FAR EASTERN UNIVERSITY INSTITUTE OF NURSING

CASE PRESENTATION of CHOLECYSTECTOMY

Submitted to: Miss Glenda Santos RN, MAN Miss Victoria Arceli RN, MAN

Submitted by: BSN 207 - GROUP 25 A Alamani, Jollybenson A. Alberto, Jamela Mer D. Alcantara, Jaycel M. Alfonso, Lester E. Amihan, Ma. Luvimae N. Bernardo, Naomi F. December 3, 2011

OPERATING ROOM CASE PRESENTATION I. Patients Data Patients Name: Age: Gender: Date of Birth: Address: Religion: Civil Status: Attending Physician: Operation Performed: Type of Surgery: Surgeon: Date of Operation/Case No. : Type of Anesthesia: Anesthesiologist: II. Anatomy/ Structure/ Function JLP 25 years old Female May 24, 1986 Sabang, Baliuag Bulacan Roman Catholic Married Dr. Bugay Cholecystectomy Open cholecystectomy Dr. Rolando Valones December 1, 2011 / 11-11-5113 Spinal anesthesia Dr. Dennis S. Lazaro

a) Definition of operation performed:

Open cholecystectomy- surgery in which the permit cholecystectomy -- removal of the gallbladder.

abdomen

is

opened

to

This operation has been employed for over 100 years and is a safe and effective method for treating symptomatic gallstones, ones that are causing significant symptoms. At surgery, direct visualization and palpation of the gallbladder, bile duct, cystic duct, and

blood vessels allow safe and accurate dissection and removal of the gallbladder. Intraoperative cholangiography has been variably used as an adjunct to this operation. The rate of common bile duct exploration for choledocholithiasis (gallstones in the bile duct) varies from 3% in series of patients having elective operations to 21% in series that include all patients. Major complications of open cholecystectomy are infrequent and include common duct injury, bleeding, biloma, and infections. Open cholecystectomy is the standard against which other treatments must be compared and remains a safe surgical alternative. b) Discussion of anatomy involved:

The digestive system prepares food for use by hundreds of millions of body cells. Food when eaten cannot reach cells (because it cannot pass through the intestinal walls to the bloodstream and, if it could not be in a useful chemical state. The gut modifies foo physically and chemically and disposes of unusable waste. Physical and chemical modification (digestion) depends on exocrine and endocrine secretions and controlled movement of food through the digestive tract. Stomach contractions send signals to the brain making us aware of our hunger. Glucose level in the blood is maintained. Insulin decreases glucose in blood making us feel hungry. Levels of glucose in the blood are monitored by receptors (neurons) in the stomach, liver, intestines, they send signals to the hypothalamus in the brain. Mouth Food enters the digestive system via the mouth or oral cavity, mucous membrane lined. The lips (labia) protect its outer opening; cheeks form lateral walls, hard palate and soft palate form anterior/posterior roof. Communication with nasal cavity behind soft palate. Floor is muscular tongue. Tongue has bony attachments (styloid process, hyoid

bone) attached to floor of mouth by frenulum. Posterior exit from mouth guarded by a ring of palatine/lingual tonsils.Enlargement sore throat, tonsillitis. Food is first processed (bitten off) by teeth, especially the anterior incisors. Suitably sized portions then retained in closed mouth and chewed or masticated (especially by cheek teeth, premolars, molars) aided by saliva Ducted salivary glands open at various points into mouth. This process involves teeth (muscles of mastication move jaws) and tongue (extrinsic and intrinsic muscles). Mechanical breakdown, plus some chemical (ptyalin, enzyme in saliva). Taste buds allow appreciation, also sample potential hazards (chemicals, toxins). Swallowing In leaving the mouth a bolus of food must cross the respiratory tract (trachea is anterior to esophagus) by a complicated mechanism known as swallowing or deglutination which empties the mouth andensures that food does not enter the windpipe. Swallowing involves coordinatedactivity of tongue, soft palate pharynx and esophagus. The first (buccal) phase is voluntary, food being forced into the pharynx by the tongue. After this the process is reflex. The tongue blocks the mouth, soft palate closes off the nose and the larynx rises so that the epiglottis closes off the trachea. Food thus moves into the pharynx and onwards by peristalsis aided by gravity. If we try to talk whilst swallowing food may enter the respiratory passages and a cough reflex expels the bolus. Esophagus The esophagus (about 10") is the first part of the digestive tract proper and shares its distinctive structure. Basic tissue layers of the gut are: 1. Mucosa- Innermost, moist lining membrane. Epithelium (friction resistant stratified squamous in esophagus, simple beyond) plus a little connective tissue and smooth muscle. 2. Sub mucosa- Soft connective tissue layer, blood vessels, nerves, lymphatic 3. Muscularisexterna- Typically circular inner layer, longitudinal outer layer of smooth muscle 4. serosal fluid- producing single layer. Stomach C shaped, left side abdominal cavity (because liver is on right). Cardio esophageal sphincter guarding entrance from esophagus is of doubtful anatomical integrity (though functionally the diaphragmatic pinch cock serves). Pyloric sphincter guarding the outlet is much better defined. Fundus, body and pylorus recognized as distinct regions. Stomach secretes both acid and mucus (for self-protection). Surface area increased by rugae. Serves as a temporary store for food which is also churned by muscular layers (three here) to form chyme, creamy substance voided via pyloric sphincter to duodenum

