CORTEZ, Oliver D. DE ROXAS, Jennifer M. GARCIA, Clarisse C. LINATOC, Mary Rose E PORNASDORO, Ma. Crystal M. SERNA, John Jerome Jonathan M. TATAD, Carizsa Armina D. TAGLE, Angelica A.
Case Presentation CHOLELITHIASIS GROUP 2 2
TABLE OF CONTENTS PAGE
TITLE PAGE 1
INTRODUCTION 3
PATIENTS PROFILE 9
HISTORY TAKING 10
REVIEW OF SYSTEMS 11
ANATOMY AND PHYSIOLOGY 14
PATHOPHYSIOLOGY 17
MEDICAL MANAGEMENT 19
LABORATORY AND DIAGNOSTIC WORKUPS 22
DRUG STUDY 30
NURSING CARE PLAN 35
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CHOLELITHIASIS (Gallstones)
Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones may be as small as a grain of sand or as large as a golf ball.
CAUSES There are two main types of gallstones: Stones made of cholesterol, which are by far the most common type. Cholesterol gallstones have nothing to do with cholesterol levels in the blood. Stones made of bilirubin, which can occur when red blood cells are being destroyed (hemolysis). This leads to too much bilirubin in the bile. These stones are called pigment stones.
RISK FACTOR NON MODIFIABLE MODIFIABLE Family history Genetic Ethnic background Female Age Obesity Rapid weight loss Diet
SYMPTOMS Pain in the right upper or middle upper abdomen (biliary colic) o May be constant o May be sharp, cramping, or dull o May spread to the back or below the right shoulder blade Fever Yellowing of skin and whites of the eyes (jaundice) Other symptoms that may occur with this disease include: Clay-colored stools Nausea and vomiting
EXAMS AND TESTS
Tests used to detect gallstones or gallbladder inflammation include: Abdominal ultrasound Abdominal CT scan INTRODUCTION REPORTER: LINATOC, MARY ROSE and TAGLE, ANGELICA A. 4
Your doctor may order the following blood tests: Bilirubin Liver function tests Pancreatic enzymes
TREATMENT
SURGERY LAPAROSCOPIC CHOLECYSTECTOMY This procedure uses smaller surgical cuts, which allow for a faster recovery. Patients are often sent home from the hospital on the same day as surgery, or the next morning. OPEN CHOLECYSTECTOMY (GALLBLADDER REMOVAL) was the usual procedure for uncomplicated cases. However, this is done less often now.
MEDICATION CHENODEOXYCHOLIC ACIDS (CDCA) OR URSODEOXYCHOLIC ACID (UDCA, URSODIOL) may be given in pill form to dissolve cholesterol gallstones. However, they may take 2 years or longer to work, and the stones may return after treatment ends. LITHOTRIPSY Electrohydraulic shock wave lithotripsy (ESWL) of the gallbladder has also been used for certain patients who cannot have surgery. Because gallstones often come back in many patients, this treatment is not used very often anymore.
POSSIBLE COMPLICATIONS Blockage of the cystic duct or common bile duct by gallstones may cause the following problems: Acute cholecystitis Cholangitis Cholecystitis - chronic Choledocholithiasis Pancreatitis Prevention Increase fiber in the diet
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LAPAROSCOPIC SURGERY Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first- choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection. Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety. Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports. To begin the operation, the patient is placed in the supine position on the operating table and anesthetized. A scalpel is used to make a small incision at the umbilicus. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (the area bound by the inferior border of the liver, cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases, it can be done in about an hour. Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS". Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection and adhesions. Most patients can be discharged on the same or following day as the surgery, and can return to any type of occupation in about a week. Furthermore, flexible instruments are being used in laparoscopic surgery by some surgeons. 6
An uncommon but potentially serious complication is injury to the common bile duct, which connects the cystic and common hepatic ducts to the duodenum. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. This surgery should be performed by an experienced biliary surgeon. Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder. Adhesions and gangrene can be serious, but converting to open surgery does not equate to a complication. During laparoscopic cholecystectomy, gallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5 cm have been identified as risk factors for complications. Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy
Biopsy After removal, the gallbladder should be sent for pathological examination to confirm the diagnosis and look for an incidental cancer. If cancer is present, a reoperation to remove part of the liver and lymph nodes will be required in most cases.
