St Anne College Lucena Inc. Diversion Rd. Bry Gulang Gulang, Lucena city city College of Nursing
IN PARTIAL FULFILLMENT OF OUR REQUIREMENTS REQUIREMENTS IN RELATED LEARNING EXPERIENCE (105)
I Patient profile Biographical Data
Name:
Mr. X
Age:
46 years old
Sex:
Male
Nationality:
Filipino
Date of Birth:
August 28, 1962
Place of Birth:
General Santos City
Civil Status:
Married
Address:
Lucban Quezon
Religion:
Christianity (Roman Catholic)
Educat cational onal at attainme nment: nt:
Hig High Sch School Graduate
The nose was symmetrical with no deformities, skin lesions, massses present. Nasal septum is intact and in midline. No nasal flaring flaring was observed. observed. No discharges were present. No tenderness in his sinuses upon palpation. Ears:
Ears were symmetrical with same size bilaterally and color consistent with face. Pinnas were free from lesions, masses, swelling, redness, tenderness, and discharges and were in line with the eyes. External canals were clear with no cerumen seen. No inflammation, masses, discharges and foreign bodies noted. Gross hearing acuity was good. No pain on the mastoid process was reported upon palpation. Mouth and Throat: Mouth was proportional and symmetrical. Lips were rust colored and were dry with no presence of ulcerations, sores or lesions. Teeth were yellowish in color with some dental caries noted. Right upper u pper first premolar tooth was absent. Tongue was in central position and moves freely with no swelling or ulcerations observed. Gag reflex was present as evidenced by patient swallowing. Tonsils were not inflamed. Halitosis was also noted. Neck and Lymph nodes: Neck was symmetrical with no masses or swelling noted. No jugular vein
Symmetrical shoulder movement observed during respiration. Spine was located at the midline with no discrepancies noted. Shoulders, arms, elbows and forearms were free from nodules, deformities and atrophy. Range of motion was not limited. Neither pallor nor bone enlargements were noted upon inspection of the upper extremities. Upper extremities were not edematous. Radial and brachial pulses were present. Hip joint and thighs were symmetrical with no deformities present. No edema noted at both legs. No inflammation noted in the lower extremities. Range of motion was active and not limited.
IV final final diagnoses. diagnoses. Acute cholecystitis cholecystitis B, Present Health history Symptom (PTA) Pt prior to admission, Mr X experienced right upper quadrant pain associated with a sense of bloatedness, without nausea and vomiting. The pain was tolerable so he did not seek medical attentio attention n yet. He said he also had an increased increased level of pain tolerance so he also didn’t mind to take any pain relievers. Until three days prior to admission, patient had severe right upper quadrant pain, which was said to be
Grandmother unknown
Grandfather unknwon
Father
Grandfather Hypertension
Grandmother
Mother
Step-brod died at the the age of 18 because
Younger sister Anna died o f car accident at age o f six years Patient X . Hypertension and choloAnna
Breakfast
I cup of rice and fried egg
Morning snack
Coke and sandwich
Lunch
2 cap of rice and sinegang
Dinner
2 cap of rice and adobong baboy
B Regular Routine of diet (weekly) Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Breakfast
I cup of rice, 1 cup of coffee and hotdog
I cup of rice, 1 cup of coffee and tocino
I cup of rice, 1 cup of coffee and fried egg
I cup of rice, 1 cup of coffee and fried chicken
I cup of rice, 1 cup of coffee. Corne beef
I cup of rice, 1 cup of coffee and maling
I cup of rice, 1 cup of coffee and
Lunch
2cup of rice and sinegang
2 cup of rice and adobong
2 cup of rice and pinangat
2 cup of rice and langkang
2 cup of rice and monggo
2 cup of rice and sisig
2cup of rice and
V Disease Entity A Definition Cholecy Cholecysti stitis tis is an inflam inflammat mation ion of the gallbl gallbladde adderr wall wall and nearby nearby abdomin abdominal al lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones gallstones are bilirubinate bilirubinate of either either black or brown pigment. pigment. In Asia, pigmented pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East.
