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 May 25, 2010
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Calculous Cholecystitis
A Case StudyPresented to the Faculty,
Ateneo de Davao Universi tyCollege 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 PepinoRio Remonde
Kevin Melvin RoaKrystle Rustia
BSN-3H-4a
May 25, 2010
TABLE OF CONTENTS
I. Introduction........................................................................................1
II. Objectives (General & Specific)........................................................3
III. Patient’s Data......................................................................................6
IV. Family Background and Health History..........................................7
V. Definition of Complete Diagnosis......................................................14
VI. Developmental Data............................................................................17
VII. Physical Assessment............................................................................26
VIII. Anatomy and Physiology....................................................................34
IX. Etiology and Symptomatology...........................................................37
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.
Page | 36
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,
Tenth Edition 1983 page 1823
The patient
is not
diabetic.
Page | 37
Lippincott Williams and Wilkins Handbook
of Diseases Third Edition, page 184
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
Lippincott Williams and Wilkins Handbook
of Diseases Third Edition, page 184
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
in the Western countries
The patient
is Filipino.
She is
predisposed
to having
pigment
stones.
Page | 38
Sources:
Lippincott Williams and Wilkins Handbook
of Diseases Third Edition, page 184
http://www.diabetesmonitor.com/learning-
center/gallstones.htm
Precipitating Factors
Present/ Absent
Rationale Justification
PregnancyABSENT 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/Modules/gallstns.cfm
No rapid weight loss
was noted by the patient.
Page | 39
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
Lippincott Williams and Wilkins Handbook of Diseases Third
Edition, page 184
http://www.fbhc.org/Patients/Modules/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
Provide a gown without snaps, and ask the patient to remove all jewelry
Take ultrasound if the patient’s bladder is fluid filled for better results
Page | 71
DRUG STUDY
Generic Name: Meperidine Hydrochloride
Brand Name: DemerolClassification: Opioid agonist analgesicOrdered Dose: 50mg IVTT now then prn for abdominal pain Mode Of Action: Acts as agonist at specific opioid receptors in the CNS to
produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same with endorphins
Indications: Relief of moderate to severe acute pain.
Keep opioid antagonist and facilities readily available during parenteral administration
Use caution when injecting to patients with hypotension Reduce dosage of Demerol in patients receiving
phenothiazines or other tranquilizers Reassure that addiction is unlikely to occur Use Demerol with extreme caution in patient with renal
dysfunction Give only prescribed dosage Avoid alcohol, antihistamines, sedatives, tranquilizers Do not take left over medications for other disorders Keep out the reach of children Take Demerol with food, small frequent meals May use laxative if constipation occurs Avoid driving or doing activities that require alertness
because it could cause drowsiness and impaired visual activity.
Bibliography: 2005 Lippincott’s Nursing Drug Guidewww.drugs.com/demerol.htmlwww.rxlist.com/demerol-drug.htm
Classification: Gastro-intestinal antispasmodicOrdered Dose: 20mg 1amp IVTT nowMode Of Action: It's a competitive antagonist of the actions of acetylcholine
and other muscarinic agonists. Hyoscine works by relaxing the muscle that is found in the walls of the stomach, intestines and bile duct (gastrointestinal tract) and the reproductive organs and urinary tract (genitourinary tract)
Indications: This medication is used to relieve bladder or intestinal spasms.
Contraindications: Hypersensitivity to hyoscine butylbromide, Patients with prostatic enlargement, paralytic ileus or pyloric stenosis, ulcerative colitis, closed angle glaucoma
Side Effect: Nausea, vomiting, loss of appetite, constipation, dry mouth, rash, itching, swelling of the hands or feet, trouble breathing, increased pulse, dizziness, diarrhea, vision problems, eye pain
pain, psuedomembranous colitis GU: Nephrotoxicity Hematologic: bone marrow depression,
thrombocytopeniaNursing Responsibilities:
Culture infection before starting therapy Have vitamin K available in case of
hypoprothrombinemia Discontinue if hypersensitivity occurs Avoid alcohol while taking drug Take only prescribed dosage Complete antibiotic therapy, don’t skip doses Do not use extra medicine to make up the missed dose Do not use drug if you are allergic to penicillins and
cephalosporins Antibiotic medicines can cause diarrhea, which may be
a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor.