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EQUIPMENTS: Camera unit - (sterilizable head and cable, video control unit) Connector cables from camera to monitor Video Monitor Light Source Light transmission fibre-optic cable Insufflator Carbon Dioxide Cylinder Carbon dioxide pressure regulator valve (optional - see description below) Tubing and Luer-lock adapter for carbon dioxide to patient Suction irrigation apparatus (optional) Cautery machine with cables and foot control Power control equipment (Transformer/spike and surge suppresser) Power extension cord Telescope Trocars and cannulas- 2 x 11mm, 2 x 5.5mm, 11 to 5.5mm reducer(1), 11- 7mm reducer(optional) Verress Needle (optional) 2 Atraumatic graspers 1 toothed grasper 1 curved dissector 1 clip applicator with suitable clips 1 dissection hook 1 pair scissors 1 suction irrigation cannula 1 sterilization ring applicator (if sterilization is to be done) 1 pair hook scissors (optional) 1 cautery spatula (optional) 1 gallstone retrieving forceps (optional) 1 needle holder (optional)
STEPS This is one of the most commonly performed procedures in the western world. It is often done as a day case procedure and when correctly performed is associated with little post-operative pain or morbidity. The following steps are generally taken: 1. General anesthesia 2. Creation of pneumoperitoneum: 1cm subumbilical (or transumbilical) incision. Dissection to peritoneum and insertion of trocar. Insufflation using CO2 and insertion of camera. 3. The patient is placed with their head down and tilted to the left position. 4. Placement of at least two other ports. A grasper is inserted at the top of the gallbladder and locked into place. The camera assistant then uses the other hand to 8
apply upwards traction on the gallbladder in order to maximise the surgeons access to Calots triangle. 5. The surgeon then either uses one or two ports to dissect around Calots triangle using a grasper, Pledget and hook diathermy. 6. Clips are then placed around the cystic artery and duct two below and one above where they will be cut. 7. Scissors are then used to cut the duct and artery. 8. The gall bladder is then dissected off the liver and a bag is used to remove it out of the abdomen. 9. The surgeon then looks around for any bleeding or bile leak and performs washout if necessary. 10. The ports are opened and gas stopped to remove free gas. 11. The peritoneum is closed at the umbilicus then the subcutaneous tissue and skin are closed. 12. The rest of the ports are closed at the skin only. 13. Dressings are placed and the patient woken up.
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NAME : Mrs. Y. ADDRESS : San Pablo City AGE : 49 years old CIVIL STATUS : Married NATIONALITY : Filipino RELIGION : Catholic OCCUPATION : Teacher CHIEF COMPLAINT : RUQ Abdominal Pain ATTENDING PHYSICIAN : Dr. Gabriel Eala ADMITTING DIAGNOSIS : Cholelithiasis MEDICAL CASE TYPE : Surgery (Adult)
ADMISSION DATE & TIME : March 26, 2013 at 04:45 PM ADMISSION NUMBER : 10442 CASE NUMBER : 009876 ROOM : C201 DISCHARGE DATE : March 29, 2013 FINAL DIAGNOSIS : Cholecystolithiasis OPERATION PERFORMED : Lap Cholecystectomy PATIENTS PROFILE REPORTER: LINATOC, MARY ROSE 10
History of Present Illness Three (3) months prior to admission patients was diagnosed to have cholelithiasis given with unrecalled medications. Since then, patient was asymptomatic for almost three (3) months but opted to undergo surgery due to abdominal pain hence admission.
Past Medical History This is the fourth (4 th ) time the patient been hospitalized. The 1 st three hospitalizations were due to giving birth via ceasarean section. According to the patient she has no allergies on food and medication.
Personal and Social History The client eats 2 cups of rice every meal and more than 1 serving of meat (pork, chicken and beef). She doesnt eat much vegetable. She drinks plenty of water and no exercised activity done in her daily living. She has her normal bowel movement ranging from 3-5 times a week and urine output of almost 8 times a day. She takes a bath every day and had 5-6 hours of sleep. She had no enough rest in everyday due to busy schedule in her teaching lesson. She had her annual check up Family History According to the patient she has no known hereditary disease that run within their family.
PATIENTS HISTORY REPORTER: LINATOC, MARY ROSE 11
Patient is ambulatory, with mark of fatigue and discomfort due to abdominal pain at the right upper quadrant rated as 7 from a scale of 0-10 as 10 being the highest. Body Part Examined Finding Norms HEAD Skull -normocephalic -absence of masses
Proportional to the size of the body/round/with prominence in the frontal area and the occipital are posteriorly symmetrical in all planes.
Hair -with long hair evenly distributed -black in color
Black evenly distributed and covers the whole scalp, thick shiny, free from split ends Face
-round and symmetrical -no pain and tenderness -with wrinkles
Round, symmetrical. Smooth and free from wrinkles and no involuntary movements. Eyes -no discharge, lesion, redness, and swelling -slightly yellowish sclera -pale conjunctiva -pupil black and symmetrical
Parallel, evenly placed, symmetrical, with scant amount of secretions, both eyes are bright and clear. Nose -without discharges and lesions -symmetrical nares -moist, pink mucosal walls
Symmetric straight. No discharge or flaring. Non- tender, no lesions. PHYSICAL EXAMINATION REPORTER: CORTEZ, OLIVER D. 12
Respiratory System
Lungs: Clear and Symmetrical Patient has a respiratory rate of 22 bpm. Slightly elevated because of pain experienced from RUQ
Soft, Pink, or Reddish Ears -without lesions, discharges and discomfort -auricles are symmetrical
Parallel, symmetrical, proportional to the size of the head. Bean shaped, helix is in line with the outer canthus of the eye Firm cartilage. Abdomen -globular tender -with right upper quadrant pain Pain scale: 7 No tenderness, relaxed abdomen, with smooth consistent tension. Bowel sound present Upper & lower Extremities
-No lumps -Fingers are equal in numbers -symmetrical -nails are clean and well- trimmed
Firm, equal in size, bilaterally, equal in numbers, clean and symmetrical. Hair distribution is even. Equal number of digits 13
Patients blood pressure ranges from 120/70-130/80 mmHg. Extremities are warm to touch and peripheral pulses are present. Radial pulse is 87 bpm which is within normal range.
