Final Output

TABLE OF CONTENTS
I.
ABSTRACT
-----------------------------------------------------
II.
2
ACKNOWLEDGEMENT
--------------------------------------------
page
III.
3
INTRODUCTION
--------------------------------------------
page
IV.
4
SIGNIFICANCE OF THE STUDY
-----------------------------------
page
page
Nursing Education
Nursing Practice
Nursing Research
Scope and Limitation
V.
VI.
THEORETICAL FRAMEWORK ----------------------------------------- page 7

OBJECTIVES OF THE STUDY ----------------------------------------- page 8
General
Specific
VII.
PATIENTS PROFILE -----------------------------------------------------
page
9
Nursing Health History
Physical Assessment
VIII.
IX.
X.
XI.
ANATOMY AND PHYSIOLOGY

-------------------------------- page 21
PATHOPHYSIOLOGY --------------------------------------------------- page 24
DIAGNOSTIC TESTS --------------------------------------------------- page 26
MEDICAL AND SURGICAL MANAGEMENT --------------------- page 30
Drug study
XII.
NURSING MANAGEMENT --------------------------------------------- page 42
Nursing Care Plan

XIII.
XIV.
DISCHARGE PLAN (M. E. T. H. O. D.) ------------------------ page 48

REFERENCES ------------------------------------------------------- page 50
Abstract
1 | Page
This study shows the interpretation and analysis of the disease condition
and health status of a chosen patient from the Northern Mindanao Medical
Center Surgical Ward. This study aims to draw a conclusion and find appropriate
nursing interventions to improve patient condition and thus, facilitate promotion of
optimal wellness.
Acknowledgement
2 | Page
We, CUSN 4 would like to express my gratitude to my clinical instructor

Mr. Raymond D. Dizon, and to our practicing clinical instructors, Ms. Dinah
Toledo,who gave me the possibility to complete these case study.I am deeply
indebted to our clinical instructorsand whose help, suggestions, knowledge,
experience, and encouragement helped us at all times of our duties.
We
would
like
to
thank
the
staffs
and
supervisors
of
NMMCSurgicalDepartment. It was one of the best learning experiences working

with them. We deeply appreciate their help and this experience brought us
another level of being a nursing student.
Also very special thanks to NMMC for providing us a golden opportunity to
work or duty in this prestigious hospital. It is really a privilege and a great honor
to have a duty in NMMC because through this I am able to enhance my
knowledge, skills, attitude, and teamwork. Luckily, our learning from the theories
helped us face the challenges competitively in caring for patients needing
emergency care. We had the opportunity to practice our creative skills and
resourcefulness in order to give our clients the quality of care they deserve.
Choosing nursing interventions that advance the client to improve their health
and maximum independence or prevent the progress of the disease have always
been our goal.
And so, we have learned to personalize care and to prioritize problems
and interventions. We had also emphasized in the study the role of the nurse as
a health care provider and as a health educator in assisting the client and
significant others to go through this difficult time of their life.
3 | Page
Introduction
Sixty pecent to 80% of pancreatic tumors occur in the head of the
pancreas (Zinner & Ashley, 2007). Tumors in this region of the pancreas obstruct
the common bile duct where the duct passes throught the head of the pancreas
to join the pancreatic duct and empty at the ampulla of Vater into the duodenum.
The tumors producing the obstruction may ariese from the ampulla of Vater.1
Obstructive jaundice is a condition in which there is blockage of the flow of
bile out of the liver. This results in redirection of excess bile and its by-products
into the blood, and bile excretion from the body is incomplete. Bile contains many
by-products, one of which is bilirubin, a pigment derived from dead red blood
cells. Bilirubin is yellow, and this gives the characteristic yellow appearance of
jaundice in the skin, eyes, and mucous membranes. Symptoms of obstructive
jaundice include yellow eyes and skin, abdominal pain, and fever.
Any type of obstruction that blocks the flow of bile from the liver can cause
obstructive jaundice. Most commonly, gallstones create the blockage. Other
causes of obstruction include inflammation, tumors, trauma, pancreatic cancer,
narrowing of the bile ducts, and structural abnormalities present at birth.
(http://www.healthgrades.com/conditions/obstructive-jaundice)
As a health care provider, promoting health through providing strategic
care to patients and to actively involve of the development of the nursing
profession are one of the sole responsibilities that needs to be carried out in a
standard manner. In addition to the conventional nursing duties of observing,
assessing and recording symptoms and treatments, emotional support to the
patient and family is provided. Accordingly, all nurses should have a fundamental
understanding of the evaluation and nursing management of OBSTRUCTIVE
JAUNDICE SECONDARY TO PANCREATIC HEAD NEW GROWTH WITH
LIVER METASTASIS. It is in the light of this cause this case study was made.
1Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Medical-Surgical Nursing. Philadelphia: Lippincott
Williams & Wilkins.
4 | Page
Background of the Study
Patient was a 40-year-old male, who was admitted at Northern Mindanao

Medical Center with a chief complaint of jaundice. He was diagnosed with
Obstructive Jaundice Probably secondary to Obstructive Jaundice Secondary to
Pancreatic Head New Growth with Liver Metastasis. This condition is interesting,
and to present a case about obstructive jaundice to our clinical instructor and
practicing clinical instructions would be a great honor. Through this, it will provide
us more knowledge on what type of care we are going to provide.
Significance of the study
Nursing Education
This study can be a useful learning guide in nursing education as this can
be used by the students as a reference for future studies regarding obstructive
jaundice and related cases. This case study will enable the students to learn how
to assess patients with any signs of this condition and be able to provide
appropriate nursing care and management.
Nursing Practice
This case study can be used as a tool in nursing practice because it
provides nursing interventions for patients with obstructive jaundice secondary to
pancreatic head new growth with liver metastasis. This study can give a good
intervention to the disorder so that an established nursing action can be quickly
utilized. Through this study, important information regarding this illness has been
gathered this will be helpful on the students to have an understanding on the said
illness.
5 | Page
Nursing research
This study can be used as a baseline data for further research of the
current management of patients with obstructive jaundice. There might be some
information in this study that can be a good use for research studies. It is also
important as a researcher to gain new information, better interventions and
techniques to provide to the patients. This condition, obstructive jaundice
secondary pancreatic head new growth with liver metastasis, is described its
prodromal signs and symptoms and how this condition affects people. Therefore,
the symptoms are introduced (for early detection) treatment (for information) and
management.
Scope and Limitations of the Study
This case study discusses about obstructive jaundice secondary to

pancreatic head new growth with liver metastasis. It includes essential concepts
in relation to the said condition such as the patients profile and health history,
nursing assessment and clinical manifestations; drug study and diagnostic
exams. The anatomy and physiology is also included as well as the
pathophysiology of with its associated factors. The medical and nursing
management along with the discharge plans and other relevant data are also
being covered.
The scope of the plan covers during the course of duty last January 26-27,
January 30 and January 8, 2015. The physical assessment and nursing
management cover the above mentioned dates.
6 | Page
Theoretical Framework
Florence Nightingales Environmental Theory was anchored in caring of
the patient. Environmental theory is crucial to health and to the clients ability to
regain normal level of functioning and it is the major component of nursing care.
This theory consists of concept of ventilation, warmth, light, diet, cleanliness, and
noise. She emphasized the use of environment to assist patients recovery.
Concerns of the environmental theory are as follows: (1) proper ventilation focus
on the architectural aspect of the hospital. Without proper ventilation,
microorganism will attach more to the suspected host and will cause more illness
to the patient, especially that the patient is having sepsis condition. (2) Light has
quite as real and tangible effects to the body. Adequate lighting can relax the
patient inside their respect rooms or wards. (3) Cleanliness and sanitation. This
theory assumes that dirty environment was the source of infection and rejected
the germ theory. Her nursing interventions focus on proper handling and
disposal of bodily secretion sand sewage, frequent bathing for patients and
nurses, clean clothing and hand washing. (4) Warmth, and quiet, in these
manner, appropriate warmth, and giving the patient a quiet time would give them
the best possible comfort they can get in the hospital setting. (5) Unnecessary
noise is not healthy for recuperating patients. (6) Dietary intake. Appropriate
balanced diet will aid the patients healing process in a timely manner. (7) Petty
management proposed the avoidance of psychological harm. Upsetting news
should not be discussed inside the hospital such as war or outbreaks of harmful
events for it will worry and stress the patient resulting to a delay in healing.
Hence, applying this theory with obstructive jaundice secondary to
pancreatic head new growth with liver metastasis would be beneficial in the
aspect of their health such as physical, psychological, social, and spiritual. It will
also then apply to the patients total of independence, religion and environment.
7 | Page
Objectives of the Study

