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

TABLE OF CONTENTS

I.Introduction ................................................................................................... 1 II.Objectives (General & Specific) ................................................................... 3 III.Patients 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 X.Pathophysiology ............................................................................................. 47 XI.Doctors Order ............................................................................................... 50 XII.Diagnostic Exam ............................................................................................ 62 XIII.Drug Study ..................................................................................................... 72 XIV.Procedural Report ......................................................................................... 87 XV.Nursing Theories ........................................................................................... 94 XVI.Nursing Care Plan ......................................................................................... 100 XVII.Discharge Plan (M. E. T. H. O. D.) & Prognosis ........................................ 123 XVIII.Recommendation ........................................................................................... 130 XIX.References ...................................................................................................... 133

ACKNOWLEDGMENT

The Group 4-1 of section 3H, would like to acknowledge the contributions of the following groups and individuals to the development of this case presentation. To the Almighty God for blessing them with wisdom, competence and genuine passion and giving them the strength to finish this presentation. The group dedicates to Him the fruits of their hard-earned achievement. To the staff of the Davao Medical School Foundation Hospital-3C for being accommodating to the students and for giving them additional teachings during their exposure in the said hospital. They have also been very willing to allow the students to obtain records necessary for this presentation. To their respected clinical instructor for this rotation, Daphny Grace Peneza, R.N., R.M., M.N., for her support and guidance to the group. She has imparted knowledge that would furthermore enhance the students understanding of their patients case, thus making them ready to present this case presentation. To their client, Meg, and her family, for being open and generous enough to

disclose personal information that would be helpful for this study. The group would also like to thank them for their patience throughout the duration of the study and for giving the group the opportunity to care for Selecta and apply what they have learned. To the proponents respective family and friends for their prayers as well as their financial support. They have also been a source of inspiration of the students. To the members of this group for working hard and giving their efforts, time and resources in conducting the study and for the completion of the written output.

INTRODUCTION One of the body organs that we can live without is the gallbladder. However, does this mean it is of no use to the body? The gallbladder is a pearshaped organ situated underneath the liver. Its function is to store bile and release it as needed for digestion. Bile emulsifies the fats in food, breaking them to small fragments so they can be further digested and absorbed in the small intestine. If the gallbladder is not working as it should, the digestion of fats can be seriously impaired. One of the common gallbladder diseases is calculous cholecystitis. Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading to poor drainage of bile. Trapped bile can irritate and inflame the walls of the bladder, thus leading to inflammation. Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman & Brandt, 2006). It affects women more often than men and is more likely to occur at the age of 20-50 or over 60. Asians are also more prone to develop pigment stones. Moreover, people who are obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. In the United States, it is estimated that 6.3 million men and 14.2 million women aged 20 to74 had gallbladder disease (Everhart, Khare, Hill, Maurer, 1999). In the Philippines, an extrapolated prevalence of 5, 073, 040 people are affected by the disease (http://digestive.niddk.nih.gov/statistics). Gallstones that do not cause symptoms do not require treatment. However, if gallstones cause, disruptive, recurring episodes of pain, surgical removal of the gallbladder is recommended. Recently, the Group 3H-4a had a patient who was diagnosed with symptomatic calculous cholecystitis and underwent laparoscopic

cholecystectomy. The group chose this case for they see it fit for their perioperative concept. Rarely do they interact with patients who had minimally invasive surgery. The proponents are hoping that through this case study, they will be more knowledgeable and aware about such gallbladder disorder and the surgical procedure done for the said disease. They are also interested to know
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the proper and necessary nursing management that will be given to a patient affected by the disease. Moreover, they would also like to impart their learning to their families and their community regarding the prevention and care if ever such condition will arise in the scenario. As nursing students, they are hoping that this study will help them become more efficient and better nurses in the future. The student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well.

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OBJECTIVES General objective: Within 2 weeks exposure to various clinical areas, the group should have been able to present a comprehensive case study which explains the pathology, the treatment and the appropriate medical and nursing management regarding the condition of their chosen client. The group also aims to perform the necessary nursing interventions to help alleviate the patients condition and improve her health. Specific Objectives: The proponents also created certain aims that will help them in achieving their general objectives. Within 2 weeks of exposure, the proponents aim to: Cognitive: Gather pertinent data regarding the past and present health history of the patient through interview and assessment; Draw the family genogram of the patient; Define the complete diagnosis of the patient by directly citing it from three different sources; Ascertain the patients developmental status using the theories of Robert Havighurst, Erik Erikson and Lawrence Kohlberg; Conduct a thorough cephalocaudal assessment obtained from the client; Review the anatomy and physiology of the organs affected in the patients disease; Present the etiology and symptomatology of the disease; Trace the pathophysiology of the patients disease; Obtain the doctors orders and make rationales for each order;

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 Obtain, analyze and interpret laboratory and diagnostic procedures done on the patient and include the normal and abnormal values and findings for comparison, and the specific nursing responsibilities associated with each diagnostic procedure; Make drug studies on each drug given to the client, correlate them with the disease process, explain why such drugs were ordered, and present important interventions in administering the drug; Identify three nursing theories that can be applied to the patients condition; Present specific, measurable, attainable, realistic, and time-bounded nursing care plans for the patient; Correlate the different nursing theories with the nursing care plans that are presented in this case study; Make a discharge plan for the patient with the use of M.E.T.H.O.D.; Validate patients prognosis according to the following categories: onset of illness, duration of illness, precipitating factors, willingness to take medications and treatment, age, environmental factors and family support; Broaden our scope of knowledge about the disease and the appropriate Nursing Care for the patient with the disease; Psychomotor: Find a patient who will be the subject of their case presentation; Render health teachings to the patient and her significant others to promote health; Provide care based on the various nursing care plans formulated by the researchers and the patient herself;

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 Share information about calculous cholecystitis and the factors that cause the development of such disease and its complications; Share how the disease affects those affected by it and the systems involved in its occurrence; Affective: Establish rapport with the patient and significant others; Show genuine concern and willingness in serving the client; Be aware of the clients progress on the succeeding interactions; Appropriately state the bibliography of all resources used in order to prevent plagiarism and promote honesty.

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PATIENTS DATA Clients Code Name: Age: Gender: Birth date: Address: Nationality: Religion (Denomination): Civil Status: Spouse: Educational Attainment: Occupation: Height: Weight: Health Insurance: Meg 38 years old Female November 6, 1971 Upper Sirib, Calinan Davao City Filipino Christian (Roman Catholic) Married Bobong 4th year high School House keeper 5ft 2inches 62 kgs. Phil Care

Hospital: Vital Signs on Admission:

Davao Medical School Foundation (DMSF) BP: 130/80 mmHg PR: 79 bpm RR: 19 cpm T: 37 C

Unit: Chief Complaint: Admitting Physician: Admitting Diagnosis: Final diagnosis Surgical procedure

3C- 324-5 Pain at right upper quadrant Dr. Walter Batucan Acute Cholelithiasis Calculous Cholecystitis Laparoscopic cholecystectomy

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FAMILY BACKGROUND AND HEALTH HISTORY A. Family Background Meg is the second child among Mamang and Papangs four children. All children of Mamang were born through Normal Spontaneous Vaginal Delivery without any complications. She delivered all her children at their house with the help of mananabang. The family has been residing in Sirib, Calinan Davao City since the marriage of Papang and Mamang. Their home is near their farm. The client, Meg has 3 siblings namely: Kenny (Male, deceased), Luigi (Male, 30, married), and Dora (Female, 28, married). Meg graduated high school and didnt to proceed to college because she helped her family tend their farm. According to the patient, her father and mother are still alive and they suffer from hypertension and diabetes. She said that the family lineage of her mother also suffers from heart problems as well as kidney problems. Two of her uncles on fathers side underwent surgery, cholecystectomy, and had the same condition as Meg. Her older brother died due to motorcycle accident. Luigi was diagnosed with hypertension and Dora had a history of UTI. There was no one else in her immediate family that suffered cholecystitis aside from Meg herself. Meg got married to Bobong in the 1998. They were blessed with 3 children. Her 3 children were delivered through Normal Spontaneous Vaginal Delivery, all were born in the Maternity clinic in Calinan. Her eldest child is now studying in 4th grade. So far, none of her children suffer a serious illness. In terms of their expenses, Bobong is the one that provides money for their daily expenses. Bobong is a Supervisor at DABCO and has a wage of approximately 10,000 a month. Meg said that they budget the
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money well for them to have food and to provide the necessary daily needs and expenses. By helping tend to the 2 hectare farm of the patients parents, they also get their share. They plant coconut trees, bananas, and pineapples in their farm.

Lifestyle The patient has sedentary lifestyle. When Meg stopped going to school, she helped her mother with household chores. Right now, she is busy taking care of Bobong and their 3 children. She is the one who cooks, cleans the house, and does the laundry of the whole family. Sometimes, she does gardening in their backyard. According to her, she only works in the house, but still, she experiences fatigue from doing household chores especially since she is the only one who does the laundry. She reported that she doesnt smoke, but her husband does; he smokes almost one pack a day. Meg said that she drinks liquor very seldom; she only consumes a half of glass or a glass of liquor occasionally. The family has good relationship. At night, they watch television together and this serves as their bonding time. Occasionally, they gather together with her relatives when there are fiestas, birthday celebrations and other special occasions. She is not so active in terms of social organizations such as GKK (Gagmayng Kristohanong Katilingban), but she sometimes joins in the events in their community like the fiesta. She sometimes goes to church on Sundays together with her children.

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Meg sleeps around 9:00 oclock at night and wakes up around 5:00 oclock in the morning to prepare things needed of her husband. She is the one who cooks the baon of her husband for work. Meg said that she eats at least two times a day in small meals. She said naga-diet diet man ko kay tabaan nako sa akoang lawas, nagsugod ko katong 36 years old pako, pero karong tuiga giundangan na nako ang pagdiet-diet. For breakfast she usually eats, bulad, bagoong, ginamos and bread. Every morning, she always drinks coffee. In a day, she can consume at least 3 cups of coffee. Her lunch and supper are sometimes vegetables that are found in their backyard such as kamunggay, upo, okra, talong and tinangkong. She is not fond of eating pork and beef. She said that before, she limits herself from eating fatty foods since she aimed to lose weight because she was afraid of becoming obese. Also, she is so fond of drinking soft drinks. In a day she can consume 4 glasses of coke. But she also drinks approximately 5-6 glasses of water. She also loves to eat salty foods, especially junk foods. According to her, she has no allergy from any form of food.

B. Past Health History Meg and her husband preferred to have artificial family planning than natural family planning. She started using birth control pills since she was 36 years old. She said that she is not sure if she completed her immunizations. Her mother forgot already and the records were lost. They only avail of the services of the health center very seldom. She said that their house was far from the health center so they werent able to avail of all of the services. She also experienced common illnesses such as cough, colds, fever, measles and even chickenpox. They only treated it at home, since her mother knows how to make use of different herbal medicines such as
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kalabo, mayana, buyo, gabon, and tawa-tawa. Also, they sometimes bought over-the-counter drugs such as paracetamol, Neozep, and Medicol. With regards to how long she experienced those usual illnesses, she said dili man jud ko maabtan ug simana sa akoang kalintura ug bisan ubo. She experienced measles when she was a 1-year old and had chickenpox when she was 10-year old. Meg had her menarche when she was 11 years old. Meg reported that she got pregnant with her 1 st child at the age of 28; unfortunately, she had miscarriage on the 1st week of pregnancy. She was hospitalized at Robillo Hospital, Calinan Davao City. Completion curettage was performed to her. Again, on her 3 rd pregnancy, she had a miscarriage and was hospitalized on the maternity clinic and underwent completion curettage. She reported that in almost all her pregnancies, she experienced an increased blood pressure, usually 140/90. After delivering her third child at the age of 36, Bobong and Meg decided to make use of family planning. Meg started to take birth control pills until now to prevent unexpected pregnancy.