Store at room temperature away from moisture, heat, and light
If you get a skin rash, do not treat yourself.Bibliography: 2005 Lippincott’s Nursing Drug Guide
GU: incontinence, retention, change in libido, menstrual irregularities
Other: phlebitis and thrombosis at injection site, hiccups, fever, diaphoresis, pain at injection site
Nursing Responsibilities:
Carefully monitor pulse, respiration rate and blood pressure during administration
Keep addiction – prone patients under careful surveillance
Ensure ready access to bathroom if GI effects occur Provide small, frequent meals to prevent GI upset Establish safety precautions if CNS changes occur Monitor liver and kidney function, CBC during long term
therapy Taper dose gradually after long term therapy Discuss risk of fetal abnormalities with patients desiring
to become pregnant
Page | 77
Take drug exactly as prescribed Do not stop drug abruptly during long term therapy Caregiver should learn to assess seizures and monitor
patient Use of barrier contraceptive is advised while on this
drug Avoid alcohol, sleep inducing drugs
Bibliography: 2005 Lippincott’s Nursing Drug GuideMIMS 113th edition 2007www.drugs.com/valium.html www.medicinenet.com/diazepam/article.htm
Mode Of Action: Competitively inhibits action of histamine at histamine2 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 agonists, gastrin, and pentagastrin
Indications: Against ulcer brought about by NPO due to surgical procedure
Contraindications: Hypersensitivity to ranitidine, lactationDrug Interactions: Increased effects of warfarinSide Effect: Constipation, nausea, vomiting, breast enlargement,
thrombocytopenia, pancytopenia Local: pain at IM site, local burning pain at injection site
Nursing Responsibilities:
Administer oral drug with meals and hs Decrease doses in renal and liver failure Provide concurrent antacid therapy to relieve pain Avoid cigarette smoking as it decreases
effectiveness Have regular medical follow-up to evaluate
response Adjust environment (lights, temp, noise) to prevent
headache Using ranitidine may increase your risk of
developing pneumonia Avoid drinking alcohol. It can increase the risk of
damage to your stomach If you think you have taken too much of this
medicine contact a poison control center or emergency room at once.
If you need to take an antacid you should take it at least 1 hour before or 1 hour after this medicine. This medicine will not be as effective if taken at the same time as an antacid.
If you get black, tarry stools or vomit up what looks like coffee grounds, call your doctor or health care professional at once. You may have a bleeding ulcer.
Bibliography: 2005 Lippincott’s Nursing Drug GuideMIMS 113th edition 2007www.rxlist.com/zantac- www.medicinenet.com/ranitidine/article.htmhttp://www.healthline.com/goldcontent/ranitidine
Classification: Fat soluble vitamin; antifibrinolytic agent Ordered Dose: 1amp now
Mode Of Action: Vitamin K is required for the liver to make factors that are necessary for blood to properly clot (coagulate), including factor II (prothrombin), factor VII (proconvertin), factor IX (thromboplastin component), and factor X (Stuart factor).
Indications: Preoperatively: to activate clotting factors to decrease chances of bleeding during surgical procedure
Contraindications: Hypersensitivity to benzyl alcohol, Drug Interactions: Coumarin and indanedione derivatives
Side Effect: No known side effects for this drug; bruising and bleeding are less likely to happen.
Adverse Effects: No known adverse effects reported
Nursing Responsibilities:
Instruct patient to take only prescribed order If a dose is missed, take as soon as remembered
unless almost time for the next dose Cooking does not destroy substantial amounts of
Vitamin K Caution patient to avoid IM injection and activities
leading to injury Patient should not drastically alter diet while taking
Vitamin K Use a soft toothbrush until coagulation effect is
corrected Advise patient to report any signs of
bleeding/bruising Patient should be advised not to take OTC drugs
Page | 80
without advice of health care provider Advise patient to inform health care provider of
medication regimen prior to treatment or surgery Emphasize importance of frequent lab test to
Mode Of Action: Arcoxia reduces pain and inflammation by blocking COX-2, an enzyme in the body.Arcoxia does not block COX-1, the enzyme involved in protecting the stomach from ulcers.Other anti-inflammatory medicines (NSAIDS) block both COX-1 and COX-2.Arcoxia relieves pain and inflammation with less risk of stomach ulcers compared to NSAID
Indications: relief of acute pain
Contraindications: Hypersensitivity to arcoxia and it’s ingredients such as etoricoxib
Drug Interactions: warfarin, a medicine used to prevent blood clots rifampicin, an antibiotic used to treat tuberculosis and
other infections water pills (diuretics) ACE inhibitors and angiotensin receptor blockers,
medicines used to lower high blood pressure or treat
thrombocytopenia, pancytopenia Local: pain at IM site, local burning pain at injection site
Nursing Responsibilities:
Take Arcoxia only when prescribed by your doctor.
For the relief of chronic musculoskeletal pain the recommended dose is 60 mg once a day.
If you have mild liver disease, you should not take more than 60 mg a day. If you have moderate liver disease, you should not take more than 60 mg every other day.
