I. INTRODUCTION Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East. Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation.
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I. INTRODUCTION
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining.
Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the
gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called
cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the
gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of
cholelithiasis is approximately $5 billion in the United States, where 75-80% of
gallstones are of the cholesterol type, and approximately 10-25% of gallstones are
bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate,
although recent studies have shown an increase in cholesterol stones in the Far East.
Gallstones are crystalline structures formed by concretion (hardening) or accretion
(adherence of particles, accumulation) of normal or abnormal bile constituents.
According to various theories, there are four possible explanations for stone formation.
First, bile may undergo a change in composition. Second, gallbladder stasis may lead to
bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics
and demography can affect stone formation.
Risk factors associated with development of gallstones include heredity, Obesity,
rapid weight loss, through diet or surgery, age over 60, Native American or Mexican
American racial makeup, female gender-gallbladder disease is more common in women
than in men. Women with high estrogen levels, as a result of pregnancy, hormone
replacement therapy, or the use of birth control pills, are at particularly high risk for
gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-fiber/high-
cholesterol/high-starch diets all may contribute to gallstone formation.
Sometimes, persons with gallbladder disease have few or no symptoms. Others,
however, will eventually develop one or more of the following symptoms; (1) Frequent
bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables
such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains
in the upper right part of the abdomen. This pain occurs when a gallstone causes a
blockage that prevents the gallbladder from emptying (usually by obstructing the cystic
duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the
common bile duct, which leads into the intestine blocking the flow of bile from both the
gallbladder and the liver. This is a serious complication and usually requires immediate
treatment.
The only treatment that cures gallbladder disease is surgical removal of the
gallbladder, called cholecystectomy. Generally, when stones are present and causing
symptoms, or when the gallbladder is infected and inflamed, removal of the organ is
usually necessary. When the gallbladder is removed, the surgeon may examine the bile
ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts
are not removed so that the liver can continue to secrete bile into the intestine. Most
patients experience no further symptoms after cholecystectomy. However, mild residual
symptoms can occur, which can usually be controlled with a special diet and medication.
II. NURSING ASSESSMENT
A. Personal History
Mr. Aproniano Castro is a 56 year old male, a Filipino citizen who resides at Pulong
Santol, Porac Pampanga. He was born on January 22, 1950 at Pulong Santol, his
religious affiliation is Roman Catholic and he is married to Mrs. Brigida M. Castro. He
is a jeepney driver bound in Porac-Angeles route. He is also the president of their
jeepney’s association. Mr. Castro usually works for 10 to 12 hours a day usually around
7am to 7 pm. He always sleeps around 9 in the evening and wakes up at 6 in the morning.
His wife was the one who prepares him the breakfast and the snack. He has day-offs but
uses this day in working as the president of the jeepney association. He usually eats
instant food and love eating foods which has condiment like “patis”, vinegar and soy
sauce. He also love eating vegetable salads and fatty salty food. He is not also choosy on
the food he eats because he really eat a lots. He seldom drinks alcohol and smoke.
Regarding the finances about health he is using his wife’s PHILHEALTH card to
compensate the finances needed. Family Health and Illness History
B. Family Health and Illness History
According to Mr. Castro that the familial disease he knows that they have in their
family was the hypertension that is on his father’s side. His father died because of heart
attack and her mother died of natural cause. He also added that cholecystitis is prone to
their family, because of one of his siblings also had acquired this disease.
C. History of Past and Present Illness
This is the second time Mr. Castro been admitted into this hospital (Porac District
Hospital). On his first admission into this hospital he had undergone throidectomy
operation, which is almost 3 years ago. He had not experience any accident and injuries,
even though his job is prone to accident particularly vehicular accident. He also added
that he had an ashtma when he was 7 years old that lasts when he is 21 years old, his
ashtma just stopped when he start drinking alcohol beverages as he said.
