and resilient hair Silky and resilient hair Normal
FACE
1. Facial Features Inspection Symmetric or slightly asymmetric
facial features
Slightly asymmetric facial features
Normal
2. Symmetry of facial movements Inspection Symmetric facial movements Symmetric facial movements Normal
EYES
EYEBROWS
1. Hair distribution Inspection Hair evenly distributed Hair evenly distributed Normal
2. Alignment Inspection Symmetrically aligned Symmetrically aligned Normal
3. Skin quality and movement
Inspection by asking the client to raise and lower
the eyebrows intact skin, equal movements intact skin, equal movements Normal
EYELASHES
2. Direction of curl Inspection Curl slightly outward Curl slightly outward Normal
EYELIDS
Surface characteristics
Inspection Skin intact, no discharge and discoloration
Skin intact, no discharge and no discoloration
Normal
Frequency of blinking Inspection Approximately 15-20 involuntary
blinks per minute 18 blinks/min. Normal
CONJUNCTIVA
BULBAR CONJUNCTIVA
1. Color, texture and presence of lesions
Inspection by reverting the eyelids
Transparent. Capillaries sometimes evident. No presence of
lesions
Transparent. Capillaries sometimes evident. No presence
of lesions
Normal
PALPEBRAL CONJUNCTIVA
1. Color, texture and presence of lesions
Inspection, by retracting the eyelids with thumb
and index finger and
side.
SCLERA
1. Color Inspection Sclera appears white Slightly yellow in color Deviation from normal
due to effect of bilirubin in the blood streams CORNEA
1. Clarity and texture Inspection using a
penlight
Transparent, shiny and smooth Transparent, shiny and smooth
Normal
PUPIL
1. Color, shape and symmetry of size Inspection Black in color, round equal in size Black in color, round equal in size
Normal
EARS
AURICLES
1. Color, symmetry of size and position
Inspecting for position. Note the level at which the superior aspect of the auricle attaches to the head in relation to
the eyes.
Color same as the facial skin, symmetrical, auricle aligned with
the outer canthus of the eye.
2. Texture, elasticity and areas of tenderness
Palpation by gently pulling the auricle
downward then backward and folding
the pinna.
Mobile, firm and not tender. Mobile, firm and not tender. Pinna recoils after being folded.
Normal
NOSE
1. External nose for deviations in shape, size or color and flaring or
discharge from the nares. Inspection Symmetric; no discharge or
flaring; uniform color
Symmetric; no discharge or
flaring; uniform color Normal
2. External nose for any areas of tenderness, masses and
displacements of bone and cartilage
Palpation No tenderness masses and displacements
No tenderness masses and displacements
Normal
3. Patency
Inspection (by asking the client to close the mouth and then exert pressure or the nares, and breathe through the
opposite nares and repeat for the other)
Air moves freely as the client breathes through the nares
Air moves freely as the client breathes through the nares
Normal
4. Mucosa
Observation and inspection
pink; clear watery discharge; No lesions and swelling
Mucosa pink; clear watery discharge; No lesions and
swelling noted Normal
6. Sinuses Palpation Not tender No tenderness noted Normal
MOUTH
LIPS AND BUCCAL MUCOSA
1. Outer lips for symmetry of contour, color and texture
Inspection Uniform pink color; soft, moist, smooth texture
Uniform pink color; soft, moist,
smooth texture Normal
2.Inner lips and buccal mucosa for color, moisture, texture and the
presence of lesions Inspection and
palpation
Uniform color; moist, no lesions Uniform color; moist, no lesions Normal
TEETH AND GUMS
1. Characteristics Inspection Smooth white tooth enamel, pink
gums with moist, firm texture.