C. History of Present Illness On the second week of December 2009, Meg felt mild pain at the right upper quadrant of her abdomen. She neglected it thinking that its nothing serious and might be just an episode of indigestion. After three days, the pain went away. But after two weeks, pain recurred at a higher scale (5/10). Because of this, she was forced to seek medical advice. She went to Isaac T. Robillo Memorial Hospital Calinan, Davao City and was asked to have ultrasound of the whole abdomen. After 2 days, the result was released and they found out that there were stones in her gallbladder. She was advised by the doctor to undergo surgery, cholecystectomy. However,
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the patient resisted the doctors advice due to fear of surgery. She was given medications as an alternative (the patient already forgot the name of medications prescribed). She was instructed by the doctor to increase water intake and have a low fat diet, unfortunately, she wasnt able to follow the doctors order and still continued with her usual lifestyle. Meg said that she still felt the pain after the check-up but she could still tolerate it. She just took medications that were prescribed by the doctors to alleviate the pain she felt. Last May 5 this year, three days prior to admission, the patient again experienced right upper quadrant pain which lasted until the present condition. This was characterized to be progressive pain with a pain scale of 8 out of 10. There was no radiation noted and no associated symptoms. Two days prior to admission, pain recurred with a pain scale of 10 out of 10. This prompted Meg to seek consultation, hence, admission.

On May 8, 2010, the patient was admitted at Davao Medical School Foundation at Surgical Ward, room 324 bed 5 under the service of Dr. Batucan, with admitting diagnosis of Acute Cholelithiasis.

D. Effects/Expectations of Illness to Self/Family

Biological: When Meg knew about her condition that she needs to undergo surgery, she didnt know what to do. She was very worried about herself because she has fear of not waking up after surgery. She feared having complications of not having a gall bladder anymore.

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Psychosocial: Also, she is worried about her 3 children, who still need care and guidance from their mother. This made her decide not to go through with the surgery before. Meg wants to overcome her illness so that she can still spend time with her family and friends. Furthermore, she said that she wants to be in good condition as much as possible so that she can do her daily task in everyday life for her family. The client is worried about her condition because she has many plans in life together with her family. Spiritual: Still, Meg is still hopeful to overcome her challenges in life. The client still has faith in the Creator, and she continues to pray to Him. She believes that everything will be alright with the help of the creator. Also, her children were worried about their mother, whos suffering from such condition. Her husband, Bobong is trying his best to support his wife. Bobong was worried about Meg because for him, it makes him suffer seeing his wife suffering. In addition, their relatives are also extending their care and prayers for Meg because they are worried and concerned for her. The client is also very thankful because her family, relatives and friends are still there giving support to her for her fast recovery. They are always there and look after her in the hospital and to aid her physically, mentally, emotionally, and spiritually.

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Genogram

Maternal

Side
Lola, , o

Paternal Side
Mamita, ,

Lolo, K ,

Papito,

Ana, ,
70

Lala, K,

67

Sis, ,
64

Mamang, 60, D

Po, c, 67

Jose, c, , D,
64

Papang, 62

- Female -Male #- age - Heart problems -deceased D- diabetic K- Kidney problem o- old age c- cholelithiasis a- accident
Bebe three, 2 Dora, 28, K

Kenny, a, Luigi, 30,

Meg, , Bobong, 45,

c, 38

Bebe two, 7

Bebe one, 10

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DEFINITION OF COMPLETE DIAGNOSIS Complete Diagnosis: Calculous Cholecystitis

Calculous

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape and composition. Source: Boyer, M. (2006). Brunner and Suddarths Textbook of MedicalSurgical Nursing, 11th ed., p. 1347. Lippincott Williams & Wilkins.

Calculus (pl. calculi) is also called stone; an abnormal stone formed in body tissues by accumulation of mineral salts. Calculi are usually found in the biliary and urinary tracts.

Source: http://medical-dictionary.thefreedictionary.com/calculi. Retrieved May 15, 2010. Calculi (stones) can be divided into two groupsrenal calculi and gallstones. The majority of gallstones are composed principally of cholesterol and other calcium salts.

Source: Iyengar, V. Elemental Analysis of Biological Systems: Biomedical, Environmental, Compositional and Methodological Aspects of Trace Elements, Vol. 1, p. 49.

Cholecystitis

Cholecystitis is the inflammation of the gallbladder. In more than 90% of the cases, gallstones are present.

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Source: White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.

Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation)

Source: Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers.

Inflammation of the bladder which may be either acute or chronic.

In

an

acute cholecystitis, the blood flow to the gallbladder may become compromised which in turn will cause problems with the filling and emptying of the gallbladder. A stone may block the cystic duct which will result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. Chronic cholecystitis occurs when there have been recurrent episodes of blockage of cystic duct.

Source: Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill.

Calculous Cholecystitis

Acute cholecystitis is inflammation of the gallbladder. There are two major types of acute cholecystitis calculous and acalculous. In calculous cholecystitis, gallstones obstruct the gallbladder outlet leading to poor drainage of bile. In physical exam, patients may exhibit Murphys sign right upper quadrant pain elicited by palpation under the right costal margin when the patient inspires.

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Source: Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.

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DEVELOPMENTAL DATA According to Taylor, Lillis, LeMone and Lynn (2008), growth and development are orderly and sequential as well as continuous and complex. All humans experience the same growth patterns and developmental levels, but, because these patterns and levels are individualized, a wide variation in biologic and behavioral changes is considered normal. Within each developmental level, certain milestones can be identified; for example, the time the infant rolls over, crawls, walks, or says his or her first words. Although growth and development occur in individual ways for different people, certain generalizations can be made about the nature of human development for everyone. Robert Havighursts Developmental Task Theory Robert Havighurst believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing societal conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Successful achievement leads to happiness and success in late tasks, whereas unsuccessful achievement leads to unhappiness, societal disapproval, and difficulty in later tasks. The developmental tasks arise from maturation, personal motives, and values that determine occupational and family choices, and civic responsibility. (Taylor, et al. 2008)

Stage Middle Age(30-40)

Description In the middle years, men and women reach the peak of their influence upon society, and

Result

Justification

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at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it. Selecting a mate Learning to live with a partner Starting family Rearing children Achieved The patient married and started a family last 1998. She is happy with her husband since she receives care and unconditional love from him. She works together with her husband in taking care of and rearing their children by providing their physiological,

psychological, and emotional needs.

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The patient has no job, however, she is the one managing the house, by cleaning, washing clothes, doing other Managing home Getting started in occupation Achieved household chores and being a

peacemaker when trouble happens among her children. managing the She is the one to have a

house

peaceful and organized home. Meg is also responsible for budgeting their money needed to sustain them in their everyday living. She sees to it that her husbands salary is well budgeted and not put into waste.

Taking on civic responsibility

Achieved

The patient is doing her responsibilities as a Filipino citizen by following laws in our country such as not throwing garbage anywhere, and following traffic rules. She is also a registered voter.

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Patient verbalized that if she were not admitted in the hospital, she would really vote in the 2010 Presidential elections. She also pays taxes

(property tax and cedula) as part of her responsibility as a citizen.

Erik Eriksons Psychosocial Development Theory Erikson emphasized developmental change throughout the human life span. In Eriksons theory, eight stages of development unfold as we go through the life span. Each stage consists of a crisis that must be faced. According to Erikson, this crisis is not a catastrophe but a turning point of increased vulnerability and enhanced potential. The more an individual resolves the crises successfully, the healthier development will be. It is patterned to the Psychosexual Development of Sigmund Freud but more concentrated on what task and conflict should a person be able to manage in a certain age group. That is termed psychosocial development. He described eight stage of development: 1. Infancy 2. Early childhood 3. Late childhood 4. School age 5. Adolescence 6. Young adulthood 7. Adulthood 8. Maturity
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Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or unsuccessful.

Stage Middle Adulthood: 25-65 years

Description

Result

Justification

The significant task is to perpetuate culture and transmit values of the culture through the family (taming the Working towards achieving goal As a wife and a mother of three children, she is the one who inculcates values in the family whom she acquired from her parents. She makes sure that her children will be raised with good attitude and as good Filipino Citizens. As of now, her children are dependent and still with them, she still doesnt know what her feelings will be when her children will leave home someday. Today, she is busy taking care of her children and her husband as those are the responsibilities of a mother and wife.

Ego Development Outcome: Generativity vs. Self

kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when a person is in this stage, she often fear inactivity and meaninglessness. As the children leave home, or the persons relationships or goals

absorption or Stagnation

Basic Strengths:

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Production and Care

changes, she may be faced with major life changesthe mid-life crisisand struggle with finding new meanings and purposes. If a person doesn't get through this stage successfully, she can becomes self-absorbed and

stagnate. Significant relationships are within the workplace, the community and the family. Creativity, productivity, concern for others concern, or self-indulgence, of interests selfand

lack

commitments

Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352 http://www.learningplaceonline.com/st

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ages/organize/Erikson.htm

Lawrence Kohlbergs Levels of Moral Development Lawrence Kohlberg outlined the different planes of moral adequacy, based on his continued interest in how children would react to varying moral dilemmas. Kohlberg stated that ethical behavior was based on moral reasoning, which in turn could be broken down into six specific developmental stages. The stages are progressive, in that it is highly improbable for someone to regress backwards. Once a person acquires the functionalities of higher stages of moral development, it will be difficult for him to lose these abilities and revert to lower levels of growth. Every stage follows another, making it difficult for a person to jump forward and virtually skip an entire stage.

The levels and stages are as follows: Level 1: Preconventional Stage1: Punishment/obedience Stage2: Instrumental/relativist Level 2: Conventional Stage3: Approval Seeking Stage4: Law and order Level 3: Postconventional Stage5: Social Contract Stage6: Universal-ethical

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Stage Postconventional Level Stage Social Contract

Description

Result

Justification

At stage 5 social contract and utilitarian orientation, correct

Achieved

She sees that most of the laws are correct and worth to be followed. She said that she follows the rules of the country and the city she lives in. She doesnt want nuisance in the society because she believes that to be able to live in a serene place, people must maintain and establish respect with themselves and then to others.

5: behavior is defined in terms of societys law. Laws can be changed, however, to meet societys needs, while

maintaining respect for self and others.