Duodenum First part of small intestine. C shaped 10" long and curves around head ofpancreas and entry of common bile duct (accessory organs of digestion, pancreas, liver see below). Chemical degradation of small controlled amounts of food controlled by pyloric sphincter begins here, enzymes secreted by pancreas and duodenum itself aided by emulsifying bile (which also lowers pH). Duodenal ulcers caused by squirting of acid stomach contents into duodenal wall opposite sphincter. Small Intestine Jejunum (8 feet) and ileum (12 feet) continue degenerative process. Surface area increased by plicacirculares (circular folds) carrying villi: cells of villi carry microvilli. Each villus has a capillary and a lacteal (lymphatic capillary) Absorption of digested foodstuffs is via these to the rich venous and capillary drainage of the gut. Towards the end of the small intestine accumulations of lymphoid tissue (Peyer's patches) more common. Undigested residue of food is rich in bacteria. Large Intestine Jejunum terminates at caecum. Caecum is small saclike evagination, important in some animals as a repository for bacteria/other organisms able to digest cellulose. A blind ending appendix may give trouble (appendicitis) if infected. The large intestinehas three longitudinal muscle bands (taenia coli) with bulges in the wall (haustra) between them. These may evaginate in the elderly to become diverticuli and infected in diverticulitis. The large intestine resorbs water then eliminates drier residues as feces. Regions recognized are the ascending colon, from appendix in right groin up to a flexure at the liver, transverse colon, liver to spleen, descending colon, spleen to left groin, then sigmoid (S-shaped) colon back to midline and anus. Anus has voluntary and involuntary sphincter and ability to distinguish whether contents are gas or solid. No villi in large intestine, but many goblet cells secreting lubricative mucus. Accessory digestive organs: Salivary glands Three pairs, parotid, submandibular, sublingual. Mumps begins as infective parotitis in the parotid glands in the cheek. The others open into the floor of the mouth. Saliva is a mixture of mucus and serous fluids, each produced to various extents in various glands. Also contains salivary amylase, (starts to break down starch) lysozyme (antibacterial) and IgA antibodies. Pancreas Endocrine and exocrine gland. Exocrine part produces many enzymeswhich enter the duodenum via the pancreatic duct. Endocrine part produces insulin, blood sugar regulator.

Liver Multifunctional: important in this context since the capillaries of the small intestine drain fat and other nutrient rich lymph into it via theHepatic portal system. Liver and gallbladder A cleftlike lumen, the bile canaliculus is between the cells of each hepatic cord. Bile produced by the hepatocytes, flow through the bile canaliculi to the hepatic duct in the portal of triads. The hepatic duct converge and empty into the right and left hepatic ducts, which transport bile out of the liver. The right and left hepatic ducts units form a single common hepatic duct. The common hepatic duct is joined by the cystic duct from the gallbladder to form the common bile duct. The gallbladder is a small sac on the inferior surface of the liver that stress and concentrates bile. Bile is responsible in making the color of the stool dark brown.Bile, a watery greenish fluid is produced by the liver and secreted via the hepatic duct and cystic duct to the gall bladder for storage, and thence on demand via the common bile duct to an opening near the pancreatic duct in the duodenum. It contains bile salts, bile pigments (mainly bilerubin, essentially the non-iron part of hemoglobin) cholesterol and phospholipids. Bile salts and phospholipids emulsify c) Functions of organs/body parts involved:

The gallbladder is a saclike structure on the inferior surface of the liver that is about 8cm long and cm wide. Three tunics form then gallbladder wall: 1. the inner mucosa folded into rugae that allow the gallbladder to expand. 2. amuscularis, which is a layer of the smooth muscle that allows the gallbladder to contract

3. an outer covering serosa. The cystic duct connects the gallbladder into common bile duct. Bile is continually secreted by liver and flows through the cystic duct to the gallbladder, where 40-70ml of bile can be stored. While the bile is in the gallbladder, water and electrolytes are absorbed, and bile salt and pigmented becomes as much as 5-10 times more concentrated than they were when secreted by the liver. Contraction of the gallbladder moves the stored bile into duodenum. Secreting released from the duodenum stimulate bile secretion, primarily by increasing the water and bicarbonate ion content of bile. Cholecystokinin released from the duodenum stimulates the gallbladder to contract and sphincter of bile duct and hepatopancreatic ampulla relax. To a lesser degree, parasympathetic stimulation through the vagusnercescause the gallbladder to contract. Thus large amount of concentrated bile move rapidly into duodenum. Bile salt also increases bile secretion through a positive feedback system. Over 90% of bile salt are reabsorbed in the elium and carrired in the blood back to liver, where they contribute further bile secretion. The loss of bile salt in the feces is reduced by this recycling process. d) Etiology of the disease: A gallstone, is a lump of hard material usually range in size from a grain of sand to 3-4 cms. They are formed inside the gall bladder formed as a result of precipitation of cholesterol and bile salts from the bile. Types of gallstones and causes

Cholesterol stones Pigment stones Mixed stones - the most common type. They are comprised of cholesterol and salts

Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason. Low grade infection in the gall bladder is another factor in the development of gall stones. Pigment stones are small, dark stones made of bilirubin. Bilirubin is the pigment secreted by the liver The exact cause is not known. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anaemia in which too much bilirubin is formed. Other causes are related to excess excretion of cholesterol by the liver in the bile. They include the following:

Gender. Women between 20 and 60 years of age are twice as likely to develop gallstones as men. Obesity. Obesity is a major risk factor for gallstones, especially in women. Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or birth control pills Cholesterol-lowering drugs. Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides. Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.

e) Signs and symptoms: Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called "silent stones." Gallstone symptoms can be similar to those of many other conditions such as heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. Accurate diagnosis is, therefore important. Symptoms may vary and often follow fatty meals, and they may occur during the night:

Abdominal bloating Recurring intolerance of fatty foods Severe pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours

It may be associated with:

Pain in the back between the shoulder blades Pain under the right shoulder Nausea or vomiting Indigestion & belching

f) Intra and post-operative risk factors: Possible Complications Complications are rare, but no procedure is completely free of risk. If you are planning to have a cholecystectomy, your doctor will review a list of possible complications, which may include:

Gallstones that have accidentally spilled into the abdominal cavity Bleeding Infection Injury to other nearby structures or organs

Reactions to general anesthesia Blood clots

Some factors that may increase the risk of complications include:

Age: 60 or older Pregnancy Obesity Smoking Malnutrition Recent or chronic illness Diabetes Heart or lung problems Bleeding disorders Alcoholism and use of street drugs Use of certain medicines

III. Procedure a) Skin Preparation:

Clean the skin: 1. From the nipples to the pubis. 2. From the posterior axillary fold on the right side to the anterior axillary fold on the left. 3. Use two swabs on sticks with aqueous povidone iodine, followed by one to dry off. 4. Dry the skin completely or adhesive drape edges will not stick down.

b) Draping:

First, they placed a folded drape sheet from the foot to the knees. Then, the scrub nurse selected the sheet and handed one end to the surgeon across the operating site. The second drape sheet was handled in the same manner. This sheet was placed above the incision site with the edge of the sheet just above the incision site. Next, they placed a sterile sheet with an appropriate size of a hole in the middle and put it around the selected incision site. Then, four towel clips were clamped on all edges and connecting them to the two drape sheets.

c) Position:

Lateral shrimp position (during anesthesia injection)

Supine position (during the procedure)

d) Anesthesia (technique used):

Spinal anesthesia, also called spinal analgesia or sub-arachnoid block (SAB), is a form of regional anesthesia involving injection of a local anesthetic into the Subarachnoid space, generally through a fine needle, usually 3.5inches (9 cm) long. For extremely obese patients, some anesthesiologists prefer spinal needles which are seven inches (18 cm) long. T he tip of the spinal needle has a point or small bevel. Recently pencil point needles have been made available. Indications: This technique is very useful in patients having an irritable airway (bronchial asthma or allergic bronchitis), anatomical abnormalities which make endotracheal intubation very difficult (micrognathia), borderline hypertensives where administration of general anesthesia or endotracheal intubation can further elevate the blood pressure, procedures in geriatric patients. It is the technique of choice for diabetic patients. Contraindications: Non-availability of patient's consent, local infection or sepsis at the site of lumbar puncture, bleeding disorders, space occupying lesions of the brain, disorders of the spine and maternal hypotension.

e) Incision Site:

Right side of the upper abdomen

f) Discuss the procedure: Step I: Incision Types of Incision: Upper Right SubCostal Incision Kocher's Incision Modified Kocher's Incision Transverse Incision

The incision for open cholecystectomy is typically made 2 fingerbreadths below the right costal margin, although an upper midline incision can also be used Retractors are placed to retract the skin, as well as to retract the liver superiorly Step II: Exposure of the Gallbladder Retraction of the liver Inferior surface of the right lobe of the liver is retracted upwards by retracter.

 The dome of the gallbladder is initially scored with electrocautery, and a tonsil clamp is used to establish a plane in the thickened gallbladder in proximity to the gallbladder wall itself. The cautery is then used to incise the peritoneal surface of the entire dome.

Step III: Removal of the Gallbladder The fundus of the gallbladder is removed from the liver bed with blunt and sharp dissection. Care should be taken in mobilizing the infundibulum of the gallbladder to be certain that it is not adherent to the common bile duct. The cystic artery and its extension are usually encountered on the medial surface of the gallbladder. The cystic artery can be temporarily controlled with a clip on the surface of the gallbladder prior to its formal ligation. The gallbladder is then completely mobilized from the liver bed until it is attached only by the cystic duct.

 A clamp is placed on the gallbladder fundus and used to retract the gallbladder superiorly. A second clamp can be used to retract the infundibulum of the gallbladder laterally, exposing the triangle of Calot. Ideally, the cystic artery is identified, circumferentially dissected, and ligated before dissection of the gallbladder out of the gallbladder fossa. As in the laparoscopic case, care should be taken not to injure the right hepatic artery. The gallbladder is then removed from the gallbladder fossa from the top down using electrocautery. Clamps are placed proximally and distally on the cystic duct. The cystic duct is divided between the clamps, and the gallbladder is removed from the field. The cystic duct stump is suture ligated using a 3-0 silk suture The cystic duct and cystic artery stumps are examined for any signs of bile leakage or bleeding

Step IV: Closing The placement of closed suction drains is not always required. They are placed only if bile leakage from the cystic duct stump is expected or observed. If bile leakage is observed, the surgeon must rule out common bile duct injury. The fascia is closed in two layers using running or interrupted sutures. The skin is then closed with absorbable subcuticular sutures or skin staples.

