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8/13/2019 Cholecystectomy Final
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CHAPTER 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 causesa 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 bileducts,
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 becontrolled with a special diet and medication.
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CHAPTER II ASSESSMENT
A. Nursing Health History
Personal Data
Name: Mrs. Dina Natuto
Age: 70 years old
Gender: Female
Status: Married
Address: Pob. San Manuel, Tarlac
Date of Birth: Nov. 23, 1943
Place of Birth: Nueve Ecija
Religion: Roman Catholic
Date of Admission: Nov. 30, 2013
Time of Admission: 3:10pm
Chief Compliants: chills and abdominal plain
Final diagnosis: Hydrops of gallbladder secondary to cholecystolithiasis multiple
Opreation: E RUQ exploration,adhesiolysis, cholecystectomy with IOC( Intra-operative Cholangiogram), Common Bile Duct - exploration, T- tube
choledochostomy.
Past Medical History
Present Medical History
3 days prior to admission (+) fever on and off. 1 day prior to admission (+) abdominal pain at the hypogastric area to epigastric area associated
with chills.
Family Health History
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B. Physical Assessments
Physical Assessment done by the attending physician reveals that patient is;
Febrile pale anicteric sclera pinkish palpebral conjunctiva symmetrical chest expression fair pulse (-) cyanosis (+) NABS non tender abdomen
Vital Signs upon admission (Nov. 30, 2013)
o BP- 130/80 mmHgo RR-20 cpmo PR-89 bpmo Temp-38 C
Physical Assessment done by the student reveals that patient is;
Febrile Warm to touch pale and weak looking (+) dry lips (+) dry skin decreased skin turgor
Vital Signs taken and recorded as of (Nov. 30, 2013) are as follows;
o BP- 130/80 mmHgo RR-20 cpmo PR-89 bpmo Temp-38 C
C. Laboratory Exams
1. Complete Blood Count (CBC)
This is to determine blood components and the response to inflammatory process and streptococcal
infection.
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Date Ordered: Nov. 30, 201
Date Result In: Nov. 30, 2013
Results:
WBC - 14.5 g/l
RBC - 3.73 g/l
Lymphocytes - 0.15 g/l
Monocytes - 0.08 g/l
Granulocytes - 0.77 g/l
Hemoglobin126 g/l
Hematocrit - 0.34 g/l
Platelet count357 g/l
Repeat CBC
Date Ordered: Dec. 1, 2013
Date Result In: Dec. 1, 2013
Results:
WBC - 18 g/l
RBC - 3.71 g/l
Lymphocytes - 0.04 g/l
Monocytes - 0.06 g/l
Granulocytes - 0.90 g/l
Hemoglobin106 g/l
Hematocrit - 0.29 g/l
Conclusion: WBC is slightly elevated based on the normal value of 5.0-10 g/l which confirms the
presence of infection.
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2. Serum Electrolytes
Date Ordered: Nov.30, 2013
Date Result in: Nov.30,2013
Results:
Serum Sodium - 135.7 mmol/L
Potassium - 3.25 mmol/L
Chloride - 98.1 mmol/L
Repeat Serum Electrolytes
Date Ordered: Dec.1 ,2013
Date Result In: Dec. 1, 2013
Results:
Potassium - 3.24 mmol/L
Date Ordered: Dec. 6, 2013
Date Result in: Dec. 6, 2013
Results:
Serum Sodium138.1 mmol/L
Potassium2.83 mmol/L
Conclusion: The potassium level is below the normal value of 3.40-5.60 mmol/L. While the sodium level
is within nomal range based on the normal value of 134.0-148.0 mmol/L.
3. Creatinine
This is the indicator of the renal function.
Date Ordered: Dec. 4, 2013
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Result In: Dec. 4, 2013
Results: 0.8mg/dl
Conclusions: The result is within normal range based on the normal value of 0.5 - 1.7mg/dl.
4. BUN
This is an indicator of renal function and perfusion, dietary intake of CHON and the level of
protein metabolism.
Date Ordered: Dec. 4, 2013
Date Result In: Dec. 4, 2013
Results: 5.3 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, RBCs, WBCs, 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.
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D. 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 to1.5 fluid ounces. The body (corpus) and neck (collum) ofthe 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 and metabolic wastes Cholesterol and Bilirubin.
