Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

A Case Study of

A 22 YEAR OLD MALE, DIAGNOSED WITH CALCULOUS CHOLECYSTITIS

In Partial Fulfillment of the Requirements in RLE (103-A) at the

Bulacan Medical Center

(Medical Ward)

BSN 3-E (GROUP 2)

Castro, Mary Joyce Dela Cruz, Carllae Lucille

De Guzman, Liberty C.
Fabian, Shiela Marie
Ilag, Caress S.
Miranda, Marife
Roque, Lyra Cariza
Delloro, Ephraim
GABRIEL , ANER M. (Leader)
Macaranas, Carmona Jane
Pangan, Mary Grace S.
Vidon, Jill Irish Kae

September 24, 2010

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 TABLE OF CONTENTS

I. INTORDUCTION
a. Reason why ……………………………………………………………………………………. 1
b. Objectives …………………………………………………………………………………….. 3

II. NURSING HEALTH HISTORY

a. Demographic Data ……………………………………………………………………………. 5
b. History of illness (present, fast and family illness ) ………………………………………… 6
c. Genogram ……………………………………………………………………………………... 7
d. Functional Health Pattern (Prior and during hospitalization) ……………………………. 8-14
e. Growth and Development ……………………………………………………………………. 15-16

III. ANATOMY AND PHYSIOLOGY …………………………………………………………………….. 17-21

IV. PATHOPHYSIOLOGY
a. Schematic Diagram …………………………………………………………………………… 22-24
b. Definition of the disease ………………………………………………………………………. 25
c. Signs and symptoms ………………………………………………………………………….. 26
d. Precipitating factors ………………………………………………………………………….. 27-28
e. Predisposing factors ………………………………………………………………………….. 29
f. Review of system ……………………………………………………………………………… 30

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V. PHYSICAL ASSESSMENT ……………………………………………………………………………. 31-43
VI. LABORATORY AND DIAGNOSTIC PROCEDURES ……………………………………………… 44-49

VII. PATIENT AND HIS CARE

a. Medical Management …………………………………………………………………………. 50-51
b. Drugs ………………………………………………………………………………………….. 52-57
c. Diet ……………………………………………………………………………………………… 58-59
d. Exercise …………………………………………………………………………………………. 60

VIII. SURGICAL MANAGEMENT

a. Nursing Responsibilities (postoperative) and Client’s
Response…………………………………………………………………………………………… 61

IX. NURSING CARE PLAN…………………………………………………………………………………. 62-69

X. HEALTH TEACHING …………………………………………………………………………………... 70

XI. DISCHARGE PLANNING ……………………………………………………………………………… 71-72

XII. CONCLUSION …………………………………………………………………………………………… 73

XIII. BIBLIOGRAPHY ………………………………………………………………………………………… 74-75

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 I. INTRODUCTION

This is a case study of a 22 year old male nursing graduate of Our Lady of Fatima University who was rushed at Bulacan Medical Center complaining of
severe pain on the right upper quadrant of the abdomen. He was admitted last August 01, 2010 at 6:45 a.m. The patient was initially diagnosed with abdominal mass
to confirm calculous cholecystitis after performing laboratory and diagnostic tests, because the results shows that the patient is suffering from an inflamed
gallbladder due to calculi or stones. The physician then decided to perform an emergency procedure an open cholecystectomy at 11:15 am.

Calculous cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The gallbladder is an organ which aids in
the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance
in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact
contributes to the laxity of the majority. The gallbladder tends to be taken for granted or ignored of the proper care and conditioning. Lifestyle together with
heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur .

The most common cause of cholecystitis is gallstones. The bile becomes concentrated in the gallbladder. This later causes irritation and is probably the
leading cause of inflammation. Cholecystitis affects women more often than men and is more likely to occur after age 60. People who have a history of gallstones
are at increased risk for cholecystitis. In the international level, cholecystitis has an increased prevalence among people of Scandinavian descent, Pima Indians, and
Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. It affects 20.5 million people (1988-1994) with a
mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies. In the
Philippines alone, 24,913 people are affected by the disease and 139 number of reported deaths last 2007. (http://digestive.niddk.nih.gov/statistics)

Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. In calculous cholecystitis, a gallbladder stone obstructs bile outflow.
Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur, and the blood vessels in the gallbladder are compressed, compromising its

4
vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile with
Escherichia coli, klebsiella species, or streptococcus is identified with cultures obtained during surgery in a small percentage of surgical treated patients.

SIGNIFICANCE OF THE STUDY

We, the student nurses have chosen this case as we see it fit for the peri-operative concept as the patient, who is a nursing graduate had to undergone open
cholecystectomy. Moreover, despite the cholecystitis’ low incidence, we would like to give credit and to know more of the nature and function of the gallbladder.
Much often this small organ is not given importance. Thus we are in a pursuit for knowledge to be able to impart it to others. Furthermore, this case is quite
interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the
symptoms presented.
As teen-agers living in a fast-phased world and governed by schedules, just like NJE a nursing graduate, we too are predisposed to lifestyle modification –
especially diet and food preferences which can contribute to the disease. With this study, we hope to apply our learning in taking care not only of our patients but
also of ourselves.
As nursing students and future nurses, we would want to understand and appreciate more on what is happening to a patient with calculous cholecystitis.
Consequently, we are interested on what will be the necessary management that will be given. Through this, we are hoping that we will be able to find the right plan
of care and sound interventions, not forgetting the patient’s rights as a person. All in all, these will help us to become efficient nurses and better persons later on.

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OBJECTIVES

General Objective:

Our first main goal is to gain knowledge through the completion of the case study and to impart this learning to those directly and indirectly involve with the
completion of this case. In psychomotor aspect, our goal is to apply all what we have learned during the process of completing this case study to improve nursing
care that will meet NJE’s need for the improvement of his general welfare. With the knowledge gained and through the application of this knowledge, another goal
is that we will be able to empathize with the current situation of the patient and to gain some values like the value of patience and calmness which is important for
us to have in order to become better nurses in the future.

Specific Objectives:

 To determine functional health status of client with cholecystitis.

 Integrate knowledge of nursing care in post cholecystectomy client to formulate a quality nursing care plan.
 Implement appropriate nursing intervention to satisfy the patient’s needs.
 Prepare clients for understanding the purpose and significance of cholecystectomy.

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Client-centered:
 Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need.
 To identify intervention that appropriate for patient’s needs.
 Integrate psychosocial and spiritual consideration into plan of care for client with gallbladder disorder.
 Research and understand the disease process of the patient’s illness and also the possible causes and the symptoms the patient experience that may suggest
the current condition of the patient.

Student-centered:

 To use knowledge in assessing and understanding the manifestation of gallbladder disease.

 To determine the priority nursing intervention and diagnosis that we can contribute by using our knowledge that we have learned in clinical setting.
 To implement quality nursing care that suited for client undergone cholecystectomy
 Use critical thinking to evaluate the effectiveness of the nursing intervention given in meeting the needs of the patient.

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II. Nursing Health History
PATIENT’S PROFILE
Biographic Data
Name: NJE
Address: 916 Ibayo, Sto Rosario, Paombong, Bulacan
Birthday: December 04, 1987
Birthplace: Paombong, Bulacan
Age: 22 years old
Sex: Male
Status: Single
Occupation: None
Nationality: Filipino
Educational attainment: College Graduate (BS Nursing-OLFU)
Religious Orientation: Roman Catholic
Health Care Financing and usual source of Medical Care: Philhealth (beneficiary)
Date of Admission: August 01, 2010 at 6:45 a.m.
Date of operation: August 01, 2010 11:15 am.
Date discharge: August 05, 2010
Chief Complaint: Abdominal pain on the right upper quadrant
Initial Diagnosis: Cholelithiasis

Final Diagnosis: Calculous Cholecystitis

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History of Present Illness

Three months prior to admission, (May 03, 2010), NJE experienced sudden onset of pain in the right upper quadrant of the abdomen. The pain become mild
to moderate and sometimes does not relieve by position. The patient noticed loss of weight, pallor, weak and easy fatigability. The patient was worried about his
condition so he seeks medical attention to a private physician. The patient undergone abdominal ultrasound and the results revealed presence of gallstones. A day
prior to admission (July 31, 2010 10:40 pm), patient experienced severe epigastric pain radiating to the right upper quadrant of the abdomen (pain scale of 7/10),
and associated bloatedness with nausea and vomiting. There is presence of facial grimace and guarding behavior. A decrease in appetite was also experienced on
that day. According to the patient, he noticed a yellowish discoloration of his skin and a clay-colored stool. By August 01, he was rushed at Bulacan Medical Center
due to intolerable pain (pain scale of 9/10) accompanied by fever. Diagnostic exams were done such as Abdominal Ultrasound, Complete Blood Count, Platelet
Count, Prothrombin Time and Partial Thromboplastin Time. He received IVF of D5LRS 1L regulated @ 30 gtts/min. Ultrasound revealed Calculous Cholecystitis,
so the patient was advised for admission and operation.