CASE PRESENTATION CHOLECYSTITIS I. Patients Data Patients Name: Age: Gender: Date of Birth: Address: Religion: Civil Status: Attending Physician: Operation Performed: Type of Surgery: Surgeon: Date of Operation/Case No. : Type of Anesthesia: Anesthesiologist: II. NURSING HISTORY a. PAST HEALTH HISTORY The patient had childhood illness like mumps when she was 6 years old and measles when she was 3 or 4 years old. According to her, she does not have chicken pox up to now. She had complete immunization status. She has no allergies to food and medications. She was admitted for caesarean section last 2008 in Sto. Nio Hospital in Bustos, Bulacan. She was hospitalized for 3 days. b. HISTORY OF PRESENT ILLNESS Eight days prior to admission, she experienced on and off epigastric pain and radiating to her back. She also felt pain in her head, nape and around her eyes. She also felt abdominal bloating. She took Mefenamic acid 500 mg for the pain. Pain lessened but still recurrent for 8 days. She experienced loss of appetite and difficulty in falling asleep. She had her check-up last November 25, 2011. She went through ultrasound, pap smear and urinalysis. Her ultrasound impression was cholelithiasis. She was admitted last November 30, 2011 in Castro Maternity and General Hospital. c. FAMILY HISTORY There are cases of hypertension, asthma, and skin cancer on the maternal side of the patient. On her paternal side, heart diseases and breast cancer are present. JLP 25 years old Female May 24, 1986 Sabang, Baliuag Bulacan Roman Catholic Married Dr. Bugay Cholecystectomy Open cholecystectomy Dr. Rolando Valones December 1, 2011 / 11-11-5113 Spinal anesthesia Dr. Dennis S. Lazaro

III. ACTIVITIES OF DAILY LIVING Activities of Daily of Daily Living Nutrition Before Hospitalization During Hospitalization Analysis and Interpretation

According to the client before hospitalization, she eats rice at least two times a day. At breakfast the client drinks a glass (7 oz) of water every day and she drinks at least three to four times for the whole day, eats Lugaw, and eats Yohgurt. During lunch and dinner time, the client eats a serving of viands like Kalderetang Baka and a cup of rice. According to the client, she loves to eat spaghetti and palabok.

During hospitalization, the client states that there are no changes in the appetite of the client. The client also eats and consumes foods that she eats before hospitalization. And also there is no change in the amount and quality of food the client eats. The client is advised to have nothing per orem.

Interpretation: ABNORMAL The clients diet before hospitalization and the diet during her stay in the medical center are not sustaining the appropriate and adequate nutrition required for her. She seldom eats dinner because of the pain she feels during that time. She lacks carbohydrates which are required to give energy to her body. She seldom eats fruits and vegetables too. Her fluid intake is not in right amount required to consume in a day. She admitted that she frequently drinks water. ANALYSIS: An adequate food intake consists of a balance of

essential nutrients: water, carbohydrates, proteins, fats, vitamins and minerals. (Health Promotion in Nursing process) Normal fluid intake should be up to 8 to 10 glasses a day. (Kozier et.al. 2008. Fundamentals of Nursing, 8th edition). Singapore: Pearson Education Asia Pte Ltd). Proper nutrition encompasses the study of nutrients and how they are handled by the body as well as the impact of human behaviour and environment on the process of nourishments. Foods that provides nutrition for both body and mind. (Fundamentals of Nursing by Taylor) Interpretation: ABNORMAL The urinary output of the client before and during the hospitalization is little in amount. ANALYSIS: Normal Feces Color: brown Consistency: soft, formed and moist Shape: cylindrical Amount varies with diet Aromatic in smell (Kozier, et al. 2008. Fundamentals of Nursing) Urine About 1200-1500 ml Straw, amber or transparent in color Odor: faint aromatic Sterility: No microorganisms present

Elimination

At home the client urinates for at least three times a day. The color of the urine is light yellow and aromatic in odor. The client usually defecates twice a day and the usual color is yellow brown, pungent in odor and semisolid. The client does not feel any pain during urination and defecation. The client said that she perspires a lot.

The client urinates for three times a day. The color of the urine is still the same as before the hospitalization. And the client usually defecates twice a day and the usual color is yellow brown, pungent in odor and semisolid. The client does not feel any pain during urination and defecation. The client perspires less in the hospital.

Ph:4.5-8 (Kozier, et al. 2008. Fundamentals of Nursing) Voiding that is either painful or difficult (Dysuria) is an altered urinary elimination. Frequency of defecation is highly individual, varying from several times per day or 2-3 times a week. Irregular defecation habits occur when normal defecation reflexes are inhibited or ignored, which later on progressively weakens. When habitually ignored, the urge to defecate is ultimately lost. Children at play may ignore these reflexes; adults ignore them because of pressure of time or work Normal feces are made of about 75% water and 25% solid waste materials. Normal feces require a normal fluid intake; feces that contain less water may be hard and difficult to expel. (Kozier, et al. 2008. Fundamentals of Nursing) Interpretation: NORMAL The client can still continue her need for physical activity in the hospital because shes only ambulatory not immobile, capable of walking. Shes not immobile which means she can still perform a number of ROM (range-of-motion exercises) maintaining her muscle tone. She just needs assistance when

Activities

At home, the client usually helps her mother in taking care of their Sari-Sari store. The client usually watch television shows. He also plays games on cell phones and laptops. She do household chores and takes good care of her child.

