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XIV. INTRODUCTION
 Cholecystolithiasis- The medical name for hard deposits (gallstones) that may
form in the gallbladder or the occurrence of gallstones within the gallbladder.
Gallstones or calculi usually form in the gallbladder from the solid constituents of
bile; they vary in size, shape, and composition. There are two major types of
gallstones:
Cholesterol Stones- most common type, When cholesterol levels are high enough in
the bile that crystals form, then tiny stones which go on to grow.
Mix cholesterol stones- composed of more than 10% cholesterol, are usually smaller
than the pure cholesterol stones and are often faceted and multiple.
Pigment stones-is formed from excess bilirubin, a waste product created by the
breakdown of the red blood cells in the liver. (form when unconjugated pigments in the
bile precipitate to form stones)
 Four times more women than men develop cholesterol stones and gallbladder
disease, the women are usually past age 35, multiparous (most common after
pregnancy), and obese. The course of cholecystolithiasis varies among

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individuals. Some people with cholecystolithiasis have no symptoms at all, while
others may have severe abdominal pain, nausea and vomiting, and complete
blockage that may pose the risk of infection. Cholecystolithiasis can lead to
cholecystitis, inflammation of the gallbladder. Left untreated, cholecystolithiasis
can lead to serious complications such as tissue damage, tears in the
gallbladder, and infection that spreads to other parts of your body.
Cholecystolithiasis affects approximately 10% of adult population in the United
States. In the Philippines, some patients with gallstones choose to have their
gallbladders removed for peace of mind. Some even choose to have
their gallbladders removed for overseas employment purposes.In the country
alone, an extrapolated prevalence of 5,073,040 people are affected by the
disease last 2007. According to the hospital statistic report of Northern Mindanao
Medical Hospital there is 0.72% of discharge diagnosis (primary) in January to
December 2009. Excision of the gallbladder (cholecystectomy) to cure gallstone
disease is among the most frequently performed abdominal procedures. Unless
the patient’s condition deteriorates, surgical intervention is delayed until the acute
symptoms subside and a complete evaluation can be carried out.
 The diet immediately after an episode is usually limited to low-fat liquids. The
patient can stir powdered supplements high in protein and carbohydrate into skim
milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas
forming vegetables, bread, coffee, or tea may be added as tolerated. The patient
should avoid eggs, cream, pork, fried foods, cheese and rich dressings, gas-
forming vegetables, and alcohol. It is important to remind patient to avoid fatty
foods may bring on an episode. Dietary management may be the major mode of
therapy in patients who have had only dietary intolerance to fatty foods and the
vague gastrointestinal symptoms.
Specific Objectives:
The student nurses aim to achieve the following objectives in 2hours of case
presentation:

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1. Accurately present a thorough general assessment of the client which includes
physical assessment and family history taking.
2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited by
the client.
3. Thoroughly discuss, explain, and elaborate the nature of the disease process.
4. Provide appropriate and proper nursing diagnosis in line with the client’s medical
condition.
5. Formulate nursing care plans for the different problems identified.
6. Provide nursing intervention according to the standards of nursing practice.
7. Apply the learned concepts and theories of disease.
8. Appraise the effectiveness and efficacy of nursing interventions rendered to the
client.
9. Showcase the outcome of the rendered nursing interventions.
10. Convey the significance of client’s response to the rendered nursing interventions.
11. Provide concise and concrete information to the audience with regards to the
patient’s disease condition.
12. Provide appropriate environment for learning for the audience.
SCOPE AND LIMITATION
This Case Presentation will attempt to cover and discuss the disease process and present
condition of the patient as assessed in the four days of assessment and duty, at
Northern Mindanao Medical Center. It will also present the nursing and medical care as
provided during the 16hours duty (Oct. 8&9, 2012).
This case presentation will be limited to the patient’s verbalizations and significant other who partly
served as informant, laboratory results, signs and symptoms as evidenced by and observed from the
patient within the engaged days. We consider October 10, 2012 as our follow-up visit and final
assessment to our patient.