Stage Stage6: Universalethical the

6,

universal

ethical for

Working towards achieving goal She knows about universal laws, specifically about justice. She is concerning about justice, malooy gyud ko sa mga tao nga dili matagaan ug hustisya, labaw na ng mga kabus , as verbalized by the patient.

principle orientation, represents persons concern

equality for all human beings, guided by personal values and standards regardless of those

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set by society or laws. Justice might be internalized at an even higher level than society. Few adults ever reach this stage of development. (Taylor et. al, 2008)

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PHYSICAL ASSESSMENT Patients Name: Meg Age: 38 yrs. old Sex: Female Admitting Diagnosis: Acute Cholelithiasis Final Diagnosis: Calculous Cholecystitis Chief Complaint: right upper quadrant pain Date of Assessment: May 12, 2010 Time of Assessment: 4:00 pm Location of Assessment: DMSF Hospital, 3C, Room 324-5 Vital Signs upon physical assessment: Temperature : Pulse Rate: Respiratory Rate: Blood Pressure: 36.6 C 82 bpm 18 cpm 130/80 mmHg

I. General Survey The patient was received lying on bed, awake, conscious, coherent, afebrile and without IVF. She has three 0.5-cm long incisions at her epigastric and right lower rib cage areas and a 1-cm incision under her umbilicus. Incision site is dry and intact. Each incision is covered with dry and intact dressing. Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale. She is oriented to time (verbalized it was late in the afternoon), person (identified watcher correctly), place (verbalized shes in the hospital) and

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reason for admission (stated that she was admitted due to right upper quadrant abdominal pain). Patient is not in respiratory distress. Patient appears appropriate for her stated age. She stands 5 feet and 2 inches tall and weighs 62 kg. Her body mass index (BMI) is 24.9 which is normal. She has an endomorphic body type. Patient is in fair grooming as evidenced by unsoiled t-shirt she is wearing, well-kept hair and clean linens and pillows. However, it was noted that patient has halitosis. Nails were long but clean. Through the course of the physical assessment, it was observed that the patient is cooperative and has an accommodating attitude towards the student. The patient is calm. Patients speech was audible, comprehensible and in moderate pace.

II. Skin Skin is fair in color, intact and with hairs, except in the palms, soles and dorsa of the distal phalanges. Skin is dry and slightly warm upon palpation. It returns quickly to its normal state when picked up between two fingers and released. Skin texture is soft and fine while extensor surfaces such as the elbows have coarser skin. The palms and the soles are calloused. No skin breaks present aside from the incision sites on her abdomen. No edema present.

III. Hairs and Nails Upon inspection, hair was noted to be black. It is thick, oily, straight, long and well-kept. Hair is also evenly distributed as evidenced by absence of bald spots. Dandruff or flaking was not present. Other infestations, such as lice, were not noted. The color of scalp is lighter than the color of skin. Nails on both hands and feet are long but clean. Nail polish was removed. Client has a capillary refill time of 2 seconds. No clubbing of the nailbeds noted.
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IV. Head Patients head is round and normocephalic in configuration with smooth skull contour. There were no palpated masses, nodules, deformities or fractures. Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds. Facial movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions. Patient can move her head up and down and side to side. No lesions noted on the face.

V. Eyes Hairs of eyebrows are thick and evenly distributed. Eyebrows are symmetrically aligned and theres equal movement as evidenced by the patients ability to elevate and lower the eyebrows. No edema, lesions, puffiness or tenderness noted upon inspection and palpation of the periorbital area. Eyelashes are equally distributed and curled slightly outward with no ectropion or entropion. Eyelids surface is intact with no discharges and no discoloration but with noted eye bags on the lower surface. No lid lag noted. Blink reflex is present. Palpebral fissure is equal in both eyes. Bulbar conjunctiva is pale pink. Cornea is transparent and without cloudiness. Sclera is anicteric. Eyeballs are symmetrical with no bulging observed. Pupils were black in color, equally round, 3mm in size and reactive to light and accommodation. Pupils quickly constrict when a penlight is shone towards the pupil from a lateral position. Iris is dark brown in color. Client has central and peripheral vision. She can see things on the side of her eye, like the adjacent bed, even when looking straight ahead. Moreover, pupils constrict when looking at near objects and dilate when looking at far objects. During ocular motility testing, patient was asked to follow the examiners
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finger in the six cardinal fields of gaze. There was smooth, parallel movement of eyes in all direction. Both eyes move in unison. No nystagmus noted. To test her visual acuity, the students asked her to read their nameplates placed about 1 feet away from her. She was able to correctly read the names without any difficulty. Patient verbalized she doesnt use any corrective aids. She also did not report any vision difficulty or eye pain.

VI. Ears The color of the patients ears is the same as her facial skin. The skin behind the ear in the crevice is smooth and without breaks. The left and right pinna are symmetrical and aligned with the inner canthus of the eye. Pinna recoils after it is folded. Auricle is nontender upon palpation. Mastoid process is smooth and hard and no tenderness or swelling noted. External canals have minimal cerumen. No sanguinous discharges noted on the meatus. Patient was able to hear a soft whisper equally in both ears. She can also hear normal voice tones as evidenced by prompt responses to questions asked.

VII. Nose It was noted that the nostrils were symmetrical and the nasal septum is midline. There were no observed discharges draining from the clients nose. Hair is noted on the nares. Nares are patent since patient is able to breathe normally on both nostrils without difficulty when one nose is closed with digital compression and patient inhaled with mouth closed. No lesions on the external nose structure were seen. There was no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges. Clients gross smell was functional as she could identify the scent of alcohol.

Page | 29

VIII.

Mouth Mouth is proportional and symmetrical. Lips are cracked, dry, pink in

color and with no masses or congenital defect. Buccal mucosa was uniform pale pink in color and moist. The patients gum was, moist, firm and pinkish in color. No gum retraction or bleeding was noted. Teeth are of complete set. There are no spaces in between teeth. Dental carries are evident in lower right and left molar. Teeth are yellow in color. Patient has no dentures. Tongue is pink, moist, slightly rough and has thin whitish color on the surface. It is also in central position and moves freely. The base of tongue is smooth with prominent veins. No tenderness, lesions or any unusualness noted. Soft palate is light pink in color. On the other hand, hard palate is much lighter and more irregular in texture. Uvula is positioned in midline of soft palate and rises when the patient says ah. Tonsils are not inflamed. No ulcerations and exudates present. Patient has no difficulty of masticating and swallowing. Halitosis was noted. Patient has no speech disorders.

IX.

Neck Neck is symmetrical with no masses or unusual swelling upon

palpation. No jugular vein distention noted. Pulsation at carotid arteries is strong and regular in rhythm. Range of motion is normal and no pain elicited upon flexion, extension, and rotation of head. Thyroid is not enlarged upon palpation with no nodules, masses or irregularities upon palpation. Thyroid also rises when patient was asked to swallow. Trachea is symmetrical and in midline without deviation. No lymph adenopathies appreciated. No torticollis present.

Page | 30

X. Breast Breast is conical, symmetrical and skin color is lighter than exposed areas. No lesions, redness, or edema and texture is even. No dimpling or retraction. Nipples are in midline and everted pointing in the same direction. Areola and nipples are dark brown in color and has no discharges, crusting and masses.

XI. Chest/Lungs Chest skin integrity is good and intact. Patient has symmetrical chest wall movement. Point of maximal impulse is at 5th intercostal space left midclavicular line. Apical pulse is 84bpm. Patient has distinct heart sounds, with S1 louder than S2; negative for murmurs. There were no noted deformities in the clients thoracic area. There are no bulges or retraction of the intercostal spaces. Clients respiratory rate is 18 cycles per minute. Patient did not complain of chest pain or chest tightness. Guarding of the chest noted upon respiration due to the proximity of the incision site to the diaphragm. Patient is not in respiratory distress. Coughing episodes were also not observed. Vesicular breath sounds are soft and low pitched. Her breathing is deep, regular and slow with a long inspiratory phase and a short expiratory phase. With no adventitious sounds, lungs are clear to auscultation and no crackles, wheezes or rubs. It was observed that vocal fremitus is present both at the back and front of the chest when the patient says ninety-nine.

XII. Abdomen Abdomen is round. Color of skin in abdomen is slightly lighter than the rest of the body. A 0.5-cm incision was noted at the subxyphoid area. Another two 0.5-cm incisions are seen at her right lower rib cage. A 1-cm incision is also present just below her umbilicus. All four incisions are covered with dry and intact dressing. Patient complains of pain on the surgical site and verbalized,
Page | 31

Nagangulngol tong gioperhan. Pwede makahingi ug tambal para sa sakit? Patient reported a pain scale of 6 out of 10. Aortic pulsations are not visible. Umbilicus is midline and inverted. Symmetrical movement of abdomen upon respiration was noted. Upon auscultation of the abdomen, it was noted that patient has normal bowel soundshigh-pitched and occurred 16 times per minute. Abdomen is soft and there is no point tenderness. Patient was on DAT as ordered.

XIII. Back and Extremities Peripheral pulse of the patient was symmetrical and regular in rhythm; radial pulse is 82bpm. Patient has normal capillary refill of 2 seconds. The nails were pinkish in color without cyanosis and clubbing. Patient is able to ambulate freely. She was able to sit up on bed and perform range of motion on both upper and lower extremities. However, it was noted that patient has guarded and slow movement for she feels pain on her abdomen. Clients grasping ability was moderately strong on both hands. No edema or cyanosis was noted on both upper and lower extremities. There is no swelling, tenderness or nodules palpated on each joint. The shoulders, arms, elbows and forearms are free of nodules, swelling, deformities and atrophy. The skin at the back of the patient is uniform in color. Symmetrical chest expansion with respirations noted. No spinal tenderness noted. There are no skin breaks present. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks. There were no deformities or abnormalities on the bone such as scoliosis, osteoporosis and alike to be noted.

XIV.

Genito-urinary Pubic hair is present, thick in each strand, curly and equally distributed

on the mons pubis. No vaginal bleeding or any other unusual discharges noted.
Page | 32

Patient voids freely. She has no difficulty urinating and did not report dysuria. She verbalized her urine is amber in color.

XV.

Neurological Patient was received lying on bed, awake, conscious, coherent and

afebrile. Reflexes are normal and symmetrical bilaterally in both extremities. Patient is oriented to person, place and time. She has a Glasgow coma scale of 15: 4 from eye opening, 5 for verbal resoponse and 6 for motor response. She is also alert and attentive.

Page | 33

ANATOMY AND PHYSIOLOGY

GALLBLADDER The gallbladder is a hollow organ that sits just beneath the liver. In adults, the gallbladder measures approximately

8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct. Its function is to store and release bile, a fluid made by the liver.

Page | 34

CYSTIC DUCT The cystic duct is the

short duct that joins the gall bladder to the common bile duct. The cystic duct varies from 2 to 3 cm in length and terminates in the gallbladder.

Throughout its length, the cystic duct is lined by a spiral mucosal elevation, called the valvula spiralis (valve of Heister) which is

a series of crescentic folds of mucous membrane in the upper part of the cystic duct, arranged in a

somewhat spiral manner. Its length is variable and usually ranges from 2 to 4 cm. The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology (stones or passed stones). The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.

BILE The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin.

Page | 35

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: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1822 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/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: Harrisons Principles of Internal Medicine,

The patient is not diabetic.

Page | 37

Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184

Age (20-50; over age 60)

PRESENT

Many of the bodys systems and protective mechanisms become less efficient with age. Body systems and processes become sluggish.
Sources: Harrisons 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

The patient is Filipino. She is predisposed to having pigment stones.

Page | 38

in the Western countries

Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

Precipitating Factors Pregnancy

Present/ Absent

Rationale

Justification

ABSENT

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/Modul es/gallstns.cfm

No rapid weight loss was noted by the patient.

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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: Harrisons 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/Modul es/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 gallstones. Source: http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

The patient doesnt fast.

Hormone replacement therapy, or birth control pills

PRESENT

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.

The patient has been on birth control pills since she was 36 years old.

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Source: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

Low Fat Diet

PRESENT

Before dietary fat can be digested, it has to be emulsified. Bile is used for this purpose. The liver makes bile continuously and stores it in the gall bladder until such time as it is needed. However, if a low-fat diet is eaten, that bile remains in the gall bladder. Gallstones are formed when the gall bladder is not emptied on a regular basis. In people who continually resort to low-fat diets, bile is stored for long periods in the gall bladder and it stagnates. In time and it is really quite a short time a 'sludge' begins to form.