Gallstones are crystalline structures formed by concretion (hardening) or accretion (adher (adherenc encee of parti particle cles, s, accumul accumulati ation) on) of normal normal or abnorm abnormal al bile bile consti constitue tuents nts.. Accor Accordi ding ng to vari variou ouss theor theorie ies, s, ther theree are are four four poss possib ible le expla explanat natio ions ns for for stone stone formation. formation. First, First, bile may undergo a change in composition. composition. Second, gallbladde gallbladder r
However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication. B Etiology
When the outflow of bile from the gallbladder is obstructed, it becomes disten distended. ded. This This disten distensio sion n causes causes a compro compromis misee of blood blood flow flow and lymphat lymphatic ic drainage. This eventually leads to mucosal ischemia and finally necrosis. In 2000, the ability of endotoxin to cause necrosis, hemorrhage, areas of fibrin deposition, and extensive mucosal loss was demonstrated. Later, endotoxin was shown to have the capacity to abolish the gallbladder’s ability to contract in response to cholecystokinin (CCK), worsening gallbladder stasis and accelerating the process of infection. (Bile cultures are often positive for bacteria, but bacterial proliferation may be a more appropriate description of the overall process.) C Epidemiology Frequency 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.
HEPATOBILLARY
LIVER
A. Location and size of the liver- largest gland in the body, weighs approximately 1.5
5. Vita Vitami min n and and Iro Iron n Stor Storage age -stores vitamin A, D, E, K 6. Drug Drug Meta Metabo boli lism sm 7. Bil Bile For Format mation -bile is formed by the hepatocytes -compo -composed sed of water, water, electr electroly olytes tes such such as sodium sodium,, potass potassium ium,, calciu calcium, m, chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile salts -collected and stored in the gallbladder and emptied in the intestine when needed for digestion a. Lecithin Lecithin and bile bile salts salts emulsify emulsify fats fats by encasi encasing ng them in in shells shells to form form tiny spheres called micelles b. Sodium bicarbonate bicarbonate increases increases pH for optimu optimum m enzyme enzyme function function c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are wastes products excreted by the liver and eventually eliminated in the feces GALLBLADDER The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose
The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when digest digestion ion occurs occurs in the stomac stomach h and intest intestine ines, s, the gallbl gallbladde adderr contra contracts cts,, ejecti ejecting ng the concent concentrat rated ed bile bile into into the duo duodenu denum. m. Jaundi Jaundice ce a yellow yellow discol discolora oratio tion n of the skin skin and 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 is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, bile, which is released when food containing fat enters the digestive tract, tract, stimulating the secretion of cholecystokinin (CCK). The bile, bile, produced in the liver , emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile the bile becomes becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum. duodenum. BILIRUBIN PRODUCTION AND ELIMINATION Biliru Bilirubin bin is the substanc substancee that that gives gives bile bile its color. color. It is forme ormed d from from senes enesce cent nt red bloo blood d cell cells. s. In the proc proces esss of degradation, the hemoglobin from the red blood cell is broken down from biliverdin, biliverdin, which is rapidly converted to free bilirubin bilirubin thru
The solute precipitate from solution as solid crystals Crystals must come together and fuse to for Bile Bile must become sup ersaturated with wit h cho lesterol and calcium
Gallstones
Obstruction of the cystic duct and common bile duct
Impaired Skin Broken Skin and traumatized traumatized tissue integrity Pain
Increased risk for environmental exposure to pathogens
Risk for Infection
VII management A Medical Management
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The nurs The nursee conve conveys ys to the the patie patient nt that that he will will act act as the the patie patient nt’s ’s advoc advocat atee by speaking for him while the patient is in surgery. Assess health factors that affects the patient preoperatively: nutritional status, drug or alcohol use, cardiovascular status, hepatic and renal function, endocrine function, immune immune functi function, on, previo previous us medica medicatio tion n use, use, psycho psychosoc social ial factor factors, s, as well well as the spiritual and cultural beliefs. When the circulator reviews patient allergies with the patient, he ascertains that the patient has no history of allergy to radiopaque dye. Inform the patient of