TABLE OF CONTENTS

I.

Introduction A. objectives General objectives Specific objectives Patients data A. B. C. D. E. F. Vital Information Family background History of Past illness History of Present illness Effects & Expectations of illness to self & Family Genogram

II.

III. IV.

Physical Assessment Textbook Discussion a. Complete Diagnosis b. Anatomy and physiology c. Etiology and Symptomatology d. Pathophysiology Diagnostic Results Summary of Doctors Order Drug study

V. VI. VII.

VIII. Nursing care plan IX. X. Prognosis Bibliography

INTRODUCTION .This is the case of 20 year old boy who was admitted last December 2, 20011 at around 1:27 AM at Allah Valley Medical Specialists Center Incorporated with the chief complaint of abdominal pain with the admitting diagnosis of hydrops of gallbladder under the service of Dr. PJ. Acalculous cholecystitis is related to conditions associated with biliary stasis, including debilitation, major surgery, severe trauma, sepsis, long-term total parenteral nutrition (TPN), and prolonged fasting. Other causes of acalculous cholecystitis include cardiac events; sickle cell disease; Salmonella infections; diabetes mellitus; and cytomegalovirus, cryptosporidiosis, or microsporidiosis infections in patients with AIDS. An estimated 10-20% of Americans have gallstones, and as many as one third of these people develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately 500,000 operations annually. This case study aims to provide information that may help the reader to understand the occurrence and manifestations of the disease including proper care and management.

OBJECTIVES OF THE STUDY GENERAL OBJECTIVES After thorough reading, the reader will be able to impart adequate knowledge and skills about acute Cholecystitis. And discuss correctly all the related information about the disease. SPECIFIC OBJECTIVES: After two hours of reading, the listeners will be able to: 1. 2. 3. 4. 5. 6. 7. 8. 9. Know the important information regarding patients data. Know the result of the assessment done to the patient. Define comprehensively the complete diagnosis of the client. Discuss briefly the anatomy and physiology involved in the disease. Trace schematically the pathophysiology of Acute Cholecystitis. Enumerate the predisposing factors and precipitating factors of the disease. Identify the prioritized possible nursing diagnosis of the patient. Identify the Drugs that the physician orders for the wellness of the patient. Discuss the mechanism and effects of the medication to the patient.

VITAL INFORMATION PATIENTS NAME : A AGE : 12 years old SEX : Female ADDRESS : Purok 11 Talisay Lake Sebu South Cotabato DATE OF BIRTH : March 6, 1997 PLACE OF BIRTH : Lake Sebu RELIGION : Roman Catholic CIVIL STATUS : Child CITIZENSHIP : Filipino TRIBE : Ilonggo OCCUPATION : N/A EDUCATIONAL ATTAINMENT : Grade VI DATE ADMITTED : July 17,2009 TIME ADMITTED : 1:29 PM ADMITTING PHYSICIAN : Dr. Jake Albao ADMITTING DIAGNOSIS CHIEF COMPLAINTS OPERATION PERFORMED : Epigastric Pain : Epigastric pain : Cholicystectomy

NAME OF INSTITUTION Incorporated Father AGE OCCUPATION EDUCATIONAL ATTAINMENT RELIGION TRIBE MOTHER AGE OCCUPATION EDUCATIONAL ATTAINMENT RELIGION TRIBE Siblings NAME 1. AA 2. BB 9 2 AGE

: Allah Valley Medical

Specialists Center

: B : 33 Years old : Farming : Second Year High School : R. Catholic : Ilonggo : C : 30 Years old : Housewife : High School Graduate : R. Catholic : Ilonggo

SEX Female Male

SOURCE OF INFORMATION Patient Patients chart Patients Mother and Father

SOURCE OF MEDICAL FINANCING Philhealth

PHYSICAL ASSESSMENT GENERAL SURVEY Received lying on bed, awake with D5LR1L @ 20 gtts/min hooked at right metacarpal vein, infusing well, patent and intact. The patient is physically ill with uneasy condition. She looks anxious and in pain. HEAD Inspection: The patients head is proportional to the patients body size and round in shape. No lesions and deformities noted on the contrary dandruff was noted on her scalp. She has a long black hair with gray hair noted that is distributed evenly. Palpation: No tenderness noted as well as masses. FACE Inspection: The patient face is symmetric. Her skin is brown in complexion; some moles are noted. Palpation There is no masses and tenderness noted. EYES Inspection: The eye is straight and in normal position. Eyebrow is black in color and evenly distributed eyelids able to close completely. Eyelashes directed outward and intact. Eyeballs are symmetric and able to move in six cardinal movements. Pupils are equal in size, round in shape and reacts to light and accommodation. Conjunctiva is pale and moist. Sclera is anecteric, the cornea is clear and transparent, iris is black in color. Lacrimal system have enough moist. NOSE Inspection: The external nose is symmetrical and align at the center, mucosa is moist, nasal septum is intact, straight at the midline, no lesions and deformities. Palpation: There is no tenderness noted. EARS Inspection: External ear is clear, no deformities and lesion noted. She can hear whispered words within 1 foot apart. Auricle has no deformities. Palpation: No tenderness and masses noted. .LIPS AND MOUTH Inspection The patients lips appear to be dry and slightly pale. The tongue is moist, mobile, and pink in color and position in the midline. No dentures noted with incomplete set of teeth. Gums and mucosa is pink, have enough moist and no lesion noted. Tonsils are not inflamed; uvula is bell in shape, pink in color and at the midline. NECK Inspection Has coordinated movement and no discomfort noted.

