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FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
CASE PRESENTATIONof
CHOLECYSTECTOMY
Submitted to:
Miss Glenda Santos RN, MAN
Miss Victoria Arceli RN, MAN
Submitted by:
BSN 207 - GROUP 25 A
Alamani, Jollybenson A.Alberto, Jamela Mer D.
Alcantara, Jaycel M.
Alfonso, Lester E.
Amihan, Ma. Luvimae N.
Bernardo, Naomi F.
December 3, 2011
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OPERATING ROOM
CASE PRESENTATION
I. Patients Data
Patients Name: JLP
Age: 25 years old
Gender: Female
Date of Birth: May 24, 1986
Address: Sabang, Baliuag Bulacan
Religion: Roman Catholic
Civil Status: Married
Attending Physician: Dr. Bugay
Operation Performed: Cholecystectomy
Type of Surgery: Open cholecystectomy
Surgeon: Dr. Rolando Valones
Date of Operation/Case No. : December 1, 2011 / 11-11-5113
Type of Anesthesia: Spinal anesthesiaAnesthesiologist: Dr. Dennis S. Lazaro
II. Anatomy/ Structure/ Function
a) Definition of operation performed:
Open cholecystectomy- surgery in which the abdomen is opened to
permit cholecystectomy -- removal of the gallbladder.
This operation has been employed for over 100 years and is a safe and effective method
for treating symptomatic gallstones, ones that are causing significant symptoms. At
surgery, direct visualization and palpation of the gallbladder, bile duct, cystic duct, and
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blood vessels allow safe and accurate dissection and removal of the gallbladder. Intra-
operative cholangiography has been variably used as an adjunct to this operation. The
rate of common bile duct exploration for choledocholithiasis (gallstones in the bile duct)
varies from 3% in series of patients having elective operations to 21% in series that
include all patients. Major complications of open cholecystectomy are infrequent and
include common duct injury, bleeding, biloma, and infections.
Open cholecystectomy is the standard against which other treatments must be
compared and remains a safe surgical alternative.
b) Discussion of anatomy involved:
The digestive system prepares food for use by hundreds of millions of body cells.
Food when eaten cannot reach cells (because it cannot pass through the intestinal walls
to the bloodstream and, if it could not be in a useful chemical state. The gut modifies
foo physically and chemically and disposes of unusable waste. Physical and chemical
modification (digestion) depends on exocrine and endocrine secretions and controlled
movement of food through the digestive tract. Stomach contractions send signals to the
brain making us aware of our hunger. Glucose level in the blood is maintained. Insulin
decreases glucose in blood making us feel hungry. Levels of glucose in the blood are
monitored by receptors (neurons) in the stomach, liver, intestines, they send signals tothe hypothalamus in the brain.
Mouth
Food enters the digestive system via the mouth or oral cavity, mucous membrane lined.
The lips (labia) protect its outer opening; cheeks form lateral walls, hard palate and soft
palate form anterior/posterior roof. Communication with nasal cavity behind soft
palate. Floor is muscular tongue. Tongue has bony attachments (styloid process, hyoid
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bone) attached to floor of mouth by frenulum. Posterior exit from mouth guarded by a
ring of palatine/lingual tonsils.Enlargement sore throat, tonsillitis. Food is first processed
(bitten off) by teeth, especially the anterior incisors. Suitably sized portions then
retained in closed mouth and chewed or masticated (especially by cheek teeth,
premolars, molars) aided by saliva Ducted salivary glands open at various points into
mouth. This process involves teeth (muscles of mastication move jaws) and tongue(extrinsic and intrinsic muscles). Mechanical breakdown, plus some chemical (ptyalin,
enzyme in saliva). Taste buds allow appreciation, also sample potential hazards
(chemicals, toxins).
Swallowing
In leaving the mouth a bolus of food must cross the respiratory tract (trachea is anterior
to esophagus) by a complicated mechanism known as swallowing or deglutination which
empties the mouth andensures that food does not enter the windpipe. Swallowing
involves coordinatedactivity of tongue, soft palate pharynx and esophagus. The first
(buccal) phase is voluntary, food being forced into the pharynx by the tongue. After this
the process is reflex. The tongue blocks the mouth, soft palate closes off the nose and
the larynx rises so that the epiglottis closes off the trachea. Food thus moves into the
pharynx and onwards by peristalsis aided by gravity. If we try to talk whilst swallowing
food may enter the respiratory passages and a cough reflex expels the bolus.
Esophagus
The esophagus (about 10") is the first part of the digestive tract proper and shares its
distinctive structure. Basic tissue layers of the gut are:
1. Mucosa- Innermost, moist lining membrane. Epithelium (friction
resistant stratified squamous in esophagus, simple beyond) plus a little
connective tissue and smooth muscle.2. Sub mucosa- Soft connective tissue layer, blood vessels, nerves,
lymphatic
3. Muscularisexterna- Typically circular inner layer, longitudinal outer layer of smooth
muscle
4. serosal fluid- producing single layer.
Stomach
C shaped, left side abdominal cavity (because liver is on right). Cardio esophageal
sphincter guarding entrance from esophagus is of doubtful anatomical integrity (though
functionally the diaphragmatic pinch cock serves). Pyloric sphincter guarding the outletis much better defined. Fundus, body and pylorus recognized as distinct regions.
Stomach secretes both acid and mucus (for self-protection). Surface area increased by
rugae. Serves as a temporary store for food which is also churned by muscular layers
(three here) to form chyme, creamy substance voided via pyloric sphincter to
duodenum
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Duodenum
First part of small intestine. C shaped 10" long and curves around head ofpancreas and
entry of common bile duct (accessory organs of digestion, pancreas, liver see below).