the scheduled date and time of the surgery and where to report Instruct what to bring (insurance card, list of meds & allergies) Check Check the chart chart for patien patient’s t’s sensit sensitivi ivitie tiess and allerg allergies ies e.g. e.g. allerg allergy y to iodine iodine.. Document allergies noted preprocedure and document alternative used. Instruct what to leave at home such as jewelry, watch, medications and contact lenses Instruct what to wear ( loose fitting, comfortable clothes and flat shoes) Remind the patient not to eat e at or drink if directed The patient may have fear and anxiety regarding the surgical procedure and the unfamiliar environment. Explain nursing procedures before performing them and the sequence of perioperative events. Assess and document patient’s anxiety level and level of knowledge regarding the
DIAGNOSTIC
WBC
NORMAL RESULT
ACTUAL RESULT
5.0-10.0
12.9 g/l
NURSING IMPLICATION
slightly elevated indicates infection
NSG. RESPONSIBILITY
>Instruct patient to increase intake of Vitami Vitamin n C and increa increase se fluid intake >Administer antibiotic as ordered
Lymph #
3.0-4.0
1.6x1069/L
High-indicates stress, pain and acute systemic infection
>Instruct patient to increase intake of Vitami Vitamin n C and increa increase se fluid intake >Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered
NORMAL
ACTUAL
Implication
COLOR
Lig Light or pale pale Yellow
Light Yellow
Normal
CHARACTER
Clear
Slightly turbid
Abnormal
ALBUMIN
(-)
(-)
Normal
REACTION
4.6-8
6.5 pH
Normal
SPECIFIC GRAVITY
1.010-1.025
1.010
Normal
PUS CELL
0
2-4
Slightly elevated
presence infection SQUAMOUS
(-)
(+ )
Abnormal
Nursing Responsibility
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•
of •
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•
Instruct patient to increase fluid intake
Instruct patient to increase fluid intake Administer antibiotic as ordered Instruct patient to increase fluid intake Administer antibiotic as ordered
2. Mefenamic Acid 500 mg cap 3 x day (am-1pm-8pm) for 1 week E
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Instructed the patient to do exercise as tolerated such as walking
T
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Inst Instrruct ucted the pat patient ent to cont contiinue nue the medi medica cati tion on
H
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1. Encouraged patient to incre crease fluid inta ntake 2. Encouraged patient to eat foods rich in Vitamin and Nutritious Nutritious foods 3. Encourage patient to avoid salty and fatty fatty foods 4. Encourage patient to have enough rest
O
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Inst Instru ruct cted ed to to com comee back back for for foll follow ow-u -up p che check ck-u -up p on Janu Januar ary y 15, 15, 201 2010, 0, Frid Friday ay..
Remind Remind patien patients ts that that regula regularr check-up check-upss are import important ant to ensure ensure that that the patien patientt condition is constantly monitored by the doctor. If any of the following symptoms are noted, he should contact his doctor: any of the wounds start to bleed
1, Acute pain r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision
ASSESSMENT
NURSING
PLAN
NURSING
DIAGNOSIS
Subjective “masakit ang sugat ko" as verbalized by the patient
Objective •
•
•
•
with pain scale of 5/10 with facial grimaces weak appearanc e guarding behavior
Acute pain r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision (Cholecystotomy )
RATIONALE
INTERVENTION
Cholecystoto my ↓ Surgical Incision ↓ Disruption of skin, tissue and muscle integrity
After 8 hrs of nursing intervention the patient will report that her pain is lessen from a pain scale of 5/10 to 1/10.
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➢ ➢
➢
↓
➢
Stimulation of sensory nerve endings
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↓
Assess location, characteristic, onset, duration, frequency , quality and severity of pain Note location of surgical incision Perform assessment each time pain occurs, note and investigate changes from previous reports Monitor V/S Provide quiet environment and encourage adequate rest period Encourage use of relaxation technique and diversional activities
Pain ➢
Provide additional comfort measures such as back rub, changing patient’s position, change linen as necessary
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➢ ➢
➢ ➢
To assess the etiology or precipitating factors
As this can influence the amount of post-op experience To rule out worsening of underlying condition or development of complication
V/S are usually altered in acute pain To prevent fatigue
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To encourage sense of control and improve coping activities/helps control or alleviate pain
➢
To relieve general discomfort
EVALUATIO N
Goal met: Patient reported that her pain was lessened from a pain scale of 5/10 to 1/10 after 8 hours of nursing intervention.