In the hospital the client has limited activities and usually stays in the hospital bed. Client usually watches television show and plays games on cell phones and laptops.

ambulating, for example going to the comfort room, changing into a sitting position, etc. ANALYSIS: The amount of exercise you need depends on the type of lifestyle you want to maintain. For beginners, most experts recommend at least 20 minutes of exercise three times a week. These 20 minutes can be a combination of four 5-minute sessions of exercise, two 10minute sessions or 20 continuous minutes. Just doing something is better than no exercise at all. Remember, 20 minutes is considered the minimum prescribed amount of exercise for one day. As your body adjusts to this level of exercise, you should increase the amount of exercise that you are doing to continue receiving the maximum benefits. (Kozier et.al. 2008. Fundamentals of Nursing, 8th edition). Singapore: Pearson Education Asia Pte Ltd) Interpretation: NORMAL The clients hygienic pattern falls within a normal scale. After the operation, the client should recuperate a good personal hygiene as similar from her hygiene before she was hospitalized. ANALYSIS: Hygiene is the self-care by which people attend to such functions as bathing, toileting, general body hygiene and grooming. It involves care of the skin, hair, nails, teeth, oral

Hygiene

The client takes a bath everyday. She usually takes a bath in the morning and takes a half-bath during the evening. And brush her teeth two times a day with the use of a normal toothbrush. The client usually wears comfortable clothes when shes at home.

The child does sponge bath in the hospital. And brush her teeth with the use of a normal toothbrush. The client usually wears tshirt and leggings.

and nasal cavities, eyes, ears and perineal-genital areas. (Kozier & Erb. Fundamentals of Nursing. 8th Edition. Volume 1) Interpretation: NORMAL The clients sleeping pattern before and during hospitalization has big difference. She lacks sleep during her hospitalization because she experiences pain every time shell be sleeping. One factor also is stress about her operation and the sleeping environment. With the aim of promoting a good sleeping environment, nurses should keep the lights low and using as soft voice and as much as possible overcome the sound interference in the surrounding. ANALYSIS: Children require 11-12 hours of sleep each night with no disturbance to prevent undue fatigue. (Fundamentals of Nursing By Kozier Et. Al 8th Ed) Sleep is a basic human need; it is a universal biological process common to all people. Human requires sleep for many reasons: to cope with daily stresses, to prevent fatigue, to conserve energy, to restore mind and body, and to enjoy life more fully. (Fundamentals of Nursing By Kozier Et. Al 8th Ed) Environment can promote or

Sleep and Rest

The client doesnt take any nap. She usually sleeps at 10 oclock in the evening and wakes up at 8 oclock in the morning the following day.

The client has a difficulty in sleeping. She usually sleeps around 1 or 2 oclock in the morning and wakes up around 6 or 7 oclock in the morning. She experiences pain when closing her eyes.

Substance Use

The client doesnt take any medications.

After the operation the attending physician ordered Mefenamic acid 500mg/tab if there is a positive epigastric pain happens.

hinder sleep. Any change-for example, noise in the environment can inhibit sleep. Discomfort from environmental temperature (e.g. too hot or too cold) and lack of ventilation can affect sleep. Interpretation: NORMAL The patient is not going through any kind of substance abuse. She is currently taking her prescribed medicine. ANALYSIS: Smoking is a risk factor for hypertension, heart disease, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and cancer of the lung, colon, larynx, oral cavity, esophagus, bladder, pancreas, and kidney. It also worsens such conditions as respiratory infections, peptic ulcers, hiatal hernia, and gastroesophageal reflux. Not smoking promotes health by increasing exercise tolerance; enhancing taste bud function; and avoiding facial wrinkles and bad breath. (Lipincott Manual of Nursing Practice, 8th Edition)

IV. PHYSICAL ASSESSMENT

CLIENTS BODY BUILT POSTURE AND GAIT Height: 164 cm Weight: 57 kg Slouched

HYGIENE AND GROOMING SIGNS OF DISTRESS (POSTURE/FACIAL) SIGNS OF ILLNESS ATTITUDE AFFECT AND MOOD SPEECH (QUANTITY/QUALITY/ORGANIZATION)

Clean and neat In distress

Unhealthy Appearance Cooperative Appropriate to situation Understandable if repeated Moderate pace Clear Tone Logical Sequence Makes Sense Has Sense Of Reality Alert

RELEVANCE/ORGANIZATION OF THOUGHTS

Mental status Measurement Weight Normal Findings According to the Body Mass Index (BMI) Chart, BMI of 18.6-22.9 is normal, <18.5 is underweight, > or = to 23 is overweight According to the Body Mass Index (BMI) Chart, BMI of 18.6-22.9 is normal, <18.5 is underweight, > or = to 23 is overweight Vital signs Temperature Pulse rate Respiratory rate 36.5.7-37.5 60-100 12-20 cpm

Actual Findings 57 kg (125 lbs)

Interpretation Normal

Height

164 cm(54 feet)

Normal

36C 72bpm- regular 18cycles

Abnormal Normal Normal

Blood Pressure

120/80 mmHg NORMAL FINDINGS

100/70 mmHg ACTUAL FINDINGS

Deviated from normal INTERPRETATION

SKIN Inspect skin color. Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. Generally uniform except in areas exposed to the sun. No edema Pallor Deviated from normal

Inspect uniformity of skin color.