When taking the tablets, swallow them with a glass of water. Do not halve the tablet.
Take your Arcoxia at about the same time each day.
Taking Arcoxia at the same time each day will have the best effect. It will also help you remember when to take the dose.
It does not matter if you take Arcoxia before or after food.
Page | 82
Do not use Arcoxia for longer than your doctor says. Do not take a double dose to make up for the dose that
you missed. If you get an infection while taking Arcoxia, tell your
doctor. Arcoxia may hide fever and may make you think, mistakenly, that you are better or that your infection is less serious than it might be.
biosynthesis. Ampicillin has a broad spectrum of bactericidal activity against many gram-positiveand gram-negative aerobic and anaerobic bacteria. sulbactam in the UNASYN formulation effectively extends the antibioticspectrum of ampicillin to include many bacteria normally resistant to it and to other beta-lactamantibiotics.
Indications: Intra-Abdominal Infections caused by beta-lactamase producing strains of Escherichia coli, Klebsiella spp. (including K. pneumoniae*), Bacteroides spp. (including B. fragilis), and Enterobacter spp.
Contraindications: contraindicated in individuals with a history of hypersensitivity reactions to any of the penicillins.
Drug Interactions: allopurinol (Zyloprim); probenecid (Benemid); or an antibiotic such as amikacin (Amikin), gentamicin
Side Effect: Nausea, vomiting, stomach pain, bloating, gas, vaginal itching or discharge, headache, itching, swollen, black, or "hairy" tongue, thrush ;pain, swelling, or other irritation where the needle is placed.
neutropenia, prolonged bleeding time Hypersensitivity: rash, fever, wheezing, anaphylaxis Local: pain, phlebitis, thrombosis at injection site Other: superinfection, sodium overload, CHF
Nursing Responsibilities:
Culture infected area before beginning treatment Monitor serum electrolytes and cardiac status Do not use this medication if you are allergic to
ampicillin and sulbactam or to any other penicillin
Page | 85
antibiotic Antibiotic medicines can cause diarrhea, which may be
a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.
Use this medication for the entire length of time prescribed by your doctor. Your symptoms may get better before the infection is completely treated.
This medication can cause you to have unusual results with certain medical tests. Tell any doctor who treats you that you are using ampicillin and sulbactam.
Store ampicillin and sulbactam at room temperature away from moisture, heat, and light.
Provide small, frequent meals if GI upset occurs Do not use extra medicine to make up the missed dose. Seek emergency medical attention if you think you have
used too much of this medicine. If you get a skin rash, do not treat yourself.
1. Placed on supine position, reverse trendelenburg
2. Administration of General Endotracheal Anesthesia (GETA)
3. Skin over surgical site is cleansed with antiseptic solution
4. Placement of drapes.
5. Three to four small
incisions is made in
the abdomen.
Carbon dioxide gas
is introduced into
the abdomen to
inflate the
abdominal cavity so
that the gallbladder
and surrounding
organs can be more easily visualized.
Page | 88
6. The laparoscope is inserted through one of the incisions (usually at the
incision below the umbilicus) and instruments will be inserted through
the other incisions to remove the gallbladder.
7. When the procedure is completed, the laparoscope is removed.
8. The gallbladder is sent to the lab for examination
9. The skin incisions are closed with stitches or surgical staples.
10.A sterile bandage/dressing or adhesive strips is applied.
D. Nursing Responsibilities
Preoperative Phase
o Secure the informed consent for legal purposes and take note of
the following things:
1. The surgeon must provide a clear and simple explanation of
the surgical procedure.
2. The nurse may witness the patient’s signature.
4. If the patient needs additional information about the procedure,
nurse notifies the surgeon.
5. The nurse ascertains that the consent form has been signed
before administering psychoactive drugs.
6. No patient should be urged or coerced to sign an operative
permit.
7. Refusing to undergo a surgical procedure is a person’s legal
right and privilege.
o Assess for drug and alcohol abuse. Persons with history of
chronic alcoholism often suffer from malnutrition and other
systemic problems that increase the surgical risk.
o Assess the respiratory status. The goal for potential surgical
patients is optimal respiratory function.