The patient avoids fatty foods.

Source: http://www.secondopinions.co.uk/gallstones.html

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Symptomatology Signs and Symptoms Present/ Absent Rationale Justification

Right upper quadrant pain (may radiate to right scapula, shoulder, or interscapular area) biliary colic

PRESENT

patient ducts The into connected to the gallbladder came Obstruction of will cause inflammation DMSF by increased complaining

produced

intraluminal pressure and of RUQ pain. distension gallbladder. Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1825 of the

Fever (low grade)

ABSENT

patient nonspecific The not response that is mediated was by endogenous pyrogens febrile. Fever is a released from host cells in response to infectious or non-infections disorders. It may be brought about by prostaglandins released

during inflammation. Source: Carol Mattson

Page | 42

Porth (2005. Pathophysiology, Seventh edition page 205)

Murphy's sign (abrupt interruption of deep inspiration)

PRESENT

Classically Murphy's sign is The tested for during was

patient positive

the an abdominal examination; for it is performed by asking the Murphys patient to breathe out and Sign. then gently placing the hand below the costal margin on the right side at the midclavicular line approximate location (the of

the gallbladder). The patient is then instructed to inspire (breathe during in). Normally, inspiration,

the abdominal contents are pushed downward as

the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder in moving in

is tender and, downward,

comes

contact with the examiner's fingers) and winces with a 'catch' in breath, the test is

Page | 43

considered

positive.

positive test also requires no pain on performing the maneuver on the patient's left hand side. Source: http://www.turnerwhite.com/pdf/hp_nov00_m urphy.pdf

Nausea and vomiting

ABSENT

Nausea

and

vomiting The

patient

sometimes occur with biliary didnt colic. The inflammation of complain the gallbladder causes pain nausea and spasms of the vomiting. of or

abdominal muscles which may make one feel

nauseated. Source: Understanding Surgical Medical by

Nursing

Williams and Hopper page 742

Mildly elevated

ABSENT

Biliary obstruction causes The patients suppression of bile flow, bilirubin was

Page | 44

serum bilirubin

and

regurgitation

of not increased.

conjugated bilirubin into the bloodstream. Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1829

Elevated SGPT and SGOT enzymes

PRESENT

SGOT (AST) and (ALT) is The patients an enzyme found mostly in lab the liver but also in the reveal heart, the muscles, tests an

the elevated level

kidneys, the pancreas and of SGPT and in red blood cells. High SGOT elevations associated may with be enzymes. liver

disease or muscle trauma. Elevations may also be

associated with a variety of conditions including

myocardial infarction (heart attack), pancreatitis, bile

duct obstruction and more. Abnormalities enzymes of liver

including

Page | 45

AST/SGOT and ALT/SGPT are indicative of problems such as Mirrizi syndrome, or a stone in the bile duct causing inflammation. Sources http://my.diabetovalens.com /apollo/sgot.asp infection/liver

Page | 46

PATHOPHYSIOLOGY Precipitating Factors:

Predisposing Factors: Female Age 38 Ethnicity Diabetes Mellitus

Bile stagnates in the gallbladder

Birth control pills Low Fat Diet Pregnancy Rapid weight loss Obesity fasting

Pigment solute precipitate as solid crystals

Crystals clump together and form stones Gallstones

Gallbladder contracts after intake of fat to release bile Upon contraction, a stone is moved and becomes impacted on the cystic duct

CHOLELITHIASIS
Lumen is obstructed by stones Bile stasis

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Chemical reaction inside gallbladder triggers the release of inflammatory enzymes (Prostaglandins)

Fluids leak into gallbladder Edema

Inflammation of the gallbladder

Increased intraluminal pressure and distention of the gallbladder

Biliary Colic (RUQ pain)

Constriction of blood vessels

Murphys Sign

ACUTE CHOLECYSTITIS
If not treated If treated with: Continued lack of blood supply to gallbladder Continued increase in intraluminal pressure of gallbladder

Surgery, proper diet (low fat, high fiber), compliance to medications

Necrosis Rupture of gallbladder

Good prognosis

Gangrene and empyema Spread of bile indigenous microorganisms peritoneal cavity Page | 48 and into

Perforation of gallbladder

Sepsis

Death

Page | 49

DOCTORS ORDER Date 5/8/10 @ 11pm Order Admit under the care of Dr. Batucan Rationale Admitted under the care of Dr. Batucan, a surgeon, for his specialties on surgical procedures (Laparoscopic cholecystectomy) Secure consent to care Consent is an agreement between client and health care provider to give proper quality care. It is also to protect the client from harmful procedures and the institution from law suits Low fat diet Doctors were not sure whether the gallstones are either cholesterol or pigment stones. Thus, this is done to prevent any further damage to the gallbladder. Monitor VSqShift and record Monitoring vital signs is important in order to note any unusualities and to refer these as follows. Labs: Done Done Remarks Done. Patient was placed in ward 324 bed 5 Done

CBC

A complete blood count (CBC) is a series of tests used to evaluate the composition and

Done

Page | 50

concentration of the cellular components of blood. It consists of the following tests: red blood cell (RBC) count, white blood cell (WBC) count, and platelet count; measurement of hemoglobin and mean red cell volume; classification of white blood cells (WBC differential); and calculation of hematocrit and red blood cell

Platelet

Platelet count is to determine the number of platelets; If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form (thrombosis), which may obstruct blood vessels.

Done

Urinalysis

It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances

Done

Venoclysis: PNSS 1L @ 100cc/hr

PNSS is an isotonic solution to provide hydration since it

Done. IVF infusing well

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was found out that the specific gravity for urine is in the borderline (1.010). It is also to provide electrolytes, and as a medium for IVTT meds

at right metacarpal vein.

Meds:

Demerol 50mg IVTT now then prn for abdominal pain

Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation for relief of moderate to severe pain

Given

HNBB (Hyoscine NButyl Bromide) 20mg 1amp IVTT now

It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists causing smooth muscle relaxation indicated for her abdominal pain

Given

MHBR

Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. This is also to prevent ascending infection that could be caused by possible rupture of the gallbladder.

Done

Refer any

In order for the patient to be

Done
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unusualities: severe abdominal pain, vomiting 5/9/10 8:10am Start Cefoxitin (Monowel) 1g IVTT q8 ANST

assessed and evaluated properly and be managed accordingly. Cefoxitin inhibits synthesis of bacterial cell wall causing cell death which acts as a perioperative prophylaxis for surgical procedures. ANST or after negative skin test is to check whether the client is not allergic to the antibiotic. Done. Result for skin test is negative. Cefoxitin may be given to the patient.

For ultrasound tomorrow morning

This is done to visualize internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. This is also to know the condition of the gallbladder whether it ruptured or not.

Not able to comply. Patient had her ultrasound on May 11, 2010.

For total bilirubin,

Bilirubin is elvated if hepatocytes are injured and cannot metabolize or excrete bilirubin

Done. Results are normal

Direct bilirubin,

Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts

Indirect bilirubin

Increase in unconjugated bilirubin may be caused by

Page | 53

hepatic disease, cholestasis, and hemolysis

Alkaline phosphatise

High levels of alkaline phosphatise indicates liver disease

SGPT (Serum glutamic pyruvic transaminase)

SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver function. Elevation of this may possibly mean liver problems AST (aspartate aminotransferase) or SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. It is also found in lesser amounts in other tissues. Elevated levels may be caused by liver or heart disease

Done. Patients SGPT results are high

SGOT (Serum glutamic oxaloacetic transaminase)

Done. SGOT results are also high

Schedule for laparoscopic cholecystectomy on Tuesday (4/11/10) 2pm Secure consent/AC

Lap Chole was to surgically remove the gallbladder with only a small incision.

Done. Surgery was done on 4/11/10 @ 4pm

Patient has the right to be

Done.

Page | 54

consented in all procedures to be done, and for legal purposes. Anesthesia clearance is for the patient to be evaluated whether he/she is fit to undergo the operation. It is also for the anaesthesiologist to predict the operative risk and the appropriateness of the anaesthesia to be induced during operation. Inform OR For the OR to know that such case will be performed and to prepare the necessary instruments and room. This is also to coordinate availability of staff and surgeon Refer In order for the patient to be assessed and evaluated properly and be managed accordingly. 5/9/10 5:00pm May have ultrasound on Tuesday 5/11/10 This was to visualize internal organs, to capture their size, Done. Ultrasound Done Done

structure and any pathological result lesions with real time tomographic images. It is also to know whether the gallbladder has ruptured or not. retrieved on 5/11/10. Impression: Cholelithiasi s; Sonographic
Page | 55

ally normal liver and pancreas 5/10/10 1:00pm To reschedule OR tomorrow from 2pm to 4pm To inform the OR that the procedure will be moved from 2pm to 4pm Done. Patient had her surgery at 4pm of May 11, 2010. IVF TF: PNSS 1L @ KVO PNSS is an isotonic solution for hydration and as a medium for IVTT meds; KVO was done since patients hydration was good. 9:15pm Please facilitate AC AC is to assess patients rate of survival and check for what anesthetics is right for the patient, making sure that the patient isnt allergic to the anesthetic For Lap Chole tom 4pm This was to surgically remove the gallbladder with only a small incision. Patient can undergo laparoscopic cholecystectomy since gallbladder has not ruptured yet as seen on the ultrasound result. For blood chem. and Ultrasound tom Blood tests are used to determine physiological and biochemical states, such as
Page | 56

Done

Done

Done.

Done.

disease, mineral content, drug effectiveness, and organ function. 9:30pm Pre-op orders:

NPO after light breakfast (8am)

NPO is to prevent peristalsis, aspiration and injury during surgery

Done

Assess VS prior to OR

as baseline data and to detect Done any unusualities

General oral hygiene

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.

Done

IVF: D5NSS 1L @ 120cc/hr

Intravenous solutions with reduced saline concentrations typically have dextrose added to maintain a safe osmolality while providing less sodium chloride; to hydrate before surgery in preparation for disruption of homeostasis

Done

Meds:

Diazepam 10mg 1

Potentiates the effects of

Given
Page | 57

tab 2am

GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; it is also used as adjunct to General anesthesia Given

Ranitidine 150mg 1tab 2am

Inhibits basal gastric acid secretion and gastric acid secretion; patient was placed on NPO

Vitamin K

For the liver to activate clotting factors such as prothrombin, proconvertin, thromboplasstin, and stuart factor.

Given

5/11/10 1:30pm

NPO

NPO is to prevent peristalsis, aspiration and injury to the GI tract during surgery.

Done

Post op orders:

To PACU then to room

Patient must first be stabilized Done before transfer to the ward; PACU is a place with complete gadgets and staff for emergency purposes after post op.

NPO for 4 hrs then may have SD

Patient not yet fully conscious due to anesthetics, thus this

Done

Page | 58

is to prevent aspiration.

Monitor VS q15 until stable then q30 for 2hrs then q2

Monitoring vital signs is to detect any unusualities after the operation.