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E. Pathophysiology
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Risk factor
Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60
Bile must become supersaturated with cholesterol and calcium The solute precipitate from solution as
solid crystals Crystals must come together and fuse to form stones Gallstones Obstruction of the cystic
duct and common bile duct Sharp pain in the right part of abdomen Jaundice Distention of the gall
bladder Venous and lymphatic drainage is impaired Proliferation of bacteria Localized cellular irritation
or infiltration or both take place Areas of ischemia may occur Inflammation of gall bladder
CHOLECYSTITIS
CHAPTER III PLANNING
A. List of Prioritized Nursing Diagnosis
Pre-operative nursing diagnosis: Acute pain
Knowledge Deficit
Disturbed sleeping pattern
Intra-operative nursing diagnosis Deficient Fluid Volume
Post-operative nursing diagnosis: Risk for infection
Ineffective Coping
B. Nursing Care Plan
1. Acute Pain
Cues Nursing
Diagnosis
Scientific
Explanation
Objective Nursing
Intervention
Rationale Evaluation
S- ang
sakit ng
tyan ko
as
claimed
by thepatient.
O-(+)
guarding
behavior
, pain
scale of
Acute pain
related to
inflammati
on and
distortion
of thegallbladder
as
evidenced
by verbal
reports of
pain.
Due to the
presence of
stones in
the
gallbladder
it causessome
obstruction
in the cystic
duct which
in turn
causes a
sharp acute
After 4
hours of
nursing
intervent
ion the
patientwill
report
relieve of
pain.
1. Observe
and document
location,
severity (0
10scale), and
character ofpain (e.g.,
steady,
intermittent,
colicky). 2.
Promote bed
rest, allowing
patient to
- Assists in
differentiating
cause of pain,
and provides
information
about diseaseprogression/r
esolution,
development
of
complications,
and
effectiveness
Is there a change
on the patients;
a. Pain scale
b. RR
c. BP
d. Reports ofpain.
e. Facial
expressions.
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7/10,
difficulty
in
moving
as
manifest
ed by
facial
grimaces
-(+)
pallor,
V/S as
follows:
BP -
130/80
mmHg,
PR- 89
bpm,RR-
20cpm,
T- 38C
pain on the
right part of
the
abdomen.
assume
position of
comfort. 3.
Control
environmental
temperature.
4. Encourage
use of
relaxation
techniques,
e.g., guided
imagery,
visualization,
deep-
breathing
exercises.
Provide
diversionalactivities. 5.
Make time to
listen to and
maintain
frequent
contact with
patient. 6.
Administer
analgesics as
indicated.
of
interventions.
- Bed rest in
low-Fowlers
position
reduces intra-
abdominal
pressure;
however,
patient will
naturally
assume least
painful
position.
- Cool
surroundings
aid in
minimizingdermal
discomfort.-
Promotes
rest, redirects
attention,
may enhance
coping.-
Helpful in
alleviating
anxiety and
refocusingattention,
which can
relieve pain.-
Relief of pain
facilitates
cooperation
with other
therapeutic
interventions.
2. Fluid Volume Deficit
Cues Nursing
Diagnosis
Scientific
Explanation
Objective Nursing
Intervention
Rationale Evaluation
S - Deficient There is this After an 1. Provide - Information -Does the patient
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pwede
bang
maulit
ang sakit
ko as
verbaliz
ed by
the
patient
O-
Frequen
tly
asking
question
about
his
conditio
n,treatme
nt and
diet
-With
worried
gaze dry
mouth
knowledge
related to
condition,
prognosis,
treatment,
self - care,
and
discharge
needs
presence of
knowledge
deficit due
to some
unfamiliar
information
that causes
some
confusion to
the client
that needs
to be
discussed.
hour of
nurse-
patient
interacti
on the
patient
will
verbalize
understa
nding of
disease
process,
prognosi
s, and
potential
complica
tions
explanations
of reasons for
test
procedures
and
preparation
needed.
2. Review
disease
process/
prognosis.
Discuss
hospitalization
and
prospective
treatment as
indicated.
Encouragequestions,
expression of
concern.
3. Review
drug regimen,
possible side
effects
4. Instruct
patient to
avoid
food/fluidshigh 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.,
spicy foods,
caffeine,
citrus).
5. Suggest
patient limit
can decrease
anxiety,
thereby
reducing
sympathetic
stimulation.
- Provides
knowledge
base from
which
patient can
make
informed
choices. - -----
- Effective
communicati
on and
support atthis time can
diminish
anxiety and
promote
healing.
- Gallstones
often recur,
necessitating
long-term
therapy.
- Prevents/limits
recurrence of
gallbladder
attacks.
-
Promotes gas
formation,
which can
increase
gastric
distension/
discomfort.
understands and
could recall all the
teachings given?
-Is there a
significant changes
that occur on the
patients
knowledge
regarding;
a.disease
condition b.diet
c.treatment
d.medication
e.self-care needs
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gum chewing,
sucking on
straw/hard
candy, or
smoking
C. Drug Study
Name of Drug Route/
Dosage
andFrequency
Action Indication Adverse
Reaction
Nursing
Consideration
GN:Cefuroxime
BN: Zinacef
750 mg IV
Q8hrs
ANST(-)
-
Anti-infectives
-Second-
generation
cephalosphorin
that inhibits cell-
wall synthesis,
promoting
osmotic
instability;
usually
bactericidal
Perioperative
prevention
Phlebitis,
nausea,
anorexia,vomiti
ng,
maculopapular
and
erythematous
rashes,
urticarial, pain,
induration
1.Check the
doctors order.