Page | 89
o Assess the cardiovascular status. The goal in preparing any
patient for surgery is to ensure a well functioning cardiovascular
system to meet the oxygen, fluid and nutritional needs.
o Assess the hepatic and renal functioning. Presurgical goal is
optimal function of the liver and urinary system to enhance
removal of medications.
o Assess the immune functioning. An important function of the
preoperative assessment is to determine the existence of
allergies.
o Assess for the previous medication use. A medication history is
obtained from each patient because of the possibility of drug
interactions
o Make nursing diagnoses, and prepare nursing care plans to
address patient’s needs
o Teach deep-breathing, coughing and incentive Spiro meter to aid
the patient post operatively
o Encourage mobility and active body movement to avoid
complications
o Teach cognitive coping strategies such as imagery, distraction
and optimistic self-recitation to reduce fear and anxiety
o Explain the activities that may occur inside the operating room to
reduce anxiety
o Inform the patient on the following to impart knowledge on the
part of the patient and to avoid delay in surgery due to
noncompliance:
Scheduled date and time of the surgery and where to
report
What to bring such as insurance card, list of medications
and allergies
What to leave at home such as jewelry, watch, medications
and contact lenses
Page | 90
What to wear which is loose-fitting, comfortable clothes
and flat shoes
take nothing by mouth for six to 12 hours before the
surgery.
o Acquire and document patient’s vital signs for baseline data and
maintain the preoperative record
o Transport the patient to the presurgical area to prepare the patient
for surgery
o Attend to the family needs to reduce the anxiety felt by the family
o Make sure that preoperative checklist which contains the following
is accomplished:
Lab exam results in
OR services form accomplished
Patient is scheduled in OR
Anesthesiologist informed
Medicines in
Blood Typed and Matched
Field of Operation prepared
Sponged or bathed
Diet instruction given
Enema given
Make-up and nail polish removed
Jewelry removed
Oral hygiene given
Patient changed into patient’s gown
Indwelling catheter inserted
Pre-op meds given
Medicine for OR in
Intraoperative phase
Page | 91
o Position the patient:
The patient is in a supine position reverse trendelenburg.
o Skin preparation
o Circulating nurse:
Manages the operating room
Protects patient’s safety and health by monitoring the
activities of the surgical team
Checks and verifies the consent form
Ensures fire safety precautions, cleanliness, proper
temperature, humidity and lighting of the operating room
Monitors safe functioning of the equipments
Coordinates with the surgical/ perioperative team and
monitors aseptic practices
Documents operating room surgical activities
Count all needles, sponges and instruments together with
the scrub nurse
o For the scrub nurse:
Setting up sterile tables
Assisting the surgeon and assistant surgeon, taking
care of tissue specimens
Count all needles, sponges and instruments together
with the circulating nurse
Postoperative Phase
o Assess patient : appraise air exchanges status & note skin color;
verify & identify operative status & surgeon performed; assess
neurological status (LOC)
o Perform safety checks – good body alignment, side rails and
maintain patent airway and cardiovascular stability
Page | 92
o Medication
Analgesics are administered as prescribed for pain.
Antibiotics are administered to prevent infection.
o Surgical dressing is assessed periodically and reinforced when
necessary.
o HEALTH TEACHINGS
Inform the patient about the importance of complying with
the prescribed medication.
Emphasize the proper dosage of the medications taken.
Educate the client about the importance of proper
nutrition.
Encourage the client to have the prescribed diet for her
condition.
Encourage to have early ambulation in order to promote
circulation and wound healing.
Instruct to do splinting while performing deep breathing
exercises to minimize pain.
Page | 93
NURSING THEORIES
VIRGINIA HENDERSON’S DEFINITION OF NURSING
Virginia Henderson sees the nurse as concerned with both healthy and ill
individuals, acknowledges that nurses interact with clients even when recovery
may not be feasible, and mentions the teaching and advocacy roles of the
nurses. In 1955, Virginia Henderson devised her own definition as to create a
proper standard of what nursing should be, to ensure safe and competent care
for patients. Her famous definition of nursing states "The unique function of the
nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health or its recovery (or to peaceful death) that he would perform
unaided if he had the necessary strength, will or knowledge, and to do this in
such a way as to help him gain independence as rapidly as possible". In this
definition of hers, she recognized the need to be clear about the functions of the
nurse and described the nurse's role as substitutive (doing for the person),
supplementary (helping the person), or complementary (working with the
person), with the goal of helping the person become as independent as possible.
Henderson conceptualizes the nurse’s role as assisting sick or
healthy individuals to gain independence in meeting 14 fundamental
needs which is: (1) breathing normally; (2) eating and drinking adequately;
(3) eliminating body wastes; (4) moving and maintaining a desirable
position; (5) sleeping and resting; (6) selecting suitable clothes; (7)
maintaining body temperature within normal range; (8) keeping the body
clean and well-groomed to protect the integument; (9) avoiding dangers in
the environment and avoiding injuring others; (10) communicating with
others in expressing emotions, needs, fears, or opinions; (11) worshipping
according to one’s faith; (12) working in such a way that one feels a sense
of accomplishment; (13) playing or participating in various forms of
recreation; and (14) learning, discovering, or satisfying the curiosity that
leads to normal development and health, and using available health
Page | 94
facilities. When the patient was able to perform all the functions by him or
herself then the patient could be considered independent and no longer
required the aid of a nurse.