Done

Meds:

Etoricoxib 120mg PO 12mn

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Given

Tramadol 100mg 1tab 12mn

Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Given

Demerol 50mg IVTT

Half life is 3-5hrs Causes analgesia, euphoria, sedation; thus reducing pain

Given

Sultamicillin 375mg PO TID

Inhibits synthesis of bacterial cell wall causing cell death; this was indicated due to possible intra abdominal infections

Given

O2 inhalation @ 4pm until fully awake

This ensures optimum oxygenation of cells gearing towards achieving balance or homeostasis. Also this was

Done

Page | 59

for optimum respiratory level; prevents lung collapse. MHBR Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. Deep breathing exercises for 15mins TID Post op exercise is indicated To prevent lung collapse and to eliminate anesthetic gases introduced to the body 5/12/10 11:15am May have DAT Patient may eat anything as long as it cant harm her current condition Continue meds For the patient to complete the medication regimen and for continuity of care Done Done. Done Done

Wound care

Daily routine wound care is indicated in order to promote healing and/or prevent infection

Done

5/13/10 9:00am

MGH

Patient may go home after the doctor decides if unusualities are absent

Done

Home meds:

Etoricoxib 90mg PO BID

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Done. Patient was informed

Page | 60

Tramadol 100mg tab PO BID

Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Sultamicillin 375mg PO BID

Inhibits synthesis of bacterial cell wall causing cell death

C/D IVF

Terminate IVF when IVF is about 50cc

IVF discontinued Patient to come back at 5/18/10

ff. up check at 5/18/10

Follow up check up is for the patient to be assessed and evaluated properly and be managed accordingly.

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DIAGNOSTIC EXAM CBC a determination of red and white blood cells per cubic millimeter of blood. It helps health professional check any symptoms such as weakness, fatigue, or bruising. It also helps diagnose conditions such as anemia, infection and other disorders May 8, 2010 Test Hemoglobin Normal Result Remark Rationale Values 115.0- 137.0 Normal Hemoglobin carries 155.0 oxygen to and removes carbon dioxide from red blood cells. It measures total amount of hemoglobin in the blood Hematocrit 0.360.52 0.42 Normal Hematocrit measures the percentage of red blood cells in the total blood volume RBC 4.2-6.1 4.47 Normal Measures the number o RBCs per cubic millimeter Within normal range The patient may feel discomfort when blood is Within normal range Interpretation Within normal range Nursing Responsibilities There is very little risk associated with taking blood from a vein in the arm, although there is a slight risk of infection anytime the skin is broken. Strict asepsis should be observed

Page | 62

of the whole blood. WBC 5.010.0 14.1 High Determines the number of circulating WBCs per cubic millimeter of the whole blood. Elevated levels acute infections tuberculosis, pneumonia, meningitis, tonsillitis, appendicitis, colitis, etc. Neutrophil 55-75 74 Normal Phagocytes engulfing bacteria and cellular debris. It prevents or limits bacterial infections. Lymphocytes 20-35 21 Normal Cells present in the blood and lymphatic tissue that provide the main means of immunity for the body. There are three types of lymphocytes: the natural Within normal range Within normal levels.

drawn

from

vein.

Bruising may occur at

may be caused by the puncture site, or the person may feel dizzy or faint. Pressure should be applied to the puncture site until the bleeding stops to reduce bruising. Warm packs can also be placed over the puncture site to relieve discomfort

Instruct patient in dietary sources of iron such as red meat, organ meats, clean green vegetable and fortified grains

Protect the patient from potential sources of

Page | 63

killer (NK), thymus-derived lymphocytes (T cells), and bone marrow-derived lymphocytes (B cells). NK cells are found in the blood, red bone marrow, lymph nodes and spleen and are able to destroy many kinds of infected body cells and tumor cells. The T cells and B cells are involved in specific immune responses. Monocytes 2-10 4 Normal This type of granular leukocyte functions in the ingestion of bacteria and other foreign particles Eosinophil 1-8 1 Normal Functions in allergic responses and in resisting infections. Eosinophils Within normal range Within normal range

infection, monitor for signs of infection. Provide soft, bland diet high in protein, vitamins, and calories. Meticulous hand washing and strict asepsis are mandatory

Institute isolation

protective measures

immediately if there is neutrophil disorder. Also instruct the patient to observe aseptic

technique and to take caution most especially if immunocompromised. Inflammatory responses involve more than one body system. Monitor

Page | 64

mount on attack against parasitic invaders by attacking to their bodies and discharging toxic molecules from their cytoplasmic granules. Platelet 150.0400.0 278 Normal A test that direct count of platelets in whole blood. Platelets number from 100,000-500,000 per cubic millimeter and are important in triggering the sequence of events that leads to the formation of blood clots. Within normal range

the patient for worsening of the inflammatory particularly

condition, respiratory

compromised.

Encourage patient to rest between activities. Encourage patient to plan ahead and save energy for the most important activities. Encourage patient to void or stop activities that make short of breath or make heart beat faster. Encourage patient to Eat
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a diet with adequate protein and vitamins. Drink plenty of noncaffeinated and nonalcoholic fluids.

Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances May 8, 2010 TEST Glucose RESULT Negative NORMAL <50mg/dL CLINICAL SIGNIFICANCE Glucose is the type of sugar found in blood. Normally there is very little or no glucose in urine. When the blood sugar level is very high, as in uncontrolled diabetes. Glucose can also be found in urine when the kidneys are damaged or diseased. Wash hands to make sure they are clean before collecting the NURSING RESPONSIBILITIES Advise Patient to:

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Protein

Negative

<30mg/dL

Protein is normally not found in the urine. Fever, hard exercise, pregnancy, and some diseases, especially kidney disease, may cause protein to be in the urine.

urine. If the collection cup has a lid, remove it carefully and set it down with the inner surface up. Do not touch the inside of the cup with your fingers. Clean the area around your genitals.

Bilirubin

Negative

<1mg/dL

This is a substance formed by the breakdown of red blood cells. If it is present, it often means the liver is damaged or that the flow of bile from the gallbladder is blocked.

Urobilinogen

Normal

<2mg/dL

This is a substance formed by the breakdown of bilirubin. Urobilinogen in urine can be a sign of liver disease (cirrhosis, hepatitis) that the flow of bile from the gallbladder is blocked.

pH

4.5-8

Urine pH is used to classify urine as either a dilute Begin urinating into acid or base solution. The lower the pH, the greater the toilet or urinal. the acidity of a solution; the higher the pH, the greater the alkalinity. The glomerular filtrate of blood is usually acidified by the kidneys from a pH of approximately 7.4 to a pH of about 6 in the urine Finish urinating into the toilet or urinal. Carefully replace and tighten the lid on the

Blood

Negative

<510RBC/mL

Red blood cells in the urine may be caused by kidney or bladder injury, kidney stones, a urinary

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tract infection (UTI), inflammation of the kidneys (glomerulonephritis), a kidney or bladder tumor, or systemic lupus erythematosus (SLE). Ketone Negative <5 mg/dL Ketones in the urine may mean a very serious condition, diabetic ketoacidosis, is present. A diet low in sugars and starches (carbohydrates), starvation, or severe vomiting may also cause ketones to be in the urine. Nitrite Negative Negative Bacteria that cause a urinary tract infection (UTI) make an enzyme that changes urinary nitrates to nitrites. Nitrites in urine show a UTI is present. Leukocytes 25 <25WBC/m L Clarity Clear Clear Leukocyte esterase shows leukocytes in the urine. WBCs in the urine may mean a UTI is present. Urine is normally clear. Bacteria, blood, sperm, crystals, or mucus can make urine look cloudy. Specific gravity 1.010 1.010-1.030 This checks the amount of substances in the urine. It also shows how well the kidneys balance the amount of water in urine. The higher the specific gravity, the more solid material is in the urine. Color Yellow Pale to dark Many things affect urine color, including fluid

cup then return it to the lab. After the urine has flowed for several seconds, place the collection cup into the urine stream and collect "midstream" urine without stopping your flow of urine. Do not touch the rim of the cup to your genital area. Do not get toilet paper, pubic hair, stool (feces), menstrual blood, or anything else in the urine sample.

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yellow

balance, diet, medicines, and diseases. How dark or light the color is tells you how much water is in it. Vitamin B supplements can turn urine bright yellow. Some medicines, blackberries, beets, rhubarb, or blood in the urine can turn urine red-brown.

Blood Chemistry - A number of tests performed on blood serum (liquid portion of the blood). It determines certain enzymes that may be present (including lactic dehydrogenase [LDH], certain kinase [CK], aspartate aminotransferase [AST], and alanine aminotransferas [ALT]), serum glucose, hormones such as thyroid hormone and other substances such as cholesterol and triglycerides. These tests provide valuable diagnostic cues. May 9, 2010 TEST Total Bilirubin RESULT 8.3 REFERENCE 2.0 21.0 REMARK Normal RATIONALE It occurs when bilirubin production exceeds the liver's excretory capacity. This may occur because (1) too much bilirubin is being produced, (2) hepatocytes are injured and cannot metabolize or excrete bilirubin, or (3) the biliary tract is obstructed blocking the flow of

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conjugated bilirubin into the intestine Direct Bilirubin 0.9 0.0 3.4 Normal Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts Inderct Bilirubin 7.4 2.0 17.0 Normal Increase in unconjugated bilirubin may be caused by hepatic disease, cholestasis, and hemolysis SGPT 60.2 0.0 34.0 High SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver function. SGOT 55.6 0.0 31.0 High SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. Elevated levels may be caused by liver or heart disease

Alkaline Phosphate

191

64 306

Normal

When a person has evidence of liver disease , very high ALP levels can tell the doctor that the persons bile ducts are somehow blocked

Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time
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tomographic images. Ultrasound has been used by sonographers to image the human body for at least 50 years and has become one of the most widely used diagnostic tools in modern medicine.

12/28/10 Impression:

Isaac T. Robillo Memorial Hospital

05/11/10 Impression:

Davao Medical School Foundation

Non-obstructive cholelithiasis Ultrasonically normal liver, intrahepatic ducts, pancreas, spleen, aorta, paraaortic areas, kidneys and urinary bladder

Cholelithiasis Sonographically normal liver and pancreas

Nursing Responsibilities: Explain the procedure and purpose of the test Provide a gown without snaps, and ask the patient to remove all jewelry Take ultrasound if the patients bladder is fluid filled for better results

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DRUG STUDY

Generic Name:

Meperidine Hydrochloride

Brand Name: Classification: Ordered Dose: Mode Of Action:

Indications:

Demerol Opioid agonist analgesic 50mg IVTT now then prn for abdominal pain 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 Relief of moderate to severe acute pain. Pre-op: Support for of anesthesia

Contraindications: Hypersensitivity to narcotics, diarrhea, asthma, COPD, respiratory depression, pregnancy, seizure, renal dysfunction Drug Interactions: Potentiation of effects with barbiturate anesthetics Severe/fatal reactions with MAOIs Increased chances of respiratory depression, hypotension, sedation, and coma with phenothiazines Side Effect: Adverse Effects: Nausea, vomiting, loss of appetite, constipation, dizziness, sedation, drowsiness, impaired visual acuity CNS: light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, mood changes, lethargy, weakness, headache, tremor CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension
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 Dermatologic: pruritus, urticaria, bronchospasm, edema GI: nausea, vomiting, dry mouth, anorexia, constipation, GU: ureteral spasm, urinary retention, oliguria, decreased libido MAJOR: respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest Nursing Responsibilities: 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. 2005 Lippincotts Nursing Drug Guide www.drugs.com/demerol.html www.rxlist.com/demerol-drug.htm

Bibliography:

Generic Name:

Hyoscine N-butyl Bromide

Page | 73

Brand Name: Classification: Ordered Dose: Mode Of Action:

Buscopan Gastro-intestinal antispasmodic 20mg 1amp IVTT now 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 Drug Interactions: Anticholinergic agents Antihistamines Monoamine oxidase inhibitors Tricyclic antidepressants Competitively blocks prokinetic agents 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 CNS: light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, mood changes, lethargy, weakness, headache, tremor CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension Dermatologic: pruritus, urticaria, bronchospasm, edema GI: nausea, vomiting, dry mouth, anorexia, constipation, GU: ureteral spasm, urinary retention, oliguria, decreased libido MAJOR: respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest Inform patient that drug may cause blurred vision. Instruct patient to report if she experiences such symptom.
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Adverse Effects:

Nursing Responsibilities:

Bibliography:

Assess for parkinsonism and Extra-pyramidal symptoms. Assess for urinary hesitancy Assess for constipation. Caution patient to avoid alcohol because it may increase CNS depression. As appropriate, review all other significant adverse reactions and interactions Give only prescribed dosage Do not take left over medications for other disorders Keep out the reach of children MIMS 113th edition 2007 http://home.intekom.com/pharm/quatrom/q-hyosc.html http://www.medicinenet.com/hyoscine_butylbromideoral/page2.htm http://www.netdoctor.co.uk/medicines/100000395.html

Generic Name:

Cefoxitin Sodium

Brand Name: Classification: Ordered Dose: Mode Of Action: Indications:

Monowel Antibiotic, Cephalosphorin (2nd gen) 1g IVTT q8 ANST Inhibits synthesis of bacterial cell wall causing cell death Perioperative prophylaxis

Contraindications: Hypersensitivity to cephalosphorins and/or penicillins Drug Interactions: Increased nephrotoxicity with aminoglycosides Increased bleeding effects with anticoagulants Side Effect: Stomach upset, nausea, vomiting, diarrhea Adverse Effects: CNS:, dizziness, lethargy, headache CV: peripheral circulatory collapse, tachycardia,
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Nursing Responsibilities:

Bibliography:

bradycardia, arrhythmia, palpitations, hypertension, hypotension GI: nausea, vomiting, diarrhea, anorexia, abdominal pain, psuedomembranous colitis GU: Nephrotoxicity Hematologic: bone marrow depression, thrombocytopenia 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, dont 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. 2005 Lippincotts Nursing Drug Guide MIMS 113th edition 2007 www.drugs.com/cdi/cefoxitin.html www.revolutionhealth.com/drugs-treatments/cefoxitin

Generic Name:

Diazepam

Brand Name: Classification:

Valium Benzodiazepine, skeletal muscle relaxant

Page | 76

Ordered Dose: Mode Of Action: Indications:

10mg 1 tab 2am Potentiates the effects of GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation Relief of anxiety and tension; to lessen recall in patients prior to surgical procedures

Contraindications: Hypersensitivity to benzodiazepines, psychosis, shock, coma, alcoholic intoxication, pregnancy Drug Interactions: Increased CNS depression with omperazole Increased effects of diazepam with cimetidine, hormononal contraceptives Decreased effects with ranitidine Side Effect: Adverse Effects: Drowsiness, dizziness, GI upset, difficulty concentrating, fatigue, nervousness, crying CNS: drowsiness, sedation, depression, lethargy, fatigue, light headedness, disorientation, restlessness, tremor, stupor, psychomotor retardation, EPS, hallucinations, nasal congestion CV: bradycardia, tachycardia, hypotension, hypertension, edema Dependence: drug dependence Dermatologic: uticaria, pruritus, dermatitis GI: constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, hepatic dysfunction, jaundice GU: incontinence, retention, change in libido, menstrual irregularities Other: phlebitis and thrombosis at injection site, hiccups, fever, diaphoresis, pain at injection site 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
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Nursing Responsibilities:

Bibliography:

Discuss risk of fetal abnormalities with patients desiring to become pregnant 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 2005 Lippincotts Nursing Drug Guide MIMS 113th edition 2007 www.drugs.com/valium.html www.medicinenet.com/diazepam/article.htm

Generic Name:

Ranitidine Hydrochloride

Brand Name: Classification: Ordered Dose: Mode Of Action:

Zantac Histamine2 antagonist 150mg 1tab

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, lactation Drug Interactions: Increased effects of warfarin Side Effect: Constipation, nausea, vomiting, breast enlargement, impotence, headache Adverse Effects: CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo
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 CV: bradycardia, tachycardia, Dermatologic: rash, alopecia GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice GU: gynecomastia, impotence Hematologic: leucopenia, granulocytopenia, 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. 2005 Lippincotts Nursing Drug Guide MIMS 113th edition 2007 www.rxlist.com/zantacwww.medicinenet.com/ranitidine/article.htm http://www.healthline.com/goldcontent/ranitidine

Bibliography:

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Generic Name:

Phytonadione

Brand Name: Classification: Ordered Dose: Mode Of Action:

Hema K Fat soluble vitamin; antifibrinolytic agent 1amp now 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). Preoperatively: to activate clotting factors to decrease chances of bleeding during surgical procedure

Indications:

Contraindications: Hypersensitivity to benzyl alcohol, Drug Interactions: Coumarin and indanedione derivatives Side Effect: Adverse Effects: Nursing Responsibilities: No known side effects for this drug; bruising and bleeding are less likely to happen. No known adverse effects reported 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
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Source

Patient should be advised not to take OTC drugs 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 monitor coagulation factors MIMS 113th edition 2007 http://www.nlm.nih.gov/medlineplus/druginfo/natural/patien t-vitamink.html http://www.drugs.com/enc/vitamin-k.html

Generic Name:

Etoricoxib

Brand Name: Classification: Ordered Dose: Mode Of Action:

Arcoxia COX-2 Selective Inhibitor 120mg PO 12mn 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 relief of acute pain

Indications:

Contraindications: Hypersensitivity to arcoxia and its 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)
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 ACE inhibitors and angiotensin receptor blockers, medicines used to lower high blood pressure or treat heart failure lithium, a medicine used to treat a certain type of depression birth control pills hormone replacement therapy methotrexate, a medicine used to suppress the immune system Side Effect: Adverse Effects: Nausea, vomiting, diarrhea, Headache, Rash, Blurred vision, Difficulty in sleeping, Muscle cramps, Fatigue CNS: headache, malaise, dizziness, hallucinations, insomnia, vertigo, anxiety, drowsiness, confusion CV: bradycardia, tachycardia, hypertension Dermatologic: rash, urticaria GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice GU: gynecomastia, impotence Hematologic: leucopenia, granulocytopenia, thrombocytopenia, pancytopenia Local: pain at IM site, local burning pain at injection site 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. 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.
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Nursing Responsibilities:

Bibliography:

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. MIMS 113th edition 2007 http://www.drugs.com/arcoxia.html http://arcoxia-side-effects.com/

Generic Name:

Tramadol hydrochloride

Brand Name: Classification: Ordered Dose: Mode Of Action:

Ultram Central acting analgesic 100mg 1tab PO Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids but doesnt cause respiratory depression Relief of moderate to severe pain.

Indications:

Contraindications: Hypersensitivity to tramadol or opioids or intoxication with alcohol, opioids, or psychoactive drugs Drug Interactions: Decreased effectiveness with carbamezapine Increased risk of tramadol toxicity with MAOIs Side Effect: Dizziness, sedation, drowsiness, impaired visual acuity, nausea, loss of appetite Adverse Effects: CNS: sedation, dizziness, headache, confusion, dreaming, anxiety, seizures CV: hypotension, tachycardia, bradycardia, Dermatologic: pruritus, urticaria, sweating, pallor GI: nausea, vomiting, dry mouth, flatulence, constipation, Other: potential for abuse, anaphylactoid reactions Nursing Control environment ( temp, light, noise) Responsibilities: Limit use in patients with past or present history of
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addiction or dependence to opioids Caution patient not to chew or crush tablet Keep opioid antagonist readily available in case of emergency Instruct post-op patients that drug suppress cough reflex Monitor bowel function and arrange laxatives for constipation Institute safety precautions (side rails, assistive device) Provide frequent, small meals if GI upset occurs Provide back rubs, positioning, and other non pharmacological measures to alleviate pain Take drug exactly as prescribed Avoid alcohol, antihistamines, sedatives, tranquilizers while taking this drug

Bibliography:

2005 Lippincotts Nursing Drug Guide http://www.webmd.com/drugs/drug-11276Ultram+Oral.aspx http://www.drugs.com/ultram.html http://www.medicinenet.com/tramadol/article.htm

Generic Name:

Sultamicillin (ampicillin and sulbactam)

Brand Name: Classification: Ordered Dose: Mode Of Action:

Unasyn Antibiotic 375mg tab PO TID It acts through the inhibition of cell wall mucopeptide biosynthesis. Ampicillin has a broad spectrum of bactericidal activity against many gram-positive and gram-negative aerobic and anaerobic bacteria.
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sulbactam in the UNASYN formulation effectively extends the antibiotic spectrum of ampicillin to include many bacteria normally resistant to it and to other beta-lactam antibiotics. 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 (Garamycin), kanamycin (Kantrex), neomycin (Mycifradin, Neo-Fradin, Neo-Tab), netilmicin (Netromycin), streptomycin, tobramycin (Nebcin, Tobi). 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. CNS: lethargy, hallucinations, seizures GI: stomatitis, gastritis, nausea, vomiting, diarrhea, abdominal pain, pseudomembranous colitis, nonspecific hepatitis GU: proteinuria, oliguria, hematuria, pyuria Hematologic: anemia, thrombocytopenia, leukopenia, neutropenia, prolonged bleeding time Hypersensitivity: rash, fever, wheezing, anaphylaxis Local: pain, phlebitis, thrombosis at injection site Other: superinfection, sodium overload, CHF 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 antibiotic Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is
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Adverse Effects:

Nursing Responsibilities:

Bibliography:

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. http://www.rxlist.com/unasyn-drug.htm http://www.pfizer.com/files/products/uspi_unasyn.pdf http://www.drugs.com/mtm/ampicillin-and-sulbactam.html

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PROCEDURAL REPORT Date of operation: Time of Operation: Time Ended: Age: Diagnosis: Operation Performed: Type of Anesthesia: Name of Surgeon: Anesthesiologist: Scrub Nurse: Circulating nurse: May 11, 2010 4:48 pm 6:25 pm 38 years old Calculous Cholecystitis Laparoscopic Cholecystectomy General Endotracheal Anesthesia Dr. Walter Batucan Dr. Lamanosa J. Dabon, R.N. R. Napoles, R.N.

Procedural Report A. Definition of Laparoscopic Cholecystectomy The surgery to remove the gallbladder is called a cholecystectomy. The gallbladder is removed through a 5 to 8 inch long incision, or cut, in the abdomen. The cut is made just below the ribs on the right side and goes to just below the waist. This is called open cholecystectomy. A less invasive way to remove the gallbladder is called laparoscopic cholecystectomy. This surgery uses a laparoscope (an instrument used to see the inside of your body) to remove the gallbladder. It is performed through several small incisions rather than through one large incision. A laparoscope is a small, thin tube that is put into your body through a tiny cut made just below the navel. The surgeon can then see the gallbladder on a television screen and do the surgery with tools inserted in three other small cuts
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made in the right upper part of the abdomen. The gallbladder is then taken out through one of the incisions. B. Instrumentations (4) folded towels (1) oral gastric tube (1) foley catheter (1) Veress needle (1) 5mm trocar/port (1) 10mm trocar/port (1)10mm right angle laparoscopic dissector (1) 5mm right angle dissector (1) Dolphin Nose Dissecting forceps (1) scoop C. Procedure (1) Merlin dissector (1) suction irrigator (1) Bovie with spatula tip (1) endoscissors (1) cholangiogram catheter unit (1) aspirating needle (1) Laparoscope (4) metallic surgical clips (1) camera (1) light source cord (1) Bovie cord

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 the

inflate

abdominal cavity so that the gallbladder and surrounding

organs can be more easily visualized.