Past history of illness:

NJE experienced common illness such as colds, cough, chicken fox and fever during his childhood. However, he could not recall at what age he got the
disease. Her mother used “cilantro” for the management of his chicken pox. He had no food and drug allergy and he does not experience any injuries and accidents
in the past. He received oral polio vaccine (OPV), diphtheria, pertusis and tetanus (DPT) for his immunizations.

Family history of illness:

The grandparents of our patient are both deceased and he can’t recall the cause and the age of death. His father died on 1998 due to kidney disease and his
mother was 41 yrs old and still alive. He has three siblings, he was the eldest, second to him is 19 years old, the third was 15 years old and the youngest is a 12 yr.
old male. No one in his family has the same condition with him.

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 FATHER’S SIDE MOTHER’S DAY
GENOGRAM:

55 y/o 45 y/o 44 y/o 41 y/o 59 y/o 55 y/o 55 y/o

TME RME PME YMJ PMJ CMJ SMJ

22 y/o 16 y/o 13 y/o 19 y/o

NJE KJE CJE HJE

LEGEND:

MALE CALCULOUS CHOLECYSTITIS

FEMALE DECEASED UNKNOWN

CAUSE OF DEATH

PATIENT KIDNEY DSE UNKOWN AGE

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Functional Health
Pattern Prior Hospitalization During Hospitalization

Health perception He told us that the most important factors for a healthy life is just eating According to him, during his hospitalization, he feels weak but he is
and Health nutritious foods, having a balance diet and having enough hours of sleep. eager to get well so, he tries to follow the doctor’s order for fast
management He does not smoke but drinks alcohol frequently (2 bottles. of BAR every recovery. He takes his medicine on time. The following medicines
Saturday. He does not believe in faith healer. When he is in pain he will are administered to the client as part of his regimen.
take OTC drugs, when we asked him what drugs is that he told us it was
 Metronidazole- 500 mg TIV q8
mefenamic acid 500mg.  Ranitidine – 50 mg TIV q8
 Celecoxib – 200 mg OD
 Cefuroxime -750 mg TIV q8

IV Fluids

 D5LRS 1,000 mL regulated @ 30-31 gtts/min.

Nutritional and He likes to eat fried foods and he doesn’t have any eating difficulty. During his first day of hospitalization (August 01, 2010) he was
metabolic pattern Whenever the patient is suffering abdominal pain, his appetite decreases. ordered NPO in preparation for operation and change it to General
He doesn’t take any vitamin supplements. According to him when he has liquid diet on August 02, 2010 post operation and on August 03,
wound it heals well. He doesn’t have any dentures. 2010 at 12:15pm he was instructed on a DAT diet with fat restriction
to provide nutrition after the operation..

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Date Breakfast Lunch Dinner

Date Breakfast Lunch Dinner

July 29, 2010 1/2 cup of rice 1 cup of rice 1/2 cup of rice
1 fried egg 1 piece fried 2 pcs of fried
220 ml of pork chop chicken
water(1 glass) 440 ml of 220 ml of August 01, Nothing Per Nothing Per Nothing Per
water coffee with 2010 Orem Orem Orem
milk(1 cup)
AM SNACK: AFTERNOON EVENING
SNACK: SNACK:
AFTERNOON None None
AM SNACK: None
SNACK:

1 order of 240 ml of soft EVENING

Jollihotdog drink(RC cola) SNACK: August 02, 30 ml of 30 ml of 30 ml of
with 300 mL 21 grams of 2010 water water water
of coke. Garlic Adobo Kita Cheese AM SNACK: AFTERNOON EVENING
Peanut (Sugo) biscuit (2 SNACK:
SNACK:
packs) None
None
None

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 1 cup of rice 1 cup of rice 1 cup of rice
3 pieces of 2 pcs fried 2 pieces of 2x4
July 30, 2010 fried hotdog chicken 220 inches of fried August 03, Soft diet with 3 tbsp of 1 piece Boiled
340 ml of ml of water (1 beef tapa
water (1 ½ glass) 440 ml of water 2010 SAP Lugaw
egg
glasses) (2 glasses)
AFTERNOON 3 tbsp of 3o ml of
AM SNACK: SNACK: EVENING 30 ml of
350 ml Coke SNACK: Lugaw water
water
1 pc hamburger 1 pack (3 pcs)
1 cup coffee AFTERNOON
w/ cheese of Sky flakes 3o ml of
1 sliced of EVENING
150 ml of water SNACK:
chicken water
sandwich SNACK:
None
AM SNACK:
None
None
July 31, 2010 1 cup of rice 1 ½ cups of EVENING
rice
1 slice pritong SNACK:
bangus 1 pc fired pork
chop NONE
220 ml of
water(1glass) 440 ml of
water(2
AM SNACK: glasses)
AFTERNOON
1 cup coffee w/
SNACK:
milk
1 pc hamburger
w/cheese

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Elimination Pattern He doesn’t have excessive perspiration or body odor. He doesn’t have excessive perspiration or body odor.

August 01-03, 2010

Color Frequency Consistency Odor Difficulty Color Frequency Consistency Odor Difficulty

Clay-
colored/
July 28- 31, 2010 Stool Once a day Formed Foul None Stool None
gray

Amber/s
traw Urine Amber 4x a day
Urine 6X a day Clear Aromatic None
/ straw (August Aromatic
clear None
02-
03,2010)
vomit Whitish Once(July (+) food “sour With
31, 2010) fragments smell” difficulty

vomit None

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Activity-Exercise He has sufficient energy to finish his daily activities. Walking for 15 During his hospitalization he is often lying on his bed. He just listen
Pattern minutes in the morning every day, except rainy days, is his form of to radio or chats with his relatives and some of the patient in the
exercise, and he doesn’t easily get tired. When he has free time he chats ward. As of august 03, 2010.
with his friends or watch television

Activity Level

Activity Level
Feeding 0
Feeding 0
Bathing 2
Bathing 0
Bed mobility 0
Bed mobility 0
Dressing 2
Dressing 0
Grooming 0
Grooming 0
Toileting 0 Toileting 2

Level 0 – full self care

Level I-requires use of equipment
Level 0 – full self care
Level II-requires assistance or supervision from another person
Level I-requires use of equipment
Level III- requires assistance or supervision from another person or
Level II-requires assistance or supervision from another person
device
Level III- requires assistance or supervision from another person or device
Level IV- dependent or does not participate
Level IV- dependent or does not participate.

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 Sleep and rest The patient sleeps for about 7 hours and 30 minutes continuously from 11 The patient sleeps for about 4 to 5 hours at night. His sleep is
pattern p.m. – 6:30 a.m. and he does not have any difficulty falling asleep and does disrupted due to pain felt on his incision site. He takes nap 1 hour in
not take any sleeping medications. He takes nap for 2 hours in the the afternoon.
afternoon.

Cognitive and He does not have problems in vision and hearing. According to NJE, he He does not have problems in vision and hearing as well as any
Perceptual Pattern had a sharp memory. He does not have any learning difficulty. learning difficulties.

Self perception and According to NJE he sees himself as a friendly person. The things that can The patient sees himself as a friendly person. When we asked him
self concept make him frustrated are when things got out of his control. Sometimes what he feels about being hospitalized he told us that he feels fine
chats with his friend to lessen his frustration. and he added that he wants to go home already.

The patient has a nuclear family according to members, matriarchal His mother is the one who decides about financial matters in their
according to authority and neolocal according to location. He is living with family and according to him their budget is enough for his
Role and
his parents. When problem arises he and the rest of the family talk to each hospitalization.
Relationship
other to solve it. He does not belong in any social group but he has a lot of
pattern
friends in their neighborhood.

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 Sexual- According to the patient his sex life is complicated and admitted that he is The patient sexual life is inactive.
reproductive a gay.
pattern

Coping Stress When the patient feels tense he chats with his friends and when he has The big change in his life is when he found out that he has gallstones.
tolerance problem he usually share it with his friends to ask for their opinion to solve When he has problem he usually share it with his friends and
the problem and according to him it lessen his burdens. according to him it is effective.

Values belief According to him he doesn’t get easily the things he wanted, he works hard He prays at night before sleeping to ask God for good health.
pattern for it. Religion is important to him and his family. They also go to church
every Sunday and ask God for guidance and good health.

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 III. GROWTH AND DEVELOPMENT

Theories Stages Justification Resolution

Genital stage: post puberty

Freud’s Stage of During the final stage of psychosexual development, The patient is in the genital stage but he does The patient does not developed
Psychosexual Development the individual develops a strong sexual interest in not developed sexual interest with the opposite sexual interest with opposite sex.
the opposite sex. Where in earlier stages the focus sex rather than same sex. According to him he
was solely on individual needs, interest in the
is not attracted with girls but he enjoys hanging
welfare of others grows during this stage. If the
other stages have been completed successfully, the out with them as friends.
individual should now be well-balanced, warm and
caring. The goal of this stage is to establish a
balance between the various life areas.
The formal operational stage (20 to Adulthood)

Jean Piaget’s Stage of During this time, people develop the ability to think The client thinks rationally and logically. He is Positive The patient thinks
Cognitive Development about abstract concepts. Skills such as logical able to solve the problem with his family by logically and rationally.
thought, deductive reasoning, and systematic communicating to them and vice versa.
planning also emerge during this stage.