Smooth white tooth enamel, pink
gums with moist, firm texture Normal
2.Tongue movement Inspection
Central position, smooth lateral margins; no lesions; raised
papillae
Central position, smooth lateral margins; no lesions; raised
papillae; moves freely Normal
3. Base of the tongue, floor of the
mouth and frenulum Inspection
Smooth base of the tongue with prominent veins
Smooth base of the tongue with
4. Presence of nodules, lumps or excoriated areas
Inspection and
Palpation Smooth with no palpable nodules Smooth; no palpable nodules Normal PALATES AND UVULA
1. Hard and soft palate for odor, shape, texture and presence of bony prominences
Inspection Light pink, smooth soft palate; lighter pink, hard palate; no bony
growths.
Light pink, smooth soft palate; lighter pink, hard palate more
irregular texture; no bony growths.
Normal
2. Uvula for position and mobility Inspection Positioned in midline of soft palate Positioned in midline of soft palate
Normal
TRACHEA
1. Lateral Deviations Palpation Central Placement in midline of
neck
Central Placement in midline of neck
Normal
THORAX AND LUNGS
1. Shape and symmetry of the thorax from posterior and lateral views
Inspection Antero-posterior to transverse diameter ratio of 1:2
Ratio of 1: 2 Normal
3. Vocal (tactile) Fremitus Palpation Bilateral symmetry of vocal fremitus
Bilateral symmetry of vocal
fremitus; equal vibration Normal
4. Breath sounds Auscultation Vesicular and broncho- vesicular
breath sounds
Vesicular and broncho- vesicular
breath sounds Normal
5. Breathing Pattern Inspection Rhythmic; effortless Use of accessory muscles upon
breathing; shallow breathing
Deviation from normal due to pain (compensatory
mechanism) ABDOMEN
1. Skin integrity Inspection Unblemished skin; uniform color Impaired skin integrity with
incision on the right upper quadrant
Deviation from normal due to Cholecystectomy
on the right upper quadrant of the
abdomen.
2. Contour and symmetry Inspection Flat, rounded or scaphoid;
symmetrical
Flat; Symmetrical Normal
3. Abdominal movements associated with respirations
Observation Symmetric movements Symmetric movements Normal
4. Bowel sounds Auscultation Audible bowel sounds
Hypoactive bowel sounds
Deviation from normal due to status post cholecystectomy
5. Areas of tenderness Palpation No tenderness; relaxed abdomen Presence of tenderness Deviation from normal due to status post
cholecystectomy MUSCLES
1. Size Inspection Equal in size in both sides of the
body
Equal in size in both sides of the
body Normal
2. Contractures (Softening) Inspection No contractures No contractures Normal
3. Fasciculations and tremors Inspection Palpation No tremors No tremors Normal
4. Muscle tonicity Palpation Normally firm Firm Normal
UPPER EXTREMITIES
1. Motor strength Inspection Can perform ROM exercise for
upper extremities easily
Can perform ROM exercise Normal
2. Muscle tone Palpation Smooth and firm Smooth and firm Normal
3. Presence of lesions, deformities
and varicosities Inspection
No lesions present, no deformities,
varicosities may be present No lesions, no deformities Normal
4. Presence of edema Inspection and
LOWER EXTREMITIES
1. Motor strength Inspection Can perform ROM exercise for
lower extremities easily
Can slightly perform ROM Normal
2. Muscle tone Palpation Firm muscle tone
muscle tone not firm
Deviation from normal due to status post
cholecystectomy
3. Presence of lesions, deformities and varicosities
Inspection No lesions, varicosities may be
present, no deformities No lesions, no deformities Normal
4. Presence of edema Inspection and
Palpation
No edema edema noted
Deviation from normal due to water retention, the liver and kidney are
VI. Laboratory / Diagnostic Procedure Diagnostic Laboratory Procedures Date Indication or Purpose Result Normal values Analysis and interpreta tion of the results Nursing Responsibilities Ordered Result in
Prior During After
CBC (Complete Blood Count) August 01, 2010 August 01, 2010