Genitourinary
The patients urine is turbid in appearance.
Musculoskeletal
The patient is ambulatory. He is able to perform flexion, extension, abduction and adduction independently.
Integumentary
Patients skin is dry and warm to touch. No lesions, cracks, signs of inflammation and bruises noted. He has short hair. Nails are clean and well-trimmed.
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LIVER
The liver lies to the right of the stomach and overlies the gallbladder. The human liver in adults weighs between 1.4-1.6 kilograms. It is a soft, pinkish brown, triangular organ. It is both the largest internal organ and the largest gland in the human body.
Among the most important Liver functions are:
1. Removing and excreting of wastes and hormones as well as drugs and other foreign substances. 2. Synthesizing plasma proteins, including those necessary for blood clotting. 3. Producing Bile to aid in digestion. 4. Excretion of bilirubin. 5. Storing certain vitamins, minerals, and sugars.
ANATOMY & PHYSIOLOGY REPORTER: GARCIA, CLARISSE C. 15
GALLBLADDER
The gallbladder is a pear or oval shaped, hollow, saclike organ that lies in shallow depression on the inferior surface of the liver, to which connected by a connective tissue. Its wall is composed largely of smooth muscle. The gallbladder is connected to the common bile duct by the cystic duct. The capacity of gallbladder is 30 50 ml of bile.
Bile Bile or Gall is a bitter tasting, dark green to yellowish brown fluid, produced by the liver. It is important in digestion. It is poured into the intestine through the bile duct but the amount varies with the diet. Normal man makes 1000-1500 cc of bile per day. Some amount of bile entering our intestinal tract goes into the gallbladder as it comes down the duct. About half of the bile secreted between meals flows directly through the common bile duct into the small intestine.
Composition of Bile
1. Water and electrolytes Sodium Potassium Calcium Chloride Bicarbonate 2. Lecithin 3. Fatty Acids 4. Cholesterol 5. Bilirubin 6. Bile Salts
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PANCREAS
The pancreas is a gland organ located in the upper abdomen that has endocrine and exocrine functions. The exocrine functions include secretion of pancreatic enzymes into the gastrointestinal tract through the pancreatic duct.
The enzyme secretion includes: 1. Amylase 2. Trypsin 3. Lipase
The endocrine function consists primarily of the secretion of the two major hormones, insulin and glucagon. Four cell types have been identified in the islets:
1. A cells produce glucagon 2. B cells produce insulin 3. D cells produce somatostatin
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PATHOPHYSIOLOGY REPORTER: PORNASDORO, MARIA CRYSTAL Several stones develop Precipitate out of the bile Forms small crystals into Gallbladders mucosal surface Enlarges to grossly visible stonesREPORTER: CHOLELITHIASIS
Gallstones in the INT ROD UCT ION Increased Bile Cholesterol Irritation of Gallbladder mucosa Surface Changes Increased Mucus Secretion ImpairedGallbladderemptying Calcium Bilirubinate Irritation of Gallbladder mucosa Pigment Stones Combines with stearic acid, Lecithin and palmitic acid Forms Brown Gallstones Bile Stasis Contractile function Obstruction 18
Biliary Colic Abnormal Fat Digestion Anorexia Nausea Vomiting Weight loss Flatulence Diarrhea Fat intolerance Bacterial Proliferation Gallbladder duct infection Rupture of Gallbladder Peritonitis Jaundice Decrease bile flow Biliary Cirrhosis Bile accumulates in Liver Vit. K absorption Increase Serum Bilirubin Prorates/Tea- collared Urine Bile Stasis Contractile function Injury RUQ Pain Intraductal Pressure Obstruction Distension Blood flow & Lymphatic drainage Is compromised
Mucosal Ischemia Necrosis Release of Inflammatory Mediators Increase Permeability of Blood Vessels Fluid, Proteins and Cells enter interstitial spaces Edema Cholecystitis Inflammation of Gallbladder Increase WBC Leukocytosis Release of Pyrogens Increased Hypothalamic set point Inflammation of Gallbladder 19
DATE & TIME PROGRESS NOTE DOCTORS ORDER March 26, 2013 05:00 PM BP: 120/90 mmHg T: 36.8 C CR: 88bpm R: 22cpm WEIGHT: 77.5 kg Please admit to ROC under the service of Dr. Eala Secure consent for admission and management DAT Diagnostics CBC with PC, Prothrombine time FBS, BUN, Crea, BUA, SGOT, SGPT, Lipid Profile Whole abdomen UTZ 12 lead ECG, UA Chest X-ray Meds. Paracetamol 500mg tablet q8H PRN for fever 38.0C. Schedule patient for Lap chole w/p open chole tom March 27, 2013 at 09:30am Dr. Gloria for C-P clearance Dr. Romero for Anesthesia Give Cefuroxime (Elixime) 750 mg TIV ( ) ANST 1 hour prior Monitor VS q2 I & O q shift and record Inform all APs Refer accordingly DR. EALA/ DRA. MEDRANO March 26, 2013 05:15 PM NPO post midnight Notify Dr.Romero once C-P cleared by Dr. Gloria