Young Adulthood (19 to 40 years) Positive

Erickson’s Stage of Intimacy vs. Isolation Young adults need to form The patient share more intimately with The patient developed intimacy.
Psychosocial Development intimate, loving relationships with other people. others. He has a strong bond with his
Success leads to strong relationships, while failure friends and family.
results in loneliness and isolation.

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Kohlberg’s Stage of Moral Level 3. Post conventional Morality
Development
Stage 5 - Social Contract and Individual Rights
At this stage, people begin to account for the
differing values, opinions and beliefs of other
people. Rules of law are important for maintaining a
society, but members of the society should agree
upon these standards.
Individuative-Reflective Faith: (early 20 to
adulthood)
Fowler’s
One begins to move beyond the group identity and
Faith development pattern adopt individual views; a "de-mythologizing" stage
of faith; translates the symbols and images of one's
tradition into personal concepts and ideas; beginning
of post-conventional morality.
The patient understands the different roles of Positive
the society, and can distinguish what is right or
The patient follows rules
wrong based on internalized rules on
according to his knowledge and
conscience rather than social law. He follows
rules according to his willingness. According to willingness.
him, he will follow all the orders of the doctor
that will help to make his condition better. He
also said that he does things if he knows that it
is good for him and according to his
willingness.
The patient has a religious side of him. He Positive
believed in God and go to church every Sunday.
To his present illness, he believed in God and to The patient develops matured
the health care provider that he can overcome sense of faith
his illness.
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IV. ANATOMY AND PHYSIOLOGY

20
LIVER

 Largest organ in the body

 Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.
 Weighing 1.5 kgs.

LIVER LOBES AND LOBULES

 The liver has two lobes, separated by the falciform ligament

 Left lobe- about one sixth of the liver
 Right lobe- about five sixth of the liver.

BILE DUCTS

 Right hepatic duct- drains bile from the right functional lobe of the liver
 Left hepatic duct- drains bile from the left functional lobe of the liver
 Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 6–8 cm. Approximate width:
6 mm in adults; merges with cystic duct to form common bile duct, which opens into the duodenum.

 Cystic duct- is the short duct that joins the gall bladder to the common bile duct.
 Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder).

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FUNCTIONS OF THE LIVER

 The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months' supply),
vitamin B12, iron, and copper.
 Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in
the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood
glucose
 Ammonia conversion- use of amino acid from protein for glycogenesis results in the formation of ammonia as a byproduct. Liver converts ammonia to urea.
 Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, blood clotting factor plasma lipoproteins.
 Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies.
 Bile formation- bile is formed by the hepatocytes
- Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol, bile salts
- Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.

BILE

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions,
including the following:

 to carry away waste

 to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, bile gives feces its dark brown
color.

22
TRANSPORT OF BILE

1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts.

2. These ducts ultimately drain into the common hepatic duct.

3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the
first section of the small intestine).

4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped
organ located directly below the liver.

5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.

GALLBLADDER

 The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process.
 A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck.
 Fundus - the lower free and the expanded end of the Gall bladder.
 Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of the body is upwards, backwards,
and to the left.
 Neck-it is the “S” shaped curve present above the body, and extends up to the cystic duct. Direction is upwards, forwards and then takes a turn and becomes
downwards and backwards.

23
  It can hold 30 to 50 ml of bile.
 It lies on the undersurface of the liver’s right lobe and attached there by areolar connective tissue.
 The cystic duct connects the gallbladder to the common hepatic duct to form common bile duct.

FUNCTION OF THE GALLBLADDER

Stores bile enters to the gallbladder by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five folds to ten folds. Then later when
digestion occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice, a yellow discoloration of
the skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it
absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.

The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile,
which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.

24
 V. PATHOPHYSIOLOGY

Non Modifiable Factor: Modifiable and Precipitating Factor:

Heredity Food preference (high cholesterol/fat)

Liver excrete Liver excrete Invasion of Liver excrete

relatively high conjugated bacteria in the some
proportion of bilirubin into gallbladder unconjugated
cholesterol in the bile bilirubin into
bile bile
Calcium enters bile
Attraction of
The bacteria passively along
Leukocytes
hydrolyze with other
Bile is supersaturated
conjugated electrolytes
with cholesterol
bilirubin

Leukocytes
Unconjugated
Increase in hydrolyze
Bilirubin tends to
unconjugated bilirubin
Formation of solid form insoluble
bilirubin conjugates and
Crystals precipitates with
fatty acids
calcium
25
 Crystals must come Formation of Formation of
together and fuse to form stones Calcium
stones Bilirubinate

Gallstones in the bile ducts/gallbladder

(Cholesterol, brown/black pigment)

Mild to moderate pain/biliary colic in the right

part of the abdomen – due to functional spasm
of the cystic duct; irritation of the viscera

(July 30, 2010)

Obstruction of the bile ducts

26
 Continues irritation
of the gallbladder

Inflammation of the
gallbladder

CALCULOUS
s/s CHOLECYSTITIS s/s

Nausea and Severe Pain/biliary Fever – due

Jaundice – due to Clay-colored stool – vomiting – may colic – due to to elevated
obstruction of bile may result from accompany a inflammatory WBC because
flow problems in the biliary gallbladder attack process of bacteria
system; due to invasion in
(July 30, 2010) (July 31, 2010) (August 01, 2010)
absence of bile in the the injured
duodenum; warning gallbladder
signal that’s something
wrong with digestion (August 01,
2010)
(July 31, 2010)

Facial Guarding
grimace behavior

(August (August
01, 2010) 01, 2010)
27
 IF TREATED IF NOT TREATED

 PHARMACOLOGIC TREATMENT POSSIBLE COMPLICATIONS:

o Antimicrobials
o Narcotic Analgesics  Ischemia
o Anticholinergics  Necrosis
o Antiemetic  Rupture of gallbladder
o Gallstone solubilizer  Gangrene
 Peritonitis
 SURGICAL TREATMENT:  Liver diseases such as Liver cirrhosis, Liver Cancer
o Open/Laparoscopic Cholecystectomy
o Lithotripsy
o Endoscopic papillotomy

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 CALCUOUS CHOLECYSTITIS - is the inflammation of the gall bladder resulting from an obstruction of bile outflow due to gallstones

Signs and Symptoms

Rationale

Biliary Colic The most common symptom is pain in the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic,
which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-counter drugs and isn't helped by passing
wind. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is caused by the
functional spasm of the cystic duct when obstructed by stones, whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall.
Nausea and Vomiting These signs and symptoms may accompany a gallbladder attack. Pain is usually accompanied by nausea and vomiting.

Fever and chills Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever, also due
to the irritation and inflammation of the gallbladder wall.

Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied by chills

Loss of appetite and Anorexia The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain. Fat absorption is
also impaired for the lack of bile salts; As a result, rapid loss of weight and anorexia can occur.

Jaundice Due to obstruction of the bile flow.

Clay-colored stool may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal that’s something wrong with digestion

Nausea and vomiting may accompany a gallbladder attack

Facial grimace and Guarding Accompanied by pain

behavior

29
Precipitating Factors:

Factors Rationale

Increased intake of cholesterol and saturated fats has all been postulated to cause cholesterol gallstones.
Diet (high cholesterol, high fats)
If there is an increased production of cholesterol, bile is being supersaturated with cholesterol, that leads in formation of crystals/stones.

Hypolipidemic agents (clofibrate, gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol
Medications gallstones by two fold to three fold.

Estrogen therapy is associated with an increased risk of developing cholesterol gallstone; estrogen increases biliary cholesterol secretion.

Oral contraceptive steroids increase biliary cholesterol secretion and saturation but do not affect gallbladder motility.

TPN is a powerful risk factor for gallstone formation. Gallstones form during TPN because of decreased gallbladder motility from lack of meal-stimulated
Total Parenteral Nutrition cholecystokinin (CKK) release, resulting in increased fasting and residual volumes.

Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. This high risk, which is 20 times normal, is
Spinal Cord Injury believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass.

Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Stone analysis has not been performed, but the elevated cholesterol
Primary Biliary Cirrhosis saturation of bile in these patients suggests that they form cholesterol stones.

Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes, diabetes mellitus itself
Diabetes Mellitus does not appear to be an independent risk factor for cholesterol gallstone disease.

Inherited hemolytic anemia, sickle cell disease, sphericytosis, thalassemia, chronic hemolysis associated with artificial heart valves, and malaria
Hemolytic Syndromes dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates, especially bilirubin
monoglucoronide, at the expense of the bilirubin diglucuronide, the predominant conjugate in healthy individuals.