2, Acute Pain, r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision
ASSESSMENT
NURSING
PLAN
NURSING
RATIONALE
EVALUATION
DIAGNOSIS
INTERVENTION
” masakit ang sugat ko pag gumaglaw ako’ as verbalized by the patient
Acute Pain, r/t Cholecystotomy disruption of skin, ↓ tissue and muscle integrity secondary Surgical Incision to Surgical ↓ incision
Objective
(Cholecystotomy)
Subjective
•
•
• • •
Facial grimace upon moving patient puts her hand above surgical incision when moving Slowed movement weak appearance Inability to ambulate or walk without assistance from others
T: 36.2 °C P: 69 bpm
After 8 hrs of nursing intervention the patient will report that her pain is lessen from a pain Disruption of skin, scale of 5/10 to tissue and muscle 1/10. integrity ↓
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Stimulation of sensory nerve endings
Assess location, characteristic, onset, duration, frequency , quality and severity of pain
Note location of surgical incision Perform assessment each time pain occurs, note and investigate changes from previous reports
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➢
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↓ Pain
➢
Monitor V/S
➢
Provide quiet environment and encourage adequate
➢
➢
To assess the etiology or precipitating factors
As this can influence the amount of postop experience To rule out worsening of underlying condition or development of complication V/S are usually altered in acute pain To prevent fatigue
Goal met: Patient reported that her pain was lessened from a pain scale of 5/10 to 1/10 after 8 hours of nursing intervention.
R: 19 cpm BP: 120/80 mmHg
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rest period Encourage use of relaxation technique and diversional activities
Provide additional comfort measures such as back rub, changing patient’s position, change linen as necessary
Administer analgesic as ordered
Instruct patient’s significant others to help patient divert pain into other things
➢
To encourage sense of control and improve coping activities/helps control or alleviate pain
➢
To relieve general discomfort
➢
To maintain acceptable level of pain
3, Impaired Skin Integrity r/t disrupted skin layers secondary to surgical incision
ASSESSMENT
NURSING DIAGNOSIS
ANALYSIS
PLAN
NURSING INTERVENTION
RATIONALE
EVALUATION
Subjective
”Medyo na ngangate tong sugat ko” as verbalized by the patient
Impaired Skin Integrity r/t disrupted skin layers secondary to surgical incision
Cholecystotomy ↓ Surgical Incision ↓ Destruction of skin layers
Objective •
•
• •
disrupted skin layers wound area is warm to touch (+)slight swelling at the incision site
After 8 hrs of nursing intervention the patient will avoid scratching at the incision site
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Inspect/assess incision site for redness, swelling or signs of evisceration
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Keep the incision site clean and dry, carefully change the dressing
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➢
↓ Broken skin and traumatized tissue
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Regularly clean the wound aseptically
↓ Impaired Skin integrity
➢ ➢
Minimize skin irritation
➢
V/S: T: 36.2 °C
➢
P: 69 bpm R: 19 cpm BP: 120/80
➢
Instruct patient to increase intake of foods rich in protein, minerals and vitamins Assess for presence or absence of local wound
➢
Redness or swelling indicates wound infection
To assist body’s natural process of infectio To promote healing and prevent infection
Preventing skin irritation eliminates a potential source of microorganism entry They aid in skin healing
Provides for early detection of developing infectious process
Goal Met (-) Scratching on the incision site after 8hours of nursing intervention.
4. Risk for infection related to presence presence of surgical incision
ASSESSMENT
NURSING DIAGNOSIS
PLAN
NURSING INTERVENTION
RATIONALE
EVALUATION
S/O: “Surgical incision at right upper quadrant” as verbalized by the patient
Objective •
•
• •
•
disrupted skin layers wound area is warm to touch (+)slight swelling at the incision site WBC is slightly elevated,12
Risk for infection related to presence of surgical incision
Surgical Procedure
After 8 hours of nursing intervention the occurrence of (Cholecystotomy infection will be ) prevented as evidenced by no ↓ Surgical Incision ↓
➢
↓
↓ Risk for Infection
Suggestive of presence of Goal Met : infection/ developing sepsis, abscess or after 8hours of peritonitis. nursing intervention
➢
Practice good hand washing and aseptic wound care.
Inspect incision and dressings. Note characteristics of drainage from wound.
•
➢
➢
Broken Skin and traumatized tissue
R: 19 cpm BP: 120/80 mmHg
➢
↓
P: 69 bpm
T: 36.2 °C
Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, and complaints of increasing abdominal pain.
•
Destruction of Skin Layers
Increased risk for environmental exposure to pathogens
V/S:
s/sx of infection will appear like diaphoresis, chills, abdominal pain and fever.
➢
➢
Administer antibiotics
➢
Reduce risk of spread of bacteria
Provides early detection of developing infectious process and monitor resolution of pre-existing peritonitis.
May be given prophylactically or to reduce number of multiplying microorganisms in the presence of infection to decrease spread and seeding of the abdominal cavity.