Virginia Henderson also believed that it was important that nursing
be based on evidence, and that research was a critical component of
improving nursing practice. She believed all nurses should have access to
literature on nursing and current nursing research to help better their
practices, and to this end, she worked to develop an index of nursing.
Virginia Henderson’s theory is one of the most valuable theories
that a student nurse has in his or her arsenal in providing care for the
clients. It provides student nurses a guide on what to focus on and on
giving priority on the care being provided to the client. The client was
admitted to Davao Medical School Foundation Hospital due to right upper
quadrant abdominal pain and was later diagnosed with Calculous
Cholecystitis. Employing this theory the student nurses noted that among
the 14 Fundamental Needs that Henderson laid out, eating and drinking
adequately and getting enough sleep and rest are given most priority.
Since the ability of the body to handle fat and other fat soluble substances
is impaired, following a diet which is specified for patients with Calculous
Cholecystitis is essential to improve the patient’s wellbeing. The diet
promoted by the student nurses to the client should be moderate in
calories and low in fat. This diet included High fiber foods (fresh fruits and
vegetables), Whole grains (such as whole wheat bread and oats) and lean
meat (such as chicken and fish). Supervising the client in her diet was
done by the student nurses in order for the client to improve her current
condition. Having enough rest and sleep is also important for the client in
order for her to reach optimum wellbeing. Having enough sleep periods
was encouraged to the client by the group. The client was made
comfortable and was placed in a stress free environment to minimize
stressors that might further compromise the client’s health.
Page | 95
ORLANDO’S THEORY
Ida Jean Orlando's theory was developed in the late 1950s from
observations she recorded between a nurse and patient. Her nursing process is
based on the manner in which all individuals act and that this process is used by
a nurse to meet a patient’s need for help; meeting this need improves the
patient’s behavior. The components of Orlando’s Nursing Process Theory are
(1.) patient behavior, (2.) nurse reaction, and (3.) nurse action. The nursing
process is set in motion by the patient’s behavior and all patient behavior, no
matter how significant, may represent a cry for help because the patient who
cannot resolve a need feels helpless, and the person’s behavior reflects this
feeling. Nurse reaction to a patient’s behavior forms the basis for determining
how a nurse acts; it consists of perception, thought, and feeling. The nurse’s first
experience with the patient’s behavior is through the senses; this perception
leads to thought, which evokes a feeling, and because these three parts occur
automatically and almost simultaneously a nurse must identify each part of the
reaction to help the patient. Nurse action is whatever the nurse says or does to
benefit the patient and when performing an action, the nurse is influenced by
stimuli related to the patient’s needs.
Orlando’s theory states that the function of the nurse is to find out and
meet the patient's immediate need for help and to use the nursing process
(nurse-patient interaction) to relieve a patient’s feelings of helplessness or
suffering.
Given the client’s current medical status, the group utilized
Orlando’s theory as they provided care and did their work. Focusing on
the client’s verbal and non-verbal cues as focusing on the immediate
people surrounding her is essential in any medical situation for it may
indicate distress or danger in one form or another. The patient may have
concerns that she will not communicate with the people around her. These
concerns may be hazardous to the client’s wellbeing and may further
compromise her health. Orlando’s theory keeps the student nurses focus
Page | 96
on the needs and concerns of the patient whether the client or her
significant others stated it or not. Learning how to interpret and validate
both verbal cues and non verbal cues is essential in any hospital situation
for not all cues is presented as it is. Therefore, the student nurses applied
Orlando’s theory to aid them in interpreting the actions and behaviors of
the patient. They also made sure to verify first what they’ve observed
before planning anything. The student nurses paid close attention to any
signs that may lead to distress that might threaten the patient’s life.
Application of the theory also helps the student nurse prepare and plan
the course of action towards the situation. This preparation leads to an
appropriate intervention by the nurse that might relieve the patient of her
distress or might even save the patient’s life.
ROY’S ADAPTATION THEORY
Roy’s Adaptation theory views the client as an adaptive system
where the goal of nursing is to help the person adapt to changes in
physiological needs, self-concept, role function & interdependent relations
during health & illness. Roy believed that the need for nursing care arises
when the client cannot adapt to internal & external environmental
demands.