30
Ileal Disease, Resection, and Bypass Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. Gallstones develop in 30-50% of patients with ileal Chron’s
disease; the risk correlates positively with the extent and duration of ileal dysfunction, Although ilieal disease or resection leads to cholesterol
supersaturation and cholesterol stone formation in some

Patients, careful studies now show that most patients with ileal dysfuncyion form black pigment, not cholesterol stones.

Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually
Biliary Infection (bacterial) E.coli or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable
associated with bile stasis, biliary tree infection, and/or retained suture material.

Obesity is strongly associated with increased gallstone prevalence. The risk is proportional to the increase in total body fat. Obese people synthesize more
Obesity cholesterol in both hepatic and nonhepatic tissues, transport it to the liver, and secrete more of it into the bile, leading to bile that is often greatly
supersaturated with cholesterol.

Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week), either by very low caloric dieting or gastric stapling, have
Rapid Weight Loss/ Fasting diets a 25-40% chance of developing gallstones within 4 months. During rapid weight loss,

biliary cholesterol saturation increases acutely as cholesterol is mobilized from adipose tissue and skin and secreted into bile.

31
Predisposing Factors:

Factors Rationale

Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. Before puberty this risk is
Gender negligible, and beyond menopause the increased risk disappears.

The incidence increases with age. Less than 5-6% of the population under age 60 has stones, in contrast to 25-30% of those over 80. It usually affects
Advancing Age people with age of over 60 but it is more prevalent after 80 years of age.

Prevalence highest in North American Indians, Chilean Indians, and Chilean Hispanics, greater in Northern Europe and North America than in Asia, lowest
Race in Japan; familial disposition; hereditary aspects

Family history alone imparts increased risk, as do a variety of inborn errors of metabolism that lead to impaired bile salt synthesis and secretion
Heredity or generate increased serum and biliary levels of cholesterol, such as defects in lipoprotein receptors (hyperlipidemia syndromes), which
engender marked increases in cholesterol biosynthesis.

Pregnancy is an independent risk factor for cholesterol gallstones. The risk increases with increasing parity, especially with more than two children. During
Parity/ Pregnancy pregnancy, elevated estrogen and progesterone levels increase biliary cholesterol secretion. Elevated progesterone also inhibits gallbladder contractility.
40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy.

32
 REVIEW OF SYSTEMS

LYMPHATIC

 Increase WBC
o There is an attraction of leukocytes due to invasion of bacteria.

GASTROINTESTINAL

 Inflammation of the gallbladder

o Due to obstruction of cystic duct and decrease blood flow that can cause invasion of bacteria, bacteria attracts leukocytes, phagocytosis occur that results in
inflammation of gallbladder

 Improper emulsification of fat (problem with GIT)

o Due to obstruction of bile out flow, there is an insufficient amount of bile that comes in the duodenum

INTEGUMENTARY

 Jaundice
o Due to obstruction bile outflow into the duodenum

RESPIRATORY

 Short shallow breathing

o Due to pain

33
 PHYSICAL ASSESSMENT

Name: NJE T – 37.2 ºC

Age: 22y/o P – 91 bpm
Date of assessment - August 02, 2010 R – 31 cpm
BP – 110/80mmHg

GENERAL APPEARANCE

Method Normal Findings Actual Findings Remarks

1. Body Built

Ht. Inspection and Proportionate, normal BMI in Proportionate

observation
Wt. relation to age
Ht:5’6’’ Normal
BMI
Wt:54kg

BMI:19.1

Deviation from normal

due to the pain @ the
2. Posture and Gait Inspection and Relaxed, erect posture, Slouched, uncoordinated incision on the right
observation coordinated movement movement upper quadrant of the
abdomen

3. Over-all Hygiene and Grooming Inspection and Clean and neat Clean and neat ; no body and Normal
Observation breath odor
34

4. Signs of Distress
Deviation from normal
Inspection and No signs of distress Present signs of distress such as
due to pain at the site of
observation facial grimace with guarding
incision at right upper
behavior
quadrant of the
abdomen

Deviation from normal

5. Obvious signs of health or illness Inspection and No signs of illness or disease Appears weak with facial grimace
due to present
observation and guarding behavior
condition; Post
cholecystectomy

MENTAL STATUS

1. Level of Consciousness/ Inspection Conscious and coherent; Oriented Oriented to date, place and time Normal
to time, place and situation situation
Orientation
Deviation from normal
due to pain at the site of
2 Emotional Status Inspection No facial grimace (+) facial grimace incision at right upper
quadrant of the
abdomen

3. Attitude Inspection Cooperative Cooperative during assessment Normal

Deviation from normal

due to pain at the site of
4. Affect/mood, appropriateness of Inspection Appropriate to the situation Responses are appropriate to the incision at right upper
responses situation; irritated quadrant of the
abdomen.

35
 SKIN

Deviation from normal

due to the effect of
1. Color Inspection Uniform in color Yellowish discoloration bilirubin that is still
present at the blood
streams.

Deviation from normal

due to water retention
2. Presence of Edema Inspection and Absence of Edema (+) peripheral edema caused by fluid shifting
from intracellular to
Palpation intravascular.

With incision at the right upper Deviation from normal

3. Presence of Lesions Inspection No Lesions
quadrant of abdomen due to status post
cholecystectomy

4. Moisture of the skin Palpation Moist in Axilla and skin folds Moist in Axilla and skinfolds Normal

5. Temperature Palpation Uniform temperature Uniform temperature Normal

6. Skin Turgor Palpation When pinched, it springs back It springs back to previous state Normal
within 3 seconds <3 seconds

NAILS

Convex curvature, angle of nail Convex curvature, angle of nail

36
1. Fingernail plate shape Inspection plate is approx. 160° plate 160° Normal

2. Fingernail and toenail bed color Inspection Highly vascular and pink in light Nail beds are highly vascular Normal
skin clients

3. Fingernail and toenail texture Inspection and Smooth texture Smooth texture Normal
Palpation

4. Tissue surrounding nails Inspection Intact epidermis Intact epidermis Normal

5. Blanch Test of Capillary refill Inspection and Prompt return to pink or usual Prompt return within 3 seconds Normal
Palpation color within 3 seconds normal capillary refill

HEAD

SKULL

Rounded, Normocephalic and Rounded, Normocephalic and

1. Shape Inspection Normal
symmetrical with frontal, parietal symmetrical with frontal, parietal
and occipital prominences. and occipital prominences.

2. Presence of nodules, masses and Smooth uniform consistency, Smooth uniform consistency,
Palpation Normal
depressions absence of nodules and masses absence of nodules and masses

3. Evenness of hair growth over the Inspection and

scalp Palpation
Hair evenly distributed Hair evenly distributed Normal

37
4. Hair thinness or thickness Inspection Thick hair Thick hair Normal

5. Hair texture and oiliness Inspection and Silky and resilient hair Silky and resilient hair Normal
Palpation

FACE

1. Facial Features Inspection Symmetric or slightly asymmetric Slightly asymmetric facial Normal
facial features features

2. Symmetry of facial movements Inspection Symmetric facial movements Symmetric facial movements Normal

EYES

EYEBROWS

1. Hair distribution Inspection Hair evenly distributed Hair evenly distributed Normal

2. Alignment Inspection Symmetrically aligned Symmetrically aligned Normal

Inspection by asking the

client to raise and lower
3. Skin quality and movement the eyebrows intact skin, equal movements intact skin, equal movements Normal

EYELASHES

1. Evenness of hair distribution Inspection Equally distributed Equally distributed Normal

38
2. Direction of curl Inspection Curl slightly outward Curl slightly outward Normal

EYELIDS

Surface characteristics
Inspection Skin intact, no discharge and Skin intact, no discharge and no Normal
discoloration discoloration

Approximately 15-20 involuntary

Frequency of blinking Inspection 18 blinks/min. Normal
blinks per minute

CONJUNCTIVA

BULBAR CONJUNCTIVA

1. Color, texture and presence of Inspection by reverting Transparent. Capillaries Transparent. Capillaries
Normal
lesions the eyelids sometimes evident. No presence of sometimes evident. No presence
lesions of lesions

PALPEBRAL CONJUNCTIVA

Inspection, by retracting
1. Color, texture and presence of Shiny, smooth, pink or red in color Pink in color, smooth and shiny Normal
the eyelids with thumb
lesions and index finger and
asking the client to look
up and down, side to
39
 side.

SCLERA

Deviation from normal

1. Color Inspection Sclera appears white Slightly yellow in color
due to effect of bilirubin
in the blood streams

CORNEA

Normal

1. Clarity and texture Inspection using a Transparent, shiny and smooth Transparent, shiny and smooth

penlight

PUPIL

1. Color, shape and symmetry of size Inspection Black in color, round equal in size Black in color, round equal in Normal
size

EARS

AURICLES

Inspecting for position.

Note the level at which
1. Color, symmetry of size and the superior aspect of Color same as the facial skin, Same color with the facial skin Normal
position the auricle attaches to symmetrical, auricle aligned with
the head in relation to the outer canthus of the eye.
the eyes.