Palpation Lymph nodes at the neck are not palpable. ABDOMEN Inspection Incision noted on the right upper quadrant with sterile dressing noted. Palpation Pain is felt during palpation. EXTREMETIES Inspection The extremities are proportionate to the trunk, skin is brown in complexion. Positive ROM noted on both upper and lower extremities. She has no difficulties in performing flexion and extension. Muscle has equal strength, able to grasp properly but dominant hand has more force than her non dominant hand. Palpation No edema noted on both extremities, patient sensation is present. Pulsation is present at the radial and dorsalis pedis. SKIN Inspection Patient appearspale, skin is dry. Good skin turgor noted. There is no lesions noted and her hair is evenly distributed. Palpation No masses and tenderness noted. Afebrile noted during palpation. NAILS Inspection Patient nail is pink in color/ her finger nails are uncut and not well trimmed specifically at his toe nails. Capillary refill return within 3 seconds after being pressed. REVIEW OF SYSTEMS GENERAL: The patient said that he never experienced fever prior toadmission. He denies of experiencing weight loss. SKIN: The patient denies any rashes and skin allergies. HEAD: The patient verbalized that nagasakit ang ulo ko kis-a he also said that he doesn't experienced any head injury and she never observed tenderness. EYES: The patient denies any eye problem. NOSE: The patient said that he also has no allergies to any odor. He denies of having sinus problem and he has no problem in term of his sense of smell.

THROAT: Patient denies any throat problem. RESPIRATORY: Patient denies any difficulty of breathing. he denies of having chest pain and hemoptysis. CARDIOVASCULAR: The patient said that he has no problems in her heart, GASTROINTESTINAL: The patient denies of any problem in his GI problems. GENITOURINARY: He said that he has a problem in urination. And she voids 5-6 times a day. He admits that his gallbladder was inflamed. MUSCULOSKELETAL: He denies of having problems in moving. He states that he is a little bit weak because of pain. PSYCHIATRIC: He denies difficulty of sleeping.

Textbook Discussion Cholecystitis is the inflammation of the gallbladder. The obstruction increases the pressure within the gallbladder leading to ischemia of the gallbladder wall and mucosa. The ischemia can lead to necrosis and perforation of the gallbladder wall.

Acute Cholecystitis Usually begins with an attack of biliary colic. The pain involves the entire Right Upper Quadrant (RUQ), and may radiate to the back, right scapula, or shoulder. Movement or deep breathing may aggravate the pain. The pain usually lasts longer than the biliary colic, continuing for 12 to 18 hours. Anorexia, nausea and vomiting are common. Fever often is present, and may be accompanied by chills. The RUQ is tender to palpation. Chronic Cholecystitis May result from repeated bouts of acute Cholecystitis or from persistent irritation of the gallbladder wall by stones. Bacteria may be present in the bile as well and often is asymptomatic. Complications of Cholecystitis include empyema, a collection of infected fluid within the gallbladder; gangrene and perforation with resulting peritonitis or abscess formation; formation of fistula into an adjacent organ; or obstruction of the small intestine by a large gallstone. Diagnostic tests Serum bilirubin is measured. Elevated direct bilirubin may indicate obstructed bile flow in the biliary duct system. Complete blood count (CBC) may indicate infection and inflammationif the WBC is elevated.

Serum amylase and lipase are measured to identify possible pancreatitis related to common duct obstruction. Abdominal X-ray may show gallstones with high calcium content. Ultrasonography of the gallbladder is a noninvasive exam that can accurately diagnose cholelithiasis. Gsllbladder scans use as an intravenous radioactive solution that is rapidly extracted from the blood and excreted into the biliary treeto diagnose cystic duct obstruction.

Source: Medical- Surgical Nursing (critical thinking in client care) P. Lemone & K. Burke; 3rd edition; page 574-575 Cholecystitis Acute inflammation of the gallbladder causes pain, tenderness, and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting and the usual signs of an acute inflammation. An empyema of the gallbladder develops if the gallbladder becomes filled with purulent fluid. Calculous Cholecystitis is the cause of more than 90% of cases of acute Cholecystitis, a gallbladder stone obstructs bile outfow. Bile remaining in the gallbladder initiates a chemical; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute choolecystitis; however, secondary infection of bile with Escherichia coli and other enteric organisms occur in about 60% of patients.