2. Inform the
patient about
the adverse
reaction.
3. Before giving
drug, ask
patient if he is
allergic to
penicillins or
cephalosphorin
s.
4. Intsruct
patient to
notify
prescriber
about rash,
loose stools,
diarrhea, or
evidence of
superinfection.5. Advise
patient
discomfort
receiving drug
IV to report
discomfort at
IV insertion
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site.
GN: Cefoxitin
Sodium
BN: Mefoxitin
1gm IV
Q8hrs
ANST(-)
-
Anti-infectives
-Second-
generation
cephalosphorin
that inhibits cell-
wall synthesis,
promoting
osmotic
instability;
usually
bactericidal
Serious
infection of the
respiratory and
GU tracts; skin;
soft-tissue,
bone, or joint
infection;
blood-stream
or intra-
abdominal
infection
caused by
susceptible
organisms(
such as E. coli
and other
coliformbacteria.
Fever, phlebitis,
diarrhea,
nausea,
vomiting,
anemia, acute
renal failure,
pain, induration.
1. Before givig
ng drug, ask
patient if he is
allergic to
penicillins or
other
cephalosphorin
s. 2. After
reconstitution,
drug may be
stored for
24hrs at room
temperature or
1 week under
refrigeration.
3. Intsruct
patient tonotify
prescriber
about rash,
loose stools,
diarrhea, or
evidence of
superinfection.
4. Advise
patient
discomfort
receiving drugIV to report
discomfort at
IV insertion
site.
GN:
Metronidazole
BN: Flagyl
500 mg IV
Q8hrs
ANST(-)
- BacterialInfectio
ns
caused
by
anaerob
ic
microor
ganisms.
- Toprevent
postope
rative
infectio
n in
Direct- acting
trichomonocid
e and
amoebicide
that works
inside and
outside the
intestines. Its
thought to
enter the cells
of
microorganism
s that contain
nitroreductase,
forming
Headache,
seizures, fever,
constipation,
nausea, pain,
edema,
peripheral
neuropathy
1. Monitor liver
function test
results
carefully in
elderly
patients. 2. Use
cautiously in
patients who
take
hepatotoxic
drug or have
hepatic disease
or alcoholism.
3. Use
cautiously in
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contami
nate or
potencia
lly
contami
nate
colorect
al
surgery.
unstable
compounds
that bind to
DNA and
inhibit
synthesis,
causing cell
death.
patients with
history of
blood
dyscrasia, CNS
disorder, or
retinal or visual
retinal
changes.
4. Record
number and
character of
stool when
drug is used to
treat
amoebiasis.
5. Observe
patient for
edema,especially if
hes receiving
corticosteroids;
Flagyl IV RTU
may cause
sodium
retention.
GN: Ketorolac
Tromethamine
BN: Toradol
15 mg/ml
IV Q6hrs
PRN
Short-term
management of
moderately
severe, acutepain for multiple
dose
treatment.
May inhibit
prostaglandin
synthesis, to
produce anti-inflammatory,
analgesics, and
antipyretic
effects.
Headache,
dizziness,
drowsiness,
hypertension,palpitation,
sedation, peptic
ulceration,
prolonged
bleeding time
1. Correct
hypovolemia
before giving.
2. Carefullyobserve
patients with
coagulopathies
and those
taking anti-
coagulants.
3. Teach
patient signs
and symptoms
of GI bleeding,
including blood
in vomit; and
black tarry
stool. Tell
patient to
notify
prescriber
immediately if
any of these
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occurs.
4. Serious GI
toxicity,
including
peptic ulcers
and bleeding,
can occur in
patient taking
NSAIDs,
despite lack of
symptoms.
CHAPTER IV - IMPLEMENTATION
Medical/ Surgical Management
1. Chest X-ray- this is used to rule out respiratory causes of referred pain.
2. Intake and Output- I&O measurement provide an other means of assessing fluid balance. This data
provide insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. These
measurement are not that accurate as body weight, however, because of relative risk of errors in
recording.
3. Electrocardiogram - The ECG is an essential tool in evaluating cardiac rhythm. Electrocardiography
detects and amplifies the very small electrical potential changes between different points on the surface
of the body as a myocardial cell depolarize and repolarize, causing the heart to contract.
4. O2 Inhalation - Oxygen therapies are used to provide more oxygen to the body into order to promote
healing and health.
5. Intravenous Rehydration - when the fluid loss is severe or life - threatening, intravenous (IV) fluids are
used for replacement.
6. Ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency
sound waves to create an image of the internal organs. Ultrasounds are used to view internal organs of
the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels.
7. Hepatobiliary scintigraphy - an imaging technique of the liver, bile ducts, gallbladder, and upper part
of the small intestine.
8. Cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast).
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9. Percutaneous transhepatic cholangiography (PTC) - a needle is introduced through the skin and into
the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray. 10.
10. Endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to
diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines
x-ray and the use of an endoscope. A long flexible, lighted tube. The scope is guided through the
patient's mouth and throat, then through the esophagus, stomach, and duodenum. The physician can
examine the inside of these organs and detect any abnormalities. A tube is then passed through the
scope, and a dye is injected which will allow the internal organs to appear on an x-ray.
11. Computed tomography scan (CT or CAT scan) - a diagnostic imaging procedure using a combination
of x-rays and computer technology to produce cross-sectional images (often called slices), both
horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body,
including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
12. Cholecystectomy- removal of the gallbladder. This procedure may be performed to treat chronic or
acute cholecystitis, with or without cholelithiasis, to remove a malignancy or to remove polyps.
13. Cholecystotomy - the establishment of an opening into the gallbladder to allow drainage of the
organ and removal of stones. A tube is then placed in the gallbladder to established external drainage.
This is performed when the patient cannot tolerate cholecystectomy.
14. Choledochoscopy- the insertion of a choledoscope into the common bileduct in order to directly
visualize stones and facilitate their extraction.
CHAPTER V DISCHARGED PLANNING
Instructed the patient and S.O to continue medication at home as ordered.1) Tergecef ( Cefixime ) 400mg/ cap, 1 capsule once a day for 7 days. (8am)2) Ciprofloxacin ( Ciprobay ) 1 gm/tab, 1 tablet once a day for 7 days. (8am)3) Omeprazole 400mg/cap, 1 capsule twice a day (7am-7pm)4) Vestar MR 35mg/tab, 1 tablet twice a day (8am-8pm)5) Clopidogrel 75mg/tab, 1 tablet once a day (8am)6) Erdostiene 300mg/tab, 1 tablet three times a day (8am-1pm-7pm)7) Levociterizine/Montelukast 10/5, 1 tablet daily at bedtime. (9pm)8) Kalium Durule tab, 1 tablet three times a day for 6 doses. (8am-1pm-7pm)9) Celecoxib 200mg/cap, 1 capsule twice a day. (8am-8pm)
Instructed patient to do deep breathing exercise, coughing technique while puttingpressure/splinting at the operative site, and walking as tolerated.
Emphasized the importance of completing the drug regimen, especially the antibiotics.
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Encouraged patient to increase oral fluid intake. Advised patient to eat nutritious foods rich inVit.C. Advised patient avoid eating salty and fatty foods.
Advised to return for the follow-up check-up on Monday, Dec.16,2013.
VI Conclusion
Cholecystitis is the inflammation of the gall bladder which is usually accompanied by gallstones
or cholelithiasis these gallstones may block the way of toxic substances that really needs to go out, but
due to this blockage this toxic substances are not then being expelled and are just being stored in the
bladder for a period of time. This then causes inflammation of the gallbladder. The treatment usually
done is the cholecystectomy. In order to lower the risk of having this kind of condition each and every
one of us must be conscious in our diet. We should try to avoid foods which are rich in salt and fats,
especially those foods which contains many seasonings. Though there is a saying that
Mas masarap pag bawal
which always pertains to the food were eating we should still be conscious on our health especially if we
want to live longer and also to avoid those life-threatening diseases which not only shorten our life but
causes us some financial problem. Remember also the saying
Mahal ang magkasakit. Just like on what our patient had experience she still has to collect money for
the operation she had underwent causing them to have debt with different persons. Let us not enjoy
ourselves with the delicious food were eating that is rich in salts and fats but we should enjoy living
because we have a healthy condition.
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VII - BIBLIOGRAPHY
Books
Joyce M. Black,PhD, RN, CPSN, CWCN & Jane Hokanson Hawks, DNSc, RN, BC,Medical- Surgical Nursing
7thedition, pg.1302-1314.
Nursing 2004 Drug Handbook, 24thEdition
Doenges, Moorhouse, & Murr, Nurses pocket guide 9thedition.
Online Resources
www.facs.orghttp://tjsamson.client.web-health.com/web-
health/topics/GeneralHealth/generalhealthsub/generalhealth/liver&gallbladder/what_gall
bladder.htmlhttp://www.emedicine.com/emerg/topic97.htmhttp://www.emedicine.com/radio/topic163.htmhttp://www.healthsystem.virginia.edu/uvahealth/adult_liver/chole.cfmhttp://www.emedicine.co
m/EMERG/topic98.htmMicrosoft Encarta 2004 Nursing Care Plan Content CD-ROM