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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 patients 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 persons 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.
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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 patients 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
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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 patients 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: Intraoperative phase o Position the patient:
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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 patients gown Indwelling catheter inserted Pre-op meds given Medicine for OR in

The patient is in a supine position reverse trendelenburg.

o Skin preparation o Circulating nurse: Manages the operating room Protects patients 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 o Medication
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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.

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NURSING THEORIES VIRGINIA HENDERSONS 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 nurses 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 ones 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 facilities. When the

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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 Hendersons 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 patients 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 clients health.

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ORLANDOS 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 patients need for help; meeting this need improves the patients behavior. The components of Orlandos Nursing Process Theory are (1.) patient behavior, (2.) nurse reaction, and (3.) nurse action. The nursing process is set in motion by the patients 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 persons behavior reflects this feeling. Nurse reaction to a patients behavior forms the basis for determining how a nurse acts; it consists of perception, thought, and feeling. The nurses first experience with the patients 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 patients needs. Orlandos 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 patients feelings of helplessness or suffering. Given the clients current medical status, the group utilized Orlandos theory as they provided care and did their work. Focusing on the clients 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 clients wellbeing and may further compromise her health. Orlandos theory keeps the student nurses focus on the needs and concerns of the patient whether the client
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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 Orlandos theory to aid them in interpreting the actions and behaviors of the patient. They also made sure to verify first what theyve observed before planning anything. The student nurses paid close attention to any signs that may lead to distress that might threaten the patients 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 patients life.

ROYS ADAPTATION THEORY Roys 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 clients 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 persons 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 involves the regulator subsystem. The basic need is the physiologic integrity, associated with oxygenation, nutrition, elimination, activity & rest and protection.

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(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 persons 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 patients 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 Roys 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 clients environment or within the client herself, that cause distress to the patients 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 patients 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 information, the proponents also listened and took notice of the patients concerns about her admission to the hospital. By doing so, the student nurses hope that any mental and emotional

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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.

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NURSING CARE PLAN Patients Name: Meg Chief Complaint: pain at the right upper quadrant of the abdomen Diagnosis: Calculous Cholecystitis Age: 38 years old Ward: 3C

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy. Date 5/12/ 10 4:30 pm Cues Subjective Cues: Verbalized Sakit pa akong opera, ngul-ngul pa. Need C O G N Objective Cues: pain scale of 6 out of 10 noted. Grimaced face noted. Guarding I V I T Nursing Diagnosis 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 Objective/Goal 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 2. Administer analgesics (e.g Tramadol) as ordered. R: Tramadol is an analgesic. It binds to mu-opioid receptors and inhibits the reuptake of Nursing Interventions 1. Monitor and assess vital signs every 2 hours. R: Vital signs are usually altered in acute pain. Evaluation 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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behavior noted. 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: T36.6C; BP130/90; RR-18;

clinical pain. Physiologic pain comes and goes, and is the result of

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 doesnt cause respiratory depression. It is for moderate to severe pain.

of client, Dili na man kaayo siya sakit, makaya na man. And reported a pain scale of 3 out of 10

P E R C E P T U A L

experiencing a highintensity 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,

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)

2. Demonstrate non pharmacologic al methods and/or use of relaxation skills and diversional activities (e.g. patient maintained moderate high

resulting in incision pain.

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PR- 81.

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 stimulationpainful or otherwiseas unpleasant. That is why a patient may feel pain in movement or physical touch in locations far from the surgical site.

R: The analgesic dose may not be adequate to raise the clients 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.

back rest position; she also performed diversional activities such as talking with her watcher) Vital Signs: T36.4C; BP120/90; RR-19; PR- 84.

4. Monitor patients pain at least every hour while awake by the use of the pain scale. R: Allows evaluation of the severity of the pain

http://www.surgeryencyc

felt by the patient. Pain

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lopedia.com/Pa-St/PostSurgical-Pain.html

is a subjective experience and only the patient can describe the pain shes 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

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doing deep breathing is to lessen the pain upon 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).

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R: These highten ones concentration upon nonpainful stimuli to 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

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R: Helps reduce pain brought about by the exertion of force necessary to perform activities

10. Encourage patient to report pain as soon as it starts and allow her to verbalize pain experienced or describe the pain shes feeling. R: Severe pain is more difficult to control and increases the clients anxiety and fatigue.

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2. Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis. Date 5/11/ 10 Cues Subjective: Gioperahan ko diri sa tiyan, as verbalized by the patient Need N U T R I 9:00 pm Objective: -post laparoscopic cholecystectom y (2 hrs) -disruption of the dermis, epidermis, and subcutaneous tissues. -with 0.5 to 1 cm incisions at the epigastrium, T I O N A L M E 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 Nursing Diagnosis Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis. Objectives/Goals At the end of 2 days nursing intervention 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. Nursing Interventions Evaluation

1. Assess dressings/ Goal Met wound every shift. 5/12/10 @ Describe wounds and observe for changes. 11:00pm : Establishes comparative baseline providing At the end of 2 opportunity for timely days nursing intervention, the intervention. patient was able to: 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. 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
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3. Demonstrate behaviors/techniques to promote healing or prevent

3. Encourage early ambulation. Assist patient in doing active and passive range of

right lower rib cage and below the umbilicus -incisions covered with dry and intact dressing -skin slightly warm to touch. Temperature: 36.8C

T A B O L I C

quadrant of the abdomen. Source: Talamini, M. (2006). Advanced Therapy in Minimally Invasive Surgery, p. 179. USA: Decker Inc.

complications

motion exercises. : Movement stimulates circulation and assists in the bodys natural process of repair.

purulent discharge.

P A T T E R N

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-Fowlers position or moderate high back rest. :Proper positioning decreases tension in the operative site and promotes healing.

3.Demonstrate behaviors/techni ques 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)

6. Instruct to wear clean, dry, loose-fitting clothes,

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preferably cotton fabric : Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for 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.
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8. Instruct the client in proper postoperative skin care. Teach client and her significant 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
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around the incision, and report to the physician. : Provides for prompt recognition of complications and facilitates prompt treatment. 10. Administer antibiotics as indicated (sultamicillin) : May be given prophylactically or to treat specific infection and enhance healing.

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3.Deficient knowledge regarding illness and treatment course related to lack of information presented. Date & Time 05/12/ Subjective 10 cues: Verbalized: @ Para asa diay ni siya (holds 6:00 pm sultamicillin tablet)? Objective cues: Frequent questioning Incorrect T I V E C O G N I R: Knowledge is important especially in health matters. Deficiency in knowledge might affect the patients health status. If ever health issues Knowledge regarding and deficit At the end of 2 illness hours nursing treatment intervention, the 1. Assess the patients current knowledge of the medications and other doctors 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 physicians explanations and the patients past experiences. R: Adults learn best when 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
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Cues

Need Nursing Diagnosis

Objective/Goal

Nursing Interventions

Evaluation

course related to patient will be lack of information able to: presented. 1. Verbalize understanding of disease process and treatment. 2. Initiate necessary lifestyle changes and participate in treatment

verbal feedback regarding understandin g of treatment regimen.

P E R C E P T U A L

are taken for granted, it may result to disorders/diseases that could have been prevented if the patient had enough knowledge regarding her current health status. Lack of knowledge about health may also contribute to occurrence of anxiety.

regimen.

teaching builds on previous knowledge or experience. Assessing recall of the physicians explanations as well as the patients past experiences and exposure to health information provides an opportunity for evaluating attitudes and the accuracy and completeness of knowledge. 2. Ask how much the patient wants to know. Consider patients preference for information in planning and teaching. R: People vary in the degree of detail they find helpful. Those who cope

participate in treatment regimen and verbalized Sa sunod mag-iwas na gyud ko ug mga taba kayo nga pagkaon.

P Source: A T Berman, A. et. al. (2008) Kozier &

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T E R N

Erbs Fundamental of Nursing Concepts, Process and Practice 8th Edition. Pearson Prentice Hall, volume Two, Chapter 42, stress and coping

with a threatening experience by avoiding it generally want to know relatively little about impending experiences, whereas those who cope by learning as much as possible about the threatening experience want to know a great deal.When possible, supporting the patients preferred learning style shows respect for individual differences. 3. Determine learning needs. Consider needs expressed by the patient and family. R: Learning needs

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determine appropriate content. Learning occurs most rapidly when its relevant to current needs. Responding to expressed needs displays sensitivity to the patients and familys concern. Identifying predictable concerns and responses and necessary self-care activities helps the nurse fulfill learning needs of which the patient and family may be unaware. 4. Present manageable amounts of information at any one time. R: Too much information at one time causes confusion.

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They patient may lose sight of key points. 5. Inform the patient about indication of medication, drug interaction and its side effects R: Allows patient to be knowledgeable about medication and avoid misconceptions. 6. Inform the patient about the diet specific for her condition (low fat, high fiber foods; avoid spicy foods, alcohol and caffeine) R: A patient who has recently had a gallbladder removed may

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suffer from diarrhea and bloating after consuming foods high in fat. Diarrhea and bloating occur because of two reasons. One reason is that fat inside the intestine absorbs more water, causing stomach upset. A second reason is that bacteria begins to digest the fat within the intestine and ultimately produces gas. When a person with gallbladder problems consumes spicy foods, , unpleasant side effects such as gas and heartburn can occur.

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7. Provide simple explanations, using easy-tounderstand terminology. R: Medical and nursing jargon distances the patient and family members. Intricate explanations may confuse or overwhelm them. 8. Discuss to the patient and to the family the importance of complying with the medications and other doctors orders. R: This lets the patient be aware of the significance of the doctors instructions. It also lets the patient know

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the consequences which might occur if instructions werent followed. Knowing the benefits of complying with the instructions encourages participation. 9. Ask for feedback. R: The patient may initially feel overwhelmed and insecure about learning because of the magnitude, urgency or unfamiliarity of necessary adaptations to illness. 10. Use review and repetition judiciously, considering individual factors. R: The unit environment
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and the patients age may contribute to a short attention span and poor retention.

11. During and after teaching, determine what learning has occurred. R: Determining learning accomplishment permits resolution of some learning needs and provides guidance for meeting others.

12. Provide information about additional learning resources, like the nearest baranggay health center in their area.

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R: Patients should be informed that there are health services in the health centers which are for free, so as to persuade them to avail it.

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DISCHARGE PLAN (M.E.T.H.O.D.)

I.

MEDICATION 1. Take medications as ordered. 2. Inform the patient to take medications on time or as directed for the full course of therapy even if feeling better. 3. Inform the client about the adverse effects and possible side effects of the medications. 4. Inform the client about the importance of taking prescribed medications and the consequences of not following the treatment regimen. 5. Encourage the patient to report or inform the health team if any of these side effects occur. Inform and explain to the client that other drugs that he is taking will probably have effects with the medication given. Moreover, emphasize the right time interval of these drugs to maximize its effects and avoid further complications. 6. Provide information for better understanding regarding therapeutic regimen.

II.

EXERCISE 1. Promote regular light exercise and exercise as tolerated. 2. Encourage exercise in lower and upper extremities to promote good circulation. 3. Inform patient about proper exercise regimen to avoid injury. 4. Alternate rest periods with activity. 5. Encourage walking exercise.