Source: Brunner & Suddarths textbook of Medical-Surgical Nursing Volume 2; 10th edition ; S. Smeltzer & B. Bare; page 1126 Cholecystitis - is inflammation of the gall bladder. Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation of bile, bile stasis, and secondary infection by gut organisms, predominantly E coli and Bacteroides species. The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel. Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis. Stones in the gallbladder may not cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified. Symptoms Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first. This is usually accompanied by a low grade fever, vomiting and nausea. More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs

if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction. Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, & diarrhea. Diagnosis Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:

fever (usually low grade in uncomplicated cases) tender right upper quadrant +/- Murphy's sign

Source: http://en.wikipedia.org/wiki/Cholecystitis Cholecystitis is inflammation of the gallbladder, a small organ near the liver that plays a part in digesting food. Normally, fluid called bile passes out of the gallbladder on its way to the small intestine. If the flow of bile is blocked, it builds up inside the gallbladder, causing swelling, pain, and possible infection. Causes of cholecystitis A gallstone stuck in the cystic duct, a tube that carries bile from the gallbladder, is most often the cause of sudden (acute) cholecystitis. The gallstone blocks fluid from passing out of the gallbladder. This results in an irritated and swollen gallbladder. Infection or trauma, such as an injury from a car accident, can also cause cholecystitis. Acute acalculous cholecystitis, though rare, is most often seen in critically ill people in hospital intensive care units. In these cases there are no gallstones. Complications from another severe illness, such as HIV or diabetes, cause the swelling. Long-term (chronic) cholecystitis is another form of cholecystitis. It occurs when the gallbladder remains swollen over time, causing the walls of the gallbladder to become thick and hard. Symptoms The most common symptom of cholecystitis is pain in your upper right abdomen that can sometimes move around to your back or right shoulder blade. Other symptoms include:

Nausea or vomiting. Tenderness in the right abdomen. Fever. Pain that gets worse during a deep breath. Pain for more than 6 hours, particularly after meals.

Older people may not have fever or pain. Their only symptom may be a tender area in the abdomen. Diagnosis: Diagnosing cholecystitis begins when you describe your symptoms to your doctor. A physical exam follows. Your doctor will carefully feel your right upper abdomen looking for tenderness. You may have blood drawn and an ultrasound, a test that uses sound waves to create a picture of your gallbladder. Ultrasound may reveal

gallstones, thickening of the gallbladder wall, extra fluid, and other signs of cholecystitis. This test also allows doctors to check the size and shape of your gallbladder. You could also have a gallbladder scan, a nuclear scanning test that checks how well your gallbladder is working. It can also help find blockage in the tubes (bile ducts) that lead from the liver to the gallbladder and small intestine (duodenum). TreatmentTreatment for cholecystitis will depend on your symptoms and your general health. People who have gallstones but don't have any symptoms may need no treatment. For mild cases, treatment includes bowel rest, fluids and antibiotics given through a vein, and pain medicine. The main treatment for acute cholecystitis is surgery to remove the gallbladder (cholecystectomy). Often this surgery can be done through small incisions in the abdomen (laparoscopic cholecystectomy), though sometimes it requires a more extensive operation. Your doctor may try to reduce swelling and irritation in the gallbladder before removing it. Occasionally acute cholecystitis is caused by one or more gallstones becoming stuck in the main tube leading to the intestine, called the common bile duct. Treatment may involve an endoscopic procedure (endoscopic retrograde cholangiopancreatography, or ERCP) to remove the stones in the common bile duct before the gallbladder is removed. In rare cases of chronic cholecystitis, you may also receive medicine that dissolves gallstones over a period of time. Source: http://www.webmd.com/digestive-disorders/tc/cholecystitis-overview

ANATOMY AND PHYSIOLOGY

The Gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process. Anatomy

The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct. The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.[2][3] The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver [4] . It is at the same level as the transpyloric plane.

Microscopic anatomy The different layers of the gallbladder are as follows:

The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining. Under the epithelium there is a layer of connective tissue (lamina propria). Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum. There is essentially no submucosa separating the connective tissue from serosa and adventitia.

Function The gallbladder stores about 50 ml (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.

After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum. Vertebrates have gallbladders, but invertebrates don't. This is because vertebrates eat in boluses while invertebrates are constantly eating. To digest a large bolus of food requires a large amount of digestive secretions, hence the presence of a gallbladder.