Callista Roy noted different stimuli that would affect a client’s adaptive
response, namely the focal stimuli, which constitute the greatest degree of
change impacting upon the person and is the stimulus most immediately
confronting the person, the contextual stimuli which are all other stimuli of the
person’s internal & external world that can be identified as having a positive or
negative influence on the situation, and the residual stimuli which are those
internal or external factors whose current effects are unclear. With that said,
Callista Roy theorized that there are four adaptive modes: (1.) Physiological
mode which represents physical response to environmental stimuli & primarily
Page | 97
involves the regulator subsystem. The basic need is the physiologic integrity,
associated with oxygenation, nutrition, elimination, activity & rest and protection.
(2.) Self-concept mode which relates to the basic need for psychic integrity
(psychological & spiritual aspect)
a. Physical self – has components of body image & body sensation
b. Personal self – has components of self-consistency, self-ideal &
moral-ethical-spiritual self. (3.) Role function mode which identifies the patterns
of social interaction of the person in relation to others reflected by; (a.) primary
role which determines the majority of a person’s behavior & is defined by age,
sex and developmental stage. (b.) Secondary role - assumed to carry out the
tasks required by the stage of development & primary role.(c.) Tertiary role – are
temporary, freely chosen & may include activities related to hobby. (4.)
Interdependence mode – identifies patterns of human value, affection, love &
affirmation.
The proponents conceptualized that the patient’s well being
depends upon her ability to adapt to her current condition. Being able to
adapt to her illness may lead to a faster recovery. However failure to adapt
and cope up may lead to a decline in her health status. Therefore it is the
role of the student nurses to help the patient cope up with her ailment. Use
of Roy’s Adaptation Theory guided the student nurses that the goal of
nursing in this theory is the promotion of adaptive responses in relation to
the four adaptive modes. Nursing seeks to reduce ineffective responses &
promote adaptive responses as output behavior of the person. With that,
the proponents first identified the stressors, either in the client’s
environment or within the client herself, that cause distress to the patient’s
mental and emotional status. Having identified the said stressors, the
student nurses planned the action to be done and implemented it. One of
which is providing vital information about the patient’s current condition.
By providing the patient information, her false beliefs towards her ailments
may be reduced. Anxiety, which is the fear of the unknown, may also be
alleviated through giving the patient information. Aside from giving
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information, the proponents also listened and took notice of the patient’s
concerns about her admission to the hospital. By doing so, the student
nurses hope that any mental and emotional stress may be reduced. This
decrease in stressors hopefully will lead the patient to a faster recovery.
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NURSING CARE PLAN
1. Acute pain related to presence of surgical incision secondary to status post laparoscopic
cholecystectomy.
2. Impaired skin integrity related to surgical procedure: laparoscopic cholecystectomy secondary to
calculous cholecystitis
3. Deficient knowledge regarding illness and treatment course related to lack of information presented.
4. Risk for infection related to presence of surgical incision.
5. Risk for imbalanced body temperature related to exposure to anesthesia secondary to status post
laparoscopic cholecystectomy.
Page | 100
NURSING CARE PLAN
Patient’s Name: Meg Age: 38 years old
Chief Complaint: pain at the right upper quadrant of the abdomen Ward: 3C
Diagnosis: Calculous Cholecystitis
1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy.
Date Cues Need Nursing Diagnosis Objective/Goal Nursing Interventions Evaluation
5/12/
10
4:30
pm
Subjective Cues:
Verbalized “Sakit
pa akong opera,
ngul-ngul pa.”
Objective Cues:
pain scale of 6 out
of 10 noted.
Grimaced face
noted.
Guarding
behavior noted.
C
O
G
N
I
T
I
V
Acute pain related to
presence of surgical
incision secondary to
status post laparoscopic
cholecystectomy.
R: Pain is a common
aftermath for every
surgery after the
anesthesia wore down.
Pain is recognized in two
different forms:
physiologic pain and
At the end of 3
hours nursing
intervention, the
patient will be able
to:
1. Report a
decrease in pain
intensity to a
scale of 3 out of
10.
2. Demonstrate
non–
1. Monitor and assess
vital signs every 2 hours.
R: Vital signs are usually
altered in acute pain.
2. Administer analgesics
(e.g Tramadol) as
ordered.
R: Tramadol is an
analgesic. It binds to
mu-opioid receptors and
inhibits the reuptake of
GOAL MET
At the end of
rendering 3 hours
nursing
intervention, the
patient was able
to:
1. Report pain as
relieved and
controlled as
evidenced by
verbalization
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Slow and limited
movement of the
upper extremities
Patient is 1 day
post operative
0.5 mm incision
noted on the right
lower rib cage and
the subxyphoid
area; 10mm
incision below the
umbilicus.
Incisions are
covered with dry
and intact
dressing.
Vital Signs: T-
36.6°C; BP-
130/90; RR-18;
PR- 81.