As for his present illness, he was admitted into this hospital because of cholecystitis,
he was admitted last February 13, 2006. He was been diagnosed with cholecystitis with
multiple cholelithiasis a month prior to admission due to severe epigastric pain and
weight loss and was advised to remove his gallbladder. He just did not have his
cholecystectomy done immediately due to financial problem. When the money needed
for his operation was enough he then goes to Porac District Hospital last February 13,
2005 for his operation. He was diagnosed and surgically operated by Dr.
Serrano.According to Mr. Castro. Upon admission he had undergone some laboratory
examination such as UTZ, Chest X-ray, U/A, CBC, FBS, BUN,Creatinine and ECG. His
initial medication were H2bloc and Cefuroxime.
D. Physical Examination
Physical Assessment done by the attending physician reveals that patient is; afebrile with pink palpebral conjunctiva (-) cyanosis (+) NABS non tender abdomen
Vital Signs upon admission (February 13, 2006)BP- 130/90 RR-19 PR-84 Temp-36.5 oC Physical Assessment done by the student reveals that patient is;
afebrile with pink palpebral conjunctiva (+) dry lips (+) paleness (+) dryskin decreased skin turgor (-) bowel movement (-) weakness
Vital Signs taken and recorded as of February 15, 2006 are as follows;BP- 140/90PR- 85RR- 21Temp- 36.4 oC
III. ANATOMY AND PHYSIOLOGY
Gallbladder, muscular organ that serves as a reservoir for bile, present in most
vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the
right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in)
long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to
1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend
backward, upward, and to the left. The wide end (fundus) points downward and forward,
sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder
consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and
unstriped muscle (tunica muscularis); and an inner mucous membrane coat (tunica
mucosa).
The function of the gallbladder is to store bile, secreted by the liver and transmitted
from that organ via the cystic and hepatic ducts, until it is needed in the digestive process.
The gallbladder, when functioning normally, empties through the biliary ducts into the
duodenum to aid digestion by promoting peristalsis and absorption, preventing
putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by
pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work,
by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake
of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses
This is to determine blood components and the response to
inflammatory process and streptococcal infection.
Date Ordered: February 13, 2006
Date Result In: February 13, 2006
Results:
WBC - 10.9 g/l
RBC - 5.5 g/l
Lymphocyte - 27
Conclusion:
WBC is slightly elevated based on the normal value of 4.3-10 g/l which
confirms the presence of infection.
2. Fasting Blood Sugar
This is to measure the blood glucose levels.
Date Ordered: February 13, 2006
Date Result In: February 13, 2006
Results:
94.8 mg/dl
Conclusion:
The result is within normal range based on the normal value of < 126
mg/dl.
3. Creatinine
This is the indicator of the renal function
Date Ordered: February 13, 2006
Date Result In: February 13, 2006
Results:
1.0 mg/dl
Conclusions:
The result is within normal range based on the normal value of 0.60-1.7
mg/dl.
4. BUN
This is an indicator of renal function and perfusion, dietary intake of
CHON and the level of protein metabolism
Date Ordered: February 13, 2006
Date Result In: February 13, 2006
Results:
10.7 Mg/dl
Conclusions:
The result is within normal range based on the normal value of mg/dl.
5. Urinalysis
Urinalysis yields a large amount of information about possible disorders of
the kidney and lower urinary tract, and systematic disorders that alter urine composition.
Urinalysis data include color, specific gravity, pH, and the presence of protein, RBC’s,
WBC’s, bacteria, Leukocyte, esterase, bilirubin,glucose, ketones, casts and crystals.
Date Ordered: February 10, 2006
Date Result In: February 10, 2006
Results:
Color- yellow
Specific Gravity- 0.010
Sugar/ Albumin- negative
Pus cells- 0.1 hpf
Conclusions:
The results are normal but there is a presence of pus cells in the urine
which means that there is also the presence of infection.
VI. Patients Care
a. Nursing Care Plan
Preoperative NCP
1. Acute Pain
Cues Nursing Diagnosis
Scientific Explanations
Objectives Nursing Interventions
Rationale Evaluation
S
O- pain scale
of 7/10- difficulty in
moving as manifested by facial grimaces
- (+) pallor- (+) muscle
guarding- RR- 30- BP- 140/90
Acute pain related to inflammation and distortion of the gallbladder as evidenced by verbal reports of pain.
Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen.
After 4 hours of nursing intervention the patient will report relieve of pain.
1. Observe and document location, severity (0–10 scale),and character of pain (e.g., steady, intermittent, colicky).
2. Promote bedrest, allowing patient to assume position ofcomfort.
3. Control
- Assists in differentiating cause of pain, and providesinformation about disease progression/resolution,development of complications, and effectiveness ofinterventions.
- Bedrest in low-Fowler’s position reduces intra-abdominalpressure; however, patient will naturally assume leastpainful position.
- Cool surroundings
Is there a change on the patients;
a. Pain scale
b. RRc. BPd. Reports
of paine. Facial
expressions.
environmental temperature.
4. Encourage use of relaxation techniques, e.g., guidedimagery, visualization, deep-breathing exercises. Providediversional activities.
5. Make time to listen to and maintain frequent contact withpatient.
6. Administer analgesics as indicated
aid in minimizing dermal discomfort.
- Promotes rest, redirects attention, may enhance coping.
- Helpful in alleviating anxiety and refocusing attention,which can relieve pain.
- Relief of pain facilitates cooperation with othertherapeutic interventions,
2. Fluid Volume deficient
Cues Nursing Diagnosis
Scientific Explanations
Objectives Nursing Interventions
Rationale Evaluation
S
O- (+) pallor- (+) body
weakness- (+)
vomiting- with poor
skin turgor
- (+) dry skin
- (+) dry mouth
Fluid Volume Deficient related to vomiting
Because of vomiting excessive losses through normal routes occur thus causes Fluid Volume Deficient
After series of NI the pt. will maintain adequate fluid volume as evidenced by moist mucous membranes and good skin turgor,
1. Maintain accurate record of I&O, noting output less thanIntake, increased urine specific gravity. Assessskin/mucous membranes, peripheral pulses, and capillaryrefill.
2. Perform frequent oral hygiene
3. Provide skin and mouth care
- Provides information about fluid status/circulatingvolume and replacement needs.
- Decreases dryness of oral mucous membranes; reducesrisk of oral bleeding.
- Skin and mucous membranes are dry, with decreased
Is there still the presence of;
a. vomitingb. dry skinc. dry
mouthd. poor skin
turgore. body
weakness
4. Increase fluid intake
5. Ascertain patient’s beverage preferences, and set up a 24-hr schedule for fluid intake. Encourage foods with highfluid content.
6. Administer antiemetics, e.g., prochlorperazine(Compazine) as ordered by the physician.
elasticity, because of vasoconstriction and reducedintracellular water.- promotes hydration.
- Relieves thirst and discomfort of dry mucous membranesand augments parenteral replacement.
- Reduces nausea and prevents vomiting.
Post-operative NCP3. Knowledge Deficit
Cues Nursing Diagnosis
Scientific Explanations
Objectives Nursing Interventions
Rationale Evaluation
S “pwede bang maulit ang sakit ko” as verbalized by the patient
O- Frequently
asking question about his condition, treatment and diet
- With worried gaze
Deficient knowledge related to condition,prognosis, treatment, self-care, and discharge needs
There is this presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed.
After an hour of nurse-patient interaction the patient will Verbalize understanding of disease process, prognosis, and potential complications.
1. Provide explanations of/reasons for test procedures andpreparation needed.
2. Review disease process/prognosis. Discuss hospitalizationand prospective treatment as indicated. Encouragequestions, expression of concern.
3. Review drug regimen, possible side effects.
- Information can decrease anxiety, thereby reducingsympathetic stimulation.
- Provides knowledge base from which patient can makeinformed choices. Effective communication and supportat this time can diminish anxiety and promote healing.
- Gallstones often recur, necessitating long-term therapy.
- Prevents/limits
- Does the patient understands and could recall all the teachings given?