DR. ROMERO March 26, 2013 05:30 PM Cleared for procedure Solucortef 250mg, give 125mg IV at 8pm and 125mg 1 hour prior to OR. Inform all APs
DR. GLORIA March 26, 2013 08:00 PM D5NR 1L x 12
DR. GLORIA MEDICAL MANAGEMENT REPORTER: TAGLE, ANGELICA A. 20
March 27, 2013 12:05 AM IVF to follow: D5NR 1L x 12 DR.GLORIA March 27, 2013 08:35 AM Pre-Op Order Maintain on NPO Pre-meds: Midazolam 2.5mg Nalbuphine 5mg IV Cocktail now To OR on call DR. ROMERO March 27, 2013 03:15 PM Post-op Order Transfer to PACU Monitor VS q15 minutes Place on moderate back rest NPO Encourage deep breathing exercises Present IVF to run at 30gtts/min IVF TO FF-D5 NR 1L to run for 8hours -D5 NM 1L to run for 8hours -D5 NR 1L to run for 8hours Meds - continue Cefuroxime 750 mg IV q 8hours -Ranitidine 50 mg IV q 8hours -Diclofenac Na (Dosanac) 75 mgdeep IM (intragluteal) single dose -Tramadol (Tramal) 100 mg IV q 8hours PRN for severe pain Specimen for histopath Refer accordingly DR. ROMERO March 27, 2013 04:00 PM Ketorolac (Ketodol) 30mg IV q 8hours for 2 doses; 1 st dose at 2am tomorrow DR.ROMERO March 27, 2013 04:00 PM BP: 120/70mmHg T: 36.0C CR: 77bpm RR: 20cpm Urine Output: 450cc To room VS q1
DR.GLORIA March 28, 2013 08:00 AM Progressive diet: genera liquid to DAT May remove FC Once on DAT, may consume IV shift Cefuroxime to oral 500mg TID Daily wound dressing May sit up on bed DR. R. RAYMUNDO March 28, 2013 10:00 AM Post-Anesthesia order If OK with Dr. Eala start Celecoxib 200mg 1cap PO BID start this afternoon 21
DR. ROMERO March 28, 2013 10:02 AM Ok to carry out orders of Dr. Romero DR.EALA March 28, 2013 01:45 PM No new orders DR. R. RAYMUNDO March 29, 2013 08:10 AM Afebrile (+) BM
For discharge anytime notify Dr. Eala for follow-up and meds DR.EALA/ DR. R. RAYMUNDO March 29, 2013 10:40 AM Ok for discharge DR. R. RAYMUNDO 22
DIAGNOSTIC IMAGING REPORT Date done: January 9, 2013
Ultrasound of whole abdomen:
The liver is normal in size measuring 13.7 x 9.2cm in sagittal and AP diameter, contour with mild diffuse parenchymal echo pattern. No discrete parenchymal lesion is seen. The intrahepatic and extrahepatic bile ducts appear normal.
The gallbladder is well visualized showing multiple shadowing echogenicities seen intraluminally the largest is seen at the neck region measuring 2.1 cm. The wall is not thickened. The common bile duct is not dilated measuring 0.4 cm.
The visualized spleen is normal in size measuring 7.3 x 3.6 cm, smooth contour and homogenous echo pattern with no evidence of discrete mass lesion nor calcification.
The head, body and visualized proximal tail of the pancreas are normal in size and contour. No lithiasis or masses are seen. The main pancreatic duct is not dilated. The aorta, periaortic and paracaval areas are unremarkable.
The right kidney measures 10.3 cm x 4.9 cm with cortical thickness of 1.2cm and the left kidney measures 10.5cm x 5.1cm with cortical thickness of 1.2cm. Both kidneys are normal in size.
The cortical thickness, cortical echogenicity, cortico-medullary differentiation, renal sinus complexes and perinephric areas are unremarkable.Thepelvocalyceal systems and ureters are not dilated.
The urinary bladder shows no evidence of reflective intraluminal echoes. Its walls are smooth and unthickened. Pre-void vol.= 154.8ml Post-void vol=15.1ml Residue in post micturation = 9.8%
The uterus is anteverted, measuring 8.3 x 5.7cm. The endometrial stripe is intact, measuring 1.0cm
The ovaries are not visualized due to overlying gas. Negative for posterior cul de sac fluid. LABORATORY & DIAGNOSTIC WORKUPS
REPORTER: DE ROXAS, JENNIFER M. Legend for laboratory result: Abnormal
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Interpretation: Mild fatty infiltration of the liver Cholelithiases Normal spleen, pancreas, kidneys and urinary bladder Normal anteverted uterus Non-visualized ovaries due to overlying gas Please correlate clinically
Fatty infiltration of the liver refers to the accumulation of fat in the liver cells It could be diffuse or focal in nature. In case of diffuse fatty infiltration, there is an excessive accumulation of triglycerides in the entire liver. In case of focal fatty liver, only a part of the liver is affected and the infiltration of triglycerides is non-uniform. Other factors that may lead to fatty infiltration of liver include long-term parenteral nutrition (intravenous administration of nutrients), prolonged use of steroids or excessive endogenous production of steroids. Fatty liver can also occur during pregnancy. Fatty infiltration of liver may or may not produce any symptoms. However, symptoms may appear when accumulation of fat in the liver leads to inflammation of the liver.