Generally uniform except in areas exposed to the sun. No edema

Normal

Inspect edema

presence

of

Normal

Observe and palpate skin moisture.

Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity.) Uniform; within normal range. When pinched, springs back previous state. skin to

Moist in skin folds

Normal

Palpate skin temperature.

Uniform; Cold

Deviated from normal

Note skin turgor (fullness or elasticity) by lifting and pinching the skin on an extremity. NAILS Inspect fingernail plate shape to determine its curvature and angle. Inspect fingernail texture. Inspect color. fingernail bed

Skin spring back to previous state when pinched

Normal

Convex curvature; angle of nail about 160 o . Smooth texture. Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation

Convex curvature, angle approximately 160 Smooth Pallor

Normal

Normal Deviated from normal

in longitudinal streaks. Inspect tissues surrounding nails. Perform blanch test of capillary refill. Intact epidermis. Intact epidermis Normal

Prompt return of pink or usual color (generally less than 4 seconds.)

Return to usual color

Normal

HEAD Inspect the skull for size, shape and symmetry. Rounded (normocephalic and symmetric, with frontal, parietal, and occipital prominences); smooth skull contour. Smooth, uniform consistency; absence of nodules or masses. Scalp lighter than the color of the facial skin No tenderness Evenly distributed Thick hair Silky, resilient hair Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Symmetric movements facial Normocephalic, smooth skull contour Normal

Palpate the skull for nodules, masses and depressions. Color and appearance of scalp Areas of tenderness Hair evenness of growth Hair thickness or thinness Texture and oiliness Inspect the facial features.

Smooth, uniform consistency, no nodules or masses Scalp lighter than the color of the facial skin No tenderness Evenly distributed Thick hair Silky, resilient hair Symmetric features facial

Normal

Normal

Normal Normal Normal

Normal

Note symmetry of facial movements. EYES Inspect the eyebrows for

Symmetric movements

facial

Normal

Hair evenly distributed;

Hair evenly distributed;

Normal

hair distribution and alignment and skin quality and movement. Inspect the eyelashes for evenness of distribution and direction of curl. Inspect the eyelids for surface characteristics, ability to blink, and frequency of blinking.

skin intact; eyebrows symmetrically aligned; equal movement. Equally distributed; curled slightly outward.

skin intact; eyebrows symmetrically aligned; equal movement. Equally distributed; curled slightly outward. Normal

Skin intact, no discharge, no discoloration; lids close symmetrically; approximately 15 to 20 involuntary blinks per minute, bilateral blinking. Transparent

Skin intact, no discharge, no discoloration; lids close symmetrically; 17 involuntary blinks per minute, bilateral blinking.

Normal

Color, texture, and presence of lesion in bulbar conjunctiva Color, texture, and presence of lesion in palpebral conjunctiva Color and clarity of sclera Inspect the cornea for clarity and texture.

Transparent

Normal

Shiny, smooth, pink or red

Shiny, smooth, pink

Normal

White Transparent, shiny and smooth; details of the iris are visible. Black in color; equal in size normally 3 to 7 mm in diameter; round, smooth border. Illuminated pupil constricts and nonilluminated pupil constricts, pupil constricts when looking at near object and dilate when looking at far object; pupil converge when near object is moved toward the nose Both eyes move in coordination and

White Transparent, shiny and smooth; details of the iris are visible. Black in color; equal in size normally 4mm in diameter; round, smooth border. Illuminated pupil constricts and nonilluminated pupil constricts, pupil constricts when looking at near object and dilate when looking at far object; pupil converge when near object is moved toward the nose Both eyes move in coordination and

Normal Normal

Inspect the pupils for color, shape and symmetry of size.

Normal

Light reaction accommodation

and

Normal

Eye

alignment

and

Normal

coordination

unison, with alignment

parallel

unison, with alignment Able to read 20/150

parallel

Assess near vision. Assess distance vision.

Able to read newsprint. 20/20 vision Snellen-type chart. on

Normal Normal

EARS Inspect the auricles for color, symmetry of size and position. Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye o about 10 from vertical. Mobile, firm, and not tender; pinna recoils after it is folded. Dry cerumen, grayishtan color, or sticky. Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye o about 10 from vertical. Mobile, firm, and not tender; pinna recoils after it is folded. Dry cerumen, grayishtan color, or sticky. Normal

Palpate the auricles for texture, elasticity, and areas of tenderness. Inspect ear canal for cerumen, skin lesions, pus, and blood. Assess clients response to normal voice tones. Perform watch tick test.