Etiology
Predisposing Factor Age Rationale Remarks The incidence of Cholecystitis Present increases with age. Patient is 20 years old therefore it is present. Gallstone are 2.3 times more Present frequent in females than in males, resulting in a higher incidence in females. Patient is male. Indian and Scandinavian Not Present people have the highest prevalence of Cholecystitis. In United state white people have a highest prevalence than black people. Patient is Asian, hence not present. Excessive cholesterol intake combined with a sedentary lifestyle increases

Sex

Heredity

Precipitating Factors Lifestyle

Present

Obesity

the incidence of Cholecystitis. Patient is fond of extra fatty foods and meat. Persons who are obese have higher risk in developing Cholecystitis because of the accumulation of fatty deposits that can obstruct the gallbladder.

Not Present

Symptomatology

Predisposing Factor Pain in the RUQ

Rationale This is due to the location of the Present gallbladder which is at the right quadrant. http://www.merck.com/mmhe/sec10/ch1 40/ch140c.html This is due to the inflammatory process that is happening to the body as a Present defense mechanism. . http://www.merck.com/mmhe/sec10/ch1 40/ch140c.html

Low grade fever

Nausea Tenderness abdomen in

This is due to the irritation in the present gastrointestinal area. http://www.merck.com/mmhe/sec10/ch1 40/ch140c.html the This is due to the inflammation of an present organ which is situated at the abdomen. http://www.merck.com/mmhe/sec10/ch1 40/ch140c.html

Loss of appetite

weakness

This symptom may not be present present always but according to some sources this can be happen to older person. http://www.merck.com/mmhe/sec10/ch1 40/ch140c.html This is just present to older persons. present http://www.merck.com/mmhe/sec10/ch1 40/ch140c.html

PATHOPHYSIOLOGY
Predisposing Factors Age (20 year old) Sex (Male) Race Precipitating Factors Lifestyle

Obstruction of the cystic duct Distention of the gallbladder Impaired venous and lymphatic drainage Proliferation of bacteria occurs Localized cellular irritation Ischemia

Inflamed gallbladder Empyema will occur

If Treated: >MEDICAL MANAGEMENT: Medication for s/sx depends on the physician prescription. >SURGICAL MANAGEMENT: -Laparoscopic Cholecystectomy - Cholecystectomy with common bile duct combination. -Choledochostomy >NURSING MANAGEMENT: -Health teaching especially on the diet (low fats and low salts diet) Hospitalization

If not Treated: >May result to more severe complications

further bile duct obstruction Enzyme bile duct obstruction Pancreatic enzymes Regurgitation Pancreatitis

Recovery Hemorrhage WELLNESS Coma DEATH

NOTRE NAME OF TACURONG COLLEGE City of Tacurong

DRUG STUDY
Name of the Patient: Attending Physician: Diagnosis: Date: NAME Generic: Tramadol Brand: Ultram Classification: Opioids Analgesic MODE OF ADMINISTRATION Route: IVTT ANST (-) Dosage: 50mg Time: q8 DRUG ACTION Mechanisms of Action: Unknown. A centrally acting synthetic analgesic compound not chemically related to opiates. Thought to bind to opioids receptor and inhibit reuptake of norepinephrine and serotonin. Bibliography: Nursing Drug Handbook 2005, Page 405, 406 Indication; Moderate to moderately severe pain A
Dr. Jake Albao

Post-op Cholecystectomy July 19, 2009 SIDE EFFECT CNS: Dizziness, vertigo headache, malaise, sleep disorder CV: vasolidation EENT: visual disturbance GI: nausea, constipation, vomiting dyspepsia, dry mouth, diarrhea, abdominal pain, anorexia, flatulence. GU: urine retention, urinary frequency, proteinuria. Musculoskeletal: hypertonic SkinL pruritus, diaphoresis rash. ADVERSE EFFECT CNS: CNS stimulation, asthenia, anxiety, confusion coordination disturbance euphoria, nervousness, seizure Respiratory: Respiratory depression.

Prepared by: Checked by: CONTRAINDICATION Contraindicated in the patient hypersensitivity to drug or other opioid breastfeeding woman, and in those with acute intoxification from alcohol, hypnotics centrally acting analgesic, opioids or psychotropic drug. Serious hypersensitivity reaction can occur, usually after the first dose. Patient with history of anaphylaxis to codeine and other opioids may be at an increase risk. SPECIAL PRECAUTION Use cautiously in patient at risk for seizures or respiratory depression, in patient with increased intracronial pressure or head injury, acute abdominal coordination or renal or hepatic impairment; or in patient with physical dependence an opioids. DRUG INTERACTION Drug-Drug Carbomazepine: May increased