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SPECIAL EXAMINATION : PROTHROMBIN TIME (COAGULATION CHECK)
Prothrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot. Date done: March 25, 2013
Normal Value Result Interpretation Indication Nursing Responsibilities Prothrombin Time
10-13 secs. 14.4secs
Prolonged A prolonged PT means that the blood is taking too long to form a clot. This may be caused by conditions such as liver disease, vitamin K deficiency, or a coagulation factor deficiency Provide safety measures to prevent bleeding
Prothrombin is a protein produced by your liver that helps your blood to clot. When you bleed, a series of chemicals (clotting factors) activate in a stepwise fashion. The end result is a clot which stops the bleeding. One step in the process is prothrombin turning into another protein called thrombin. A prothrombin time test can be used to check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working. Increased PT may also be due to: Bile duct obstruction, liver disease, vitamin K deficiency, etc.
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HEMATOLOGY Date done: March 26, 2013
Normal Values Result Interpretion Indication Nursing Responsibilities Hemoglobin M: 14-18 F:12-16
12.8 g/dl normal
RBC M:4.5-5.0 F:4.0-4.5 4.7 x 10^12/L elevated May indicate dehydration. Monitor for signs of dehydration Hematocrit M: 40-54 F:37-47 37.1% normal
Platelet count 150-400 274 normal
WBC 5-10 5.8 x 10^9/ L normal Differential count: Neutrophil Segmenters
40-75
57.9 % normal
Lymphocytes 20-45 47% Elevated acute bacterial and viral infections acute-phase reactions (observed as a response to acute stress). Assess pt. for signs and symptoms of infection Administer meds as ordered Monocytes 2-6 4.9 % normal
Lymphocyte is a type of white blood cell present in the blood. Approximately 15% to 40% of white blood cells are lymphocytes. Lymphocytes help provide a specific response to attack the invading organisms. Increase in lymphocytes is generally the result of acute bacterial and viral infections, leukemias, lymphomas, ulcerative colitis, and acute-phase reactions (observed as a response to acute stress
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CLINICAL CHEMISTRY Date done: March 26, 2013
Normal Values Result Interpretion Indication Nursing Responsibilities GENERAL Glucose 3.05-6.38 5.43 mmol/L normal
BUN 2.15-7.16 3.42 mmol/L normal
Creatinine 45-84 53.04mmol/ L normal
Total BILIRUBIN 0-18.8 19.1 mol/L Elevated May be due to hemolysis disease of the liver presence of gall stones in the bile duct
Assess patients skin color Observe for any untoward signs and symptoms LIPIDS Cholesterol 0-5.2 6.02 mmol/L Elevated hyperlipide mia Health teachings: importance of keeping the diet low in fatty food, especially food containing saturated fat, and eat lots of fruit, vegetables Triglycerides 0.2.3 0.87 mmol/L normal
HDL- cholesterol No risk: >1.68
Moderate risk
Moderate : 1.15- 1.68 1.65 mmol/L
High risk: < 1.15
LDL- cholesterol 0-3.37 3.02 mmol/L normal
ENZYMES SGOT
0-145
13.0 /L
normal
SGPT 0-31 28 /L normal
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Bilirubin is a byproduct of the liver processing waste. When the liver isn't functioning properly, bilirubin may begin to build up in the body.Causes are Liver failure, Gilbert syndrome, gallbladder infections and certain medications such as antibiotics, pain relievers and birth control pills, can all cause adults to have high bilirubin levels. Pancreatic cancer, allergic reaction to a blood transfusion, hepatitis, blocked bile ducts and sickle cell anemia can also cause high levels
Cholesterol is a fatty substance known as a lipid and is vital for the normal functioning of the body. It is mainly made by the liver but can also be found in some foods we eat.
Having an excessively high level of lipids in your blood (hyperlipidemia) can have an effect on your health. High cholesterol itself does not cause any symptoms, but it increases your risk of serious health conditions.
Cholesterol is carried in your blood by proteins, and when the two combine they are called lipoproteins. There are harmful and protective lipoproteins known as LDL and HDL, or bad and good cholesterol.
Low-density lipoprotein (LDL): LDL carries cholesterol from your liver to the cells that need it. If there is too much cholesterol for the cells to use, it can build up in the artery walls, leading to disease of the arteries. For this reason, LDL cholesterol is known as "bad cholesterol".
High-density lipoprotein (HDL): HDL carries cholesterol away from the cells and back to the liver, where it is either broken down or passed out of the body as a waste product. For this reason, it is referred to as "good cholesterol" and higher levels are better
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X-RAY EXAMINATION Date done: March 26, 2013
CHEST: Lung fields are clear Pulmonary vascular markings are normal Heart is not enlarged Diaphragm, sulci and bony thorax are unremarkable.