- Is there a significant changes that occur on the patients knowledge regarding;
a. disease condition
b. dietc. treatmentd. medicatione. self-care
needs
4. Instruct patient to avoid food/fluids high in fats (e.g.,whole milk, ice cream, butter, fried foods, nuts, gravies,pork), gas producers (e.g., cabbage, beans, onions,carbonated beverages), or gastric irritants (e.g., spicyfoods, caffeine, citrus).
5. Suggest patient limit gum chewing, sucking on straw/hardcandy, or smoking.
recurrence of gallbladder attacks.
- Promotes gas formation, which can increase gastricdistension/discomfort.
b. Drug Study
Name of Drug Date Ordered
Route/ Dosage and Frequency
Action Indication Adverse Reaction
Nursing Consideration
GN: H2Bloc (Pepcidine)BN: Famotidine
02-13-06 PO20 mg tab at bedtime
- Anti-ulcer- competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion
-for short term treatment of duodenal ulcer
- headache, dizziness, malaise, dry mouth
1. Check for doctor’s order2. not to be given in patients hypersensitive to drugs3. Inform the patient about the possible side effect of the drug4. Instruct patient to take drug with food5. Advised patient to take drug once daily usually at bed time6. Advise patient to report abdominal pain or blood in stools or is vomiting.
GN: CefuroximeBN: Zinacef
02-13-06 IV750 mg every 8o prior to OR (30 to 60 minutes before)
- anti-infective- a 2nd generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability
- perioperative prophylaxis
- Nausea and Vomiting
1. Check for doctor’s order2. Perform ANST prior to admission3. Should not be given if positive skin test4. Slow IV push5. Inform the patient about the possible side effect of the drug6. Advise patient to report any discomfort on the IV insertion site
Name of Drug Date Ordered
Route/ Dosage and Frequency
Action Indication Adverse Reaction
Nursing Consideration
GN: Clomipramine HClBN: Placil
02-13-06 PO10 mg tab, at 6 am
- Anti-depressants
- for depression and chronic pain
- headache, dizziness, malaise, dry mouth
1. Check for doctor’s order2. not to be given in patients hypersensitive to drugs3. Inform the patient about the possible side effect of the drug
GN: Gentamicin DulfateBN: Genticin
02-14-06 IV80 mg amp, every 80
- Anti-infective- inhibits protein synthesis
- endocarditis prophylaxis for GI or GU procedure or surgery
- Nausea and Vomiting, headache, dizziness
1. Check for doctor’s order2. Perform ANST prior to admission3. Should not be given if positive skin test4. Slow IV push5. Inform the patient about the possible side effect of the drug6. Advise patient to report any discomfort on the IV insertion site7. Monitor urine output, specific gravity, U/A, BUN and creatinine levels
Name of Drug Date Ordered
Route/ Dosage and Frequency
Action Indication Adverse Reaction
Nursing Consideration
GN: AmpicillinBN: Omnipen
02-14-06 IV1 g amp, every 80
- Anti-infective- inhibits protein synthesis
- endocarditis prophylaxis for GI or GU procedure or surgery
- Nausea and Vomiting, headache, dizziness
1. Check for doctor’s order2. Perform ANST prior to admission3. Should not be given if positive skin test4. Slow IV push5. Inform the patient about the possible side effect of the drug6. Advise patient to report any discomfort on the IV insertion site
GN: MgSO4 02-14-06 IV0.03% 7ml every 120
-anti-convulsant-replaces magnesium and maintains magnesium level
- magnesium supplementation
- drowsiness, hypotension
1. Use parenteral magnesium with extreme caution in patients with impaired renal function2. Test knee jerk and patellar reflexes before each additional dose3. check magnesium level after repeated doses4. Monitor fluid intake and output5. Monitor renal function
- short term management of moderately severe, acute pain
- dizziness, sedation, headache, flatulence, nausea and vomiting
1. Check for doctor’s order2. Perform ANST prior to admission3. Should not be given if positive skin test4. Slow IV push5. Inform the patient about the possible side effect of the drug6. Advise patient to report any discomfort on the IV insertion site