Gallega and Lelim Section: BSN 4 Date: NURSING RESPONSIBILITIES 1. Consider the patients 10 rights R: to ensure proper administration of drug and most of all to avoid mistakes. 2. Practice proper hand washing R: Hand washing deters the spread of microorganism thus preventing nosocomial infections. 3. Reassess patient level of pain at least 30 minutes after administering. R: to assess patients conditions and effectiveness of drug 4. Assess the breathing pattern of the patient R: Assessing the respiratory rate of the patient is important to prevent respiratory depression and have immediate actions. 5. Monitor bowel and bladder function, anticipate the need for laxatives R: Monitoring these function will aide the patient if he/she as feeling of constipation. 6. For better analgesic effects, give drug before onset of intense pain R: Giving the drug this way will minimize effect of intense pain thus promoting comfort to the client. 7. Monitor patient for drug dependence R: Drug can produce dependence similar to

tramadol metaboism, patients receiving long term carbamazephine therapy at up to 800mg daily may need up to twice the recommended dose of tremadol.

that of codiene and dextropropoxyphene and thus potential for abuse. 8. Educate the patient about the purpose and administration of drug R: doing this will relieve patients anxiety, making them aware and facilitate cooperation 9. Instruct patient to rest after R: resting promotes relaxation and comfort to the patient 10. Assess the patient sleep pattern before giving the drug. R: Sleep disturbance its one of the side effect of tramadol by doing this proper intervention and action should be done.

NAME Generic: Ampicillin Brand: Ampicin Classification: Antibiotics

DRUG ACTION Mechanisms of Action: Inhibits cell wall synthesis during bacterial multiplication

SIDE EFFECT CNS: anxiety, dizziness and fatigue CV: thrombophlebitis GI: nausea, and vomiting abdominal pain, diarrhea, gastritis GU: vaginitis Skin: Pain at the injection site

CONTRAINDICATION Contraindicated in patient hypersensitivity to drug

MODE OF ADMINISTRATION Route: IVTT ANST (-) Dosage: 1 grm Time: q8

Bibliography: Nursing Drug Handbook 2005, Page 78, 80

ADVERSE EFFECT CNS: Lethargy, hallucination, agitation, seizures, depression. CV: vein irritation GI: diarrhea, glossitis, stomatisis, enterocolitis and black hairy tongue. GU: Interstitial nephiritis, nephropathy Hematologic: Anemia thrombocytopenia, eosinophilia.

Indication; Respiratory tract or skin structure infections.

NURSING RESPONSIBILITIES 1. Consider the patients 10 rights R: considering this will ensure that the medication is given correctly and most all avoid unnecessary mistakes. 2. Explain to the client about the administration of the drug R: Explaining this to the client facilitate awareness and cooperation 3. Practice proper hand washing first R: Proper hand washing deters the spread of microorganisms and transferring of microorganism to the patient 4. Administer the drug right away after being SPECIAL PRECAUTION prepared R: to promote sterility and effectives of the drugs Use cautiously in patient with 5. Conduct skin testing first other drug allergies because of R: Skin testing is important to avoid allergic possible cross-sensitivity and in reaction those with mononucleosis 6. Give the drug 10-15 minutes because of high risk of R: Giving the drug at the right span of time will maculopopular rash. prevent pain at injection site. vein irritation thus promoting comfort 7. Instruct patient to rest after administration and raise side rails DRUG INTERACTION R: Lethergy, hallucination, dizziness and agitation may occur swallowing patient to rest and Drug-Drug raising side raise promotes comfort and further Hormonal contraceptives: may injury. decrease hormonal 8. Watch sign and symptoms of hypersensitivity such contraceptive effectiveness. as sythematous, maculopopular rash, urticaria and snaphylaxis. R: This factors will indicate adverse reaction to the drug. 9. Advise patient to report discomfort at injection site R: For immediate management and action, for comfort measures. 10. At home instruct patient to take drug 1 to 2 hours before or 2 to 3 hours after meal R: to prevent GI irritation

NOTRE NAME OF TACURONG COLLEGE City of Tacurong Name of the Patient: Attending Physician: Diagnosis: Date: A
Dr. Jake Albao

Post-op Cholecystectomy July 19, 2009

Prepared by:

DRUG STUDY

Checked by:

Gallega and Lelim Section: BSN 4 Date:

NAME Generic: Ranitidine Brand: Zantac Classification: Anti-ulcer drug MODE OF ADMINISTRATION Route: IVTT Dosage: 40mg Time: q8

DRUG ACTION Mechanisms of Action: Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2 receptor sites parietal cells decreasing gastric acid secretions. Bibliography: Nursing Drug Handbook 2005, Page 712, 713 Indication; Duodenal and gastric ulcer

SIDE EFFECT CNS: vertigo, malaise headache EENT: blurred vision Hepatic: Jaundice Others: burning and itching at injection site.