General Objectives:
At the end of this case, the students will be expected to acquire adequate
knowledge, attitude and skills in providing holistic care for patients who has an
OBSTRUCTIVE JAUNDICE with the cooperation of the family and the significant
others and with the collaboration of the other health care team.
Specific Objectives:
This case study aims to:
a. Present patients condition and management in a graded case
presentation.
b. Identify the factors that caused the condition of the patient.
c. Provide anatomy and physiology of the body systems involved in the
disease process.
d. Provide necessary information regarding the disease condition, its
manifestations, pathophysiology and scope of affected body systems.
e. Present nursing care plans and apply the necessary nursing care
regimens from the identified priority nursing diagnosis in agreement
with the patients chief problems.
f. Elucidate and related the medications and its specific details and
actions appropriate to the patients condition.
g. Accept constructive criticisms and necessary remarks positively from
the clinical instructor.
PATIENTS PROFILE
DEMOGRAPHIC DATA
8 | Page
Patient D is a 40-years-old, Filipino, Male, from Lanao Del Norte, born last
March 14, 1974. He is a Muslim. He finished secondary school, and was not able
to proceed due to financial constraints. He was admitted in Northern Mindanao
Medical Center last January 23, 2015 in the Emergency department and
transferred to the surgical ward. His chief complaint for hospitalization was
because of jaundice. He was referred from a private hospital in Iligan City. He
had an admitting blood pressure of 120/60 mmHg, pulse rate of 100 bpm,
respiratory rate of 23 cpm, and temperature of 37.8 degrees Celsuis. He was
then diagnosed of having an OBSTRUCTIVE JAUNDICE SECONDARY TO
PERIAMPULLARY SEPSIS DUE TO ANEMIA.
HEALTH PATTERN ASSESSMENT

A. History of Past Illness
Patient was hospitalized at a local hospital and had surgery of
appendectomy in the year 1990.
B. Present Health History
Patient was a 40-year-old male, who was admitted at Northern Mindanao
Medical Center with a chief complaint of jaundice. One month prior to admission,
patient had sudden onset of epigastric pain, stabbing in character, radiating to
the back area. No consult was done. No medications were taken.
Three weeks prior to admission, his epigastric pain persisted associated
with yellowish discoloration of skin, post-prandial vomiting, pruritus, & melena.
Patient consulted at an herbolaryo but noted no relief.
Four days prior to admission, the condition persisted, associated with
body malaise, and dizziness. Hence, sought consult at a private physician and
9 | Page
ultrasound was done which revealed a periampullary mass. Hence, referred in

our institution and subsequently admitted.
D. Family Health History

Patient D claimed a familial condition of hypertension on both sides of his
parents and that his family usually consults to an herbolarios. He is married to
his 28-years-old wife who currently does not have known condition. Together,
they have 3 children, 9-years-old female, a 7-years-old male, and a 4-years-old
female all in good health condition.
E. NUTRITIONAL PATTERN
Patient claimed he eats vegetables and small amounts of meat, not pork,
with 2 cups of rice 3 times daily. He usually drinks plenty amount of water, about
6 to 8 glasses of water per day with no vitamin supplements taken.
His special diet in the hospital is low fat diet, and high protein diet.
However, he claimed he had a poor appetite. Due to this reduced appetite, he
lost weight from 170 kilograms to 49 kilograms, his current weight.
F. LIFESTYLE PATTERN
Patient D was a chain smoker for 8 years. He used to consume one pack
per 24 hours. He stopped smoking for one year already. He rarely drinks
alcoholic beverages amounting 120 ml, just to try out of curiosity. He claims to
drink soda for snacks, 500 ml bottle. He drinks herbal coffee one cup early in the
morning every day. He has no known allergies of food or medications and other
allergy irritants.
He is a farmer. He does not have a regular exercise and sees farming as
his form of exercise. His leisure activity is to make sure his plants grow well by
cleaning its surroundings. He does not have adequate sleeping pattern since he
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experienced signs and symptoms of his illness. He claimed that hecould not
sleep during the time he was not brought in NMMC.
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PHYSICAL ASSESSMENT
STATEMENT OF GENERAL APPEARANCE
During assessment, the patient is conscious, and coherent, lying on bed with ongoing intravenous fluid of D5 LR 1000 ml regulated at
30 drops per minute, infusing well at right arm. With a side drip of Aminoleban 450 ml plus 50 ml of D50 water. Skin is yellow in color with
severe pruritus in his upper and lower extremities. He is well oriented to time, place, person and knows the reason for his admission.
FINDINGS
REVIEW OF SYSTEMS
SYSTEMS
January 25, 2015
January 30, 2015
February 8, 2015
INTEGUMENTARY
Skin color is yellow; appears supple.
Skin
Turgor:
<1
second
below Skin
Turgor:
<1
second
below Skin
Turgor:
<1
second
below
Clavicles, and <1 second at the Clavicles, and <1 second at the Clavicles, and <1 second at the
Sternum
Sternum
Sternum
Hair is black, thin and fine textured Hair is black, thin and fine textured Hair is black, thin and fine textured
and evenly distributed on the scalp.
Nails are pale, with capillary refill of1 Nails are pale, with capillary refill of 1 Nails are pale, with capillary refill of 1
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second.
second.
second.
With an axillary temperature of 37.9 With an axillary temperature of 38.4 With an axillary temperature of 38.0
degrees Celsius.
degrees Celsius.
degrees Celsius.
Mid abdominal and right lower
quadrant surgical wound dressings
dry and intact.
Head
is
symmetrical,
normocephalic
with
rounded, Head
smooth
is
symmetrical,
skull normocephalic
with
rounded, Head
smooth
is
symmetrical,
skull normocephalic
with
rounded,
smooth
skull
HEAD
contour positioned at midline and contour positioned at midline and contour positioned at midline and
erect with no lumps or ridges.
EYES
Eyebrows are symmetrically aligned; Eyebrows are symmetrically aligned; Eyebrows are symmetrically aligned;
equal movement with no presence of equal movement with no presence of equal movement with no presence of
flakes, scars, or lesions.
Conjunctivas of the eyes were pale Conjunctivas of the eyes were pale Conjunctivas of the eyes were pale
and scleras were yellow.
Pupil
reaction
accommodation
to
is

light
and Pupil
reaction
symmetrically accommodation
to
is

light
and Pupil
reaction
symmetrically accommodation
to
is
light
and
symmetrically
equal, 2mm in size diameter. Both equal, 2mm in size diameter. Both equal, 2mm in size diameter. Both
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eyes
are
brisk
and
uniform
constriction to light.
in eyes
are
brisk
and
uniform
in eyes
are
brisk
and
uniform
in
Yellow color as his facial skin. The left Yellow color as his facial skin. The left Yellow color as his facial skin. The left
and the right pinna are symmetrical and the right pinna are symmetrical and the right pinna are symmetrical
and are aligned with the inner canthus and are aligned with the inner canthus and are aligned with the inner canthus
EARS
of the eye. Non-impacted cerumen is of the eye. Non-impacted cerumen is of the eye. Non-impacted cerumen is
present on both ears with intact present on both ears with intact present on both ears with intact
tympanic membrane.
Symmetrical;
straight;
tympanic membrane.
uniform
in Symmetrical;
straight;
tympanic membrane.
uniform
in Symmetrical;
straight;
uniform
in
color; no discharges but alar flaring color; no discharges but alar flaring color; no discharges but alar flaring
noted.
NOSE
noted.
noted.
Air moves freely as the patient Air moves freely as the patient Air moves freely as the patient
breathes through the nares.