A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. The test is used to detect infection or inflammation and also used to help monitor the body’s response to various treatments and to monitor bone marrow function, and to determine the need for further tests, such as differential count. WBC 10.6 5.0-10.0x1 09/L Above normal range. An elevated number of leukocyte s can result from infectious diseases (usually bacterial origin), and with trauma or surgery. -Check if there’s a doctor’s order for CBC -Explain the procedure to the patient -Use standard precaution and sterile technique when getting specimen -apply pressure on the venipuncture site after withdrawing specimen -Label the specimen container with name, age, date and time the specimen was
obtained,room no., the doctor who ordered the specimen. -Send the specimen to the laboratory immediately
Hemoglobin is an important
component of red blood cells that carries oxygen and carbon dioxide to and from tissues. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration. HGB 168 M: 140-170 F: 120 – 150 g/dL Within normal range Measures the percentage of RBC in a blood volume. The test is performed to help diagnose blood disorders, such as polycythemia, anemia or abnormal dehydration, blood transfusion decisions for severe symptomatic anemias, and the effectiveness of those transfusions. HCT 0.48 M: 0.40 - 0.60 F: 0.38 – 0.40 Within normal range
The smallest formed elements in blood that promote blood clotting after an injury. The test is performed to determine if blood clots normally, evaluate platelet production, and to diagnose and monitor a severe increase or decrease in platelet count PLT 268 150 – 450 X109/L Within normal range
A small white blood cell (leukocyte) that plays a large role in defending the body against disease. Evaluate bacterial and viral infection, immune disease, leukemia, and ulcerative colitis Lymphocytes 0.36 0.2-0.35 Above normal range
Prothrombin time 1. Control 13.0 12-15 sec Within normal range 2. Activity 70-100 74.3 % Within normal range 3. INR 0.8 – 1.2 1.14 Within normal range 4. Partial thromboplast in Time 35-45 sec 38.7 Within normal range
Abdominal ultrasound August 01, 2010 August 01, 2010 To visualize abdominal structures by using non-invasive diagnostic technique in which high-frequency sound waves are passed into internal
bofy structures.
The gallbladder is not distended measuring 5.5 x 2.5 cm. the previously noted solitary gallstone has increase in size from 5-6.1 mm. wall is not thickened.
Impression:
IMPRESSION
> Solitary Cholecystitis with increase in size
>> Explain the purpose and the procedure of the test.
> Instruct him not to eat solid food for 12 hours prior to exam to allow greatest dilation of the gallbladder >Inform patient that ultrasound is a noninvasive procedure. >> explain the following: >patient will be ask to lie on the examination couch next to ultrasound machine >the area to be scanned will be exposed and a clear water-soluble gel will be applied to the skin for the transmission of sound waves into the patient’s body > Patient can expect to resume her/his normal activities immediately. >inform patient regarding the result
>a scan probe will then be
placed in
contact with patient’s body and move over the skin to examine the tissues below. >the parient will experience no pain during the procedure >Ultrasound scans take approximately 30 min. to complete.
VII. Patient and His Care A. Medical Management MEDICAL MANAGEMENT TREATMENT DATE ORDERED/ DATE PERFORMED/ DATE CHANGE OR DC GENERAL DESCRIPTION INDICATIONS/ PURPOSE CLIENTS RESPONSE TO THE PROCEDURE NURSING RESPONSIBILITIES 1.) IVF (D5LRS) >Regulated @ 30-31 gtts/min Date ordered/performed August 01, 2010 Date discontinued: August 03,2010 5% Dextrose in Lactated Ringers Solution
For rehydration No signs of dehydration.
PRIOR:
Determined the type of solution to be infused. The rate of flow or the time over which the
infusion is to be completed. Assess the vital signs, skin turgor.
DURING:
Prepare the infusion set. Spike the solution container. Prime the tubing.
Perform aseptic technique. Initiate the infusion. Regulate the infusion. AFTER:
Document relevant data. Monitor client’s response.
Evaluate if IV flow is consistent with what ordered.