ADVERSE EFFECT Anaphylaxis, angio edema

CONTRAINDICATION NURSING RESPONSIBILITIES Contraindicated in patient 1. Before giving the drug, Practice Proper hand hypersensitivity to drug and those washing with acute prophyria R: proper hand washing will reduce presence of microorganism in your hands, thus it will prevent another complication to your pt. 2. Check the patency of the IV tube, before reducing the medicine. R: checking the patency of the IV tube will facilitate easy administration of the drug thus reducing discomfort to the patient 3. Administer the medicine once it has been prepared. R: Administering the drug after preparing will reduce incidence of mistake and ensuring the SPECIAL PRECAUTION sterility and effectiveness of the medication 4. Assess patient for abdominal pain, advice to Use cautiously in patient with report blood and stool hepatic dysfunctions R: These factors may indicate internal bleeding 5. Give the medication slowly about 10-15 minutes R: burning and itching at the injection site, usually the complains of the patient, therefore give it slowly to prevent it. 6. Before giving the drug, educate first the patient DRUG INTERACTION about the purpose of it. R: Giving information to the patient will facilitate cooperation and relieve their anxiety. Drug-Drug 7. Instruct patient to rest after taking the drug Antacids: May interfere with

ramitidine absorption stragger doses, if possible. Diazepam: may decreased absorption of diazepam monitor patient closely.

R: Having the patient to rest will promote relaxation and comfort. 8. Instruct patient to report any unusualities R: Instructing our patient to report unusualities will help us to provide proper and prompt treatment 9. Before giving the drug asses if the patient has taken a meal. R: Assessing if the patient has taken any food, because the drug works better when the stomach is empty.

NAME Generic: Gentamycin Brand: Garamycin Classification: Anti infectives MODE OF ADMINISTRATION Route:

DRUG ACTION Mechanisms of Action: Generally bactericidal, inhibits protein synthesis by binding directly to the 305 ribosomal sbmit. Bibliography: Nursing Drug Handbook 2005, Page 67, 70

SIDE EFFECT CNS: fever, headache, lethargy, confusion, dizziness, numbness, vertigo, ataxia CV: hypotension EENT: blurred vision, tirnitus GI: vomiting, nausea GU: possible increase in urinary excretion of cast. Skin: rash, urticaria, pruritus, pian in the injection site.

CONTRAINDICATION Contraindicated to patient hypersensitivity to drug and other aminoglycosides

SPECIAL PRECAUTION Use cautiously in neonates, infants, elderly patient and patient with impaired renal

NURSING RESPONSIBILITIES 1. Conduct skin testing as ordered R: conducting skin testing before giving the drugs will help prevent allergies for their complication to the patient and will know what treatment to give. 2. Practice proper hand washing before giving the drug R: proper hand washing will prevent transfer of microorganism from 1 patient to another 3. Evaluate patients hearing before and during therapy R: to notify the physician if the patient complains of tinitus, vertigo or hearing loss 4. Weight patient and review renal function studies R: Reviewing those important data is essential

IVTT Dosage: 800mg Time: q8 Indication; To prevent endocarditis for GI or GU procedure or surgery

ADVERSE EFFECT CNS: encephalorathy seizures GU: nephrotoxicity Hematologic: leukofenia, thrombocytopenia, agranulocytosis Respiratory: apnea Others: Anaphylaxis

function or neuromuscular disorder. 5.

6. DRUG INTERACTION Drug-Drug Acyclovir, comphotericin B cephalosporins, cisplatin, methroxfluane, vancomycin other aminosylosides. May increase ototoxicity and nephrotoxicity monitoy hearing and renal function test results.

7.

8. 9. 10.

because the drug will possibly increase urinary excretion of cast Instruct patient to report any unusualities R: Unusualities happens any time after drug administration, so instructing the pt. to do so will help prevent further complication provide bedpan or empty bucket at the patients bedside R: providing bedpan or empty bucket will help because once the patient experience vomiting, just give it to the patient so the she bed of the patient will not be messy Raise the side rails of the patients bed R: Once the patient has taken the drug, advise reaction occurs, like dizziness, vertigo, blurred vision and lethargy occurs, so patient safety should be practiced. Monitor vital signs q 4 or as ordered. R: Monitoring vital signs of the patient is essential because this drug can cause hyptension. Instruct patient to rest R: resting will help minimize the side effects of the drug Monitor patients breathing pattern R: assessing the breathing pattern

NAME Generic: Ketorolac Brand: Toradol Classification: NSAID

DRUG ACTION Mechanisms of Action: Unknown. Produces anti-inflammatory analgesic and antipyretic effects possibly by inhibiting prostaglandin synthesis Bibliography: Nursing Drug Handbook 2005, Page 369, 371 Indication; Short term management of moderately severe, acute pain.