Nasogastric tube for lavage is in
place.
MOUTH
Lips are moist but pale in color.
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He has missing molar teeth.
Gums are pale in color;
No weakened tongue muscle; no No weakened tongue muscle; no No weakened tongue muscle; no

presence of oral thrush.
Pharynx
Uvula is midline; mucosa pale in color Uvula is midline; mucosa pale in color Uvula is midline; mucosa pale in color
and no lesions or ulcerations noted.
No discomfort noted in all extremities; No discomfort noted in all extremities; No discomfort noted in all extremities;
equal muscle strength (Scale: 4/4)as equal muscle strength (Scale: 4/4)as equal muscle strength (Scale: 4/4)as
the patient turns his head from left to the patient turns his head from left to the patient turns his head from left to
right; up and down; and circular right; up and down; and circular right; up and down; and circular
NECK
motion.
Trachea
motion.
centrally
located
midline of the neck.
in
the Trachea
motion.
centrally
located
in
the Trachea
centrally
located
in
the
No palpable lymph nodes noted on No palpable lymph nodes noted on No palpable lymph nodes noted on
any of the areas of the neck.
CHEST AND LUNGS
Equal
lung
expansion

and Equal
lung
expansion

and Equal
lung
expansion
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and
vocal/tactile fremitus on both lung vocal/tactile fremitus on both lung vocal/tactile fremitus on both lung
fields upon palpation. AP ratio is 2:1 fields upon palpation. AP ratio is 2:1 fields upon palpation. AP ratio is 2:1
chest
shape.
Upon
auscultation, chest
shape.
Upon
auscultation, chest
shape.
Upon
auscultation,
normal breath sounds are heard. normal breath sounds are heard. normal breath sounds are heard.
Resonant sound is heard on both Resonant sound is heard on both Resonant sound is heard on both
fields upon percussion.
Respiratory Rate : 23 CPM
The patients precordial area is flat; The patients precordial area is flat; The patients precordial area is flat;
there was no lift or heaves.
CARDIOVASCULAR
The point of maximal impulse was The point of maximal impulse was The point of maximal impulse was
located at the fifth left intercostal located at the fifth left intercostal located at the fifth left intercostal
space or along the breast line in line space or along the breast line in line space or along the breast line in line
with the nipples.
with the nipples.
with the nipples.
No thrills noted upon palpation;
HEART RATE OF 98bpm.
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Blood Pressure of 100/60 mmHg.
Breasts were even with smooth skin, Breasts were even with smooth skin, Breasts were even with smooth skin,
uniform
fair
skin
color
with
the uniform
fair
skin
color
with
the uniform
fair
skin
color
with
the
abdomen. During palpation, there was abdomen. During palpation, there was abdomen. During palpation, there was
no tenderness, masses or nodules no tenderness, masses or nodules no tenderness, masses or nodules
BREAST AND AXILLA
noted
with
subclavicular
the
and
patients
axillary, noted
with
supraclavicular subclavicular
the
and
patients
axillary, noted
with
supraclavicular subclavicular
the
and
patients
axillary,
supraclavicular
lymph nodes. No discharges in the lymph nodes. No discharges in the lymph nodes. No discharges in the
patients nipples.
patients nipples.
patients nipples.
Has not defecated for 4 days, last Defecated at 1PM, soft but clay Last
bowel
movement
was
on
bowel movement was on January 22, colored stool. No pain reported upon February 4, 2015. Nothing per orem
2015.
GASTROINTESTINAL
bowel movement.
Normal Bowel Sounds: 3 clicks per Normal Bowel Sounds: 8 clicks per
minute (NBS: 5-30 cpm).
minute (NBS: 5-30 cpm).

Right upper quadrant pain, pain scale
started February 5, 2015 until further

observation.
Normal Bowel Sounds: 5 clicks per
minute (NBS: 5-30 cpm)
of 8/10.
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No malodorous penile discharge
Appropriate distribution of pubic hair Appropriate distribution of pubic hair Appropriate distribution of pubic hair
for age (Maturation State: Stage 4 for age (Maturation State: Stage 4 for age (Maturation State: Stage 4
coarse and curly; covers more area) coarse and curly; covers more area) coarse and curly; covers more area)
GENITOURINARY
No masses noted on the scrotum.
No swelling noted.
No swelling noted.
No swelling noted.
Urinary output of 2100 ml per 24 Urinary output of 2000 ml per 24 Urinary output of 1500 ml per 24
hours, deep orange in color and hours, deep orange in color and hours, amber in color.
MUSCULOSKELETAL
foamy urine.
foamy urine.
Functional level classification:
= 2 (requires help from another

person)

person)

person)
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Bilateral non-pitting edema on the
upper and lower extremities, +2.
upper and lower extremities, +2.
lower extremities, +1.
Bilateral warmth on both arms and
legs of the client.
legs of the client.
legs of the client.
No limited range of motion, and
have equal muscle strength (5/5) on
all extremities.
all extremities.
all extremities.
Spine is midline and gait is
coordinated
coordinated
coordinated
There was no missing finger or
bone enlargement on the hands
and wrists.
and wrists.
and wrists.
There were no lesions noted on the There were no lesions noted on the There were no lesions noted on the
back. Skin color at the back and the back. Skin color at the back and the back. Skin color at the back and the
extremities are similar with the rest extremities are similar with the rest extremities are similar with the rest
of the body.
of the body.
of the body.
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ANATOMY AND PHYSIOLOGY

The liver, gallbladder and small intestine are connected by a series of thin
tubes called bile ducts. The bile ducts are part of the digestive system. The bile
ducts and gallbladder are also part of the biliary system, or biliary tract.
Figure
2.1
Location of the Bile Ducts
Figure 1.1 Location of common bile duct
Structure
The common bile duct is a very thin tube, about 10 12.5 cm (4-5 inches)
long. A series of ducts come together to finally form the common bile duct:
Many tiny tubules within the liver collect bile from the liver cells.
These tiny tubules come together to form small ducts. These small
ducts then join together into larger ducts that form the right and left
hepatic ducts.
The right and left hepatic ducts exit the liver and join to form the
common hepatic duct.

The common hepatic duct and the cystic duct join to form the
common bilde duct. The cystic duct connects the gallbladder (a
small organ that stores bile) to the common bile duct.
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The common bile duct passes through the pancreas before it

empties into the first part of the small intestine (duodenum). The
lower part of the common bile duct joins the pancreatic duct to form
a channel called the ampulla of Vater or it may enter the duodenum
directly.
Intrahepatic bile ducts

The bile ducts within the liver are called intrahepatic bile ducts. These
small ducts join together into larger ducts, ending in the left and right hepatic
ducts. The right and left lobes of the liver are drained by these ducts.
Extrahepatic bile ducts
The extrahepatic bile ducts are outside the liver. The extrahepatic ducts
include the part of the right and left hepatic ducts that are outside the liver, the
common hepatic duct and the common bile duct. (The cystic duct is also outside
the liver, but cancers
of the cystic duct are
grouped
with
gallbladder cancers.)
The
extrahepatic
bile ducts may be

further divided based
Figure 3The Bile Ducts
on their location:
Perihilar bile ducts

o The hilum or hilar area is the area where the right and left
hepatic ducts leave the liver and join to form the common
hepatic duct. It also includes the point where the cystic duct
joins the common hepatic duct. Because these ducts are
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close to the liver, they may be referred to as the proximal
extrahepatic bile ducts.

Distal extrahepatic bile duct
o The distal extrahepatic bile duct includes the common bile
duct. It is farther away from the liver, between the junction of
the cystic duct to the common hepatic duct and the ampulla
of Vater (but does not include these structures).
Function
The extrahepaticbile ducts are part of a network of ducts that carry bile
from the liver and gallbladder to the small intestine. Bile is a yellowish-green fluid
made by the liver. Bile flows from the liver, through the hepatic ducts, into the
cystic duct and to the gallbladder, where it is stored.
Bile helps digest the fat in foods. Bile is mainly made up of:
Bile salts
Bile pigments (such as bilirubin)
Cholesterol
Water
If the bile is not needed for digestion, it flows into the cystic duct and then
into the gallbladder, where it is stored. When bile is needed to digest food,
the gallbladder contracts and releases bile into the cystic duct. The bile
then flows into the common bile duct and is emptied into the small
intestine, where it breaks down fats.
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PATHOPHYSIOLOGY
Legends:
Predisposing Factors
Precipitating Factor
Disease Process
Lab Results
Treatment
Signs and Symptoms
Complication
Precipitating
Factors:
- Coffee tea
- Smoker (8yrs)
Predisposing Factors:
- Age
Accumulation of carcinogens
Mass formation in the

pancreatic head
Inflammatory
response
WBC: 10.45
x10^3/uL
Temp. 38.4C
Acetaminophen 500
mg PO PRN
Piperacillin/tazob
actam 4.5 grams
IVTT Q8H
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Common bile duct

obstruction
Accumulation of bile in the

biliary tract and gallbladder
Dilatation of the intra and

extra hepatic ducts
Gallbladder and biliary tree

distention
SGT: H 50.80 u/l

Bilirubin:
Yellow eyes,
oral mucosa,
and skin
Clay colored
stool
Redirection of bile and

excess by-products into
the blood
Total: 8.90 mg/dl

Albumin: 5.80
Pruritus
Decreased bile in the
intestinal tract
(hypobilirubinemia)
Generalized
edema
Trendelenburg
position
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Pain scale 8 out 10
Dyspepsia and intolerance to fatty foods
Nausea and vomiting
Weight loss: 170 kg 49

kg
3 clicks per minute
Lactulose 30 mg PO
No appetite
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DIAGNOSTIC TESTS AND LABORATORY RESULTS