Chemical degradation of small controlled amounts of food controlled by pyloric
sphincter begins here, enzymes secreted by pancreas and duodenum itself aided by
emulsifying bile (which also lowers pH). Duodenal ulcers caused by squirting of acidstomach contents into duodenal wall opposite sphincter.
Small Intestine
Jejunum (8 feet) and ileum (12 feet) continue degenerative process. Surface area
increased by plicacirculares (circular folds) carrying villi: cells of villi carry microvilli. Each
villus has a capillary and
a lacteal (lymphatic capillary) Absorption of digested foodstuffs is via
these to the rich venous and capillary drainage of the gut. Towards the
end of the small intestine accumulations of lymphoid tissue (Peyer's
patches) more common. Undigested residue of food is rich in bacteria.
Large Intestine
Jejunum terminates at caecum. Caecum is small saclike evagination, important in some
animals as a repository for bacteria/other organisms able to digest cellulose. A blind
ending appendix may give trouble (appendicitis) if infected. The large intestinehas three
longitudinal muscle bands (taenia coli) with bulges in the wall (haustra) between them.
These may evaginate in the elderly to become diverticuli and infected in diverticulitis.
The large intestine resorbs water then eliminates drier residues as feces. Regions
recognized are the ascending colon, from appendix in right groin up to a flexure at the
liver, transverse colon, liver to spleen, descending colon, spleen to left groin, then
sigmoid (S-shaped) colon back to midline and anus. Anus has voluntary and involuntarysphincter and ability to distinguish whether contents are gas or solid. No villi in large
intestine, but many goblet cells secreting lubricative mucus.
Accessory digestive organs: Salivary glands
Three pairs, parotid, submandibular, sublingual. Mumps begins as infective parotitis in
the parotid glands in the cheek. The others open into the floor of the mouth. Saliva is a
mixture of mucus and serous fluids, each produced to various extents in various glands.
Also contains salivary amylase, (starts to break down starch) lysozyme (antibacterial)
and IgA antibodies.
Pancreas
Endocrine and exocrine gland. Exocrine part produces many enzymeswhich enter the
duodenum via the pancreatic duct. Endocrine part produces insulin, blood sugar
regulator.
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Liver
Multifunctional: important in this context since the capillaries of the small intestine
drain fat and other nutrient rich lymph into it via theHepatic portal system.
Liver and gallbladder
A cleftlike lumen, the bile canaliculus is between the cells of each hepatic cord. Bileproduced by the hepatocytes, flow through the bile canaliculi to the hepatic duct in the
portal of triads. The hepatic duct converge and empty into the right and left hepatic
ducts, which transport bile out of the liver. The right and left hepatic ducts units form a
single common hepatic duct. The common hepatic duct is joined by the cystic duct from
the gallbladder to form the common bile duct. The gallbladder is a small sac on the
inferior surface of the liver that stress and concentrates bile. Bile is responsible in
making the color of the stool dark brown.Bile, a watery greenish fluid is produced by the
liver and secreted via the hepatic duct and cystic duct to the gall bladder for storage,
and thence on demand via the common bile duct to an opening near the pancreatic duct
in the duodenum. It contains bile salts, bile pigments (mainly bilerubin, essentially the
non-iron part of hemoglobin) cholesterol and phospholipids. Bile salts and phospholipids
emulsify
c) Functions of organs/body parts involved:
The gallbladder is a saclike structure on the inferior surface of the liver that is about 8cm
long and cm wide. Three tunics form then gallbladder wall:
1. the inner mucosa folded into rugae that allow the gallbladder to expand.
2. amuscularis, which is a layer of the smooth muscle that allows the gallbladder to
contract
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3. an outer covering serosa. The cystic duct connects the gallbladder into common bile
duct.
Bile is continually secreted by liver and flows through the cystic duct to the gallbladder,
where 40-70ml of bile can be stored. While the bile is in the gallbladder, water and
electrolytes are absorbed, and bile salt and pigmented becomes as much as 5-10 timesmore concentrated than they were when secreted by the liver. Contraction of the
gallbladder moves the stored bile into duodenum. Secreting released from the
duodenum stimulate bile secretion, primarily by increasing the water and bicarbonate
ion content of bile. Cholecystokinin released from the duodenum stimulates the
gallbladder to contract and sphincter of bile duct and hepatopancreatic ampulla relax.
To a lesser degree, parasympathetic stimulation through the vagusnercescause the
gallbladder to contract. Thus large amount of concentrated bile move rapidly into
duodenum. Bile salt also increases bile secretion through a positive feedback system.
Over 90% of bile salt are reabsorbed in the elium and carrired in the blood back to liver,
where they contribute further bile secretion. The loss of bile salt in the feces is reduced
by this recycling process.
d) Etiology of the disease:
A gallstone, is a lump of hard material usually range in size from a grain of sand
to 3-4 cms. They are formed inside the gall bladder formed as a result of precipitation of
cholesterol and bile salts from the bile.
Types of gallstones and causes
Cholesterol stones Pigment stones
Mixed stones - the most common type. They are comprised of cholesterol and salts
Cholesterol stones are usually yellow-green and are made primarily of hardened
cholesterol. They account for about 80 percent of gallstones. Scientists believe
cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or
not enough bile salts, or when the gallbladder does not empty as it should for some
other reason. Low grade infection in the gall bladder is another factor in the
development of gall stones.
Pigment stones are small, dark stones made of bilirubin. Bilirubin is the pigment
secreted by the liver The exact cause is not known. They tend to develop in people who
have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell
anaemia in which too much bilirubin is formed.
Other causes are related to excess excretion of cholesterol by the liver in the bile.
They include the following:
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Gender. Women between 20 and 60 years of age are twice as likely to develop
gallstones as men.
Obesity. Obesity is a major risk factor for gallstones, especially in women.
Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or birth
control pills
Cholesterol-lowering drugs. Diabetes. People with diabetes generally have high levels of fatty acids called
triglycerides.
Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes theliver to secrete extra cholesterol into bile, which can cause gallstones.
e) Signs and symptoms:
Many people with gallstones have no symptoms. These patients are said to be
asymptomatic, and these stones are called "silent stones." Gallstone symptoms can be
similar to those of many other conditions such as heart attack, appendicitis, ulcers,
irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. Accurate diagnosisis, therefore important.
Symptoms may vary and often follow fatty meals, and they may occur during the
night:
Abdominal bloating
Recurring intolerance of fatty foods
Severe pain in the upper abdomen that increases rapidly and lasts from 30
minutes to several hours
It may be associated with:
Pain in the back between the shoulder blades
Pain under the right shoulder
Nausea or vomiting
Indigestion & belching
f) Intra and post-operative risk factors:
Possible Complications
Complications are rare, but no procedure is completely free of risk. If you are planning
to have a cholecystectomy, your doctor will review a list of possible complications,
which may include:
Gallstones that have accidentally spilled into the abdominal cavity
Bleeding
Infection
Injury to other nearby structures or organs
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Reactions to general anesthesia
Blood clots
Some factors that may increase the risk of complications include:
Age: 60 or older
Pregnancy Obesity
Smoking
Malnutrition
Recent or chronic illness
Diabetes
Heart or lung problems
Bleeding disorders
Alcoholism and use of street drugs
Use of certain medicines
III. Procedure
a) Skin Preparation:
Clean the skin:
1. From the nipples to the pubis.
2. From the posterior axillary fold on the right side to the anterior axillary fold on the left.
3. Use two swabs on sticks with aqueous povidone iodine, followed by one to dry off.
4. Dry the skin completely or adhesive drape edges will not stick down.
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b) Draping:
First, they placed a folded drape sheet from the foot to the knees. Then, the scrub nurse
selected the sheet and handed one end to the surgeon across the operating site. The second
drape sheet was handled in the same manner. This sheet was placed above the incision site withthe edge of the sheet just above the incision site. Next, they placed a sterile sheet with an
appropriate size of a hole in the middle and put it around the selected incision site. Then, four
towel clips were clamped on all edges and connecting them to the two drape sheets.
c) Position:
Lateral shrimp position (during anesthesia injection)
Supine position (during the procedure)
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d) Anesthesia (technique used):
Spinal anesthesia, also called spinal analgesia or sub-arachnoid block (SAB), is a form of regional
anesthesia involving injection of a local anesthetic into the Subarachnoid space, generally
through a fine needle, usually 3.5inches (9 cm) long. For extremely obese patients, some
anesthesiologists prefer spinal needles which are seven inches (18 cm) long. T he tip of the
spinal needle has a point or small bevel. Recently pencil point needles have been made
available.
Indications:
This technique is very useful in patients having an irritable airway (bronchial asthma or allergic
bronchitis), anatomical abnormalities which make endotracheal intubation very difficult
(micrognathia), borderline hypertensives where administration of general anesthesia or
endotracheal intubation can further elevate the blood pressure, procedures in geriatric patients.
It is the technique of choice for diabetic patients.
Contraindications:
Non-availability of patient's consent, local infection or sepsis at the site of lumbar puncture,
bleeding disorders, space occupying lesions of the brain, disorders of the spine and maternal
hypotension.
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e) Incision Site:
Right side of the upper abdomen
f) Discuss the procedure:
Step I: Incision
Types of Incision:
Upper Right SubCostal IncisionKocher's Incision
Modified Kocher's Incision
Transverse Incision
The incision for open cholecystectomy is typically made 2 fingerbreadths below the right
costal margin, although an upper midline incision can also be used
Retractors are placed to retract the skin, as well as to retract the liver superiorly
Step II: Exposure of the Gallbladder
Retraction of the liver
Inferior surface of the right lobe of the liver is retracted upwards by retracter.
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The dome of the gallbladder is initially scored with electrocautery, and a tonsil clamp is
used to establish a plane in the thickened gallbladder in proximity to the gallbladder wall
itself. The cautery is then used to incise the peritoneal surface of the entire dome.
Step III: Removal of the Gallbladder
The fundus of the gallbladder is removed from the liver bed with blunt and sharp
dissection. Care should be taken in mobilizing the infundibulum of the gallbladder to be
certain that it is not adherent to the common bile duct. The cystic artery and its extension
are usually encountered on the medial surface of the gallbladder. The cystic artery can be
temporarily controlled with a clip on the surface of the gallbladder prior to its formal
ligation. The gallbladder is then completely mobilized from the liver bed until it is attached
only by the cystic duct.
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A clamp is placed on the gallbladder fundus and used to retract the gallbladder
superiorly. A second clamp can be used to retract the infundibulum of the gallbladder
laterally, exposing the triangle of Calot.
Ideally, the cystic artery is identified, circumferentially dissected, and ligated before
dissection of the gallbladder out of the gallbladder fossa. As in the laparoscopic case,
care should be taken not to injure the right hepatic artery. The gallbladder is then removed from the gallbladder fossa from the top down using
electrocautery.
Clamps are placed proximally and distally on the cystic duct. The cystic duct is divided
between the clamps, and the gallbladder is removed from the field.
The cystic duct stump is suture ligated using a 3-0 silk suture
The cystic duct and cystic artery stumps are examined for any signs of bile leakage or
bleeding
Step IV: Closing The placement of closed suction drains is not always required. They are placed only if
bile leakage from the cystic duct stump is expected or observed. If bile leakage is
observed, the surgeon must rule out common bile duct injury.
The fascia is closed in two layers using running or interrupted sutures.