MODE OF ADMINISTRATION Route: IVTT Dosage: 30mg Time: q8

SIDE EFFECT CNS: drowsiness, sedation, dizziness, headache CV: edema, hypertension palpitation GI: nausea, dyspepsia GI pain, diarrhea, peptic ulceration on vomiting constipation, flatulence, stomatitis Skin: pruritus, rash diaphoresis Others: pain at injection site ADVERSE EFFECT CV: Arhytmias Hematologic adhesion, purpura, prolongned bleeding time Parethesia

CONTRAINDICATION NURSING RESPONSIBILITIES Contraindicated in patients 1. Conduct skin testing before drug administration hypersensitive to drug and in R: Conducting skin testing before giving the drug those with active peptic ulcer will prevent allergic reaction, this granting the disease, recent GI bleeding or patient safety. perforation advance renal 2. Assess the client if he had peptic ulcer or GI impairment, cerebrovascular bleeding before or prior to admission bleeding, hemorrhagic diathesis R: Assessing these factor to the client will be or incomplete hemostasis, and essential because ketorolac is contraindicated in those at risk for renal to patient who has this factor because it impairment from volume prolonged the bleeding time, therefore patient is defection or at risk for bleeding a risk for bleeding 3. Give the drug 10-15 minutes R: Burning and pain at injection site, usually the complains of the client, therefore give the drug slowly to avoid the situations 4. Before administration, check first if there is a bad SPECIAL PRECAUTION flow R: Checking if there is a back flow is important because it provide sterility and comfort to the Use cautiously in patient with client hepatic or renal impairment or cardiac decomposition 5. Monitor patients vital signs q 4 or as ordered specially the blood pressure, before and after R: Monitoring this is very important to know if patient, hypertensive, because ketorolac can cause hypertension 6. Raise the rails after giving to drug R: drowsiness, sedation and headache, dizziness DRUG INTERACTION might occur for raising the side rails will prevent patient from falling thus preventing further Drug-Drug injuries Ace inhibitor: May cause renal 7. Instruct patient to increase fluid intake impairment, particular in R: Taking this drug can cause renal impairment, volume depleted patients avoid maintaining hydration will prevent this

using together in volume depleted patient

8. Instruct the watcher to report any unusualities R: for immediate action and management 9. Before giving the drug, carefully observe patient with coagulopathis R;prevent platelet aggregation

ASSESSMENT

NEEDS NURSING DIAGNOSIS

NURSING CARE PLAN GOAL/OBJECTIVE

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Date: 07-21-09 8AM Subjective data: Masakit pa ang tahi ate. Pain scale of 7 out of 10. Objective data: Conscious Weak Dry lips Facial grimacing Pallor noted Right lower quadrant tenderness noted Guarding of the stomach V/S: BP-100/70 mmHg T-37 C P-80bpm R-25 cpm

C O G N I T I V E P E R C E P T U A L P A T T E R N

General 1. Observe and ~Assists in differentiating Date: 7-21-09 Pain acute r/t Objective: document location, cause of pain and 3PM inflammatory To promote optimal severity and provides information about Goal partially met pt. process as activity; exercise rest and characteristics of pain. disease progression. reported pain is evidenced by facial sleep. 2. Note response to ~Severe pain not relieved controlled. grimacing and meds and report to by routine meaning may guarding of the site Specific physician if pain is not indicate developing of pain Objectives: being relieved. complications. After 2h of NSG 3. Promote bed rest, ~Bed rest in low-fowlers RATIONALE intervention patient will be allowing patent to position reduces intraUnpleasant able to: costume position of abdominal pressure. sensory and comfort. Report pain is emotional 4. Use of soft/cotton Reduced irritation/dryness controlled. experience arising of the skin and itching Demonstrates use linens; cool/moist from actual or compress is indicated. sensation. of relaxation potential tissue 5. Control ~Cool surroundings, and techniques and damage or environmental in minimizing dermal divisional described in terms temperature. comforts. activities. of such damage. 6. Encourage use of ~promotes rest, redirects relaxation techniques; attention; may enhance guided imagery, coping. visualization 7. Make time to listen ~Helpful in alleviating and maintain frequent anxiety and refocusing contact with patient. attention which can relieve 8. Administer pain. medication as ordered .To treat infectious like paracetamol. process, reducing inflammation.

ASSESSMENT Date:07-21-09 8AM Subjective data: Ano gale ni siya ate,bakit nagkaganito. As verbalized. Objective data: Pallor noted Yellowish eyeball Weakness noted Decreased appetite noted Apprehension Dark color urine Facial grimacing Pallor noted V/S: BP-100/70 mmHg T-37 C P-80bpm R-25 cpm

NEEDS NURSING DIAGNOSIS C O G N I T I V E P E R C E P T U A L P A T T E R N

GOAL/OBJECTIVE

NURSING INTERVENTIONS 1. stablished rapport to the patient. 2.