Clinical Chemistry Section
Depending on the doctors order, these chemical components in our body
determine what specific type of chemical components needs supplement to fully
recover our bodys cell functioning. These tests also determine or, sometimes,
rules out what organ are affected when a client is in a state of illness.
Lab result: 01/25/2015
Time: 7:00 AM
HEMATOLOGY REPORT
TEST
WHITE BLOOD CELLS
RED BLOOD CELLS
HEMOGLOBIN
HEMATOCRIT
MCV
MCH
MCHC
RDW
PDW
MPV
DIFFERENTIAL COUNT
Lymphocyte (%)
Neutrophil (%)
Monocyte (%)
EosinophilS (%)
Basophils (%)
Bands/Stabs (%)
PLATELET
RESULT
H 17.55
L 3.43
L 8.60
L 27.10
L 79.00
L 25.70
31.70
H 17.70
10.40
9.80
UNIT
10^3/uL
10^6/Ul
g/dL
%
fL
Pg
g/dL
%
fL
fL
REFERENCE
5.0 10.0
4.2 5.4
12.0 - 16.0
37.0 - 47.0
82.0 98.0
27.0 31.0
31.5 35.0
12.0 - 17.0
9.0 -16.0
8.0 12.0
L 8.40
H 84.40
H 21.60
L 0.60
0.20
%
%
%
%
%
%
10^3/uL
17.4 48.2
43.4 76.2
4.5 10.5
1.0 3.0
0.0 2.0
1.0 3.0
150 400
H 484
INTERPRETATIONS:
a.) WBC count: It is a blood test to measure the number of white blood cells (WBCs)
in the blood. It help fight infections. They are also called leukocytes. An increase
WBC count means that the patient is having an infection.
b.) RBC count: It is a blood test that measures how many red blood cells (RBCs) in
the body. It determines how much oxygen in the body is delivered and how well it
works. This test can help diagnose different kinds of anemia (low number of
28 | P a g e
RBCs) and other conditions affecting red blood cells. In this case the patients
RBC count is lower than normal which means that the patient maybe anemic.
c.) Hemoglobin Count: It is a blood test that measures how much hemoglobin is in
the body. Hemoglobin is a protein in red blood cells that carries oxygen. The
hemoglobin test is a commonly ordered blood test and is almost always done as
part of a complete blood count (CBC). The patients hemoglobin count is lower
than normal which means that the patient is poorly nourished, and maybe
hypoxic.
d.) Hematocrit Count: It is a blood test that measures the percentage of the volume
of whole blood that is made up of red blood cells. This measurement depends on
the number of red blood cells and the size of red blood cells. The patients
hematocrit count is lower than normal which means that he maybe anemic.
e.) Mean Corpuscular Volume (MCV): It is a measurement of the average size of
RBCs. Patient results shows a lower count indicating the his RBCs are smaller
than normal (microcytic); caused by iron deficiency anemia.
f.) Mean Corpuscular Hemoglobin: It is a calculation of the average amount of
oxygen-carrying hemoglobin inside the red blood cell. Mirrors MCV results; small
red cells would have a lower value.
g.) Redistribution width (RDW): It is a calculation of the variation size or RBCs.
Indicates mixed population of small and large RBCs; immatuer RBCs tend to be
alrger. For example, in iron deficiency anemia or pernicious anemia, there is high
variation (anisocytosis) in RBC size (along with variation in shape poikilocytosis), causing an increase in the RDW.
h.) Lymphotcytes - Responsible for immune responses. There are two main types of
lymphocytes: B Cells and T cells. The B cells make antibodies that attack
bacteria and toxins while the T cells attack body cells themselves when they
29 | P a g e
have been taken over by viruses or have become cancerous. Lymphoctes

secrete products (lymphokines) that modulate the functional activities of many
other types of cells and are often present at sites of chronic inflammation. Patient
may have lymphocytopenia caused by infection.
i.) Neutrophils -The real number of white blood cells. Neutrophils are key
components in the system of defense against infection.
Patient may have
neutrophilia may caused by bacterial infections and inflammation.

j.) Monocyte A type of white blood cell used to evaluate and manage blood
disorders, certain problems with the immune system, and cancers, including
monocytic leukemia. This test may also be used to evaluate for the risk of
complications after a heart attack. An increased percentage of monocytes may
be due to chronic inflammatory disease.
k.) Eosinophils - A normal type of white blood cell that has coarse granules withint its
cytoplasm. Eosinophils are produced in the bone marrow and migrate to tissues
throughout the body. When a foreign substance enters the body, other types of
WBC (lymphocytes and neutrophils) release substances to attract eosinophils
and then release toxic substances to kill the invader. Since there is a suspected
inflammatory disorder, patients results shows high in eosinophils.
l.) Platelet - The smallest cell-like sturctures in the blood and are important for blood
clotting and plugging damaged blood vessels. Patient has increased platelet
count. It indicates increased variation in the size of the platelets, which may
mean that a condition is present that is affecting the platelets.
Lab Result: 01/29/2015
TEST
WHITE BLOOD CELLS
RED BLOOD CELLS
HEMOGLOBIN
HEMATOCRIT
MCV
MCH
MCHC
Time: 9:56 AM
RESULT
H 10.18
L 4.07
L 10.00
L 31.10
L 76.40
L 24.60
32.20
UNIT
10^3/uL
10^6/Ul
g/dL
%
fL
Pg
g/dL
REFERENCE
5.0 10.0
4.2 5.4
12.0 - 16.0
37.0 - 47.0
82.0 98.0
27.0 31.0
31.5 35.0
30 | P a g e
RDW
PDW
MPV
DIFFERENTIAL COUNT
Lymphocyte (%)
Neutrophil (%)
Monocyte (%)
EosinophilS (%)
Basophils (%)
Bands/Stabs (%)
PLATELET
H 19.70
12.30
10.50
%
fL
fL
12.0 - 17.0
9.0 -16.0
8.0 12.0
L 9.20
H 78.70
10.40
1.50
0.20
%
%
%
%
%
%
10^3/uL
17.4 48.2
43.4 76.2
4.5 10.5
1.0 3.0
0.0 2.0
1.0 3.0
150 400
366
INTERPRETATIONS:
1) WBC count: It is a blood test to measure the number of white blood cells (WBCs)
in the blood. It help fight infections. They are also called leukocytes. An increase
WBC count means that the patient is having an infection.
2) RBC count: It is a blood test that measures how many red blood cells (RBCs) in
the body. It determines how much oxygen in the body is delivered and how well it
works. This test can help diagnose different kinds of anemia (low number of
RBCs) and other conditions affecting red blood cells. In this case the patients
RBC count is lower than normal which means that the patient maybe anemic.
3) Hemoglobin Count: It is a blood test that measures how much hemoglobin is in
the body. Hemoglobin is a protein in red blood cells that carries oxygen. The
hemoglobin test is a commonly ordered blood test and is almost always done as
part of a complete blood count (CBC). The patients hemoglobin count is lower
than normal which means that the patient is poorly nourished, and maybe
hypoxic.
4) Hematocrit Count: It is a blood test that measures the percentage of the volume
of whole blood that is made up of red blood cells. This measurement depends on
the number of red blood cells and the size of red blood cells. The patients
hematocrit count is lower than normal which means that he maybe anemic.
5) Mean Corpuscular Volume (MCV): It is a measurement of the average size of
RBCs. Patient results shows a lower count indicating the his RBCs are smaller
than normal (microcytic); caused by iron deficiency anemia.
31 | P a g e
6) Mean Corpuscular Hemoglobin: It is a calculation of the average amount of

oxygen-carrying hemoglobin inside the red blood cell. Mirrors MCV results; small
red cells would have a lower value.
7) Redistribution width (RDW): It is a calculation of the variation size or RBCs.
Indicates mixed population of small and large RBCs; immatuer RBCs tend to be
alrger. For example, in iron deficiency anemia or pernicious anemia, there is high
variation (anisocytosis) in RBC size (along with variation in shape poikilocytosis), causing an increase in the RDW.
8) Lymphotcytes - Responsible for immune responses. There are two main types of
lymphocytes: B Cells and T cells. The B cells make antibodies that attack
bacteria and toxins while the T cells attack body cells themselves when they
have been taken over by viruses or have become cancerous. Lymphoctes
secrete products (lymphokines) that modulate the functional activities of many
other types of cells and are often present at sites of chronic inflammation. Patient
may have lymphocytopenia caused by infection.
9) Neutrophils -The real number of white blood cells. Neutrophils are key
components in the system of defense against infection.
Patient may have
neutrophilia may be caused by bacterial infections and inflammation.