•
•
(-) chills, (-) diaphoresis (-) report of increasing abdominal pain afebrile with a body temp of 36.9°C
5. Anxiety related to Surgical incision.
Assessment
Subjective Natakot ako sa operasyon baka kong anu ang mag yari sa akin. Objective
Nursing Diagnosis
Anxiety related to upcoming surgical operation.
Plan
Inflammation of gall bladder
CHOLECYSTITIS ➢
Restlessness Reports of uncertainty and being scared
T: 36.2 °C P: 69 bpm R: 19 cpm BP: 120/80 mmHg
surgical operation (Cholecystotomy)
Anxiety to scheduled surgical operation
Within my 4 hour care care,, the the clie client nt will be able to:
1.Verbalize awareness of feelings of anxiety and health ways to deal with them.
Nursing Interventions
➢
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➢
2. Report anxiety is reduced to a manageable level.
➢
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Rationale
Be avai availa labl blee to the the ➢ patie patient. nt. Mainta Maintain in frequent contacts with the the pati patien ent/ t/SO SO.. Be available available for listening listening and talking as needed Identify patient’s ➢ perception of the threat represented by the situation Encour Encourage age patien patientt to ➢ acknowledge reality of stress stress without without denial denial or reas reassu sura ranc ncee that that ever everyt ythi hing ng will will be alright. Pr ov ovide info inform rmat atio ion n abou aboutt measures measures being taken to correct or alleviate condition. ➢ Assist Assist SO to respond in a positive manner to patient and situation
Review coping
➢
Establishes rapport, promotes expression of feelings. Demonstrates concern and willingness to help. Helpful in discussing sensitive subjects Helps recognition of extent of anxiety anxiety and identificat identification ion of measures that may be helpful for the individual. Helps patient to accept what is happening and reduce level of anxiety. anxiety. False reassurance reassurance is not helpfu helpful, l, becaus becausee neithe neither r nurse nurse nor patien patientt knows knows the final outcome. Information can prov provid idee reas reassu sura ranc nce/ e/ help help reduce fear of the unknown. Promotes Promotes reduction reduction of anxiety anxiety to see others remaining calm. Because anxiety is contagious, if SO/ SO/ staf stafff exhi exhibi bitt thei their r anxiety, anxiety, the patient’s patient’s coping coping abil abilit itie iess can can be adve advers rsel ely y affected. Provides Provides opportunity opportunity to build
Evaluation
C. PHARMACOLOGIC
Name of Dr Dru g
GN: H2Bloc (Pepcidine)
Route/ Do Dosage and Frequency
PO
BN: Zinacef
- Anti-ulcer
20 mg tab at bedtime
- competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion
IV
- anti-infective
BN:Famotidine
GN: Cefuroxime
Action
750 mg every 8o prior to OR (30 to 60 minutes before)
- a 2nd generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability
Indication
Adverse Reaction
-for short term treatment of duodenal ulcer
- headache, dizziness, malaise, dry mouth
NURSING RESPONSIBILITY
1. Check Check for for doctor doctor’s ’s order order 2. Know Know the 10 Righ Rights ts in drug drug administration
Pharmacokinetics
45% Absorbed after oral and IM administration.
3. not to to be give given n in patie patients nts hypersensitive to drugs 4. Inform Inform the the patien patientt about about the possible side effect of the drug 5. Instru Instruct ct patie patient nt to take take drug drug with food 6. Advise Advised d patien patientt to take take drug drug once daily usually at bed time 7. Advise Advise pati patient ent to to report report abdominal pain or blood in stools or is vomiting. - perioperative prophylaxis
- Nau Nause seaa and and Vomi Vomiti ting ng
1. Chec Check k for for doct doctor or’s ’s orde order r 2. Know Know the the 10 Righ Rights ts in drug drug administration
3. Perform Perform ANST ANST prior prior to admission 4. Should Should not not be give given n if positi positive ve skin test 5. Slow Slow IV push push 6. Inform Inform the pati patient ent abou aboutt the possible side effect of the drug 7. Advise Advise pati patient ent to to report report any any discomfort on the IV insertion site
Approximately 50% of serum cefuroxime is bound to protein. Serum pharmacokinetic parameters for CEFTIN Tablets and CEFTIN for Oral. absorbed from the gastrointestinal tract and rapidly hydrolyzed by nonspecific esterases in the intestinal mucosa and blood and blood to cefuroxime.