MEDICAL MANAGEMENT TREATMENT DATE ORDERED/ DATE PERFORMED/ DATE CHANGE OR DC GENERAL DESCRIPTION INDICATIONS/ PURPOSE CLIENTS RESPONSE TO THE PROCEDURE NURSING RESPONSIBILITIES Oxygen therapy (3LPM via face mask) Date ordered/performed: August 01, 2010 Date discontinued: August 02,2010 - Oxygen therapy is the administration of oxygen as medical intervention. Oxygen is essential for cell metabolism, and in turn, for tissue oxygenation.
-it is an
administration of oxygen at
concentration greater than that in room air to prevent hypoxemia and hypoxia. -facilitate breathing -to increase oxygen saturation in tissues -the patient relieved difficulty of breathing. -the patient demonstrate adequate oxygenation PRIOR:
Check for the doctor’s order including the flow rate of O2
Check and how to administer for the oxygen tank, humidifier, and flow rate meter if they are working.
Place “no smoking” sign at the head or foot of the bed.
DURING:
Assess for kinks and obstruction Secure the tubing, comfortably. Observe for moisture in the mask to
prevent aspiration.
Observe the pressure necrosis.
AFTER:
Check for client’s response to the therapy. Check for the skin irritation.
B.Drugs Name of drug Date ordered, taken/given Date changed/ D/C Route of administration, dosage, frequency General action, Classification, Mechanism of Action
Indications/Purpose Client response to the medication, actual side effects Nursing Responsibilities Generic Name: RANITIDINE Brand Name: ZANTAC Date ordered: August 01, 2010 50 mg TIV Q8 Stock Dose: 25 mg/mL Classification: H2 RECEPTOR BLOCKER GENERAL ACTION >anti-ulcer MECHANISM OF ACTION
>Competitively inhibits the
action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin.
INDICATION
>Short-term treatment of active duodenal ulcer
> Maintenance therapy for duodenal ulcer at reduced dosage
>Short-term treatment of active, benign gastric ulcer Clients response >decreased abdominal pain Side effects >abdominal pain, constipation, PRIOR
1. Assess patient for contraindication. 2. Assess for baseline data.
3. Tell patient that he may experience side effects brought about by the drug.
DURING
1. Administer the drug slowly.
AFTER
1. Instruct him to report intolerable side effects so as prompt intervention could be done.
2. Instruct him to report adverse effects that he may experience.
.Name of drug Date ordered, taken/given Date changed/ D/C Route of administration, dosage, frequency
General action, Classification,
Mechanism of Action Indications/Purpose
Client response to the medication, actual side effects
Nursing Responsibilities Generic Name: VITAMIN K Brand Name: Aquamephyton Date ordered: August 01, 2010 10 mg TIV Q8 Classification: Fat soluble vitamin GENERAL ACTION >anti-coagulant
MECHANISM OF ACTION >Vitamin K is essential for the hepatic synthesis of factors II, VII, IX, and X, all of which are essential for blood clotting. Vitamin K deficiency causes an increase in bleeding tendency, demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding. Indication: >Prevention of bleeding, >hypoprothrombinemia Clients response >N/A Side effects: >N/A PRIOR
1. Assess for contraindication. 2. Assess for baseline data. 3. Teach patient not to take other supplements, unless directed by prescriber, to take this medication as directed.
4. Tell patient that he may experience side effects brought about by the drug and to report symptoms of bleeding: bruising, nosebleeds, bleack tarry stools, hematuria. DURING
1.Slowly administer the medication AFTER
1.Instruct patient to report adverse effect that he may experience
Name of drug Date ordered, taken/given Date changed/ D/C Route of administration, dosage, frequency General action, Classification, Mechanism of Action Indications/Purpose
Client response to the medication, actual side effects Nursing Responsibilities Generic Name: CEFUROXIME-SODIUM Brand Name: CEFUROXIME Date ordered: August 01, 2010 750 mg TIV Q8 Stock dose: 750 mg/50 mL Classification: ANTIBIOTIC;CEPHAL OSPORIN (2ND GENERATION) GENERAL ACTION: >Bactericidal MECHANISM OF ACTION >inhibits synthesis of bacterial cell wall, causing cell death.