TEST
WHITE BLOOD CELLS
RED BLOOD CELLS
HEMOGLOBIN
HEMATOCRIT
MCV
MCH
MCHC
RDW
PDW
MPV
DIFFERENTIAL COUNT
Lymphocyte (%)
Neutrophil (%)
Monocyte (%)
EosinophilS (%)
Basophils (%)
Bands/Stabs (%)
Time: 7:00 PM
RESULT
H 10.45
L 4.12
L 10.10
L 31.90
L 77.40
L 24.50
31.70
H 21.20
12.70
10.70
UNIT
10^3/uL
10^6/Ul
g/dL
%
fL
Pg
g/dL
%
fL
fL
REFERENCE
5.0 10.0
4.2 5.4
12.0 - 16.0
37.0 - 47.0
82.0 98.0
27.0 31.0
31.5 35.0
12.0 - 17.0
9.0 -16.0
8.0 12.0
L 9.80
H 78.30
9.50
1.90
0.50
%
%
%
%
%
%
17.4 48.2
43.4 76.2
4.5 10.5
1.0 3.0
0.0 2.0
1.0 3.0
32 | P a g e
PLATELET
H 452
10^3/uL
150 400
INTERPRETATIONS:
a) WBC count: It is a blood test to measure the number of white blood
cells (WBCs) in the blood. It help fight infections. They are also called
leukocytes. An increase WBC count means that the patient is having
an infection.
b) RBC count: It is a blood test that measures how many red blood cells
(RBCs) in the body. It determines how much oxygen in the body is
delivered and how well it works. This test can help diagnose different
kinds of anemia (low number of RBCs) and other conditions affecting
red blood cells. In this case the patients RBC count is lower than
normal which means that the patient maybe anemic.
c) Hemoglobin Count: It is a blood test that measures how much
hemoglobin is in the body. Hemoglobin is a protein in red blood cells
that carries oxygen. The hemoglobin test is a commonly ordered blood
test and is almost always done as part of a complete blood count
(CBC). The patients hemoglobin count is lower than normal which
means that the patient is poorly nourished, and maybe hypoxic.
d) Hematocrit Count: It is a blood test that measures the percentage of
the volume of whole blood that is made up of red blood cells. This
measurement depends on the number of red blood cells and the size
of red blood cells. The patients hematocrit count is lower than normal
which means that he maybe anemic.
e) Mean Corpuscular Volume (MCV): It is a measurement of the average
size of RBCs. Patient results shows a lower count indicating the his
RBCs are smaller than normal (microcytic); caused by iron deficiency
anemia.
f) Mean Corpuscular Hemoglobin: It is a calculation of the average
amount of oxygen-carrying hemoglobin inside the red blood cell.
Mirrors MCV results; small red cells would have a lower value.
33 | P a g e
g) Redistribution width (RDW): It is a calculation of the variation size or

RBCs. Indicates mixed population of small and large RBCs; immatuer
RBCs tend to be alrger. For example, in iron deficiency anemia or
pernicious anemia, there is high variation (anisocytosis) in RBC size
(along with variation in shape - poikilocytosis), causing an increase in
the RDW.
h) Lymphotcytes - Responsible for immune responses. There are two
main types of lymphocytes: B Cells and T cells. The B cells make
antibodies that attack bacteria and toxins while the T cells attack body
cells themselves when they have been taken over by viruses or have
become cancerous. Lymphoctes secrete products (lymphokines) that
modulate the functional activities of many other types of cells and are
often present at sites of chronic inflammation. Patient may have
lymphocytopenia caused by infection.
i) Neutrophils -The real number of white blood cells. Neutrophils are key
components in the system of defense against infection. Patient may
have neutrophilia may caused by bacterial infections and inflammation.
j) Platelet - The smallest cell-like sturctures in the blood and are
important for blood clotting and plugging damaged blood vessels.
Patient has increased platelet count. It indicates increased variation in
the size of the platelets, which may mean that a condition is present
that is affecting the platelets.
BLOOD CHEMISTRY
A blood chemistry is a test that measures the level of several substances
in the blood (such as electrolytes). It tells about the general health of a person, it
can look up problems, and finds out whether treatment for a specific problem is
working.
34 | P a g e

Blood Urea Nitrogen
Creatinine
Electrolytes:
Potassium
Sodium
Liver Profile:
S.G.O.T/AST
S.G.P.T/ALT
ALK Phos
Bilirubin:
Total`
Direct
Indirect
Total Protein
Albumin
Globulin
A/G Ratio
INTERPRETATIONS:
Time: 9:56PM
Results
H 43.82 mg/dl
0.50 mg/dl
Reference Values
10 50 mg/dl
0.6 1.2 mg/dl
3.44 mmol/l
137.23 mmol/l
3.5 5.3 mmol/l

135 145 mmol/l
H 50.80 U/L
31.90 U/L
203.80 U/L
0 37 U/L
0 42 U/L
80.0- 306.0 U/L
H 8.90 mg/dl
H 5.60 mg/dl
H 3.30 mg/dl
L 6.21 g/dl
H 5.80 g/dl
2.41 g/l
1.07
0.20 1.70 mg/dl

0.00-0.25 mg/dl
0-0.10 mg/dl
6.6 8.7 g/dl
3.8 5.1 g/dl
1.8 3.2 g/L
1.5 2.4
a) Blood Urea Nitrogen A blood test that reveals the function of the kidneys
and the liver. It measures the amount of urea nitrogen that is in the blood.
A high result suggests that the kidneys or the liver may not be working
properly.
b) SGOT/AST Aspartate aminotransferase (AST) test measures the
amount of this enzyme in the blood. AST is normally found in red blood
cells, liver, heart, muscle tissue, pancreas, and kidneys. Formerly was
called serum glutamic oxaloacetic transaminase (SGOT). Low levels of
AST are normally found in the blood. When body tissue or an organ such
as the heart or liver is diseased or damaged, additional AST is released
into the blood stream. The amount of AST in the blood is directly related to
the extent of the tissue damage. After severe damage, AST levels rise in 5
to 10 hours and remain high for about 4 days.
c) Bilirubin Measured to diagnose and/or monitor liver disease, such as
cirrhosis, hepatitis, or gallstones. It is also used to evaluate people with
sickle cell disease or other causes of haemolytic anemia who may have
episodes when excessive red blood cell destruction takes place,
increasing levels. Bilirubin can be measured as a total level and/or as
35 | P a g e
conjugated and unconjugated levels for these purposes. More commonly,

the laboratory uses a chemical test to detect water-soluble forms of
bilirubin, termed direct bilirubin, which is an estimate of the amount of
conjugated bilirubin. By subtracting this from the total bilirubin, an indirect
estimate (indirect bilirubin) of unconjugated bilirubin is obtained.
a. Direct (conjugated) Elevated than the unconjugated means there
is some kind of blockage of the bile ducts. This may occur with
tumors or scarring of the bile ducts.
b. Indirect (unconjugated) Increased levels may indicate haemolytic
or pernicious anemia.
c. Total Protein Frequently ordered as part of a comprehensive
metabolic panel (CMP). It provides the persons general nutritional
status, such as when someone has undergone a recent,
unexplained weight loss. It can be ordered along with other tests to
provide information when someone has symptoms that suggest a
liver, kidney, or bone marrow disorder, or to investigate the cause of
abnormal pooling of fluid in tissue (edema). A low total protein level
suggests liver disorder, a kidney disorder, or a disorder in which
protein is not digested or absorbed properly. Low levels seen in
severe malnutrition and with conditions that cause malabsorption,
such as celiac disease or inflammatory bowel disease (IBD).
d. Albumin Made mainly in the liver. It helps keep the blood from
leaking out of blood vessels. Albumin also helps carry some
medicines and other substances through the blood and is important
for tissue growth and healing. Increased blood albumin may be due
to dehydration.
e. A/G Ratio Albumin/Globulin Ratio are routinely included in the
panels of tests performed as part of a physical, such as a
Comprehensive Metabolic Panel (CMP), so they are frequently
assessed as a part of an evaluation of a persons overall health
status. A low A/G ratio may reflect overproduction of globulins, such
36 | P a g e
as seen in multiple myeloma or autoimmune diseases, or

underproduction of albumin, such as may occur with cirrhosis, or
selective loss of albumin from the circulation, as may occur kidney
disease (nephrotic syndrome).
Time: 11:38 PM
Albumin = (L) 2.50 g/dl