The skin is then closed with absorbable subcuticular sutures or skin staples.
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CASE PRESENTATION
CHOLECYSTITIS
I. Patients Data
Patients Name: JLP
Age: 25 years old
Gender: Female
Date of Birth: May 24, 1986
Address: Sabang, Baliuag Bulacan
Religion: Roman Catholic
Civil Status: Married
Attending Physician: Dr. Bugay
Operation Performed: Cholecystectomy
Type of Surgery: Open cholecystectomy
Surgeon: Dr. Rolando Valones
Date of Operation/Case No. : December 1, 2011 / 11-11-5113
Type of Anesthesia: Spinal anesthesiaAnesthesiologist: Dr. Dennis S. Lazaro
II. NURSING HISTORY
a. PAST HEALTH HISTORY
The patient had childhood illness like mumps when she was 6 years old and measles
when she was 3 or 4 years old. According to her, she does not have chicken pox up to now.
She had complete immunization status. She has no allergies to food and medications. She
was admitted for caesarean section last 2008 in Sto. Nio Hospital in Bustos, Bulacan. She
was hospitalized for 3 days.
b. HISTORY OF PRESENT ILLNESS
Eight days prior to admission, she experienced on and off epigastric pain and radiating
to her back. She also felt pain in her head, nape and around her eyes. She also felt
abdominal bloating. She took Mefenamic acid 500 mg for the pain. Pain lessened but still
recurrent for 8 days. She experienced loss of appetite and difficulty in falling asleep. She had
her check-up last November 25, 2011. She went through ultrasound, pap smear and
urinalysis. Her ultrasound impression was cholelithiasis. She was admitted last November
30, 2011 in Castro Maternity and General Hospital.
c. FAMILY HISTORY
There are cases of hypertension, asthma, and skin cancer on the maternal side of the
patient. On her paternal side, heart diseases and breast cancer are present.
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III. ACTIVITIES OF DAILY LIVING
Activities of
Daily of Daily
Living
Before Hospitalization During Hospitalization Analysis and Interpretation
Nutrition According to the client
before hospitalization,
she eats rice at least
two times a day. At
breakfast the client
drinks a glass (7 oz) of
water every day and
she drinks at least
three to four times for
the whole day, eats
Lugaw, and eats
Yohgurt. During lunch
and dinner time, the
client eats a serving of
viands likeKalderetang Baka and
a cup of rice.
According to the
client, she loves to eat
spaghetti and palabok.
During hospitalization,
the client states that
there are no changes in
the appetite of the client.
The client also eats and
consumes foods that she
eats before
hospitalization. And also
there is no change in the
amount and quality of
food the client eats. The
client is advised to have
nothing per orem.
Interpretation:
ABNORMAL
The clients diet before
hospitalization and the diet
during her stay in the medical
center are not sustaining the
appropriate and adequate
nutrition required for her. She
seldom eats dinner because of
the pain she feels during that
time. She lacks carbohydrates
which are required to give
energy to her body. She seldom
eats fruits and vegetables too.
Her fluid intake is not in rightamount required to consume in
a day. She admitted that she
frequently drinks water.
ANALYSIS:
An adequate food intake
consists of a balance of
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essential nutrients: water,
carbohydrates, proteins, fats,
vitamins and minerals.
(Health Promotion in Nursing
process)
Normal fluid intake should be
up to 8 to 10 glasses a day.
(Kozier et.al. 2008.
Fundamentals of Nursing, 8th
edition). Singapore: Pearson
Education Asia Pte Ltd).
Proper nutrition encompasses
the study of nutrients and how
they are handled by the body
as well as the impact of human
behaviour and environment onthe process of nourishments.
Foods that provides nutrition
for both body and mind.
(Fundamentals of Nursing by
Taylor)
Elimination At home the client
urinates for at least
three times a day. The
color of the urine is
light yellow and
aromatic in odor. Theclient usually
defecates twice a day
and the usual color is
yellow brown,
pungent in odor and
semisolid. The client
does not feel any pain
during urination and
defecation. The client
said that she perspires
a lot.
The client urinates for
three times a day. The
color of the urine is still
the same as before the
hospitalization. And the
client usually defecatestwice a day and the usual
color is yellow brown,
pungent in odor and
semisolid. The client does
not feel any pain during
urination and defecation.
The client perspires less
in the hospital.
Interpretation:
ABNORMAL
The urinary output of the client
before and during the
hospitalization is little in
amount.
ANALYSIS:
Normal Feces
Color: brown
Consistency: soft, formed and
moist
Shape: cylindrical
Amount varies with diet
Aromatic in smell
(Kozier, et al. 2008.
Fundamentals of Nursing)
Urine
About 1200-1500 ml
Straw, amber or transparent in
color
Odor: faint aromatic
Sterility: No microorganisms
present
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Ph:4.5-8
(Kozier, et al. 2008.
Fundamentals of Nursing)
Voiding that is either painful or
difficult (Dysuria) is an altered
urinary elimination.
Frequency of defecation is
highly individual, varying from
several times per day or 2-3
times a week.
Irregular defecation habits
occur when normal defecation
reflexes are inhibited or
ignored, which later on
progressively weakens. Whenhabitually ignored, the urge to
defecate is ultimately lost.
Children at play may ignore
these reflexes; adults ignore
them because of pressure of
time or work
Normal feces are made of
about 75% water and 25% solid
waste materials.
Normal feces require a normal
fluid intake; feces that contain
less water may be hard and
difficult to expel.
(Kozier, et al. 2008.
Fundamentals of Nursing)
Activities At home, the client
usually helps her
mother in taking care
of their Sari-Sari store.
The client usually
watch television
shows. He also plays
games on cell phones
and laptops. She do
household chores and
takes good care of her
child.