III.

TREATMENT 1. Instruct the patient to continue drug therapy as ordered. 2. Inform the patient as well as family the dangers of non compliance to treatment regimen.
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3. Discuss to the patient the complications and other problems that might arise from the condition. 4. Inform the patient to exercise and do breathing exercises. 5. Instruct the patient to report to the health team promptly about any changes on health condition. 6. Encourage patient to strictly comply with the doctors orders, especially in taking prescribed medications. 7. Encourage the patient to have followed up visitations to the physician after discharge.

IV.

HEALTH TEACHINGS 1. Encourage patient to avoid strenuous activities. 2. Improving nutritional intake; meal planning is implemented with High fiber moderate calorie, low fat and low salt as the primary goal. 3. Encourage to balance diet and intake of nutritious food such as vegetables and lean meat, avoiding high fat foods. 4. Check with healthcare provider to evaluate progress of the condition. 5. Encourage to have adequate hydration. Water is the best source of fluid that is needed by the body to maintain its function. 6. Instruct to avoid alcoholic beverages due to a compromised hepatic system. 7. Encourage to have a restful and quiet atmosphere at home. 8. Encourage patient to use relaxation skills when in pain. 9. Encourage patient to seek emotional and social support especially to family and friends to promote strength and comfort. 10. Check the condition with a healthcare provider to evaluate progress of the condition.

V.

OUTPATIENT 1. Remind patient on the arrangements to be made with the physician for follow-up checkups.
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2. Follow-up check up regularly in order to monitor and properly manage patients illness. 3. Inform to continue medication as ordered. 4. Instruct to have a follow-up check up or refer to the physician if the patient is uncomfortable. 5. Instruct the patient and significant others to report for any irregularities.

VI.

DIET 1. The diet recommended for the client is High fiber moderate calorie, low fat and low salt 2. Encourage patient to increase nutritious foods intake by eating fresh fruits and vegetables, whole grain products, and lean meat. 3. Recommend to eat 5 or more servings of vegetables and fruits each day. 4. Encourage to choose whole grain foods instead of white flour and sugars. 5. Advise to try to limit meats that are high in fat and cut back on processed meats like hot dogs and bacon. 6. Inform patient to avoid food such as salted, cured, smoked, or canned meat. 7. Increase oral fluid intake. Hydration is needed by the body to transport nutrients needed by the body. 8. Instruct to avoid drinking of alcoholic beverages as much as possible. 9. Encourage not to forget to get some type of light exercise because the combination of good diet and regular exercise will help in the maintenance of healthy weight and the feeling of more energetic.

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PROGNOSIS

Good

Fair

Poor

Justification Signs and symptoms of her current illness first appeared on the second week of December 2009. After three days, the pain disappeared. But after two weeks, pain recurred in a higher scale of pain (5/10). Because of this, she was forced to seek medical advice and consult at Robillo Memorial Hospital. On May 5, 2010, three days prior to admission, the patient again experienced right upper quadrant pain. This was characterized to be progressive pain with a pain scale of 8

Onset of the illnesses

out of 10. There was no radiation noted and no associated symptoms. Two days prior to admission, pain recurred with a pain scale of 10 out of 10. This prompted Meg to seek consultation, hence,

admission. On May 8, 2010, the patient was admitted at Davao Medical School Foundation at Surgical Ward, room 324 bed 5 under the service of Dr. Batucan, with admitting diagnosis of Acute

Cholelithiasis. Based on the data, the onset of illness of the client first started on December of 2009. Patient did not comply with her doctors order to modify her diet (low fat, high fiber) and this led to
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exacerbation of her illness. Because of the patients onset of illness, the

proponents rated the area as fair. The clients hepatic system has been compromised since December 2009, 5 Duration of illnesses

months before admission to DMSF Hospital. Because of the span of the illness of the client, the proponents rated the Duration of Illness as fair. The precipitating factors of Calculous Cholecystitis present in the client were (1) Hormone replacement therapy, or birth

Precipitating factors

control pills and (2) a Low Fat Diet. Given that the client has a few of the precipitating factors present and has none of the much more serious precipitating factors, the proponents rated the Precipitating factors as good. Before she was brought to DMSF, she had a consult first at the Robillo Hospital.

Willingness to take medications and treatment

There, she was instructed to revise her diet into a low fat, high fiber diet. She was also instructed to drink lots of fluids. However, patient was not able to comply with this treatment plan and this later on led to worsening of her condition. On the positive note, she was later on able to follow instructions about her treatment regimen and cooperate with the health care team when she was admitted at
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DMSF. Because of these reasons, the proponents rated the Willingness to take medications and treatment as fair. Most of the bodys protective Age

mechanisms become less efficient with age. Since the patient is 38 years old, the proponents rated the age factor as fair. The proponents rated the Environmental

Environment al factors

factor as good for the reason that there is nothing in her environment at home or at work that can decrease her health status and further compromise her wellbeing. The clients family is very supportive and willing to comply with the therapy in order for the patient to get well, even with their financial problems. The patient also

Family support

stated that her family provides her with all the emotional support she needs. Members of her family frequently visit her in the hospital and she is able to verbalize any concern to them. Her husband is also present and is able to provide her support as she undergoes her current condition. Computation:

Poor:(0*1)/7 = 0/7 Fair: (4*2)/7= 8/7

TOTAL

Good: (3*3)/7= 9/7 Total: 17/7 or 2.42 (Good Prognosis)

*Scoring for General Prognosis: 1-1.6 = Poor Prognosis; 1.7-2.3 = Fair Prognosis; 2.4-3.0 = Good Prognosis

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Rationale for a Good Prognosis The patient has a good chance of recuperating from her current ailment as evidenced by the study done. The onset and duration of the illness, the absence of the much more serious precipitating factors, her willingness to take medication and treatment, and the support of the patients family made the prognosis better, increasing the chance of her recovery from her current ailment. The current status of her condition is very manageable and there is a good chance that she can recover as long as she is determined enough to achieve optimum well being. Therefore, according to the research and the calculations done by the proponents, the patient has a very good chance of recovering from her ailment.

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RECOMMENDATION This case study about Calculous Cholecystitis gave the group more information and knowledge in making an actual management for this kind of problem. Thus, the members of the group have realized the need of promoting and maintaining optimal health to both the patient and her significant others. With these, the group would like to recommend the following. To the client: The patients participation and willingness to be assessed and comply with the therapeutic regimen is needed for an effective management and prevention of complications. The patient is encouraged to always reach for wellness, and be cautious enough to know what her body needs and to recognize her limitations in complying therapeutic regimen. Also, the patient is encouraged to follow the discharge plan for the betterment of her condition while at home. She is also recommended to have her regular follow-up checkups to evaluate her condition. The patient is enlightened to be more open with her feelings regarding her current condition, family problems and concerns about her health To the clients family: The patients family plays an important role in the improvement of patients condition because they are source of strength and inspiration to deal with the disease. The family is encouraged to be sensitive enough to know the patients need and weaknesses that they may be able to render their support and care. Just with their presence and affection can help the patient feel that she is being loved and that she can successfully surpass the challenges that are brought by her illness. The feeling of being secured and accepted is what also the patient needs to achieve optimal state of well being.

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To the community: The community should also be sensitive with the clients condition, not treating her like she is incapable of doing her daily activities. They must still respect the client even with the illness. They must also be understanding enough and let the client feel security and acceptance. They should be more aware about this kind of condition. More knowledge should be acquired by the community to be able to know how to manage this kind of illness and how to prevent the occurrence of the illness within the community. To the government: Budget for health must be increased so that patients would be able to receive adequate amount of health services from government hospitals. They should also disseminate vital information regarding illnesses that may affect the bodys hepatic system. They should also make sure that people from far flung areas have access to medical services. Being able to access even basic medical attention may lead to a decrease in certain ailments of the genitourinary system. To professional health workers: Health care providers should be passionate about their job, giving proper care and support to their clients. Health workers should be sensitive to the clients feelings and emotions. They should be open for conversation to know what the client is feeling at the moment. They should also continue their work even though they receive little or sometimes no salary at all, thinking that what theyre doing is for humanitarian reasons. To the College of Nursing: They should provide more exposure to the students on a consistent area to further increase their experience regarding the concept. They should also do proper scheduling of duties so that students wouldnt be stressed out with their case presentations, clearing any scheduling matters with the students. They should also make sure that the student nurses are respected and treated well by
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their superiors. Also, they should make sure that their students are safe while on their duty, and if able, provide prophylactic treatment to avoid endangering the lives of the students. The College of Nursing should be more sensitive to the needs of the students and should be open to any comments or suggestions. To the Student Nurses: Give appropriate nursing care and follow out doctors order properly to avoid any errors and give better care to the clients. Cooperation with the healthcare team is also essential to provide better quality care. They should also be honest in the data collecting done to the patient, putting in mind that they are dealing lives. They should treat the client as a fellow human being giving quality care and service. They must also research about the disease to enhance their knowledge about it. They must also be updated with current updates that could be beneficial to the nurse, the client and the rest of the healthcare team.

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REFERENCES Berman, A. et. al. (2008) Kozier & Erbs Fundamental of Nursing Concepts, Process and Practice 8th Edition. Pearson Prentice Hall, volume Two, Chapter 42, stress and coping Boyer, M. (2006). Brunner and Suddarths Textbook of Medical-Surgical Nursing, 11th ed. Carol Mattson Porth (2005). Pathophysiology, Seventh edition. Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers. Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill. Everhart, JE, Khare, M, Hill, M, Maurer, KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117:632. Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated. Harrisons Principles of Internal Medicine, Tenth Edition 1983. Iyengar, V. Elemental Analysis and of Biological Systems: Aspects Biomedical, of Trace

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Elements, Vol. 1, p. 49. Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 MIMS 113th edition 2007 Talamini, M. (2006). Advanced Therapy in Minimally Invasive Surgery, p. 179. USA: Decker Inc. Taylor, Lillis, LeMone and Lynn (2008),Fundamentals of Nursing: The Art and Science of Nursing Care, 6th edition. Understanding Medical Surgical Nursing by Williams and Hopper page 742 White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.
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 http://arcoxia-side-effects.com/ http://digestive.niddk.nih.gov/statistics http://home.intekom.com/pharm/quatrom/q-hyosc.html http://medical-dictionary.thefreedictionary.com/calculi http://www.diabetesmonitor.com/learning-center/gallstones.htm http://www.drugs.com/arcoxia.html http://www.drugs.com/enc/vitamin-k.html http://www.drugs.com/mtm/ampicillin-and-sulbactam.html http://www.drugs.com/ultram.html http://www.healthline.com/goldcontent/ranitidine http://www.learningplaceonline.com/stages/organize/Erikson.htm http://www.medicinenet.com/hyoscine_butylbromide-oral/page2.htm http://www.medicinenet.com/tramadol/article.htm http://www.netdoctor.co.uk/medicines/100000395.html http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-vitamink.html http://www.pfizer.com/files/products/uspi_unasyn.pdf http://www.rxlist.com/unasyn-drug.htm http://www.turner-white.com/pdf/hp_nov00_murphy.pdf http://www.webmd.com/drugs/drug-11276-Ultram+Oral.aspx www.drugs.com/valium.html www.medicinenet.com/diazepam/article.htm www.medicinenet.com/ranitidine/article.htm www.revolutionhealth.com/drugs-treatments/cefoxitin www.rxlist.com/zantac-

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