40

2. Texture, elasticity and areas of
tenderness
1. External nose for deviations in
shape, size or color and flaring or
discharge from the nares.
2. External nose for any areas of
tenderness, masses and
displacements of bone and cartilage
3. Patency
4. Mucosa
5. Nasal Septum
Palpation by gently
pulling the auricle
downward then Mobile, firm and not tender. Mobile, firm and not tender. Normal
backward and folding Pinna recoils after being folded.
the pinna.
NOSE
Symmetric; no discharge or Symmetric; no discharge or
Inspection Normal
flaring; uniform color flaring; uniform color
Palpation No tenderness masses and No tenderness masses and Normal
displacements displacements
Inspection (by asking
the client to close the
mouth and then exert Air moves freely as the client Air moves freely as the client Normal
pressure or the nares, breathes through the nares breathes through the nares
and breathe through the
opposite nares and
repeat for the other)
Observation and pink; clear watery discharge; No Mucosa pink; clear watery
inspection lesions and swelling discharge; No lesions and
swelling noted Normal
Inspection intact and in midline intact and in midline Normal
41
6. Sinuses Palpation Not tender No tenderness noted Normal

MOUTH

LIPS AND BUCCAL MUCOSA

1. Outer lips for symmetry of

Uniform pink color; soft, moist,
contour, color and texture Uniform pink color; soft, moist,
Inspection smooth texture Normal
smooth texture

2.Inner lips and buccal mucosa for

color, moisture, texture and the
Inspection and Uniform color; moist, no lesions Uniform color; moist, no lesions Normal
presence of lesions
palpation

TEETH AND GUMS

Smooth white tooth enamel, pink Smooth white tooth enamel, pink
1. Characteristics Inspection Normal
gums with moist, firm texture. gums with moist, firm texture

Central position, smooth lateral Central position, smooth lateral

margins; no lesions; raised margins; no lesions; raised
2.Tongue movement Inspection papillae papillae; moves freely Normal

3. Base of the tongue, floor of the Smooth base of the tongue with Smooth base of the tongue with
Inspection Normal
mouth and frenulum prominent veins prominent veins

42
4. Presence of nodules, lumps or Inspection and
Smooth with no palpable nodules Smooth; no palpable nodules Normal
excoriated areas Palpation

PALATES AND UVULA

1. Hard and soft palate for odor, Light pink, smooth soft palate; Light pink, smooth soft palate;
Inspection Normal
shape, texture and presence of bony lighter pink, hard palate; no bony lighter pink, hard palate more
prominences growths. irregular texture; no bony
growths.

2. Uvula for position and mobility Inspection Positioned in midline of soft palate Positioned in midline of soft Normal
palate

TRACHEA

1. Lateral Deviations Palpation Central Placement in midline of Central Placement in midline of Normal
neck neck

THORAX AND LUNGS

1. Shape and symmetry of the thorax Inspection Antero-posterior to transverse

from posterior and lateral views diameter ratio of 1:2
Ratio of 1: 2 Normal

2. Respiratory Excursion Palpation Full symmetric chest expansion Thumb separated 3cm Normal

43
 Bilateral symmetry of vocal Bilateral symmetry of vocal
3. Vocal (tactile) Fremitus Palpation Normal
fremitus fremitus; equal vibration

Vesicular and broncho- vesicular Vesicular and broncho- vesicular

4. Breath sounds Auscultation Normal
breath sounds breath sounds

Deviation from normal

5. Breathing Pattern Inspection Rhythmic; effortless Use of accessory muscles upon
due to pain
breathing; shallow breathing (compensatory
mechanism)

ABDOMEN

Deviation from normal

1. Skin integrity Inspection Unblemished skin; uniform color Impaired skin integrity with due to Cholecystectomy
incision on the right upper on the right upper
quadrant quadrant of the
abdomen.

2. Contour and symmetry Inspection Flat, rounded or scaphoid; Flat; Symmetrical Normal
symmetrical

3. Abdominal movements associated Observation Symmetric movements Symmetric movements Normal

with respirations
Deviation from normal
due to status post
4. Bowel sounds Auscultation Audible bowel sounds Hypoactive bowel sounds cholecystectomy

44
 Deviation from normal
5. Areas of tenderness Palpation No tenderness; relaxed abdomen Presence of tenderness
due to status post
cholecystectomy

MUSCLES

Equal in size in both sides of the Equal in size in both sides of the
1. Size Inspection Normal
body body

2. Contractures (Softening) Inspection No contractures No contractures Normal

3. Fasciculations and tremors Inspection Palpation No tremors No tremors Normal

4. Muscle tonicity Palpation Normally firm Firm Normal

UPPER EXTREMITIES

1. Motor strength Inspection Can perform ROM exercise for Can perform ROM exercise Normal
upper extremities easily

2. Muscle tone Palpation Smooth and firm Smooth and firm Normal

3. Presence of lesions, deformities No lesions present, no deformities,

Inspection No lesions, no deformities Normal
and varicosities varicosities may be present

Inspection and
4. Presence of edema No edema no edema noted Normal
Palpation

45
 LOWER EXTREMITIES

1. Motor strength Inspection Can perform ROM exercise for Can slightly perform ROM Normal
lower extremities easily

Deviation from normal

due to status post
2. Muscle tone Palpation Firm muscle tone muscle tone not firm cholecystectomy

No lesions, varicosities may be

3. Presence of lesions, deformities Inspection No lesions, no deformities Normal
present, no deformities
and varicosities

Deviation from normal

due to water retention,
4. Presence of edema Inspection and No edema edema noted the liver and kidney are
Palpation compensated.

46
 VI. Laboratory / Diagnostic Procedure

Diagnostic Date Indication or Result Normal Analysis Nursing Responsibilities

Laboratory Purpose values and
Ordered Result Prior During After
Procedures interpreta
in
tion of
the
results

A white blood cell Above -Check if there’s -Use standard -Label the
count is a normal a doctor’s order precaution and specimen
CBC August 01, August determination of WBC 10.6 5.0- range. An for CBC sterile container with
number of WBC or elevated technique when name, age,
(Complete 2010 01, leukocytes/unit 10.0x1 number getting date and time
Blood 2010 volume in a sample 09/L of specimen the specimen
of venous blood. leukocyte -Explain the was
Count) The test is used to s can procedure to the -apply pressure obtained,room
detect infection or result patient on the no., the doctor
inflammation and from venipuncture who ordered
also used to help infectious site after the specimen.
monitor the body’s diseases withdrawing
response to various (usually specimen
treatments and to bacterial
monitor bone origin), -Send the
marrow function, and with specimen to
and to determine the trauma or the laboratory
need for further surgery. immediately
tests, such as
differential count.

47
Hemoglobin is an
important
component of red HGB 168 M: Within
blood cells that normal
carries oxygen and 140-
range
carbon dioxide to 170
and from tissues.
The hemoglobin
F: 120
determination test is
– 150
used to screen for
diseases associated g/dL
with anemia and in
determining acid-
base balance. The
oxygen carrying
capacity of the blood
is also determined
by the Hemoglobin
concentration.

Measures the
percentage of RBC
in a blood volume. HCT 0.48 M: 0.40 Within
The test is
performed to help - 0.60 normal
diagnose blood range
disorders, such as F: 0.38
polycythemia,
– 0.40
anemia or abnormal
dehydration, blood
transfusion decisions
for severe
symptomatic
anemias, and the
effectiveness of
those transfusions.

48
The smallest formed
elements in blood
that promote blood PLT 268 150 – Within
clotting after an
injury. The test is 450 normal
performed to range
determine if blood X109/L
clots normally,
evaluate platelet
production, and to
diagnose and
monitor a severe
increase or decrease
in platelet count

A small white blood

cell (leukocyte) that
plays a large role in Lymphocytes 0.36 0.2- Above
defending the body
against disease. 0.35 normal
Evaluate bacterial range
and viral infection,
immune disease,
leukemia, and
ulcerative colitis

49
 Prothrombin time

Within
1. Control 13.0 12-15
normal
sec range

Within
2. Activity 70-100 74.3 %
normal
range

Within
3. INR 0.8 – 1.2 1.14
normal
range

4. Partial Within
35-45 38.7
thromboplast normal
in Time sec range

50
 The gallbladder is not distended >> Explain the > Patient can
measuring 5.5 x 2.5 cm. the previously noted >> explain the
purpose and the expect to
solitary gallstone has increase in size from 5-
procedure of the following: resume
6.1 mm. wall is not thickened. test. her/his normal
activities
Impression: >patient will be
immediately.
ask to lie on the
examination
> Instruct him
couch next to
not to eat solid
ultrasound
food for 12 >inform
IMPRESSION machine
To visualize hours prior to patient
abdominal exam to allow regarding the
> Solitary Cholecystitis with increase greatest dilation result
structures by using
non-invasive in size of the
Abdominal August 01, August gallbladder
diagnostic
ultrasound 2010 01, 2010 technique in which
high-frequency
sound waves are >the area to be
passed into internal >Inform patient
scanned will be
bofy structures. that ultrasound
exposed and a
is a noninvasive
clear water-
procedure.
soluble gel will
be applied to
the skin for the
transmission of
sound waves
into the
patient’s body

51
>a scan probe
will then be
placed in
contact with
patient’s body
and move over
the skin to
examine the
tissues below.