In the hospital the client
has limited activities and
usually stays in the
hospital bed. Client
usually watches
television show and plays
games on cell phones
and laptops.
Interpretation:
NORMAL
The client can still continue her
need for physical activity in the
hospital because shes only
ambulatory not immobile,
capable of walking. Shes not
immobile which means she can
still perform a number of ROM
(range-of-motion exercises)
maintaining her muscle tone.
She just needs assistance when
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ambulating, for example going
to the comfort room, changing
into a sitting position, etc.
ANALYSIS:
The amount of exercise you
need depends on the type of
lifestyle you want to maintain.
For beginners, most experts
recommend at least 20 minutes
of exercise three times a week.
These 20 minutes can be a
combination of four 5-minute
sessions of exercise, two 10-
minute sessions or 20
continuous minutes. Just doing
something is better than no
exercise at all. Remember, 20minutes is considered the
minimum prescribed amount of
exercise for one day. As your
body adjusts to this level of
exercise, you should increase
the amount of exercise that
you are doing to continue
receiving the maximum
benefits.
(Kozier et.al. 2008.
Fundamentals of Nursing, 8
th
edition). Singapore: Pearson
Education Asia Pte Ltd)
Hygiene The client takes a bath
everyday. She usually
takes a bath in the
morning and takes a
half-bath during the
evening. And brush
her teeth two times a
day with the use of a
normal toothbrush.
The client usually
wears comfortable
clothes when shes at
home.
The child does sponge
bath in the hospital. And
brush her teeth with the
use of a normal
toothbrush. The client
usually wears tshirt and
leggings.
Interpretation:
NORMAL
The clients hygienic pattern
falls within a normal scale.
After the operation, the client
should recuperate a good
personal hygiene as similar
from her hygiene before she
was hospitalized.
ANALYSIS:
Hygiene is the self-care by
which people attend to such
functions as bathing, toileting,
general body hygiene and
grooming. It involves care of
the skin, hair, nails, teeth, oral
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and nasal cavities, eyes, ears
and perineal-genital areas.
(Kozier & Erb. Fundamentals of
Nursing. 8th
Edition. Volume 1)
Sleep and Rest The client doesnt
take any nap. She
usually sleeps at 10
oclock in the evening
and wakes up at 8
oclock in the morning
the following day.
The client has a difficulty
in sleeping. She usually
sleeps around 1 or 2
oclock in the morning
and wakes up around 6
or 7 oclock in the
morning. She
experiences pain when
closing her eyes.
Interpretation:
NORMAL
The clients sleeping pattern
before and during
hospitalization has big
difference. She lacks sleep
during her hospitalization
because she experiences pain
every time shell be sleeping.
One factor also is stress about
her operation and the sleeping
environment. With the aim of
promoting a good sleepingenvironment, nurses should
keep the lights low and using as
soft voice and as much as
possible overcome the sound
interference in the
surrounding.
ANALYSIS:
Children require 11-12 hours of
sleep each night with no
disturbance to prevent unduefatigue.
(Fundamentals of Nursing By
Kozier Et. Al 8th
Ed)
Sleep is a basic human need; it
is a universal biological process
common to all people. Human
requires sleep for many
reasons: to cope with daily
stresses, to prevent fatigue, to
conserve energy, to restore
mind and body, and to enjoy
life more fully.
(Fundamentals of Nursing By
Kozier Et. Al 8th
Ed)
Environment can promote or
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hinder sleep. Any change-for
example, noise in the
environment can inhibit sleep.
Discomfort from environmental
temperature (e.g. too hot or
too cold) and lack of ventilation
can affect sleep.
Substance Use The client doesnt
take any medications.
After the operation the
attending physician
ordered Mefenamic acid
500mg/tab if there is a
positive epigastric pain
happens.
Interpretation:
NORMAL
The patient is not going
through any kind of substance
abuse. She is currently taking
her prescribed medicine.
ANALYSIS:
Smoking is a risk factor for
hypertension, heart disease,peripheral vascular disease,
chronic obstructive pulmonary
disease (COPD), and cancer of
the lung, colon, larynx, oral
cavity, esophagus, bladder,
pancreas, and kidney. It also
worsens such conditions as
respiratory infections, peptic
ulcers, hiatal hernia, and
gastroesophageal reflux.
Not smoking promotes health
by increasing exercise
tolerance; enhancing taste bud
function; and avoiding facial
wrinkles and bad breath.
(Lipincott Manual of Nursing
Practice, 8th Edition)
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IV. PHYSICAL ASSESSMENT
CLIENTS BODY BUILT Height: 164 cmWeight: 57 kg
POSTURE AND GAIT Slouched
HYGIENE AND GROOMING Clean and neat
SIGNS OF DISTRESS(POSTURE/FACIAL)
In distress
SIGNS OF ILLNESS Unhealthy Appearance
ATTITUDE Cooperative
AFFECT AND MOOD Appropriate to situation
SPEECH(QUANTITY/QUALITY/ORGANIZATION)
Understandable if repeatedModerate paceClear Tone
RELEVANCE/ORGANIZATION OFTHOUGHTS
Mental status
Logical SequenceMakes SenseHas Sense Of Reality
Alert
Measurement Normal Findings Actual Findings Interpretation
Weight According to the Body
Mass Index (BMI) Chart,BMI of 18.6-22.9 is
normal, or = to 23
is overweight
57 kg (125 lbs) Normal
Height According to the Body
Mass Index (BMI) Chart,
BMI of 18.6-22.9 is
normal, or = to 23
is overweight
164 cm(54 feet) Normal
Vital signs
Temperature 36.5.7-37.5 36C Abnormal
Pulse rate 60-100 72bpm- regular Normal
Respiratory rate 12-20 cpm 18cycles Normal
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NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
SKIN
Inspect skin color. Varies from light to
deep brown; from
ruddy pink to light pink;
from yellow overtones
to olive.