E
P
E
R
C
E
P
T
U
A
L
P
clinical pain. Physiologic
pain comes and goes,
and is the result of
experiencing a high-
intensity sensation. It
often acts as a safety
mechanism to warn
individuals of danger
(e.g., a burn, animal
scratch, or broken
glass). Clinical pain, in
contrast, is marked by
hypersensitivity to
painful stimuli around a
localized site, and also is
felt in non-injured areas
nearby. When a patient
undergoes surgery,
tissues and nerve
endings are traumatized,
resulting in incision pain.
pharmacological
methods and/or
use of relaxation
skills and
diversional
activities, as
indicated, for
individual
situation.
norepinephrine and
serotonin; causes many
effects similar to opioids
but doesn’t cause
respiratory depression. It
is for moderate to severe
pain.
3. Evaluate the
effectiveness of
analgesic at regular
intervals after each
administration, also
observing for any
signs and symptoms
of untoward effects
(e.g. respiratory
depression, nausea
and vomiting)
R: The analgesic dose
of client, “Dili
na man kaayo
siya sakit,
makaya na
man.” And
reported a
pain scale of 3
out of 10
2. Demonstrate
non–
pharmacologic
al methods
and/or use of
relaxation
skills and
diversional
activities (e.g.
patient
maintained
moderate high
back rest
Page | 102
A
T
T
E
R
N
This trauma overloads
the pain receptors that
send messages to the
spinal cord, which
becomes
overstimulated. The
resultant central
sensitization is a type of
posttraumatic stress to
the spinal cord, which
interprets any
stimulation—painful or
otherwise—as
unpleasant. That is why
a patient may feel pain
in movement or physical
touch in locations far
from the surgical site.
http://
may not be adequate to
raise the client’s
pain threshold or may be
causing intolerable or
dangerous side
effects or both. Ongoing
evaluation will assist in
making necessary
adjustments for effective
pain management.
4. Monitor patient’s pain
at least every hour
while awake by the
use of the pain scale.
R: Allows evaluation of
the severity of the pain
felt by the patient. Pain
is a subjective
experience and only the
position; she
also
performed
diversional
activities such
as talking with
her watcher)
Vital Signs: T-
36.4°C; BP-
120/90; RR-19;
PR- 84.
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www.surgeryencyclopedi
a.com/Pa-St/Post-
Surgical-Pain.html
patient can describe the
pain she’s feeling.
5. Instruct and
demonstrate use of
deep breathing
exercise. Also
instruct patient to do
splinting while doing
deep breathing
exercises.
R: Deep breathing
increases oxygen in the
body and prevents
atelectasis. Deep
breathing exercise also
provides
comfort.Splinting while
doing deep breathing is
to lessen the pain upon
Page | 104
respiration.
6. Position the patient
properly in bed.
Elevate head of bed.
Maintain anatomic
alignment
R: Alignment helps
prevent pain from
malposition and it
enhances comfort
7. Encourage
diversional activities
(TV/radio,
socialization with
others, mental
imaging).
R: These highten ones
concentration upon
nonpainful stimuli to
Page | 105
decrease one's
awareness and
experience of pain.
8. Provide rest periods
to facilitate comfort,
sleep, and relaxation
R: The patient's
experiences of pain may
become exaggerated as
the result of fatigue.
Adequate rest helps
provide comfort
9. Assist patient in
doing her activities of
daily living
R: Helps reduce pain
brought about by the
exertion of force
necessary to perform
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activities
10.Encourage patient to
report pain as soon
as it starts and allow
her to verbalize pain
experienced or
describe the pain
she’s feeling.
R: Severe pain is more
difficult to control and
increases the client’s
anxiety and fatigue.
2. Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis.
Date Cues Need Nursing Diagnosis Objectives/Goals Nursing Interventions Evaluation
5/11/10
Subjective: N Impaired skin integrity related to surgery:
At the end of 2 days nursing intervention
1. Assess dressings/ wound every shift.
Goal Met
Page | 107
@
9:00 pm
“Gioperahan ko diri sa tiyan,” as verbalized by the patient
Objective:
-post laparoscopic cholecystectomy (2 hrs)
-disruption of the dermis, epidermis, and subcutaneous tissues.
-with 0.5 to 1 cm incisions at the epigastrium, right lower rib cage and below the umbilicus
U
T
R
I
T
I
O
N
A
L
-
M
E
T
A
B
laparoscopic cholecystectomy secondary to calculous cholecystitis.
Rationale:
Laparoscopic cholecystectomy is a less invasive way to remove the bladder. It is performed through inserting a laparoscope just below the navel. Three additional ports are inserted by making three other incisions in the epigastrium and in the right upper quadrant of the abdomen.