Impression: NORMAL CHEST FINDINGS
CLINICAL MICROSCOPY (URINALYSIS) Date done: March 26, 2013
Normal Values Result Interpretion Indication Nursing Responsibilities PHYSICAL Color
Varying degrees of yellow
yellow normal
Transparency clear Slightly turbid abnormal bacterial infection Advice pt. for adequate hydration and personal hygiene Reaction Usually acidic acidic normal
Specific Gravity 1.000- 1.038 1.025 normal
CHEMICAL Protein negative negative normal Sugar negative negative normal MICROSCOPIC Red blood cells 0-2/ hpf
Pus cells 1-3/ hpf 5-7/hpf abnormal Bladder infection
Assess for possible signs of infection Health teachings about hygiene Epithelial cells negative + abnormal bladder infection Avoid contaminatio 29
n of sample Amorphous Urates negative few abnormal uric acid stone,urolithi asis. Report the findings to the physician Mucous threads negative few abnormal irritation, inflammation, or infection in the urinary tract
Bacteria negative + abnormal bacterial infection Administer meds as ordered
Urinalysis can be simply explained as the analysis of urine, which helps to detect certain diseases. This test can provide valuable information regarding the health condition of the person. While urinalysis is mainly conducted to find out the diseases of the urinary system, it may also come up with some information that can point towards other medical conditions. Turbid (cloudy) urine may be a symptom of bacterial infection, but can also be caused by crystallization of salts. It is usually considered abnormal. It may be the result of blood, pus, sperm, or bacteria present in the urine.
Possible causes of the presence of pus cells in urine include: Kidney infection, Bladder infection, Infection in urethra, Inflammation due to presence of bladder stones or kidney stones, Immune disorders, Allergies or growths anywhere along the genitourinary system.
In case of older females, parabasal squamous epithelial cells (smallest and immature epithelial cells of the vagina) may be found in urine samples. This is mostly seen in post-menopausal women, who have low estrogen levels. Large number of transitional cells in the urine could be an indication of some health problem. One of the possible causes is bladder infection.
Amorphous Urates indicates uric acid crystals in the urine. Higher than acceptable levels of uric acid crystals in urine can be caused by gout, Lesch-Nyhan syndrome, cardiovascular disease, diabetes, uric acid stone, urolithiasis, and metabolic syndrome.
Mucus threads in a urinalysis are considered to be normal in small amount of them. They appear long, thin, and wavy ribbon like. If there is a large amount of them, it may mean there is an irritation, inflammation, or infection in the urinary tract.
Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and because of their ability to rapidly multiply in urine standing at room temperature. Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted in view of clinical symptoms. 30
Name of Drug Action/ Classification Indication Contraindication Side Effect Adverse Effect Nursing Consideration CEFUROXIME (elixime) 750 mg TIV
Inhibits cell wall synthesis promoting osmotic instability usually bactericidal.
Pharyngitis, tonsillitis, otitis media, lower respiratory infections, UTI, gonorrhea, dermatologic infections, treatment of early Lyme disease.
Contraindicated in patients hypersensitive to drug or other cephalosporin.
nausea vomiting stomach pain mild diarrhea cough stuffy nose muscle pain joint pain or swelling; headache, drowsiness feeling restless, irritable, or hyperactive mild itching or skin rash. Large doses can cause cerebral irritation and convulsions; nausea, vomiting, diarrhea, GI disturbances; erythema multiforme, Stevens-Johnson syndrome, epidermalnecrolysis. Potentially Fatal: Anaphylaxis, nephrotoxicity, pseudomembranous colitis. Check for history: Hepatic and renal impairment, lactation, pregnancy Check the Physical: Skin status, LFTs, renal function tests, culture of affected area, sensitivity tests
MIDOZALAM (dormicum)2.5 mg IV Short acting hypnotic
Depresses the limbic system and reticular formation by increasing or facilitating the inhibitory neurotransmitter activity.
Sedation in pre surgical or diagnostic procedures, induction and maintenance of anesthesia.
monitor drug effectiveness assess for apnea, respiratory depression which may be increased in elderly. assess degree of amnesia assess injection site ensure the availability of resuscitation equipment, oxygen to support airway. DRUGS STUDY REPORTER: TATAD, CARISZA ARMINA 31
NALBUPHINE (nubain) 5 mg IV Analgesic
Binds with opiate receptors in the CNS; ascending pain pathways in limbic system, thalamus, midbrain, altering perception of emotional response to pain. Relieves pain.
Relief of moderate to severe pain; pre op analgesia; supplement to balanced anesthesia; surgical anesthesia; obstetrical analgesia.
Hypersensitivity, pregnancy.
weak or shallow breathing; fast or slow heart rate cold, clammy skin confusion, hallucinations, unusual thoughts or behavior; severe weakness or drowsiness; feeling like you might pass out. Sedation, drowsiness, sweating, nausea, dry mouth, dizziness, headache, vomiting.
Assess patients condition before therapy, obtain drug history. monitor vital signs especially respiratory rate. discuss with patient that dizziness, drowsiness, confusion are common. instruct patient to change position slowly and avoid getting up without assistance. DICLOFENAC (dosanac) 75 mg IM (intragluteal) single dose
Inhibits cyclooxygenase (COX), an enzyme needed for the biosynthesis of prostaglandin, subsequent decrease in prostaglandin result to the analgesic, antipyretic and anti inflammatory effects.