Normal

Normal

Normal voice audible.

tones

Normal voice audible.

tones

Normal

Able to hear ticking in both ears. Sound is heard on both ears or is localized at the center of the head (Weber negative.) AC > Rinne.) BC (positive

Able to hear ticking in both ears. Sound is heard on both ears weber negative

Normal

Perform Webers test.

Normal

Conduct Rinne test

Right-AC=9>BC=8; Left-AC=10>BC=8 Positive rhine

Normal

NOSE Inspect the external nose for any deviations in shape, size, or color and flaring or discharge from the nares. Symmetric and straight; no discharge or flaring; uniform color. Symmetric and straight; no discharge or flaring; uniform color. Normal

Presence of redness, swelling, growth and discharge in nasal cavity Lightly palpate the external nose to determine any areas of tenderness, masses, and displacements of bone and cartilage. Test patency nasal cavities. of both

Mucosa is pink; clear watery discharge; no lesion Not tender; no lesions.

Mucosa is pink and no lesion

Normal

Not tender; no lesions.

Normal

Air moves freely as the client breathes through nares. Nasal septum and in midline. intact

Air moves freely as the client breathes through nares. Nasal septum and in midline. intact

Normal

Inspect nasal between the chambers.

septum nasal

Normal

Palpate for tenderness of sinuses. MOUTH Inspect the outer lips for symmetry of contour, color and texture.

Not tender.

No tenderness

Normal

Uniform pink color; soft, moist and smooth texture; symmetry of contour. Uniform pink color; moist, smooth, soft, glistening, and elastic texture.

Uniform pink color; soft, moist and smooth texture; symmetry of contour Uniform pink color; moist, smooth, soft, glistening, and elastic texture.

Normal

Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture and the presence of lesions. Inspect gums for the color and condition. Inspect the tongue for position, color, and texture.

Normal

Pink gums, firm texture to gums. Central position; pink color; dry, slightly rough; thin whitish coating.

Red gums, firm texture to gums. Central position; pink color; dry, slightly rough; thin whitish coating.

Normal

Normal

NECK AND LYMPH NODES Palpate lymph nodes and note for tenderness. Inspect and palpate trachea for placement. Not palpable. Not palpable Normal

Central placement in midline of the neck;

Central placement in midline of the neck;

Normal

spaces are equal on both sides. ABDOMEN Inspect the abdomen for skin integrity. Unblemished skin Uniform color Silver-white striae (stretch marks) or surgical scars Inspect the abdomen for contour and symmetry: Observe the abdominal contour 9profile line from the rib margin to the pubic bone) while standing at the clients side when the client is supine. Ask the client to take a deep breath and to hold it. Assess the symmetry of contour while standing at the foot of the bed. If distention is present, measure the abdominal girth by placing a tape around the abdomen at the level of the umbilicus. Observe abdominal movements associated with respiration, peristalsis, or aortic pulsations. Flat, rounded (convex), or scaphoid (concave)

spaces are equal on both sides.

Unblemished skin Uniform color Silver-white striae (stretch marks) or surgical scars

Normal

Normal

Flat, rounded (convex), or scaphoid (concave)

Normal

No evidence of enlargement of liver or spleen

There is a slight enlargement between epigastric and hypochondriac region.

Deviated from normal

Symmetric contour Symmetric contour

Normal

Symmetric movements caused by respirations Visible peristalsis very lean people in

Symmetric movements caused by respirations Visible peristalsis very lean people in

Normal

Aortic pulsations in thin persons at epigastric area

Aortic pulsations in thin persons at epigastric area

Observe pattern

the

vascular

Symmetric movements caused by respirations Visible peristalsis very lean people in

Symmetric movements caused by respirations Visible peristalsis very lean people in

Normal

Aortic pulsations in thin persons at epigastric area

Aortic pulsations in thin persons at epigastric area

Normal

Auscultate the abdomen foe bowel sounds, vascular sounds, and peritoneal friction rubs.

Audible bowel sounds Absence bruits of arterial

Audible bowel sounds Absence bruits of arterial

Normal

Absence of friction rub Perform light palpation first to detect areas of tenderness and/or muscle guarding. Systematically explore all four quadrants. Ensure that the clients position is appropriate for relaxation of the abdominal muscles, and warm the hands. Perform deep palpation over all four quadrants No tenderness; relaxed abdomen with smooth, consistent tension

Absence of friction rub No tenderness; relaxed abdomen with smooth, consistent tension normal

No tenderness; relaxed abdomen with smooth, consistent tension May not be palpable Border feels smooth Not palpable

No tenderness; relaxed abdomen with smooth, consistent tension May not be palpable Border feels smooth Not palpable

Normal

Palpate the liver to detect enlargement and tenderness Palpate the area above the pubic symphysis if the clients history indicates possible urinary distention

Normal

Normal

MUSCULOSKELETAL SYSTEM Inspect muscles for size. Equal size on both sides of the body. Equal size on both sides of the body. Normal

Inspect the muscles and tendons for contractures (shortening) and tremors.

No contractures; tremors.

no

No contractures; tremors.

no

Normal

Palpate muscles at rest to determine muscle tonicity. Test for strength (neck, upper and lower extremities.) Inspect the skeleton for structure. Palpate the bones locate any areas edema or tenderness. to of

Normally firm.

firm

Normal

Equal strength on each body side.

Equal strength on each body side.

Normal

No deformities.