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II. PATIENT’S PROFILE
Name: Galupo, Cysethe
Sex: Female
Birthday: July 2, 1980
Age: 30 years old
Address: Gingoog City
Religion: Roman Catholic
Nationality: Filipino
Occupation: Entrepreneur
Civil status: Married
Spouse name: Aljames Galupo
Occupation: Farmer
Educational Attainment: Business Management Graduate; Xavier University (2003)
Date of admission; October 5, 2012
Diagnosis: Cholecystolithiasis
Heredo-Familial Disease
According to the patient, her mother was hypertensive and her father (deceased)
suffered from diabetes and then later on turned into multi organ failure. She was the 3rd
among the 4 children. Her eldest brother Constantine Cana, 42 years old suffered from
meningitis after delivery .He is mentally retarded as a result of the disease. The second
child, 32 years old, died because of a gunshot wound. And she was the 3rd child, who
according to her was the only one in the family that developed cholecystolithiasis. And
lastly, the youngest was Cerobim Cana, deceased as well caused by a gunshot wound
when he was 15 years old.

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Gynaecological History
The client had her menarche at the age of 11, with a duration of about a week.
But with the onset of her puberty her monthly decreased to just 3 days. She has a
regular monthly period which she expects every 3rd week of the month. She doesn’t
experience any irregularities with her monthly period.
Food and Drug allergy
Patient has no known food and drug allergies.
Diet and Lifestyle
Patient is not a picky eater as stated by her. She eats anything and drinks soda every
day. She also said that she can’t eat without a glass or a bottle of soda together with her
meal. She has a history of smoking and drinking alcoholic beverages occasionally and
has since quit after giving birth to her eldest child.
History of Admission
She was previously admitted last August 24, 2012 at NMMC because she gave birth
to her 3rd child via caesarean section. She had also tubal ligation done after the 3rd
delivery because she had delivered all three babies via caesarean section which was
advised by her Ob-Gyne. The patient was admitted at northern Mindanao Medical
Center with complaints of abdominal pain that is radiating to the back.

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CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS
Patient X went to Maria Reyna Hospital for check-up due to severe abdominal pain and
she was then diagnosed with Cholecystolithiasis. She was advised to undergo an
operation worth 80,000.00 but then refuse to it due to lack of financial assistance and
then decided to transfer at Northern Mindanao Medical Center.
Two days prior to admission Patient complains of severe abdominal pain that is
radiating to the back.
Patient’s chief complaint is severe abdominal pain radiating to the back.

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III. DEVELOPMENTAL DATA
Erik Erickson 8 Stages of Development Young Adulthood: 18 to 35
Ego Development Outcome: Intimacy and Solidarity vs. Isolation
Basic Strengths: Affiliation and Love
In the initial stage of being an adult we seek one
or more companions and love. As we try to find mutually
satisfying relationships, primarily through marriage and
friends, we generally also begin to start a family, though
this age has been pushed back for many couples who
today don't start their families until their late thirties. If
negotiating this stage is successful, we can experience
intimacy on a deep level.
If we're not successful, isolation and distance from
others may occur. And when we don't find it easy to
create satisfying relationships, our world can begin to shrink as, in defense, we can feel
superior to others.
Our significant relationships are with marital partners and friends.
Erikson's sixth stage, Intimacy vs. Isolation, occurs during young adulthood.
Intimacy with other people is possible only if a reasonably well integrated identity
emerges from stage five.
Robert J. Havighurst
*Assisting teenage children to become responsible and
happy adults.
* Achieving adult social and civic responsibility.
* Reaching and maintaining satisfactory performance in
one’s occupational career.
*Developing adult leisure time activities.
* Relating oneself to one’s spouse as a person.

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* To accept and adjust to the physiological changes of middle age.
*Adjusting to aging parents.
INTERPRETATION
The information listed above made by these two famous theorist are being
exhibited by our patient. Basing on what we have assessed and upon interviewing we
have known that some characteristics that a normal 30 year old are present. On the first
developmental theory which is from Eric Erickson wherein the major conflict a person
may encounter when he will reach this stage is intimacy and solidarity vs. Isolation, our
patient has successfully entered this stage even though she still wasn’t able to achieve
most of her dreams but she believed starting to build a family and having a wonderful
children are one of her greatest dream. In this stage, people are starting to build there
own lives and to be established as a person that every is dreaming of like having a
degree after studying in college, having descent work with good financial outcomes, to
live independently without asking some financial support from their parents, and one of
the highlights in this stage is to find a partner who will become a companion for the rest
of their lives and having a children. Being unable to achieve our goals and aspiration
prior to what we have planned will cause us a sense of isolation, we are having difficulty
in accepting facts that we have failed to achieve what we have planned before specially
people are trying to seize and compare you from other people who become successful
in their chosen careers. Unable to find a perfect partner or having no mature relation
ship to someone when you reach this stage will cause us an isolation, people tend to
seek attention more to their partners and to someone special because they can express
more of their feeling to them rather to their parents and friends. On the second theory by
Robert Havighurst, people tend to exhibit the characteristics of parenting muchtime.
They act us a protector and a guide to their children by leading them to the right attitude
in order for their children to become a good person when they grow. so that people will
not blame the parents. Their major role is to guide their children so that they will not be
mislead to something that is inappropriate, it always reflect on how the parents have
raised their children.