Relief of pain and inflammation in various conditions; joint disorders and other painful conditions following some surgical procedures.
chest pain, weakness, shortness of breath, slurred speech, problems with vision or balance; black, bloody, or tarry stools coughing up blood or vomit that looks like coffee grounds swelling or rapid weight gain, urinating less than usual or not at all;
Assess patients and family's knowledge of drug therapy. Teach patient that drug must be continued to prescribe time to be effective. Inform patient that drug may be taken with food or milk to prevent GI distress. Do not crush or chew drugs. Instruct patient to use caution when driving because drowsiness, dizziness may occur. Teach patient to take with full glass of water to enhance absorption. RANITIDINE (raxide) 50 mg IV q8
Inhibits histamine at H2, receptor site in the gastric parietal cells, which inhibits gastric acid secretion.
Management of various GI disorders like dyspepsia, GERD, peptic ulcer.
Hypersensitivity. history of acute porphyria. long term therapy.
constipation, diarrhea, fatigue, headache, insomnia, muscle pain, nausea, and vomiting. Cardiacarrythmias, bradycardia, headache, fatigue, dizziness, depression, insomnia, nausea, take exactly as directed. do not increase dose, mat take several days before noticeable relief. avoid alcohol follow diet as physician reccomends. use caution when driving 32
vomiting, abdominal discomfort, diarrhea, constipation pancreatitis. or engaging in tasks requiring alertness. report chest pain or irregular heartbeat. TRAMADOL (tiamide) 100 mg IV q8 PRN for pain
Centrally acting analgesic not chemically related to opioids but binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin.
Moderate to severe pain
Hypersensitivity. acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic agents.
agitation, hallucinations, fever, fast heart rate, overactive reflexes, nausea, vomiting, diarrhea, loss of coordination, fainting; seizure (convulsions); a red, blistering, peeling skin rash; shallow breathing, weak pulse. Vasodilatation, dizziness, headache, anxiety, confusion, coordination disturbances, nervousness, sleep disorder seizures.
assess patients pain monitor input and output ratio and check decreasing output which may indicate retention. assess patients knowledge on drug therapy advice patient to avoid alcohol and OTC medication without medical advice. warn ambulatory patients to be careful when getting out of bed or walking without assitance. KETOROLAC (ketodol) 30 mg IV q8 Analgesic
analgesic, anti- inflammatory antipyretic.
short term management of moderate to severe acute post- operative pain.
active peptic ulcer disease, renal impairement, dehydration, during labor or delivery, lactation, history of asthma.
chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;sudden numbness or weakness, especially on one side of the body;sudden severe headache, confusion, problems with vision, speech, or balance;black, bloody, or tarry ocular irritation, allergic reaction, acute renal failure, liver failure, hypertension, rash, nausea, diarrhea, headache, drowsiness.
Assesspatients pain before and 1 hour after treatment. Assess for hypersensitivity reactions. Advise patient to report persistence or worsening of pain. Instruct patient to report bleeding, bruising, fatigue. Instruct patient to use caution when driving because drowsiness and dizziness may occur. 33
stools; coughing up blood or vomit that looks like coffee grounds;slow heart rate;
HYDRO CORTISONE (solucortef) 250 mg, 125 mg IV and 125 mg 1 hour prior to OR Adrenal corticosteroid
glucocorticoid with anti- inflammatory effect because of its ability to inhibit prostaglandin synthesis. it can also cause the reversal of increases capillary permeability.
treatment of primary or secondary adrenal cortex insufficiency, rheumatic disorders, collagen diseases, dermatologic disease, allergic states, hematologic disorders.
fungal infections, psychosis, acute glomerulonephritis, amebiasis, nonasthmaticbrochial disease; children less than 2 years old, AIDS, TB.
problems with your vision;swellin g, rapid weight gain, feeling short of breath;severe depression, unusual thoughts or behavior, seizure (convulsions); bloody or tarry stools, coughing up blood; Depression, Flushing, sweating, headache, mood changes, hypertension, circulatory collapse, thrombophlebitis, embolism, tachycardia, edema, fungal infections, blurred vision, diarrhea, nausea, abdominal distension. Warn patient receiving long term therapy about Cushingoid symptoms. Advise patient to wear/carry emergency ID as steroid user. Instruct patient to notify physician of decreased therapeautic response for proper dose adjustment. Instruct patient to monitor and report signs of infection.
PARACETAMOL Decrease fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its Relief of mild to moderate pain; treatment of fever.
Hypersensitivity; intolerance to tartrazine, alcohol, table sugar, saccharin.
rashes shortness of breath low numbers of white blood cells (leucopenia)
Assess patients fever or pain. Advise patient to avoid alcohol Teach patient to recognize signs of chronic overdose. Tell patient to notify physician for pain or fever lasting for more than 3 days.
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minimal effect on peripheral prostaglandin synthesis. ISOFLURANE (Forane) 50 ml
Inhibits neurotransmitt er release
Induction and maintenance of general anesthesia.
Hypersensitivity to isoflurane or to other halogenated agents, history of malignant hyperpyrexia; susceptibility to malignant hyperthermia.
Arrhythmias, elevation of WBC counts, hypotension, respiratory depression, shivering, nausea, and vomiting during post operative period.