Pallor Deviated from normal
Inspect uniformity of skin
color.
Generally uniform
except in areas
exposed to the sun.
Generally uniform
except in areas
exposed to the sun.
Normal
Inspect presence of
edema
No edema No edema Normal
Observe and palpate skin
moisture.
Moisture in skin folds
and the axillae (varies
with environmental
temperature and
humidity, body
temperature, and
activity.)
Moist in skin folds Normal
Palpate skin temperature. Uniform; within normal
range.
Uniform; Cold Deviated from normal
Note skin turgor (fullness
or elasticity) by lifting and
pinching the skin on an
extremity.
When pinched, skin
springs back to
previous state.
Skin spring back to
previous state when
pinched
Normal
NAILS
Inspect fingernail plate
shape to determine its
curvature and angle.
Convex curvature;
angle of nail about 160
o.
Convex curvature,
angle approximately
160
Normal
Inspect fingernail texture. Smooth texture. Smooth Normal
Inspect fingernail bed
color.
Highly vascular and
pink in light-skinned
clients; dark-skinned
clients may have brown
or black pigmentation
Pallor Deviated from normal
Blood Pressure 120/80 mmHg 100/70 mmHg Deviated from normal
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in longitudinal streaks.
Inspect tissues
surrounding nails.
Intact epidermis. Intact epidermis Normal
Perform blanch test of
capillary refill.
Prompt return of pink
or usual color(generally less than 4
seconds.)
Return to usual color Normal
HEAD
Inspect the skull for size,
shape and symmetry.
Rounded
(normocephalic and
symmetric, with frontal,parietal, and occipital
prominences); smooth
skull contour.
Normocephalic,
smooth skull contour
Normal
Palpate the skull for
nodules, masses and
depressions.
Smooth, uniform
consistency; absence
of nodules or masses.
Smooth, uniform
consistency, no
nodules or masses
Normal
Color and appearance of
scalp
Scalp lighter than the
color of the facial skin
Scalp lighter than the
color of the facial skin
Normal
Areas of tenderness No tenderness No tenderness Normal
Hair evenness of growth Evenly distributed Evenly distributed Normal
Hair thickness or thinness
Texture and oiliness
Thick hair
Silky, resilient hair
Thick hair
Silky, resilient hair
Normal
Inspect the facial features. Symmetric or slightly
asymmetric facial
features; palpebral
fissures equal in size;
symmetric nasolabial
folds.
Symmetric facial
features
Normal
Note symmetry of facial
movements.
Symmetric facial
movements
Symmetric facial
movements
Normal
EYES
Inspect the eyebrows for Hair evenly distributed; Hair evenly distributed; Normal
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hair distribution and
alignment and skin quality
and movement.
skin intact; eyebrows
symmetrically aligned;
equal movement.
skin intact; eyebrows
symmetrically aligned;
equal movement.
Inspect the eyelashes for
evenness of distribution
and direction of curl.
Equally distributed;
curled slightly outward.
Equally distributed;
curled slightly outward.
Normal
Inspect the eyelids for
surface characteristics,
ability to blink, and
frequency of blinking.
Skin intact, no
discharge, no
discoloration; lids close
symmetrically;
approximately 15 to 20
involuntary blinks per
minute, bilateral
blinking.
Skin intact, no
discharge, no
discoloration; lids close
symmetrically; 17
involuntary blinks per
minute, bilateral
blinking.
Normal
Color, texture, and
presence of lesion in
bulbar conjunctiva
Transparent Transparent Normal
Color, texture, and
presence of lesion in
palpebral conjunctiva
Shiny, smooth, pink or
red
Shiny, smooth, pink Normal
Color and clarity of sclera White White Normal
Inspect the cornea for
clarity and texture.
Transparent, shiny and
smooth; details of the
iris are visible.
Transparent, shiny and
smooth; details of the
iris are visible.
Normal
Inspect the pupils for
color, shape and
symmetry of size.
Black in color; equal in
size normally 3 to 7
mm in diameter; round,
smooth border.
Black in color; equal in
size normally 4mm in
diameter; round,
smooth border.
Normal
Light reaction and
accommodation
Illuminated pupil
constricts and non-
illuminated pupil
constricts, pupil
constricts when looking
at near object and
dilate when looking at
far object; pupil
converge when near
object is moved toward
the nose
Illuminated pupil
constricts and non-
illuminated pupil
constricts, pupil
constricts when looking
at near object and
dilate when looking at
far object; pupil
converge when near
object is moved toward
the nose
Normal
Eye alignment and Both eyes move in
coordination and
Both eyes move in
coordination and
Normal
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coordination unison, with parallel
alignment
unison, with parallel
alignment
Assess near vision. Able to read newsprint. Able to read Normal
Assess distance vision. 20/20 vision on
Snellen-type chart.
20/150 Normal
EARS
Inspect the auricles for
color, symmetry of size
and position.
Color same as facial
skin; symmetrical;
auricle aligned with
outer canthus of eye
about 10o
from vertical.
Color same as facial
skin; symmetrical;
auricle aligned with
outer canthus of eye
about 10o
from vertical.
Normal
Palpate the auricles for
texture, elasticity, and
areas of tenderness.
Mobile, firm, and not
tender; pinna recoils
after it is folded.
Mobile, firm, and not
tender; pinna recoils
after it is folded.
Normal
Inspect ear canal for
cerumen, skin lesions,
pus, and blood.
Dry cerumen, grayish-
tan color, or sticky.
Dry cerumen, grayish-
tan color, or sticky.
Normal
Assess clients response
to normal voice tones.
Normal voice tones
audible.
Normal voice tones
audible.