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IV. MEDICAL MANAGEMENT
a. Medical Orders with Rationale
Date/time Doctor’s Order Rationale of Order
10-5-2012
@ 9:00 p.m
 Please admit under Surgery
Annex 2 Floor 1
 To provide management
fitted for patient
 Secure consent to care  To provide understanding
in the part of the client
including significant others
for any medical, surgical,
and nursing intervention
and also for legal
documentation purposes.
 Low Fat Diet  This Diet decreases Fat
intake which is beneficial in
reducing the pain brought
about the disease. The
presence of fat in he
duodenum stimulates the
release of cholecystokinin.
This hormone causes the
gallbladder to contract and
release bile. If gallbladder
is inflamed or has stones
present, the contraction will
cause severe pain to the
patient.
 Start venoclysis – D5LR iL @
30gtts/min
 To provide immediate
access to the vascular
system for the rapid

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delivery of specific
solutions without the time
required for gastrointestinal
tract absorption.
 Is a Hypertonic solutions
raises intravascular
osmotic pressure and
provides fluid, electrolytes
and calories for energy.
 LABS: CBC with Platelet
Count, Blood Typing, Serum
Creatinine, RBS, SGPT,
SGOT, PTPA, Alkaline PO4
 To check or evaluate any
deviation from normal in
blood count; blood typing
to check for what type of
blood the patient has for
possible blood transfusion;
creatinine is an indicator of
the renal function; RBS
measure the blood glucose
levels without the need of
fasting; SGPT and SGOT
assists in differentiating
whether the jaundice
requires surgical treatment,
as in case of obstructive
jaundice due to gall
bladder stones; PTPA
(obsolete name for
prothrombin time)
measures how long it takes
blood to clot and is used to
check for bleeding

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problems; Alkaline PO4 to
test liver functions
 Meds:
1.Cefuroxime 750mg IVTT every
8 hrs., ANST( - )
2.Ranitidine 50mg IVTT every 8 hrs.
3.Tramadol 50mg IVTT every 8 hrs,
4. Hyoscine-N-ButylBromide 10mg
IVTT every 8 hrs.
 An antibacterial used to
treat for bacterial infection/
prophylaxis treatment post
operatively.
 An antacid used to reduce
gastric acid secretion
 A non-opiod analgesic for
acute to severe pain
 antispasmodic drug used
to treat conditions
associated with spasms of
the gastrointestinal tract,
such as cramping.
 I & O every shift  To determine fluid
retention
 Monitor Abdominal Status
every 4 hours
 To monitor signs for any
possible complications
related to the case
 For Elective cholecystectomy  To remove the inflamed
Gallbladder.
 Secure consent for
procedure
 The surgery is an invasive
procedure, the consent
indicates the willingness of
the patient of such
procedure.

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 Refer accordingly  To Inform the attending
physicians for any
complications and
reactions
10-6-2012
7am
 Low Fat Diet  This diet decreases Fat
about the disease.
 Continue Meds  For continuity of treatment
regimen
 IVFTF: D5LR iL @
30gtts/min
 To provide fluid and
electrolyte balance and for
hydration purposes
 For Elective Open
Cholecystectomy on
10/9/2012
 To remove the inflamed
Gallbladder.
 Secure consent for
procedure
 The surgery is an invasive
procedure, the consent
indicates the willingness of
the patient of such
procedure
 Inform OR and
Anesthesiologist
 For the OR staff and
Anesthesiologist to reserve
the date and prepare for
the upcoming surgery
 Refer Accordingly  To Inform the attending
physicians for any
complications and
reactions
10-7-2012
7am
 Low fat Diet  This diet decreases Fat