Monitor pts. Vital signs before, during, and after the course of therapy. Explain to the pt. the reason and process of procedure. Inform patient of post operative side effects such as shivering, nausea and vomiting. 35
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE: >giniginaw ako as verbalized by the patient
OBJECTIVE: > Temperature of 36C >With presence of Chills
Ineffective thermoregulation due to surgical environment and use of anesthetic agents
Within 2- 3 hours of nursing intervention at the PACU, the patients temperature will improve from 36C to 37.5C
>Vital signs monitored and recorded especially temperature
>Placed under blanket
>Placed under droplight
>Placed under thermal blanket
>Room temperature adjusted >To have baseline data in assessing the progress of the patient
>to help maintain temperature
>To provide warmth >It will help to regulate the heat coming from the droplight >To help improve patients temperature Goal partially met as manifested by latest temperature of 37C
NURSING CARE PLAN REPORTER: SERNA, JEROME and CORTEZ, OLIVER 36
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION OBJECTIVE: -with sterile dressing on post-op site Impaired skin integrity related to surgical incision There will be no untoward signs & symptoms observed such as discoloration, foul odor and excessive bleeding at the incision site after the operation and within the stay in PACU. >Assessed for any untoward signs and symptoms
>Changed dressing as required with proper aseptic technique
>To determine the condition of the patient
>To promote easy drying of wound and to prevent infection
After the operation and within the stay in PACU, the patient was properly assessed with no untoward signs & symptoms such as discoloration, foul odor and excessive bleeding at the incision site.
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ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE: parang di ko pa maigalaw ang katawan ko as verbalized by the patient.
OBJECTIVE:
-needs assistance when moving -unable to perform full range of motion by command - unable to turn to sides without assistance
Activity intolerance related to generalized muscle relaxation due to remaining effect of the anesthesia used in the surgery
After 2-3 hours of nursing intervention at the PACU the patient will manifest improvement of activity within her limitations
>Established rapport
>Assessed for any untoward manifestations related to fading effects of anesthesia such as jerking and drooling noted
>Assessed and assisted patient in light ROM
>Vital signs monitored and recorded
>Adequate rest provided
>To gain trust and cooperation
>To know if the effect of the anesthetic agent is exceeding the normal range of duration used in the patient
>For general assessment of patient including the effects in accordance with the duration of the anesthetic agents used
>To establish baseline data
>To prevent fatigue and to conserve energy Within 2-3 hours of nursing intervention at the PACU the patient was able to practice simple range of motion exercise such as light stretching with assistance and precautions.
-reduced level of consciousness -depressed cough and gag reflex -impaired swallowing
Risk for aspiration related to depressed gag & cough reflex secondary to induction of general anesthesia
After 2-3 hours of nursing intervention at the PACU, the patient will be able to maintain safety and demonstrate behaviours of return of reflexes >Vital signs monitored and recorded
>Encouraged deep breathing and coughing reflex
>Patent airway maintained by suctioning as necessary
>Positioned the patient on moderate back rest
>For baseline data
>To assess reflexes altered by anesthesia used in the patient, prevent atelectasis and improve pulmonary functions and breathing pattern
>Airway obstruction impedes ventilation and to avoid aspiration.
>To prevent aspiration and to promote lung expansion.
The patient did not show any signs of fluid accumulation like crackles and was maintained on NPO status 39
>Lung fields auscultated
>Maintained on NPO status
>To assess if there are accumulation of secretions and assess the need for suctioning.
>To prevent aspiration until the gag reflex returns
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ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME Objective -Decreased level of consciousness (Lethargic) -Slightly pale in color
Risk for injury related to decrease level of consciousness secondary to administration of pre- operational medications The patient will not experience any physical injury from perioperative up to post-operative state. >Raised side rails while transferring to operating room.
>Positioned patient properly on the operating room table with proper transferring techniques.
>Proper restraints attached to the patient while on the operating room table
>Proper grounding pads placed
>To protect and prevent the patient from fall out of the stretcher
>To assure safety of the patient & avoid further injury such as c- spine fracture.
>To prevent the patients arm and body to move and so to prevent fall.
>To prevent burns There are no physical injuries seen to patient such as bruises or fractures related to fall from perioperative up to post- operative state. 41
Risk for infection related to inadequate primary defense mechanism as manifested by post operative incision Prevent patient from having infection throughout the operation and 2-3 hours of stay at the PACU
>performed proper hand washing technique and surgical hand scrub by all surgical team of the client
>Surgical team practiced strict sterility within the operating room upon assisting in surgery
>Checked for any break in the sterility such as tear of packaging and expiration date of equipment that will be used in the >A first-line defense against nosocomial infection/cross- contamination, on the operative wound by bacteria on the hands and arms.
>breaking sterility inside the operating room while in surgical operation may lead to further complication and high risk for infection
>To prevent possible contamination of sterile field
The patient tolerated the procedure and did not show any signs of infection like fever and chills
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operation
>Vital signs monitored and recorded
>Kept incision site dry and intact at all times
>Medications administered as prescribed by the physician
>To have baseline data in assessing the progress of the patient
>soaked dressing can harbor bacteria causing further infection and complication to the patient