Normal
Perform watch tick test. Able to hear ticking in
both ears.
Able to hear ticking in
both ears.
Normal
Perform Webers test. Sound is heard on bothears or is localized at
the center of the head
(Weber negative.)
Sound is heard on bothears weber negative
Normal
Conduct Rinne test AC > BC (positive
Rinne.)
Right-AC=9>BC=8;
Left-AC=10>BC=8
Positive rhine
Normal
NOSE
Inspect the external nose
for any deviations in
shape, size, or color and
flaring or discharge from
the nares.
Symmetric and
straight; no discharge
or flaring; uniform
color.
Symmetric and
straight; no discharge
or flaring; uniform
color.
Normal
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Presence of redness,
swelling, growth and
discharge in nasal cavity
Mucosa is pink; clear
watery discharge; no
lesion
Mucosa is pink and no
lesion
Normal
Lightly palpate the
external nose to
determine any areas of
tenderness, masses, and
displacements of bone
and cartilage.
Not tender; no lesions. Not tender; no lesions. Normal
Test patency of both
nasal cavities.
Air moves freely as the
client breathes through
nares.
Air moves freely as the
client breathes through
nares.
Normal
Inspect nasal septum
between the nasal
chambers.
Nasal septum intact
and in midline.
Nasal septum intact
and in midline.
Normal
Palpate for tenderness of
sinuses.
Not tender. No tenderness Normal
MOUTH
Inspect the outer lips for
symmetry of contour,
color and texture.
Uniform pink color;
soft, moist and smooth
texture; symmetry of
contour.
Uniform pink color;
soft, moist and smooth
texture; symmetry of
contour
Normal
Inspect and palpate the
inner lips and buccalmucosa for color,
moisture, texture and the
presence of lesions.
Uniform pink color;
moist, smooth, soft,glistening, and elastic
texture.
Uniform pink color;
moist, smooth, soft,glistening, and elastic
texture.
Normal
Inspect gums for the color
and condition.
Pink gums, firm texture
to gums.
Red gums, firm texture
to gums.
Normal
Inspect the tongue for
position, color, and
texture.
Central position; pink
color; dry, slightly
rough; thin whitish
coating.
Central position; pink
color; dry, slightly
rough; thin whitish
coating.
Normal
NECK AND LYMPH NODES
Palpate lymph nodes and
note for tenderness.
Not palpable. Not palpable Normal
Inspect and palpate
trachea for placement.
Central placement in
midline of the neck;
Central placement in
midline of the neck;
Normal
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spaces are equal on
both sides.
spaces are equal on
both sides.
ABDOMEN
Inspect the abdomen for
skin integrity.
Unblemished skin
Uniform color
Silver-white striae
(stretch marks) or
surgical scars
Unblemished skin
Uniform color
Silver-white striae
(stretch marks) or
surgical scars
Normal
Inspect the abdomen for
contour and symmetry:
Observe theabdominalcontour 9profileline from the ribmargin to thepubic bone) whilestanding at theclients side whenthe client issupine.
Ask the client totake a deepbreath and to holdit.
Assess thesymmetry of
contour whilestanding at thefoot of the bed.
If distention ispresent, measurethe abdominalgirth by placing atape around theabdomen at thelevel of theumbilicus.
Flat, rounded (convex),
or scaphoid (concave)
No evidence of
enlargement of liver or
spleen
Symmetric contour
Flat, rounded (convex),
or scaphoid (concave)
There is a slight
enlargement between
epigastric and
hypochondriac region.
Symmetric contour
Normal
Normal
Deviated from
normal
Normal
Observe abdominal
movements associated
with respiration,
peristalsis, or aortic
pulsations.
Symmetric movements
caused by respirations
Visible peristalsis in
very lean people
Aortic pulsations in thin
persons at epigastric
area
Symmetric movements
caused by respirations
Visible peristalsis in
very lean people
Aortic pulsations in thin
persons at epigastric
area
Normal
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Observe the vascular
pattern
Symmetric movements
caused by respirations
Visible peristalsis in
very lean people
Aortic pulsations in thin
persons at epigastric
area
Symmetric movements
caused by respirations
Visible peristalsis in
very lean people
Aortic pulsations in thin
persons at epigastric
area
Normal
Normal
Auscultate the abdomen
foe bowel sounds,
vascular sounds, and
peritoneal friction rubs.
Audible bowel sounds
Absence of arterial
bruits
Absence of friction rub
Audible bowel sounds
Absence of arterial
bruits
Absence of friction rub
Normal
Perform light palpation
first to detect areas of
tenderness and/or muscle
guarding. Systematically
explore all four quadrants.
Ensure that the clients
position is appropriate for
relaxation of the
abdominal muscles, and
warm the hands.
No tenderness; relaxed
abdomen with smooth,
consistent tension
No tenderness; relaxed
abdomen with smooth,
consistent tension
normal
Perform deep palpation
over all four quadrants
No tenderness; relaxed
abdomen with smooth,
consistent tension
No tenderness; relaxed
abdomen with smooth,
consistent tension
Normal
Palpate the liver to detect
enlargement and
tenderness
May not be palpable
Border feels smooth
May not be palpable
Border feels smooth
Normal
Palpate the area above
the pubic symphysis if the
clients history indicatespossible urinary distention
Not palpable Not palpable Normal
MUSCULOSKELETAL SYSTEM
Inspect muscles for size. Equal size on both
sides of the body.
Equal size on both
sides of the body.
Normal
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Inspect the muscles and
tendons for contractures
(shortening) and tremors.
No contractures; no
tremors.
No contractures; no
tremors.
Normal
Palpate muscles at rest to
determine muscle tonicity.
Normally firm. firm Normal
Test for strength (neck,
upper and lower
extremities.)
Equal strength on each
body side.