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about the disease
 IVFTF: D5LR iL @
30gtts/min
 To provide fluid and
electrolyte balance and for
hydration purposes
 Continue all medications  For continuity of treatment
regimen
 For Elective Open
Cholecystectomy on
Tuesday (10/9/2012)
 To remove the inflamed
Gallbladder.
 Vital signs every 4 hours  To monitor the Vital signs
of patient for any untoward
complications
 I & O every shift  To determine fluid
retention
10-8-2012  Low fat diet  To prevent exacerbation of
pain
 Continue medications  For compliance of
medications
 For open cholecystectomy on
10/9/12
 For the removal of gall
bladder
 Secure consent to procedure  For legal purposes
 Inform OR and
anesthesiologist
 In preparation for the OR
and have the
anesthesiologist visit the
patient
 For ECG 12 lead with LLII
and TSH, T3, T4
 To check patients heart
rhythm and abnormalities
 Refer accordingly  To Inform the attending

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physicians for any
complications and
reactions
Pre- Operative Order
4:00 pm  Operating room 2nd case  For prepare patient for
surgery
 NPO post midnight  To prevent aspiration
during surgery
Meds:
 Omeprazole90 40 mg 1 tab
HS
 Inhibits gastric secretion
10-9-2012  Nothing per Orem  To prevent aspiration
during surgery
Operating room on call  To prepare patient for
surgery
-Post Operation Order-
 To PACU S/P Operation
Chole/Epidural
 For patients recovery.
 Oxygen inhalation at
4lpm/face mask and fully
awake
 To maintain pulmonary
ventilation and thus
prevent hypoxemia
 Monitor VS every 15 minutes
x 2 hours then hourly until
stable
 To know any abnormalities
and have a baseline vital
signs
 NPO  To prevent aspiration
 Flat on bed x 8 hours then
may turn to sides and elevate
head
 To prevent aspiration, to
prevent headache, for
range of motion exercise

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and for good circulation
 IVF to follow D5LR 1 liter at
30 gtts/min.
 To maintain fluid
electrolyte balance
Medications:
 Tramadol 50 mg slow IVTT 8
hours x 3 doses then PM
 Cefuroxime 350 mg IVTT
every 8 hours
 Binds to opiod receptors
and inhibits reuptake of
norepinephrine and
serotonin.
 Anti-bacterial, 2nd
generation cephalosporin
 Morphine Precaution refer if:
 BP: 90/60 RR: 12
HR: 60 Nausea and
Vomiting
Pruritus Spo2 92%
To watch out after side
effects of the drug and for
prompt intervention.
To correct unusualities as
soon as possible and to
inform the AP of the
patients condition
 Intake and Output every shift To monitor patients
physiologic status
 Refer accordingly Referral is done to correct
unusualities as soon as
possible and to inform the
attending physician on the
patients condition.
10-9-12  May transport patient back to
ward
For continuity of care

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10-10-2012
2:00 am
Temp: 38.7
degree
Celsius
 Please give paracetamol 300
milligrams IVTT now.
 For fever PRN
6:30 am  NPO  To prevent aspiration
 Change dressing  To prevent infection
 Continue meds  For compliance of
medications
 Vital Signs per shift  To monitor patients
physiologic status
 Intake and output per shift  To monitor patients
physiologic status
 D5LR 1 Liter 30gtts/min.  To replace fluid and
electrolyte loss
 Please refer  Referral is done to correct
unusualities as soon as
possible and to inform the
attending physician on the
patients condition.
2:00 pm
 Still on Intake and Output per
shift
 To monitor patients
physiologic status
 Epidural catheter remove
aseptically
 To prevent infection
5:00 pm
Temperature
: 38 degree
Celsius
 Paracetamol 600 mg IVTT q
4 hours RTC
 For fever PRN

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b. Drug Study
Generic Name: Cefuroxime
Date Ordered: October 5, 2012
Classification: Antibiotic
Dose/Frequency/Route: 750mg IVTT every 8hrs
Mechanism of Action: This drug binds to one or more of the penicillin-
binding proteins (PBPs) which inhibits the final
transpeptidation step of peptidoglycan synthesis in
bacterial cell wall, thus inhibiting biosynthesis and
arresting cell wall assembly resulting in bacterial
cell death
Specific Indication: Treatment of infections of lower respiratory tract,
urinary tract, skin and skin structures.
Contraindication: Hypersensitivity to cephalosporins.
Side Effects:  Nausea, vomiting, diarrhea, stomach pain
 Headache, dizziness
 Sleep problems (insomnia)
 Vaginal itching or discharge.
Nursing Precaution: a. Advise patient to take with meals to enhance
absorption. If tablet must be crushed, mix with
food or beverage.
b. Advise patient to maintain normal fluid intake
while using this medication.
c. Instruct patient to report these symptoms to
health care provider: bruising, bleeding, muscle
or joint pain.
d. Instruct patient to seek emergency care
immediately if wheezing or difficulty breathing
occurs.