>the parient
will experience
no pain during
the procedure

>Ultrasound
scans take
approximately
30 min. to
complete.

52
VII. Patient and His Care

A. Medical Management

DATE ORDERED/
DATE
MEDICAL GENERAL INDICATIONS/ CLIENTS NURSING RESPONSIBILITIES
PERFORMED/
MANAGEMENT DESCRIPTION PURPOSE RESPONSE TO
DATE CHANGE
TREATMENT THE
OR DC
PROCEDURE
PRIOR:
1.) IVF (D5LRS) 5% Dextrose in  Determined the type of solution to be infused.
Date For rehydration No signs of
Lactated Ringers  The rate of flow or the time over which the
ordered/performed dehydration. infusion is to be completed.
Solution
>Regulated @ 30-
August 01, 2010  Assess the vital signs, skin turgor.
31 gtts/min
Date discontinued:
DURING:
August 03,2010  Prepare the infusion set.
 Spike the solution container.
 Prime the tubing.
 Perform aseptic technique.
 Initiate the infusion.
 Regulate the infusion.
AFTER:
 Document relevant data.
 Monitor client’s response.
 Evaluate if IV flow is consistent with what
ordered.
 Assess the infusion site.

53
 DATE ORDERED/
MEDICAL GENERAL INDICATIONS/ CLIENTS NURSING RESPONSIBILITIES
DATE
MANAGEMENT DESCRIPTION PURPOSE RESPONSE TO
PERFORMED/
TREATMENT THE
DATE CHANGE
PROCEDURE
OR DC

Date
Oxygen ordered/performed: - Oxygen therapy is -facilitate -the patient PRIOR:
therapy the administration of breathing relieved  Check for the doctor’s order including the flow
August 01, 2010
oxygen as medical difficulty of rate of O2
Date discontinued: intervention. Oxygen -to increase breathing.
(3LPM via
face mask) August 02,2010
is essential for cell oxygen  Check and how to administer for the oxygen
metabolism, and in saturation in -the patient tank, humidifier, and flow rate meter if they are
turn, for tissue tissues
demonstrate working.
oxygenation.
adequate  Place “no smoking” sign at the head or foot of
-it is an oxygenation the bed.
administration of
oxygen at DURING:
concentration greater  Assess for kinks and obstruction
than that in room air  Secure the tubing, comfortably.
to prevent hypoxemia  Observe for moisture in the mask to
and hypoxia.
prevent aspiration.
 Observe the pressure necrosis.

AFTER:
 Check for client’s response to the therapy.
 Check for the skin irritation.
 Perform after care.

54
B.Drugs

Date ordered, Route of

taken/given General action, Client response to the
Name of drug administration, Indications/Purpose Nursing Responsibilities
Classification, medication, actual
dosage,
Date changed/ D/C Mechanism of Action side effects
frequency

Classification: PRIOR
H2 RECEPTOR
Generic Name: Date ordered: 50 mg INDICATION Clients response 1. Assess patient for contraindication.
BLOCKER
RANITIDINE TIV Q8 GENERAL ACTION 2. Assess for baseline data.
August 01, 2010 >Short-term treatment >decreased
3. Tell patient that he may experience
>anti-ulcer of active duodenal ulcer abdominal pain
Brand Name: Stock Dose: side effects brought about by the
ZANTAC 25 mg/mL MECHANISM OF > Maintenance therapy drug.
ACTION for duodenal ulcer at DURING
Side effects
reduced dosage
>Competitively inhibits the 1. Administer the drug slowly.
>abdominal pain,
action of histamine at the >Short-term treatment
H2 receptors of the parietal constipation, AFTER
of active, benign gastric
cells of the stomach,
ulcer 1. Instruct him to report intolerable
inhibiting basal gastric acid
side effects so as prompt intervention
secretion and gastric acid
could be done.
secretion that is stimulated
2. Instruct him to report adverse
by food, insulin, histamine,
cholinergic agonist, effects that he may experience.

gastrin, and pentagastrin.

55
 Date ordered, Route of Client response

taken/given administration, General action, Classification, to the

.Name of drug Indications/Purpose Nursing Responsibilities
dosage, Mechanism of Action medication,
Date changed/ D/C frequency actual side effects

PRIOR

1. Assess for contraindication.

Generic Name: Date ordered: 10 mg Classification: Indication: Clients response
2. Assess for baseline data.
VITAMIN K TIV Fat soluble vitamin >Prevention of
August 01, 2010 >N/A 3. Teach patient not to take other
Q8 bleeding,
Brand Name: GENERAL ACTION
supplements, unless directed by
>hypoprothrombinemia Side effects:
Aquamephyton prescriber, to take this medication as
>anti-coagulant
>N/A directed.
MECHANISM OF ACTION
4. Tell patient that he may experience
>Vitamin K is essential for the side effects brought about by the
hepatic synthesis of factors II, drug and to report symptoms of
VII, IX, and X, all of which are bleeding: bruising, nosebleeds,
essential for blood clotting. bleack tarry stools, hematuria.
Vitamin K deficiency causes an DURING
increase in bleeding tendency, 1.Slowly administer the medication
demonstrated by ecchymoses,
AFTER
epistaxis, hematuria, GI
1.Instruct patient to report adverse
bleeding.
effect that he may experience

56
 Date ordered, Route of
General action, Client response to the
taken/given administration,
Name of drug Classification, Indications/Purpose medication, actual Nursing Responsibilities
dosage,
Date changed/ D/C Mechanism of Action side effects
frequency

PRIOR

Generic Name: Date ordered: 750 mg Classification: Indication: Clients response 1. Assess patient for contraindication.
CEFUROXIME- TIV ANTIBIOTIC;CEPHAL >Maintenance Surgical 2. Assess for baseline data.
August 01, 2010 >pain is felt upon
SODIUM Q8 OSPORIN (2ND prophylaxis 3. Have vitamin K readily available
administering IV
GENERATION) in case of hypoprothrombinemia
push
occurs.
Brand Name: Stock dose: DURING
GENERAL ACTION:
CEFUROXIME
750 mg/50 mL Side effects 1.Reconsitute 1gram with 10 or more
>Bactericidal
ml of sterile water
>no side effects
MECHANISM OF
AFTER
ACTION
1. Instruct patient to avoid alcohol for
>inhibits synthesis of
3days after drug administration
bacterial cell wall,
because serious reactions often occur.
causing cell death.
2. Tell patient that he may experience
some side effects brought upon by
the drug.

57
 Date ordered, \Route of
General action, Client response to
taken/given administration, Indications/Purp
Name of drug Classification, Mechanism the medication, Nursing Responsibilities
dosage, ose
Date changed/ D/C of Action actual side effects
frequency

Generic name: Date ordered: 500 mg Classification: INDICATION Clients response PRIOR
TIV >Nitroimidazole derivative
METRONIDAZOLE August 02, 2010 >for >N/A 1. Check for doctor’s order
Q8
preoperative
HYDROCHLORIDE 2. Not to be given in patients
GENERAL ACTIONS:- prophylaxis
hypersensitive to drugs
Side effects
Stock dose: >Anti-infective
3. Inform the patient about the possible
Brand name: >dark urine
500 mg/100 mL >Anti-protozoal side effect of the drug
FLAGYL IV
MECHANISM OF DURING
ACTION
1. Inject IV port slowly, over not less than 2
>Disturbs DNA synthesis in min.

susceptible bacterial
AFTER
organism. 1. Advise patient to report abdominal
pain.

58
Name of drug Date ordered, Route of General action, Indications/Purp Client response to Nursing Responsibilities
taken/given administration, Classification, Mechanism ose the medication,
dosage, of Action actual side effects
Date changed/ D/C
frequency

Classification PRIOR

Generic name: Date ordered: 300mg, TIV now, Nonopoid analgesics and INDICATION Clients response 1. Check for doctor’s order
antipyretic
q4, PRN for ≥
PARACETAMOL August 02, 2010 >reduce body >fever decreases 2. Not to be given in patients
38°C GENERAL ACTIONS
temperature from 38°C- 37°C hypersensitive to drugs
Brand name:
> decreases body
ACETAMINOPHEN 3. Inform the patient about the possible
temperature
side effect of the drug
MECHANISM OF
DURING
ACTION

1. Inject directly slowly

> Reduces fever by acting
directly on the AFTER
hypothalamic heat-
1. Tell patient that he may experience
regulating center to cause
some side effects brought upon by the
vasodilation and sweating,
drug
which helps dissipate heat.