Interpretation:
Albumin Made mainly in the liver. It helps keep the blood from leaking out of
blood vessels. Albumin also helps carry some medicines and other substances
through the blood and is important for tissue growth and healing. Increased blood
albumin may be due to dehydration.
Electrolytes:
Sodium
Liver Profile:
ALK Phos
Bilirubin:
Total`
Direct
Indirect
Total Protein
Albumin
Globulin
A/G Ratio
Time: 12:49 PM
Results
Reference Values
136.91 mmol/L
135-145 mmol/L
H 1,265 U/L
80.0 306.0 u/L
H 25.43 mg/dl
H 20.24 mg/dl
H 6.20 mg/dl
L 5.70 g/dl
L 2.72 g/dl
2.93 g/l
L 0.95
0.20 1.20 mg/dl

0.00 0.25 mgd/l
0 0.10 mg/dl
6.6 8.7 g/dl
3.8 5.1 g/dl
1.8 3.2 g/L
1.5 2.4
INTERPRETATIONS:
a) ALK Phos Alakaline phosphatase test (ALP) is used to help detect liver
disease or bone disorders. In conditions affecting the liver, damaged liver
cells release increased amounts of ALP into the blood. This test is often
37 | P a g e
used to detect blocked bile ducts because ALP is especially high in the
edges of cells that join to form bile ducts. If one or more of them are
obstructed, for example by a tumor, then blood levels of ALP will often be
high.
b) Bilirubin Measured to diagnose and/or monitor liver disease, such as
cirrhosis, hepatitis, or gallstones. It is also used to evaluate people with
sickle cell disease or other causes of haemolytic anemia who may have
episodes when excessive red blood cell destruction takes place,
increasing levels. Bilirubin can be measured as a total level and/or as
conjugated and unconjugated levels for these purposes. More commonly,
the laboratory uses a chemical test to detect water-soluble forms of
bilirubin, termed direct bilirubin, which is an estimate of the amount of
conjugated bilirubin. By subtracting this from the total bilirubin, an indirect
estimate (indirect bilirubin) of unconjugated bilirubin is obtained.
a. Direct (conjugated) Elevated than the unconjugated means there
is some kind of blockage of the bile ducts. This may occur with
tumors or scarring of the bile ducts.
b. Indirect (unconjugated) Increased levels may indicate haemolytic
or pernicious anemia.
c. Total Protein Frequently ordered as part of a comprehensive
metabolic panel (CMP). It provides the persons general nutritional
status, such as when someone has undergone a recent,
unexplained weight loss. It can be ordered along with other tests to
provide information when someone has symptoms that suggest a
liver, kidney, or bone marrow disorder, or to investigate the cause of
abnormal pooling of fluid in tissue (edema). A low total protein level
suggests liver disorder, a kidney disorder, or a disorder in which
protein is not digested or absorbed properly. Low levels seen in
severe malnutrition and with conditions that cause malabsorption,
such as celiac disease or inflammatory bowel disease (IBD).
38 | P a g e
d. Albumin Made mainly in the liver. It helps keep the blood from
leaking out of blood vessels. Albumin also helps carry some
medicines and other substances through the blood and is important
for tissue growth and healing. Low levels are with the presence of
edema.
e. A/G Ratio Albumin/Globulin Ratio are routinely included in the
panels of tests performed as part of a physical, such as a
Comprehensive Metabolic Panel (CMP), so they are frequently
assessed as a part of an evaluation of a persons overall health
status. A low A/G ratio may reflect overproduction of globulins, such
as seen in multiple myeloma or autoimmune diseases, or
underproduction of albumin, such as may occur with cirrhosis, or
selective loss of albumin from the circulation, as may occur kidney
disease (nephrotic syndrome).
Diagnostic Studies
Ultrasound-Abdomen
Date: 01/19/2015
Clinical Data:
Impression:
DILATED INTRA AND EXTRAHEPATIC BILIARY DUCTS. Consider distal
common bile duct obstruction. Occult distal choledocholithiasis, stricture, or a
periampullary mass lesion. Suggest ECRP and/or upper abdominal CT scan with
contrast (focus at the pancreatic head).
MARKEDLY HYDROPIC GALLBLADDER DUE TO THE BILIARY DUCT
OBSTRUCTION SUGGESTIVE DILATATION OF THE PANCREATIC DUCT
DIFFUSE SECONDARY HEPATIC PARENCHYMAL DISEASE
VERY MINIMAL AGGREGARATE OF URINARY CYRSTALS/AGGREGATE,
MIDDLE CALYX, RIGHT KIDNEY
VERY MINIMAL ASCITES.
Ultrasound Whole Abdomen w/ Contrast
Date: 01/30/2015
39 | P a g e
INTERPRETATION
Tripase CT scan of the whole abdomen disclose the following findings.
The liver is normal in size with a homogenous density. There is no mass seen.
There is dilatation of the intra and extra hepatic ducts. The common bile duct is
around 1.6 cms. in widest diameter with no stone within.
The gallbladder is distended measuring around 14.2x5.6cms. There is no stone
within.
There is a solid enhancing mass at the head of the pancreas measuring around
6.5x6.0x4.8cms (LHW). The mass appears to infiltrate in the wall of the
duodenum at the second portion. There is no mass at the body and tail. The
pancreatic duct is dilated measuring around 1.4cms.
There is prompt excretion of contrast in both kidneys with intact pelvocalyceal
system. There are tiny cortical cysts in both kidneys. There are two tiny stones in
the right kidney superior pole.
The adrenal glands, spleen, abd. Aorta, urinary bladder. The bowel gas pattern is
non-obstructive.
There is minimal pleural effusion at the right.

There are osteophytes at the thoracic lumbar spine.
IMPRESSION:
CONSIDER PANCREATIC HEAD MASS INFILTRATING ON THE WALL OF THE
SECOND PORTION OF THE DUODENUM AND CAUSING EXTRA HEPATIC
BILIARY DUCT OBSTRUCTION.
DISTENDED GALL BLADDER.
TWO TINY NEPHROLITHIASIS RIGHT KIDNEY.
TINY CORTICAL CYSTS, BOTH KIDNEYS.
MINIMAL PLEURAL EFFUSION, RIGHT.
MINIMAL SPONDYLOSIS THORACO LUMBAR SPINE.
MEDICAL MANAGEMENT
40 | P a g e
DRUG STUDY #1
Generic name:Tramadol
Brand name:Ralivia
Classification:Analgesics
Dosage and Route:1 tabPO
Frequency: T.I.D.
Mechanism of Action:
Binds to mu-opioid receptors. Inhibits reuptake of serotonin and
norepinephrine in the CNS.
Indications:
Moderate to moderately severe pain (extended-release formulations
indicated for patients who require around-the-clock pain management).
Contraindications:
Hypersensitivity; Cross-sensitivity with opioids may occur
Adverse effects
CNS: Seizures, dizziness, headache, somnolence, anxiety, CNS
stimulation, sleep disorder, weakness.
GI: Constipation, nausea, abdominal pain, anorexia, diarrhea, dry mouth,
dyspepsia, flatulence, vomiting.
Derm: Pruritus, sweating.
Nursing Responsibilities/Precaution
Observe severe reactions.
Provide adequate information about the drugs.
Assess for possible drug interaction
Assess for any condition which requires precaution or contraindication.
41 | P a g e
Assess pain type, location, and intensity of pain; before and after
administration.
Assess BP and respiratory rate.
Assess bowel function routinely.
DRUG STUDY #2
Generic name:Omeprazole
Brand Name: Prilosec
Classification:Anti-secretory drug Proton pump inhibitor
Dosage: 1 tablet
Route:PO
Frequency:OD
Gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific
inhibition of the hydrogen-potassium ATPase enzyme system at the
secretory surface of the gastric parietal cells; blocks the final step of acid
production.
Indications:
Short-term treatment of active duodenal ulcer; First-line therapy in

treatment of heartburn or symptoms of gastro esophageal reflux disease
(GERD);
Short-term treatment of active benign gastric ulcer;
GERD, severe erosive esophagitis, poorly responsive symptomatic
GERD;
42 | P a g e
Long-term therapy: Treatment of pathologic hyper secretory conditions
(Zollinger-Ellisonsyndrome, multiple adenomas, systemic mastocytosis);

