Você está na página 1de 9

D.

EVALUATION
1. Patients daily program in the hospital
Daily program

Admission

1st Day

2nd Day

(September 15,

(September 16,2013)

(September 17,2013)

2013)
Nursing Problems
1. Anxiety.

2. Risk for fluid


volume deficit

3. Acute Pain r/t

irritation of nerve
endings
4. Impaired Skin
Integrity

71 | P a g e

5. Risk for Infection

r/t inadequate
primary defenses

Temperature: 35.4C

Temperature: 36.4C

Temperature: 36C

Pulse rate: 50 bpm

Pulse rate: 70 bpm

Pulse rate: 70 bpm

Respiratory rate: 15 Respiratory rate: 24 bpm


bpm
Vital Signs

Blood

Blood

Respiratory rate: 24 bpm

pressure: 110/70 Blood

pressure: mmHg

pressure:

90/60

mmHg

90/60 mmHg

Diagnostic & Lab.

Urinalysis

Procedures

Hematology

Medical and

Serum Electrolytes
Vital signs monitoring

Surgical Mgt.
Drugs

Diet

D5LRS

none

Vital signs monitoring

Blood chemistry

Vital signs monitoring

D5LRS
Tramadol

D5LRS
Tramadol

Cefuroxime

Cefuroxime

Ketorolac

Ketorolac

High protein diet

Metronidazole
High protein diet

Metronidazole
High protein diet

DAT

DAT

DAT

72 | P a g e

Exercise

Deep Breathing

Deep Breathing Exercises

Range of motion

Exercises

73 | P a g e

2. Discharge Planning
a. central condition condition of patient upon discharge
Patient was assessed and found no abnormalities nor other complications
that can inhibit him from going home. Patient only complained minimal pain on the
suture site, but found no traces of infection, like foul smelling odor or any discharge
coming from the suture site. The patient has demostrated all the health teachings
properly on the home management care plan and recognizes factors that should not
be done while he is in the process of healing.
The patient also exhibit proper mental awareness and does not seen any
manifestation of trauma or emotional distress. The patient verabalizes joy and
excitement upon discharge.
b. METHOD
M - paracetamol 500 mg/tab every 4hours for pain, mefenamic acid 500 mg/tab
every 6 hours for pain, cefuroxime 500 mg/cap for 7 days, bid.
E- patient can do bathroom commode or walking in proximal distance with rest
periods.
T-patient should take prescribed antibiotics on the time given and should take in for
the entire time that was prescribed to prevent resistance.
H-instructed patient to do wound cleaning everyday to prevent cultivation of
bacteria. Instructed patient to take the prescribed medications on time and return
on the said date for check- up
O- patient is instructed to go back for chek up on Sept.25, 2013 (Tuesday) 10 am
11:00 am at RLMMC (ONA) opd.
D-instructed patient to eat healthy foods such as green leafy vegatables and fruits
and increase intake of vitamin C for faster wound healing. Instructed patient to
prevent eating salty foods and foods rich in calcium and fats and cholesterol.
Increase intake of water for proper rehydration.

III. SUMMARY of FINDINGS


The researchers of this case study have increased their knowledge about

74 | P a g e

Cholelithiasis and there was a possibility that this condition was due to his lifestyle
and diet. In addition, be able to distinguished the signs and symptoms of
Cholelithiasis patient and create nursing care plans for those with the condition. The
nurses have developed critical thinking skills and improved nursing care and had a
better understanding of the anatomy and pathophysiology of the disease. As far as
the medications given and medical procedures of how they were related and
imparted the learning experience from direct care. For the patient and family they
have found safety measures that could minimize the occurrence of this condition to
their other member of the family. And have developed the familys support system
and roles in improving patients health status.
IV. CONCLUSION
Slightly toxic yet a memorable ward that we had this year the surgery ward.
Theres a lot of learning that will happen when you encounter the surgery ward.
Discipline is one of the major factors needed by the patient with cholelithiasis. He
must be able to know on how to tolerate his foods particularly the limitations of fats
and cholesterol intake which are one of the major factors that lead for the formation
of stones in the gallbladder`. Proper balance nutrition is a good practice for the
alleviation and minimal occurrence of this kind of disease.
For the patients medical and surgical managements, occurrence of problems
such as risk for infection prior to surgery may be prevented by means of proper
cleaning of the incision site and medications should be taken as prescribed with
proper dosages to avoid any of its adverse or side effects.
Patient interaction is really important for us to gather relevant and useful
data for our case study. As we go on, the group gained wide knowledge and
understanding about Cholelilithiasis, the problems related to this condition and the
different management that should be prioritized in order for us to have positive
outcomes in nursing problems. Good nurse-patient relationship was also established
as we conduct this study. This study helps us to identify measures to prevent
complications of the disease and also for them to have understanding about this
condition and to practice independent implementation for this kind of disease. It
also helped us how to deal with such situations, and gain more understanding about
what we learn in our lectures and better apply our skills with our attitude when it

75 | P a g e

comes to real life scenarios.