RATIONALE

EVALUATION

General Knowledge deficit Objective: regarding the To recognize the condition r/t lack of physiologic response of information as the body to the disease manifested by conditions. apprehension. Specific RATIONALE Objectives: Absence of After 2h of NSG deficiency of intervention patient will cognitive be able to: information related Verbalize to specific topic. understanding of the disease process, treatment and prognosis Initiate necessary changes in treatment regimen.

3.

4.

5.

6.

7.

8.

9.

10.

~Establishing rapport Date: 7-21-09 will gain trust and 3PM cooperation of the pt. ~V/S will serve as the Monitor the vital signs baseline data and will Goal partially met, of the pt. be in comparing the pt understand abnormal findings. her situation but ~Information aim to needs more decrease anxiety instructions. ,thereby reducing Provide explanation for sympathetic the test procedures or stimulation any preparation needed. ~Provides knowledge Discuss hospitalization base on which pt. can and prospective make informed treatment as indicated. choices. Effective communication can diminish anxiety and promote healing. ~Obesity is a risk Discuss weight factor associated with reduction program as Cholecystitis and indicated. weight loss is beneficial Instruct pt. to avoid ~Prevents or limits food or fluids high in recurrence of fats, gas produces or gallbladder attacks. gastric irritants. Review s/sx requiring medical intervention. ~Indicative of progression of disease process or development of complication requiring Recommended resting further intervention. in semi-fowlers ~Promotes flow of bile position after meals. and general relaxation during initial digestive Suggest pt. to limit process. gum chewing sucking ~Promotes gas on straw or candy or formation, which can smoking. increase gastric Discuss avoidance of distention or aspirin- containing discomfort. products, forceful ~Reduces risk of blowing of noise, bleeding related to straining. changes in coagulation in time, mucosal irritation and

NURSING CARE PLAN ASSESSMENT NEEDS NURSING DIAGNOSIS GOAL/OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

Date: 07-21-09 8AM Subjective data: No verbal cues Objective data: Pallor noted Yellowish eyeball Weakness noted Decreased appetite noted V/S BP-100/70 mmHg T-37 C P-80bpm R-25 cpm

N U T R I O N A L M E T A B O L I C P A T T E R N BY: G O R D O N

General Risk for altered Objective: nutrition less than To promote / maintain body requirements proper nutrition. r/t impaired digestion as Specific evidenced by Objectives: decreased appetite. After 2h of NSG RATIONALE intervention patient will This is an intake of be able to: nutrients insufficient Demonstrate to meet metabolic progression needs. toward desired weight. Maintain weight as appropriate to self.

Date: 7-21-09 1. Establish rapport to ~Establishing rapport will 3PM the pt. gain trust and cooperation of the pt. ~This may determine the Goal partially met, 2. Monitor V/S as the patient appropriate as possible. condition of the pt. demonstrates 3. Assess for willingness to abdominal distention, ~Nonverbal signs of frequent guarding and discomfort associated with maintain nutrition. impaired digestion and Gas reluctant to move. pain. 4. Weigh the pt. as indicated. ~It monitor effectiveness of 5. Consult with the pt. dietary plan. about like or dislike in ~Involving the pt. in planning enables pt. to have a sense food. of control and encourage 6. Provide a pleasant eating. ~Using in promoting atmosphere at meal time; remove noxious appetite or reducing nausea. stimuli. 7. Provide oral hygiene before meals. 8. Offer effervescent drinks with meals if tolerated. 9. Ambulate and increase activity as tolerated. ~A clean mouth enhances appetite. ~May lessen nausea and relieve gas. It may be contraindicated if beverage causes gas function or gastric discomfort. ~Helpful in expulsions of flatus, reduction of abdominal distention/contributes to overall recovery and sense of well being and decreases possibility of secondary

10. Provide TPN as indicated

problems related to immobility. ~Alternate feeling of may be required depending in the degree of gallbladder involvement and need for prolonged gastric rest.

BIBLIOGRAPHY

*Black, JM., J.H., Keene, AM ., Med-Surg Nsg.,clinical management for positive outcomes 6th edition vol.2 *Lippincott, Wilkins and Williams; springhouse nurses drug handbook 2007 8th edition *Doenges , W. Moorehouse and Murr , nurses pocket guide, 10th edition F.A Davis Company, philadelphua, Pennsylvania @ 2006 *Ignatavicius and Workman, medical sorsical nursing critical nking for collaborative care 5th edition vol. 2 @ 2006 * Medical- Surgical Nursing (critical thinking in client care) P. Lemone & K. Burke; 3rd edition; page 574-575

* Brunner & Suddarths textbook of Medical-Surgical Nursing Volume 2; 10th edition; S. Smeltzer & B. Bare; page 1126 *http://en.wikipedia.org/wiki/Cholecystitis *http://www.webmd.com/digestive-disorders/tc/cholecystitis-overview