Eradication of H. pylori with amoxicillin or metronidazole and
clarithromycin.
Contraindications:Contraindicated with hypersensitivity to omeprazole or its

components; Use cautiously with pregnancy lactation.
Adverse Effects:
CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety,
paresthesias,
o Dream abnormalities
Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin
GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth,
tongue
o Atrophy
Respiratory: URI symptoms, cough, epistaxis
Other: Cancer in preclinical studies, back pain, fever.
Nursing Responsibilities:
Take the drug before meals. Report severe headache, worsening
symptoms, fever, chills.
Swallow the capsules whole; do not chew, open, or crush them.
Assess routinely for epigastric or abdominal pain and frank or occult blood
in the stool, emesis, or gastric aspirate.
DRUG STUDY #3
Generic name:Lactulose
Brand Name: Cholac
Classification:Gastrointestinal agent; hyperosmotic laxative
43 | P a g e
Dosage:30 mg
Route:PO
Frequency:Hourse of Sleep
Reduces blood ammonia; appears to involve metabolism of lactose or
organic acids by resident intestinal bacteria.
Indications:
Constipation, salmonellosis. Treatment of hepatic encephalopathy.
Contraindications:
Patient who require allow lactose diet. Galactosemia deficiencty. Intestinal
obstruction.
Adverse Effects:
GI: Belching, cramps, distention, flatulence, diarrhea.
Assess for abdominal distention, presence of bowel sounds, and normal
pattern of bowel function.
Assess color, consistency, and amount of stool produced.
Patients with constipation should be advised on prevention such as eating
a balanced diet containing fibre, fresh fruit and vegetables, drinking 6-8 full
glasses of liquid each day and taking daily exercise.
Advise to drink plenty of fluid while taking this medicine.
DRUG STUDY #4
44 | P a g e
Generic name:Piperacillin/Tazobactam
Brand Name: Zosyn
Classification:Anti-infectives
Dosage:4.5 grams
Route:IVTT
Frequency:Q8H
Piperacillin:
Binds to bacterial cell wall membrane, causing cell death. Spectrum is
extended compared with other penicillins
Tazobactam:
Inhibits beta-lactamase, an enzyme that can destroy penicillins.
Therapeutic effects:
o Death of susceptible bacteria.
Indications:
Community acquired and nosocomial pneumonia caused by piperacillin
resistant, beta-lactamase- producing bacteria.
Contraindications:
Hypersensitivity
to
penicillins,
beta-lactams,
cephalosporins,
or
tazobactam.
Adverse Effects:
CNS: Seizures confusions, dizziness, headache, insomnia, lethargy.
GI: Pseudomembraneous colits; diarrhea, constipation, drug-induced
hepatitis, nausea and vomiting.
45 | P a g e
GU: Interstitial nephritis.

Derm: Rashes, urticaria.
Hemat: Bleeding, leukopenia, neutropenia.
Local: Pain, phlebitis at IV site.
Misc: Hypersensitivity reactions.
Assess for infection.

Observe for signs and symptoms of anaphylaxis reaction.
Monitor for bowel function.
Obtain for culture and sensitivity.
DRUG STUDY #5
Generic name:Acetaminophen
Brand Name: Paracetamol
Classification:Anti-pyretic , nonopioid analgesic
Dosage: 500 mg
Route:PO
Frequency:PRN
Inhibits the synthesis of prostaglandins that may serve as mediation of pain
& fever, primarily in the CNS. Has no significant anti-inflammatory
properties or GI toxicity.
o Analgesia
o Anti-pyretic
Indications:
Mild pain.
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Contraindications:
Previous
hypersensitivity,
products
containing
alcohol,
aspartame,
succharin, sugar.
Use cautiously:
o Hepatic disease/ renal disease; malnutrition.
Adverse Effects:
GI: Hepatic failure, hepatoxicity.

GU: Renal failure.
Hemat: Natropenia, pancytopenia, leukopenia.
Derm: Rash, urticaria.
Assessoverall health status.
Assess pain: type, location, & intensity.
Assess fever; note other associated signs such as diaphoresis,
tachycardia.
DRUG STUDY #6
Generic name:Phytonadine
Brand Name: Vitamin K
Classification:Vitamins
Dosage:10 mg
Route:IVTT
Frequency:Q8H
Required for hepatic synthesis of blood coagulation factors II (prothrombin),
VII, IX, and X.
o Prevention of bleeding due to hypoprothrombinemia.
47 | P a g e
Indications:
Prevention and treatment of hypoprothrombinemia, which may be
associated with: excessive doses of oral anticoagulants, salicylates, certain
anti-infective agents, nutritional deficiencies, prlonged total parenteral
nutrition.
Contraindications:
Hypersensitivity to vitamin K.
Use cautiosuly in:
o Impaired liver function.
Excercuse extreme caution:
o severe life-threatening reactions have occured following IV
administration, use other reoutes unless risk is justified.
Adverse Effects:
GI: Gastric upset, unusual taste.

Derm: Flushing, rash, urticaria.
Hemat: Hemolytic anemia.
Local: Erythemia, pain at injection site, swelling.
Misc: allergic reactions, hyperbilirubinemia.
Monitor for frank and occult bleeding.
Monitor pulse and BP frequently; notify physician immediately if symptoms
of internal bleeding or hypovolemic shock develop.
Avoid unnecessary use of injections.
DRUG STUDY #7
Generic name: Aminoleban
Brand Name: Aminoleban IV
Classification: Nutritional products
48 | P a g e
Dosage: 450 ml + 50ml of D50water

Route: IV
Frequency: kvo rate
o Given to normalize the amino acid, carbohydrate, fats, vitamins and
minerals in the plasma.
Indications:
Dietary supplement especially for patients with liver impairment. Nutritional
support
to
patients
with
chronic
liver
disease
especially
those
with
hepaticencephalopathy
Contraindications:
Patients with abnormal amino acid metabolism.
Adverse Effects:
Hypersensitivity: rare skin eruptions
GI: occasional nausea and vomiting
Others: Occasional chills, fever and headache.
Assess patients condition before starting the therapy
Be alert to adverse reaction.
Monitor temperature.
49 | P a g e
If GI reaction occur, monitor patient hydration
DRUG STUDY #8
Generic name: Ketorolac
Brand Name: Toradol
Classification:
Nonsteroidal
anti-inflammatory
agents,
nonopioid
analagesics
Dosage: 30 mg
Route: IVTT
Frequency: q8h for 3 doses
Inhibits prostaglandin synthesis, producing peripherally
mediated analgesia
Also has antipyretic and anti-inflammatory properties.
Therapeutic effect: Decreased pain.
Indications:
Short term management of pain (not to exceed 5 days total for all
routes combined)
Contraindications:
Hypersensitivity
50 | P a g e
Cross-sensitivity with other NSAIDs may exist Pre- or

perioperative use
Known alcohol intolerance
Use cautiously in:
1. History of GI bleeding
2. Renal impairment (dosage reduction may be required)
3. Cardiovascular disease
Adverse Effects:
CNS: drowsiness
RESP: asthma
CV: edema
GI: GI Bleeding
GU: oliguria
DERM: pruritis
HEMAT: prolonged bleeding time
- Assess pain (note type, location, and intensity) prior to and 1-2 hr
following
administration.
- Ketorolac therapy should always be given initially by the IM or IV

route. Oral therapy should be used only as a continuation of
parenteral
therapy.
- Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs,

acetaminophen, or other OTC medications without consulting health
care
professional.
- Advise patient to consult if rash, itching, visual disturbances,

tinnitus, weight gain, edema, black stools, persistent headche, or
influenza-like syndromes (chills,fever,muscles aches, pain) occur.
- Effectiveness of therapy can be demonstrated by decrease in
51 | P a g e
severity of pain. Patients who do not respond to one NSAIDs may

respond to another.
NURSING MANAGEMENT
NURSING CARE PLAN #1
Subjective: Sakit akong opera as verbalized.
Objective:
Pain scale of 8/10.
Right upper quadrant pain..
Guarding behavior.
Nursing Diagnosis:
Acute pain related to surgical trauma.
Goals
52 | P a g e
After 30 minutes of nursing interventions, pain intensity will decrease or

managed using non-pharmacologic pain management as verbalized.
Nursing Interventions
Independent:
Placed on moderate high back rest.
R:To promote relaxation.
Instructed to perform deep breathing exercises.
R:Deep breathing relaxes muscle tension.
Stressed the importance of using non-pharmacologic pain management
such as:
o Diversion activities.
o Relaxation technique by guided imagery.
o Repositioning.
R: To promote comfort and ease the pain.
Dependent:
Administered Tramadol50 mg P.O.T.I.D.asordered.
R: Analgesic.
Evaluation:
Goal met.
o Pain scale of 1/10.