Indication:
>Maintenance Surgical prophylaxis
Clients response
>pain is felt upon administering IV push
Side effects
>no side effects
PRIOR
1. Assess patient for contraindication. 2. Assess for baseline data.
3. Have vitamin K readily available in case of hypoprothrombinemia occurs.
DURING
1.Reconsitute 1gram with 10 or more ml of sterile water
AFTER
1. Instruct patient to avoid alcohol for 3days after drug administration because serious reactions often occur. 2. Tell patient that he may experience some side effects brought upon by the drug.
Name of drug Date ordered, taken/given Date changed/ D/C \Route of administration, dosage, frequency General action, Classification, Mechanism of Action Indications/Purp ose Client response to the medication, actual side effects
Nursing Responsibilities Generic name: METRONIDAZOLE HYDROCHLORIDE Brand name: FLAGYL IV Date ordered: August 02, 2010 500 mg TIV Q8 Stock dose: 500 mg/100 mL Classification: >Nitroimidazole derivative GENERAL ACTIONS:- >Anti-infective >Anti-protozoal MECHANISM OF ACTION
>Disturbs DNA synthesis in susceptible bacterial organism. INDICATION >for preoperative prophylaxis Clients response >N/A Side effects >dark urine PRIOR
1. Check for doctor’s order
2. Not to be given in patients hypersensitive to drugs
3. Inform the patient about the possible side effect of the drug
DURING
1. Inject IV port slowly, over not less than 2 min.
AFTER
1. Advise patient to report abdominal pain.
Name of drug Date ordered, taken/given Date changed/ D/C Route of administration, dosage, frequency General action, Classification, Mechanism of Action Indications/Purp ose Client response to the medication, actual side effects
Nursing Responsibilities Generic name: PARACETAMOL Brand name: ACETAMINOPHEN Date ordered: August 02, 2010 300mg, TIV now, q4, PRN for ≥ 38°C Classification
Nonopoid analgesics and antipyretic GENERAL ACTIONS > decreases body temperature MECHANISM OF ACTION
>Reduces fever by acting directly on the
hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat.
INDICATION >reduce body temperature Clients response >fever decreases from 38°C- 37°C PRIOR
1. Check for doctor’s order
2. Not to be given in patients hypersensitive to drugs
3. Inform the patient about the possible side effect of the drug
DURING
1. Inject directly slowly
AFTER
1. Tell patient that he may experience some side effects brought upon by the drug
Name of drug Date ordered, taken/given Date changed/ D/C Route of administration, dosage, frequency General action, Classification, Mechanism of Action Indications/Purpose Client response to the medication, actual side effects
Nursing Responsibilities Generic Name: CELECOXIB Brand Name: CELEBREX Date ordered: August 02, 2010 200 mg PO FOR PAIN Stock dose: 100 mg and 200 mg Classification: NONSTEROIDAL ANTI-INFLAMMATORY DRUG GENERAL ACTION >Pain reliever MECHANISM OF ACTION >Inhibits prostaglandin synthesis, primarily by inhibiting cyclo-oxygenase-2 thus decreasing inflammation. . Indication:
>Management of acute pain.
Contraindications:
>Contraindicated with allergies to sulfonamides, celecoxib, NSAID, or aspirin
Clients response
>verbalized
decreased pain felt
PRIOR
1. Take drug with food if GI upset occurs
2. Determine any GI bleed/ulcer history, sulfonamide allergy, aspirin and other NSAID-induced asthma, urticaria, allergic type reaction
3. Monitor sign and symptoms
4. Assess for liver or renal dysfunction; reduce dose
DURING
1. Take with foods; decreases stomach upset
AFTER
1. Tell patients that he may
experience some side effects brought about by the drug