59
 Date ordered,
taken/given Route of General action, Client response to
Name of drug administration, Classification, Indications/Purpose the medication, Nursing Responsibilities
Date changed/ dosage, frequency Mechanism of Action actual side effects
D/C

PRIOR

Generic Name: Date ordered: 200 mg Classification: . Indication: Clients response 1. Take drug with food if GI upset
CELECOXIB PO NONSTEROIDAL >Management of acute pain. occurs
August 02, 2010 FOR PAIN ANTI- >verbalized
Brand Name: INFLAMMATORY decreased pain felt 2. Determine any GI bleed/ulcer
CELEBREX Stock dose: DRUG history, sulfonamide allergy,
100 mg and aspirin and other NSAID-
Contraindications: 
200 mg GENERAL ACTION induced asthma, urticaria,
>Contraindicated with allergies
>Pain reliever to sulfonamides, celecoxib, allergic type reaction
NSAID, or aspirin
3. Monitor sign and symptoms
MECHANISM OF
4. Assess for liver or renal
ACTION
dysfunction; reduce dose
>Inhibits prostaglandin
synthesis, primarily by DURING

inhibiting cyclo- 1. Take with foods; decreases

oxygenase-2 thus stomach upset
decreasing inflammation.
AFTER

1. Tell patients that he may

experience some side effects brought
about by the drug

60
C. Diet

Indication/ Specific Nursing Responsibilities

Date General Client
Type of diet Date Change foods/fluids
Started Description Purposes Response Prior During Post
taken

NPO(Nothing 08/01/10 08/02/10 An instruction This diet is None Feels hunger -asses the level of -Strictly -Instruct the client to
Per Orem) meaning to usually ordered and thirst, understanding of monitor continue NPO as
withhold oral for preparation appears weak the patient clients prescribed by the
foods and fluids, prior to surgery behavior in physician.
but for patients specially who -Explain the following
importance of
who will undergo will undergo NPO.
surgery, the general following strictly
physician will anesthesia to NPO in terms that
the client can
allow small prevent
amount of fluid aspiration and understand and
then evaluate
intake for oral pneumonia
medication

General 08/02/10 08/03/10 Diet that allows Before DAT diet 90 ml of water Feels hunger, -Asses the level of -Strictly - General Liquid diet
Liquid Diet intake of fluid or is instructed the appears weak understanding of monitor was instructed and
liquid forms of physician first the patient clients maintained to train the
food only ordered is behavior in normal digestion
general liquid -Explain the following process.
diet to train the importance of General
following strictly
normal digestion Liquid diet
and to bring General Fluid diet
back the normal in terms that the
client can
digestion
process understand and
then evaluate

61
 -Emphasize what
kind of foods the
client can eat
during this diet.

DAT( diet as 08/03/10 (until It is a diet that Instructed Lugaw, egg and Relieved -Asses the level of -Strictly -Advised the client to
tolerated) discharge) allows the patient following a rice hunger understanding of monitor take soft foods and
to eat all general liquid the patient clients avoid food rich in fats.
types/kinds of diet for better Pinakbet and rice behavior in
foods as long as source of good -Explain that following
Monggo and rice immediate shifting
the client can nutrition. DAT diet
tolerate it. Sinigang na of foods from NPO
bangus and rice to General Fluids
to DAT without
undergoing soft
diet can result to
constipation, that’s
why we need to
emphasize eating
first soft foods
before eating any
solid foods

62
D. Exercise

Type of exercise Date started General description Indications/purpose Client response

NURSING RESPONSIBILITY

A type of exercise that  aids in good circulation The patient BEFORE:

Ambulation 08/02/10 requires the patient to tolerated the
exercise move by feet  facilitate voiding exercise but he Ensure that the patient understand the reason
felt little bit tired for doing the exercise
>Walking  stimulate peristalsis
Assist to stand to prepare for ambulation.
 prevent
DURING:
thromboembolism
Assist patient while doing the exercise if
necessary.

Check if there is difficulty in breathing

Check if he feels any pain while doing the

exercise

AFTER:

Recheck if he feels any pain after the exercise

Monitor the V/S of the patient to check if there

are changes

Document relevant data’s.

63
VIII. SURGICAL MANAGEMENT

 The circulator accompanies the anesthesia provider and the patient to the PACU; he/she gives the PACU perioperative
practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual.
 Assess the patient: appraise air exchanges status & note skin color; verify & identify operative status & surgeon
performed; assess neurological status (LOC)
 PACU nurse observes the patient’s breathing, monitors blood pressure and vital signs, and documents all
Postoperative pertinent information.
 PACU nurse assumes the role as the patient’s advocate..
 Report for abnormalities especially for signs and symptoms of shock
 Perform safety checks – good body alignment, side rails and maintain patent airway and cardiovascular
stability
Relieve pain and anxiety

Post operative:
 Patient finds it hard to sleep because of pain felt on the incision site
 Client appears weak
Client Response

Skin color improvement (August 03, 2010)

64
IX. NURSING CARE PLAN

Assessment Nursing Diagnosis Background Planning Nursing Interventions Rationale Evaluation

Knowledge

Short Term: Independent Goal met.

S: “masakit yung Acute Pain related Cholecystectomy After 2 hours of 1. Observe and document 1. Assists in After 2 hours of
tahi ko,” As to inflammation nursing intervention location, severity and differentiating cause nursing intervention
verbalized by the and distortion of the patient pain character of pain. of pain and provides the patient pain scale
patient. tissues r/t injuring Surgical incision on scale will decrease information about was decreased from
the right lower
agent quadrant of the from 6/10 – 3/10 disease progression/ 6/10 -3/10.
O:Facial Grimace
abdomen resolution,
After 8 hours of
>With guarding development of
nursing intervention
behavior complications and
the patient was
effectiveness of
>Rigidity of the Disruption of skin Long Term: reportedly relief of
tissue and muscle interventions.
abdomen pain.
integrity at RUQ After 8 hours of
2. Note location of 2.This can influence
>Pain scale of 6/10 Nursing
surgical procedure the amount of post-
intervention the
>RR= 24 cpm Stimulation of operative pain
patient will report
sensory nerve experienced
>With short and endings relieved of pain.
shallow breathing 3. To divert attention
3.Instruct/encourage use
and reduce tension
of relaxation techniques
PAIN and to relieved the
such as breathing
patient from pain.
65
 exercise

4. To divert attention
and to relieved the
Source: 4. Encouraged divisional
patient from pain.
activities.
Porth CM. (2002).
5.To prevent fatigue
Pathophysiology:
Concepts of Altered 5. Encourage adequate
Health States. rest periods.
6. Helpful in
Philippines:
alleviating anxiety
Lippincott Williams 6. Make time to listen to
and refocusing
& Wilkins. complaints and maintain
attention which can
frequent contact with the
relieve pain.
patient.

7. To impart
knowledge to the SO
7.Discuss with significant
regarding ways on
others ways where in
how they can
they can assist client and
participate in
reduce precipitating
alleviating the pain
factors that may cause
of the patient.
pain

66
 Dependent To relieve pain.

Administer medication as
prescribed. SOURCE:

Nurses pocket
guide

Diagnoses,
prioritize
interventions,
and rationale,
11th edition

67
Assessment Nursing Background Planning Nursing Rationale Evaluation
Diagnosis Knowledge Interventions

SHORT TERM : 1. Place the pt in a 1. To prevent backaches or Goal met:

surgical incision on the comfortable position. muscle aches.

S: “kumikirot ang Impaired tissue Within 2hrs of After 2hrs of nursing
right upper quadrant of 2. Monitor and
sugat ko sa integrity related nursing intervention intervention the
the abdomen, record vital signs. 2. To note any significant
tagiliran” as to surgical the patient verbalize patient verbalized
Assess general changes that may be brought
verbalized by the incision understanding of understanding of
trauma to the skin condition of skin. about by the disease.
patient (surgery) condition and condition and
causative factor. causative factor.
O: 3.Practiced aseptic
thus impairing the technique for 3. Healthy skin varies from
>Incision at right integrity of the skin
upper right cleaning /dressing/ individual to individual, but
LONG TERM: LONG TERM:
quadrant of the medicating wound should have good turgor, feel
abdomen with After 2-3 days of warm and dry to the touch, be After 2-3 days of
intact and dry Source:
nursing intervention free of impairment, and have nursing intervention
dressing
http://www.nlm.nih.gov/ the patient displays quick capillary refill. the patient displayed
>Status: post
medlineplus/ency/articl progressive 4. Emphasize progressive
operation 4.Reduced risk for infection
e/002930.htm improvement in importance of proper improvement in
cholecystectomy.
wound healing. nutrition and fluid wound healing.
intake.

68
5. Encourage
adequate period of 5. To maintain general good
rest and sleep. health and skin turgor.

6. Promote early
ambulation. 6. a.) To limit metabolic
demands, remain energy available
for healing and meet comfort
needs.

b).Promote circulation and

prevent excessive tissue pressure.