Subjective: Init ako pamati as verbalized.
Objective:
Warm to touch.
Temp: 38.4C.
53 | P a g e
Nursing Diagnosis
Hyperthermia.
Goals and Objectives
After 1 hour of nursing interventions, temperature will decrease within
normal range, 36C 37.5C.
Nursing Interventions:
Independent:
Removed extra linens.
R: To promote loss of heat through conduction.
Continuous tepid sponge bath rendered.
R: To promote heat loss by evaporation & conduction.
Suggested the use of fan.
R: To promote heat loss by convection.
Dependent:
Administered Acetaminophen 500 mg PO, PRN.
Evaluation
Goal met.
o Temp. 36.9C

Subjective: Akong tahi naa sa tiyan dapit, as verbalized.
Objective:
Wound dressing at mid-abdominal area and right lower quadrant
Nursing Diagnosis
Impaired skin integrity related to altered mechanical interruption of skin.
54 | P a g e
Goals and objectives
After 24 hours of nursing interventions, patient will display timely healing

of wound without complications.
Independent:
Kept the area clean and dry.

R: To prevent infection.
Used appropriate dressings.

R: To protect the wound and surrounding tissues.
Removed wet and wrinkled linen promptly.

R: Moisture potentiates skin breakdown.
Encouraged early ambulation.

R: Promotes circulation.
Provided optimum nutrition and increased protein intake.

R: To aid in healing and to maintain general good health.
Evaluation
Goal partially met.
After 24 hours of nursing intervention, patient displayed partial

healing of lesions without complications.
55 | P a g e
Subjective: Nag hubag akong tiil sugod pag-taod aning tubo as verbalized.
Objective:
(+1) bipedal non-pitting edema
Palpable pulse
Nursing Diagnosis
Edema related to ineffective tissue perfusion.
After 24 hours of nursing interventions, edema will cease.
Independent:
Instructed patient to elevate lower extremities as much as possible.
R: To promote venous return.
Assisted in active range of motion.
R: To promote circulation in the area.
Emphasize the importance of elevating the lower extremities above heart
level during bed time or at resting period.
R: To increase venous return.
Evaluation
Goal met.
o Edema ceased after 24 hours.

Subjective: Dili man ko ganahan mukaon. Wala ko gana, as verbalized.
Objective:
Weight loss from 170kgs to 46kgs
Loss of appetite
56 | P a g e
Decreased RBC: 4.12 10^6/Ul
Pale gums/oral mucous membranes
Pale conjunctiva and mucous membranes
Nursing Diagnosis
Imbalanced Nutrition: Less than body requirement related to failure to

absorb nutrients necessary for formation of normal red blood cells (RBCs).
After 24 hours of nursing interventions, the patient will demonstrate

behaviors to regain weight.
Independent:
Use flavoring agents like lemons and herbs, if salt is restricted.

R: To enhance food satisfaction and stimulate appetite.
Encourage patient to choose foods that are appealing

R: To stimulate appetite.
Promote pleasant and relaxing environment when possible.

R: To enhance intake.
Prevent unpleasant odors and sight.

R: May have negative effect on appetite or eating.
57 | P a g e
Provide oral care before and after meals.

R: To enhance food satisfaction.
Promote timely fluid intake by limiting fluids 1 hour prior to meal.

R: Decreases possibility of early satiety.
Dependent:
Administer (iron) mineral supplements as indicated.
Evaluation
Goal partially met. After 24 hours of nursing intervention,patient

demonstrated behaviors to regain weight.
DISCHARGE PLAN
Medication
1. Instruct patient and the family to comply with the prescribe medication.
2. Instruct patient and the family to complete the whole duration of the drug.
3. Teach the patient and the family regarding the name of the drugs, right
dosage, andproper manner of taking as well possible side effects.
Environment/exercise
1. Advice patient to take regular breaks from any activity that demands to
stresspressure on back.
2. Encourage patient to involve in exercise to enhance circulation.
3. Encourage the patient to have adequate rest and sleep.
Treatment
1. Orient the patients family about the patients condition and necessary
information/treatment and recovery process.
2. Teach patient and the family about the importance of conducive environment
forbetter recovery.
3. Encourage to comply with treatment regimen.
Health Teachings
1. Advice to take medications on time and with the right dose.
2. Instruct the patient to eat nutritious food such as vegetables and fruits.
58 | P a g e
3. Advice the patient to limit consumption of fatty foods.

4. Encourage client to choose food/ have family member bring food that seem
appealingto stimulate appetite.
5. Instruct client to provide oral care before and after meals and at bedtime.
Out patient
1. Instruct the patient to take the medications ordered by the physician.
2. Encourage the patient to comply with the scheduled check-up.
3. Instruct the patient and the family to comply with the prescribed medications.
4. Instruct the patient to visit physician immediately if any unusual ties arise.
Diet
1. Encourage patient to eat nutritious and well balance meal.
2. Instruct the patient to increase oral fluid intake.
3. Diet as tolerated is advice by attending physician to sustain his nutritional
needs.
Spiritual
1. Encourage client and family members to strengthen their relationship to Allah,
tomaintain religious practices and beliefs.
2. Advise family members to provide emotional support to the client to help him
knowthat he will always have help during most difficult times
REFERENCES
A. BOOKS
Bare, B. G., Cheever, K. H., Hinkle, J. L., & Smeltzer, S. C. (2010). Assessment
of Respiratory Function. In B. G. Bare, K. H. Cheever, J. L. Hinkle, & S. C.
Smeltzer, Textbook of Medical-Surgical Nursing (pp. 486-514).
Philadelphia: Lippincott Williams & Wilkins.
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). MedicalSurgical Nursing. Philadelphia: Lippincott Williams & Wilkins.
59 | P a g e
Vianzon, R., Garfin, A. C., Lagos, A., & Belen, R. (2013). The tuberculosis profile
of the Philippines, 2003-2011: advancing DOTS and beyond. Western
Pacific Surveillance and Response Journal, 1-6.
B. INTERNET
http://www.mumbaicancer.com/bile-duct.html
http://www.cancer.ca/en/cancer-information/cancer-type/bile-duct/anatomy-andphysiology/?region=qc
http://pathology2.jhu.edu/bileduct/anatphys.cfm
http://www.pancreaticcancerindia.com/files/hp/periampullary_tumors.html
http://www.cancer.ca/en/cancer-information/cancer-type/bile-duct/anatomy-andphysiology/?region=qc
http://www.ncbi.nlm.nih.gov/books/NBK6924/
60 | P a g e

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TABLE OF CONTENTS

THEORETICAL FRAMEWORK ----------------------------------------- page 7

PATIENTS PROFILE -----------------------------------------------------

ANATOMY AND PHYSIOLOGY

NURSING MANAGEMENT --------------------------------------------- page 42

Nursing Care Plan

DISCHARGE PLAN (M. E. T. H. O. D.) ------------------------ page 48

We, CUSN 4 would like to express my gratitude to my clinical instructor

NMMCSurgicalDepartment. It was one of the best learning experiences working

Background of the Study

Patient was a 40-year-old male, who was admitted at Northern Mindanao

Significance of the study

Scope and Limitations of the Study

This case study discusses about obstructive jaundice secondary to

Objectives of the Study

HEALTH PATTERN ASSESSMENT

ultrasound was done which revealed a periampullary mass. Hence, referred in

D. Family Health History

January 25, 2015

January 30, 2015

Skin color is yellow; appears supple.

Skin color is yellow; appears supple.

Skin color is yellow; appears supple.

and evenly distributed on the scalp.

and evenly distributed on the scalp.

erect with no lumps or ridges.

erect with no lumps or ridges.

flakes, scars, or lesions.

flakes, scars, or lesions.

and scleras were yellow.

and scleras were yellow.

breathes through the nares.

breathes through the nares.

Lips are moist but pale in color.

Lips are moist but pale in color.

Lips are moist but pale in color.

He has missing molar teeth.

He has missing molar teeth.

He has missing molar teeth.

Gums are pale in color;

Gums are pale in color;

Gums are pale in color;

No weakened tongue muscle; no No weakened tongue muscle; no No weakened tongue muscle; no

presence of oral thrush.

presence of oral thrush.

and no lesions or ulcerations noted.

and no lesions or ulcerations noted.

midline of the neck.

midline of the neck.

midline of the neck.

any of the areas of the neck.

any of the areas of the neck.

fields upon percussion.

fields upon percussion.

Respiratory Rate : 23 CPM

Respiratory Rate : 22 CPM

Respiratory Rate : 22 CPM

there was no lift or heaves.

there was no lift or heaves.

with the nipples.

with the nipples.

No thrills noted upon palpation;