V.Recommendation
To all the government officials, that they may be made aware of the severity
and incidence of patients who had Cholelithiasis and other gall bladder diseases in
hospitals and at the same time, in the community, and how strict implementation of
guidelines and imposing regulations that could help minimize the occurrence
Cholelithiasis to the people.
To the hospital administration that they may understand the liabilities they
could incur if a patient suffers a disease like this or even acquires a healthcare
associated infection while admitted within the wards in their hospital.
To the nurses, that they may help in educating clients or by comprehensively
share information to them about Cholelithiasis, the causes, the risk factors, its
management and what is it all about. An accurate nursing diagnosis can help a
nurse focus on a patients condition, whether actual or risk.
To the nursing students, that they may be taught and made well-versed on
securing a clients safety by following procedures well and by understanding an
institutions safety protocols. Always remember that a patient relies on his nurse to
take care of him and keep him away from harm. In order to become a
knowledgeable and effective nurse, one must always keep in mind the well-being of
their patients from admission to discharge.
VI. Learning Derived
One thing Ive learned as a human being, Ive learned that all of us has a limit
and we can push ourselves to that point or else like a machine our body will just
crash. Pushing yourself to limit is not just the reason why people acquire a poor
health. Itss also their own fault why their body just surrender from sickness,
lifestyle is also a main factor to have a happy and harmonious life. Happy body,
admirable lifestyle is a key a to a longer life.
As a student nurse Ive learned that in order to give a more effective
therapeutic management to your patient you should now his or her disease

76 | P a g e

condition very well. How can you provide effective care if you, yourself is not fully
educated with what condition your patient has garnered.
-Ana, Abigail Maygie A.
Case studies are a great way to improve a learning experience,
because they get the learner involved, and encourage immediate use of
newly acquired skills. They differ from lectures or assigned readings, because
they require participation and deliberate application of a broad range of skills.
The focus of our case study is Cholelithiasis and the patient underwent
an operation of Open Cholecystectomy that is actually common. This
condition could be acquired through lifestyle and diet.
In the span of our duty, we can notice how one differs from the other,
how one exerts effort from the other and how one loses from the other. For
the sick, it is hardly imagine the pain they are going through and for the
significant others, their hardships are imaginable because we all had
experienced a loved one being sick but everyone varies in dealing with
problems. The severity of the problem greatly affects ones attitude towards it
but if one has a positive disposition in life, no matter how heavy the loads
you give and no matter how deep it will reach, it will be handled as though
nothing bad will going to happen.
- Concepcion, Millette C.

Through this case study, I was able to increase my awareness of the


condition and how specific interventions could help the patient and significant
others ways to prevent such a condition and how to achieve a health
promoting behavior. Through health teachings, further complications may be
avoided and also other members can prevent themselves from contracting
the condition. As a student nurse, it is my task to promote wellness prevent
diseases and help the patient. Cope with current the condition by giving
appropriate

health

teachings.

Health

teachings

are

to

be

taught

therapeutically and in a ways comprehensible to the patients including


rationale to enhance compliance. Through proper technique I was able to

77 | P a g e

make a change in a persons life. And seeing our patients get better gave me
a sense of fulfillment and satisfaction. It also inspires me to be more effective
and efficient in whatever I do.
-DeJesus, Alexander J.

BIBLIOGRAPHY

78 | P a g e

BOOKS:
Black, Joyce M. and Hawks, Jane H., Medical Surgical Nursing, 8th
edition, 2008
Estes Zator, Mary Ellen. Health Assessment and Physical Examination,
3rd Edition, 2006.
Ignativicius and Workman. Medical- Surgical Nursing, Collaborative and
Critical Thinking Vol. 1 and 2, 2004.
Kozier, Erb, Berman, Synder. Fundamentals of Nursing, Concepts,
Process and Practice, 9th Edition.
Lippicott, Williams and Wilkins. Springhouse Nurses Drug Guide, 2007.
Mosbys Pocket Dictionary of Medicine, Nursing and Health Professions.
Smeltzer, Suzanne C. and Bare, Brenda G., Medical- Surgical Nursing,
Vol. 2 10th Edition, 2004.

Website
http://www.umm.edu/ency/article/000274.htm
http://emedicine.medscape.com/article/172216-overview
http://Wikipedia.com
http://financingdefinition.blogspot.com/2011/09/cholelithiasisdefinition-causes.html
http://www.localhealth.com/article/cholelithiasis/symptoms
http://www.nhs.uk/Conditions/Gallstones/Pages/Symptoms.aspx

79 | P a g e