Sources:

Nurses pocket guide

Diagnoses, prioritize
interventions, and
rationale, 11th edition

69
 Assessment Nursing Diagnosis Background Planning Nursing Interventions Rationale Evaluation
knowledge

S: “ Namumula Risk for infection surgical incision Short term goal: 1. Monitor vital signs. 1. Suggestive of presence Goal met.
ang sugat ko sa related to increase Note onset of fever, of infection/ developing
After 5 hours of Short term goal:
tagiliran” as environmental chills, and sepsis.
traumatized tissue nursing intervention
verbalized by the exposure to diaphoresis. After 5 hours of nursing
on the injured site the patient will
patient. pathogen intervention the patient will
identify 2.Practice good hand 2 .Reduce risk of spread of
identify intervention to
O: increasing risk of intervention to washing and aseptic bacteria/ prevent cross
prevent/ reduced the risk of
infection prevent/ reduced wound care. contamination.
>Surgical incision infection.
the risk of
at the right upper
infection. Long term goal:
quadrant of the may result to
3. Inspect incision and 3. Provides early detection
abdomen further After 1-4 days of nursing
complication if not dressings. of developing infectious
intervention the patient
>With intact, dry prevented Long term goal: process.
showed progress of wound
dressing
After 1-4 days of healing.
>Status : Post Source: nursing intervention 5. Cleanse incision site 5. Disinfects site and
Operation the patient will with povidone iodine. prevents multiplication of
Mattson Porth,
Cholecystectomy Essentials of show progress of microorganisms which may
Pathophysiology wound healing cause infection.
Concepts of Altered

70
 6. Instruct client not to 6.Microorganisms thrive at
Health Status,
Lippincott Williams wet incision site. damp areas and makes it

and Wilkins, 2007 conducive for replication

7. Provide a cool 7. Hot room temperature

environment. induces sweating which
may inhibit the healing of
wound and eventually
cause moisture at the area
delaying the healing
process.

8. Assess patient’s 8. Immobility is the greatest

ability to move. risk factor in skin
breakdown.
9. encourage change 9. to prevent pressure to
of position in a certain parts of the body
regular basis

10. emphasize 10.to maintain general good

importance of health and skin turgor
adequate
nutritional/ fluid
Intake
71
11. encourage 11.to enhance good
ambulation as tolerated circulation

Dependent:

>Administer > Prevents invasion of

medications as bacteria or microorganisms
prescribed (antibiotics) at site and eventually
prevents possible infection.

Sources:

Nurses pocket guide

Diagnoses, prioritize
interventions, and
rationale, 11th edition

72
X. HEALTH TEACHINGS

Health Teaching Rationale

Encourage to avoid intake of foods high in fat/cholesterol. After cholecystectomy, the liver still produce bile but in a slow trickle process, therefore
if the diet is high in fat, the malabsorption of fat occurs because the minimal production
of bile cannot handle the normal absorption process

Explain the importance of ambulation. To promote good circulation

Explain to the patient the importance of deep breathing exercises/ divertional activities. Deep breathing exercises/divertional activities help to reduce pain.

Explain to the patient the importance of splinting. Splinting reduces the pressure in the abdomen thus reducing the pain.

Explain to the patient not to touch the incision site with bare hands. To prevent infection.

Explain to the patient the importance of eating small frequent meals (preferably 4-6 Since cholecystectomy is done, the liver will compensate by excreting slow and low
meals) rather than to eat 3 times a day. level of bile that can cause the malabsorption of fat.

Explain the importance of proper hygiene. Prevent the spread of microorganism/cross contamination.

Explain to the patient the importance of maintaining a clean and well ventilated environment. To reduce the risk of infection and to promote patient’s comfort.

73
XI. DISCHARGE PLANNING

Medicines:

 Teach the ff: to the client with regards to proper administration of the prescribed medication
- Cefuroxime 500 mg 3X/day (TID)
- Celecoxib 200 mg PRN when feeling pain.
Environment and Exercise

 encourage to establish a clean and well ventilated environment

 avoid strenuous exercise that cause tension on the affected area and further deprivation
 Daily activities should be spaced to provide rest periods between times of exercise

Treatment

 Advise to continue to take the prescribed home medication until end of the regimen or unless specified by the physician.
 Give relevant information about the drugs, their side effects & their adverse effects.

Health Teaching:

 Explain to patient what to expect afterwards. As the anesthetic wears off, there is likely to be some pain. The anesthetist will prescribe painkillers. Suffering from
pain can slow down recovery, so it’s important to discuss any pain with the doctors or nurses.
 Instruct caring for the stitches, hygiene & bathing, and will arrange an outpatient appointment for the stitches to be removed.
 Instruct patient to comply with the home medications that would be given by his physician.
 Encourage the patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could slow down his recovery.
74
  Encourage him to comply with the dietary modifications; limit the intake of saturated fat to prevent the occurrence of serious post-cholecystectomy side-effects.
 Explain to patient to refer for unusualities immediately.

Out Patient Care:

 Instruct to visit the physician for follow-up check up after 1 week

 If any of the following symptoms are noted he should contact his doctor:
 If the wound become more painful, red, inflamed or swollen.
 If the abdomen swells
 If the pain is not relieved by the prescribed painkillers.
 If a fever develops these could be a sign of an infection that may need to be treated with antibiotics.
Diet:

 Instruct client to limit the intake of foods high in fat

 Advise the patient to eat smaller amount of foods during a single meal. Advised to eat around 5 or 6 smaller meals a day instead of 2 or 3 usual meals.

Spiritual/Safety:

 Encourage going to church and asking for guidance, encourage praying.

 Avoid strenuous activity.

75
 XII. CONCLUSION

Generally, we, the student nurses six days exposure and duty at Bulacan Medical Center have been a memorable experience to us. The exposure had been an avenue for
further development and enhancement of our skills and capabilities in rendering care and promoting holistic wellness to our clients. It reminded us again that nursing profession
entails a deep sense of responsibility and challenging tasks.

After a six (6) days of exposure at BMC Surgery Ward, we the student nurse has identified and understood the causative factors of cholecystitis, its signs and symptoms,
clinical manifestations, diagnostic studies, medical, pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. We
underwent extensive research in order to comprehensively understand our patient’s condition. Upon learning his case, it challenged and motivated us to work hard to provide the
appropriate and effective nursing intervention and care.

Moreover, cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from the
gallbladder. Predisposing factors can include heredity, age, sex and race. With t he presented factors that cannot already be modified, one has to take action towards preventing the
disease to happen. The only one who can help yourself is you alone. With the proper knowledge about the nature of the disease as well as its preventive measures along with
responsibility and sense of will, one can surely direct himself away from the complications.

- GROUP 2

76
XIII. BIBLIOGRAPHY

 http://www.nottingham.ac.uk/nursing/sonet/rlos/bioproc/resources.html
 http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html
 http://www.le.ac.uk/pa/teach/va/anatomy/case5/frmst5.html
 http://digestive.niddk.nih.gov/statistics
 Barbara Howard, Clinical and Pathologic Microbiology, 2nd Edition
 Carol Porth, Pahtophysiology Concepts of Altered Health Sciences, 7 th Edition
 Pathology 3rd Edition by Stanley L. Robbins, M.D.

 Tortora et. Al., Microbiology An Introduction, 8th Edition

 Kasper et. Al., Harrison’s Principle of Internal Medicine, 16th Edition
 Deglin, Judith H., Vallerand, April H. Davis’s Drug Guide for Nurses, 10th ed.

 Damjanov, I., Linder, J. Anderson’s Pathology. 10th edition USA: Mosby-

 Yearbook 1996.
 Fauci A. et al. Harrison’s Principles of Internal Medicine. 16th edition. USA: The
o McGraw-Hill Companies 2005.
 Bullock, B. Henze, R. Focus on Pathophysiology. Philadelphia, USA:Lippincott,
o Williams and Wilkins 2006.
 Clinical Applications of Nursing Diagnoses. F.A. Davis Company, Philadelphia.
o 4th edition.
 Nutritional Therapy and Pathophysiology. Nelms, Sucher, Long. 2007. Thomson
o Brooks/Cole, The Thomson Corporation. 10 Davis Drive Belmont, CA, USA.

77
 Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne C.
o Brunner & Suddarth’s Textbook of Medical- Surgical Nursing, 11th ed. Vol.1.
o Lippincott Williams & Wilkins, 2008.
 Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice C. Nursing Care
o Plans 7th ed. F.A. Davis Company, Philadelphia, Pennsylvania,2006.
 Karch, Amy M. 2007 Lippincott’s Nursing Drug Guide. Lippincott Williams &
o Wilkins, 2007.
 MIMS, 108th ed. CMPMedica Asia Pte Ltd, Singapore, 2004.
 Porth, Carol M. Essentials of Pathophysiology: Concepts of Altered Health States.
o 2nd ed. Lippincott Williams & Wilkins, 2007.

 pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating Room. 3rd edition
o F.A. Davis Company.Philadelphia

78