Equal strength on each
body side.
Normal
Inspect the skeleton for
structure.
No deformities. No deformities. Normal
Palpate the bones to
locate any areas of
edema or tenderness.
No tenderness or
swelling.
No tenderness or
swelling.
Normal
Inspect the joint for
swelling, tenderness,
smoothness, and
presence of nodules.
No swelling,
tenderness or nodules;
joints move smoothly.
No swelling,
tenderness or nodules;
joints move smoothly.
Normal
REFLEXES
Assess upper extremity
reflexes (biceps/ triceps/
supinator.)
+2 normal response. +2 normal response Normal
Assess lower exterimityreflexes (patellar, ankle,
plantar.)
+2 normal response. +2 normal response. Normal
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V. COURSE OF THE WARD
Admitting Diagnosis: Calulous Cholecystitis
Chief Complaint: Epigastric pain
History of Present Illness: One week prior to admission, on and off epigastric pain.
Ultrasound revealed cholelithiasis
Diet: Diet as Tolerated
IVF: D5LR x 30 gtts/min
Vital Signs:
Date Temperature Respiratory Rate Pulse Rate Blood Pressure
December 2, 2011 36 C 22 cpm 76 bpm 100/70 mm Hg
a. Diagnostics & Laboratories
CHEST X-RAY
Lungs clear
Heart not enlarged
Hemidiaphragms and costophrenic sulci are intact
IMPRESSION: Normal Chest Study
HEMATOLOGY
TEST S.I. S.I. Normal Range Interpretation
Hematocrit 0.39 M: 0.42-0.54
F: 0.36-0.46
Normal
Hemoglobin 129 M: 140-180 g/LF: 115-160 g/L
Normal
WBC 5.6 5.10 x 10 g/L Normal
Differential Normal
Segmenters 0.64 0.36-0.70 Normal
Lymphocytes 0.30 0.22-0.40 Normal
Eosonophils 0.03 0.01-0.04 Normal
Monocytes 0.03 0.00-0.06 Normal
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ABDOMINAL ULTRASOUND
(November 25, 2011)
The liver is within normal in size with homogeneous echopattern. The intrahepatic ducts are not dilated.
The common bile duct measures 3 mm. No focal cystic or solid nodule seen.
The gallbladder measures 66 x 23 mm. the wall is thin. There is an echogenic focus in the posterior wall
measuring 5 mm.
The pancreas is within normal in size and echopattern. The duct is not dilated. No focal cystic or solid
nodule seen.
The spleen is normal in size and echopattern. No focal cystic or solid nodule seen.
The right kidney measures 101 x 35 mm while the left kidney measures 105 x 47 mm. The echopattern is
homogeneous. No lithiasis or hydronephrosis seen. Both ureters are not dilated.
The urinary bladder is fairly distensible and echo free. The wall is thin.
The uterus is anteverted measuring 60 x 41 x 26 mm. the endometrium is thickened measuring 9 mm.
the echopattern is homogeneous. No focal cystic or solid nodule seen. Both adnexae are unremarkable.
IMPRESSION:
CHOLELITHIASIS
NORMAL LIVER, BILIARY TREE PANCREAS, SPLEEN, RENAL AND URINARY BLADDER.
NORMAL SIZE UTERUS WITH THICKENED ENDOMETRIUM.
NEGATIVE ADNEXAE
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VII. PROBLEMS IDENTIFIED
Significant Cues Nursing Diagnosis
Subjective:
Masakit angtagiliran ko as verbalized by patient.
Objective:
Facial mask of pain
Irritation
Self focusing
V/S taken as follows:
T: 36C
P: 76 bpm
R: 22 cpm
BP: 100/70 mmHg
Acute pain related to inflammation and
distortion of tissues.
Subjective:
Masakit ang inoperahan sa akin. Nahihirapan ako
kumilos, as verbalized by the patient.
Objective:
Facial mask of pain
Limited range
of motion
Disruption of skin
V/S taken as follows:
T: 36C
P: 76 bpm
R: 22 cpm
BP: 100/70 mmHg
Impaired tissue integrity related to
presence of secretions
Subjective:
Nilalamig nga ako simula pa kanina pagkagising
ko eh.
Objectives:
Cool skin
Pallor
Slow capillary refill
T: 36.0 C
RR: 22 cpm
PR: 76 bpmBP: 110/70
Hypothermia related to exposure to cool
or cold environment as manifested by
cool skin, paloor, and slow capillary refill.
Subjective:
Nahihirapan ako kumilos sa kalagayan ko ngayon
as verbalized by the patient.
Objective:
The patient may manifest:
Activity intolerance related to limited
range of activity
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Fatigue
Weakness
Inability in performing ADLs without assistance
with clean and dry wound dressing over right
upper quadrant
abnormal HR or BP
Pallor
Dyspnea
Exertional Discomfort
Dysrhytmias or ischemia
V/S taken as follows:
T: 36C
P: 76 bpm
R: 22 cpm
BP: 100/70 mmHg
Subjective:
Hindi ko alam gagawin sa sugat ko makati kasi at
medyo masakit, as verbalized by the patient.
Objective:
request for information
V/S taken as follows:
T: 36C
P: 76 bpm
R: 22 cpm
BP: 100/70 mmHg
Knowledge deficit regarding condition
and self care related to misinterpretation
of information
Subjective:
Nakakalungkot lang kasi hindi na ko mkakapag-
bathing suit kasi may peklat na naman eh
alam mo na yung feeling ng may natanggal sa
katawan mo as verbalized by the patient.
Objectives:
Facial expression of agitation while telling her
concern about her body image
Patient is conscious about her situation because
she asked many questions regarding the treatment
of the scar.
Body Image Disturbance related to
surgical incision secondary to
cholecystitis