Source:
Talamini, M. (2006). Advanced Therapy in
the patient will be able to:
1. Display improvement in wound healing as evidenced by intact incision site.
2. Remain free from infection as evidenced by normal vital signs and absence of purulent discharge.
3. Demonstrate behaviors/techniques to promote healing or prevent complications
Describe wounds and observe for changes.
®: Establishes comparative baseline providing opportunity for timely intervention.
2. Keep the incision site clean and dry, carefully dress wounds.
®: Keeping incision site clean and dry prevents infection; it also aids in the process of wound healing.
3. Encourage early ambulation. Assist patient in doing active and passive range of motion exercises.
®: Movement stimulates circulation and assists in the body’s natural process of repair.
5/12/10 @
11:00pm
At the end of 2 days nursing intervention, the patient was able to:
1. Maintain incision site and dressing intact and dry.
2. Remain free from infection as evidenced by normal vital signs (BP= 120/70; RR=18; PR=85; Temp=36.6) and absence of purulent discharge.
3.Demonstrate
Page | 108
-incisions covered with dry and intact dressing
-skin slightly warm to touch. Temperature: 36.8°C
O
L
I
C
P
A
T
T
E
R
N
Minimally Invasive Surgery, p. 179. USA: Decker Inc.
4. Monitor temperature every 4 hours.
®: Early recognition of developing infection enables rapid institution of treatment and prevention of further complications.
5. Place in semi-Fowler’s position or moderate high back rest.
®:Proper positioning decreases tension in the operative site and promotes healing.
®: Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for
behaviors/techniques to promote healing or prevent complications (e.g patient washes hands after using the comfort room, eats a balanced diet, and takes antibiotic medication (sultamicillin) as ordered)
Page | 109
infection. Loose clothing reduces pressure on compromised tissues, which may improve circulation/healing
7. Emphasize importance of adequate nutrition and fluid intake. Encourage patient to eat foods rich in protein, iron and vit. C.
®: Improved nutrition and hydration will improve skin condition. Protein and iron helps in repair of tissues. Vitamin C is important for immune system function and increases resistance to some pathogens.
8. Instruct the client in proper postoperative skin care. Teach client and her significant
Page | 110
others the importance of proper hand washing.
®: This is to involve the patient in caring for skin, promoting comfort, and preventing infection or other complications. Proper washing of hands deter the spread of microorganisms.
9. Instruct the client to observe for signs and symptoms of complications such as elevated temperature, redness, warmth, swelling near the surgical incision, purulent discharge, or breakdown of sutures around the incision, and report to the physician.
®: Provides for prompt recognition of complications and facilitates prompt
Page | 111
treatment.
10. Administer antibiotics as indicated (sultamicillin)
®: May be given prophylactically or to treat specific infection and enhance healing.
3.Deficient knowledge regarding illness and treatment course related to lack of information presented.
Date
&
Cues Need Nursing Diagnosis Objective/Goal Nursing Interventions Evaluation
Page | 112
Time
05/12/
10
@
6:00
pm
Subjective
cues:
Verbalized:
“Para asa
diay ni siya
(holds
sultamicillin
tablet)?”
Objective
cues:
Frequent
questioning
Incorrect
verbal
feedback
regarding
understandin
g of
C
O
G
N
I
T
I
V
E
-
P
E
R
Knowledge deficit
regarding illness
and treatment
course related to
lack of information
presented.
R: Knowledge is
important especially
in health matters.
Deficiency in
knowledge might
affect the patient’s
health status. If
ever health issues
are taken for
granted, it may
result to
disorders/diseases
that could have
At the end of 2
hours nursing
intervention, the
patient will be
able to:
1. Verbalize
understanding of
disease process
and treatment.
2. Initiate
necessary
lifestyle changes
and participate in
treatment
regimen.
1. Assess the patient’s
current knowledge of the
medications and other
doctor’s instructions and
nursing procedures and its
implications, the likelihood
of complications if these are
not followed, and the
likelihood of cure or disease
control. Specifically ask
about the physician’s
explanations and the
patient’s past experiences.
R: Adults learn best when
teaching builds on previous
knowledge or experience.
Assessing recall of the
physician’s explanations as
well as the patient’s past
Goal Met
At the end of 2
hours nursing
intervention, the
patient was able to:
1. Verbalize
kasabot nako karon
ngano ginahatagan
ko ug mga ing
aning tambal, para
pud malabanan ang
inpeksyon nako.”
2. Initiate necessary lifestyle changes and participate in treatment regimen and verbalized “ Sa sunod mag-iwas na gyud ko ug mga taba kayo nga