No deformities.

Normal

No tenderness swelling.

or

No tenderness swelling.

or

Normal

Inspect the joint for swelling, tenderness, smoothness, and presence of nodules. REFLEXES Assess upper extremity reflexes (biceps/ triceps/ supinator.) Assess lower exterimity reflexes (patellar, ankle, plantar.)

No swelling, tenderness or nodules; joints move smoothly.

No swelling, tenderness or nodules; joints move smoothly.

Normal

+2 normal response.

+2 normal response

Normal

+2 normal response.

+2 normal response.

Normal

V. COURSE OF THE WARD Admitting Diagnosis: Chief Complaint: History of Present Illness: Diet: IVF: Vital Signs: Date December 2, 2011 Calulous Cholecystitis Epigastric pain One week prior to admission, on and off epigastric pain. Ultrasound revealed cholelithiasis Diet as Tolerated D5LR x 30 gtts/min

Temperature 36 C

Respiratory Rate 22 cpm

Pulse Rate 76 bpm

Blood Pressure 100/70 mm Hg

a. Diagnostics & Laboratories CHEST X-RAY Lungs clear Heart not enlarged Hemidiaphragms and costophrenic sulci are intact IMPRESSION: Normal Chest Study

HEMATOLOGY TEST Hematocrit Hemoglobin WBC Differential Segmenters Lymphocytes Eosonophils Monocytes S.I. 0.39 129 5.6 0.64 0.30 0.03 0.03 S.I. Normal Range M: 0.42-0.54 F: 0.36-0.46 M: 140-180 g/L F: 115-160 g/L 5.10 x 10 g/L 0.36-0.70 0.22-0.40 0.01-0.04 0.00-0.06 Interpretation Normal Normal Normal Normal Normal Normal Normal Normal

ABDOMINAL ULTRASOUND (November 25, 2011) The liver is within normal in size with homogeneous echopattern. The intrahepatic ducts are not dilated. The common bile duct measures 3 mm. No focal cystic or solid nodule seen. The gallbladder measures 66 x 23 mm. the wall is thin. There is an echogenic focus in the posterior wall measuring 5 mm. The pancreas is within normal in size and echopattern. The duct is not dilated. No focal cystic or solid nodule seen. The spleen is normal in size and echopattern. No focal cystic or solid nodule seen. The right kidney measures 101 x 35 mm while the left kidney measures 105 x 47 mm. The echopattern is homogeneous. No lithiasis or hydronephrosis seen. Both ureters are not dilated. The urinary bladder is fairly distensible and echo free. The wall is thin. The uterus is anteverted measuring 60 x 41 x 26 mm. the endometrium is thickened measuring 9 mm. the echopattern is homogeneous. No focal cystic or solid nodule seen. Both adnexae are unremarkable. IMPRESSION: CHOLELITHIASIS NORMAL LIVER, BILIARY TREE PANCREAS, SPLEEN, RENAL AND URINARY BLADDER. NORMAL SIZE UTERUS WITH THICKENED ENDOMETRIUM. NEGATIVE ADNEXAE

VII. PROBLEMS IDENTIFIED Significant Cues Subjective: Masakit ang tagiliran ko as verbalized by patient. Objective: Facial mask of pain Irritation Self focusing V/S taken as follows: T: 36C P: 76 bpm R: 22 cpm BP: 100/70 mmHg Subjective: Masakit ang inoperahan sa akin. Nahihirapan ako kumilos, as verbalized by the patient. Objective: Facial mask of pain Limited range of motion Disruption of skin V/S taken as follows: T: 36C P: 76 bpm R: 22 cpm BP: 100/70 mmHg Subjective: Nilalamig nga ako simula pa kanina pagkagising ko eh. Objectives: Cool skin Pallor Slow capillary refill T: 36.0 C RR: 22 cpm PR: 76 bpm BP: 110/70 Subjective: Nahihirapan ako kumilos sa kalagayan ko ngayon as verbalized by the patient. Objective: The patient may manifest: Nursing Diagnosis Acute pain related to inflammation and distortion of tissues.

Impaired tissue integrity related to presence of secretions

Hypothermia related to exposure to cool or cold environment as manifested by cool skin, paloor, and slow capillary refill.

Activity intolerance related to limited range of activity

Fatigue Weakness Inability in performing ADLs without assistance with clean and dry wound dressing over right upper quadrant abnormal HR or BP Pallor Dyspnea Exertional Discomfort Dysrhytmias or ischemia V/S taken as follows: T: 36C P: 76 bpm R: 22 cpm BP: 100/70 mmHg Subjective: Hindi ko alam gagawin sa sugat ko makati kasi at medyo masakit, as verbalized by the patient. Objective: request for information V/S taken as follows: T: 36C P: 76 bpm R: 22 cpm BP: 100/70 mmHg Subjective: Nakakalungkot lang kasi hindi na ko mkakapagbathing suit kasi may peklat na naman eh alam mo na yung feeling ng may natanggal sa katawan mo as verbalized by the patient. Objectives: Facial expression of agitation while telling her concern about her body image Patient is conscious about her situation because she asked many questions regarding the treatment of the scar.

Knowledge deficit regarding condition and self care related to misinterpretation of information

Body Image Disturbance related to surgical incision secondary to cholecystitis