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Generic Name: Ranitidine
Classification: Histamine H2 Antagonist
Mechanism of Action: Selectively block histamine-2 receptors sites. This
blocking leads to a reduction in gastric acid
secretion and reduction in overall pepsin
production.
Specific Indication: relief of GIT drug adverse effects/Reduce Gastric
Acid Secretion
Contraindication:  Hypersensitivity to Ranitidine
 - Caution should be used with hepatic of renal
dysfunction
Side Effects:  CNS: vertigo, malaise, headache,
somnolence, confusion
 hallucinations
 EENT: blurred vision
 GI: diarrhea, constipation
 CV: arrhythmias, hypotension
Nursing Precaution:  provide comfort and safety measures if CNS
effects occur
 monitor of potentially serous adverse
effects, including cardiac arrhythmias
 Given before meal

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Generic Name: Tramadol
Classification: Non-Opioid Analgesic
Mechanism of Action: Binds to opioids receptors and inhibits the reuptake
of norepinephrine and serotonin.
Specific Indication: Moderate to severe pain
Contraindication: Acute intoxication withopioids or psychoactive
drugs
Side Effects:  CNS: Sedation, Dizziness, Headache, and
Confusion
 CV: Hypotension, Tachycardia, Bradycardia
 Dermatologic: Sweating
Nursing Precaution:  Administer with food if GI upset occurs;
 Monitor patient response,
 Give the drug before the pain becomes
intense

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Generic Name: Hyoscine – N – butylbromide
Classification: Anti spasmodic
Mechanism of Action:  stops the spasms in the smooth muscle by
preventing acetylcholine from acting on the muscle.
It does this by blocking the receptors on the muscle
cells that the acetylcholine would normally act on.
 By preventing acetylcholine from acting on the
muscle in the GI and GU tracts, hyoscine reduces
the muscle contractions. This allows the muscle to
relax and reduces the painful spasms and cramps
Specific Indication:  Spasms of the stomach, intestines or bile duct
(gastro-intestinal tract), including those associated
with irritable bowel syndrome (IBS).
 Spasms of the bladder or urinary system (genito-
urinary tract).
Contraindication:  Abnormal muscle weakness (myasthenia gravis).
 Abnormally large or dilated large intestine
(megacolon).
 Closed angle glaucoma.
 Rare hereditary problems of fructose intolerance,
glucose-galactose malabsorption or sucrase-
isomaltase insufficiency (Buscopan tablets contain
sucrose).
 Buscopan tablets are not recommended for
children under six years of age.
Side Effects: Uncommon

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 Increase in heart rate (tachycardia).
 Dry mouth.
 Reduced ability to sweat.
 Allergic skin reactions.
Rare
 Difficulty in passing urine (urinary retention).
 Hypersensitivity reactions such as narrowing of the
airways (bronchospasm), swelling of the lips, throat
and tongue (angioedema), or itchy rash.
Unknown frequency
 Anaphylactic reaction.
Nursing Precaution:  Give by direct IV after diluting it with sterile water
 Monitor I and O ratio, retention commonly causes
decreased urinary output
 Assess for constipation
 Assess for tolerance over long term therapy
Generic Name: Omeprazole
Classification: Proton pump inhibitor
Dose/Frequency/Route: 40mg 1tab HS
Mechanism of Action: An anti-secretory compound that is a gastric acid pump
inhibitor. Suppresses gastric acid secretion by inhibiting
the H+, K+, ATPase enzyme system in the partial cells.
Specific Indication: Suppresses gastric acid secretion relieving
gastrointestinal distress and promoting ulcer healing..
Contraindication: Long-term use for gastro esophageal reflux disease,

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duodenal ulcer.
Side Effects:  Nausea, vomiting, diarrhea, stomach pain
 Headache, dizziness
 Sleep problems (insomnia)
 Malaise, vertigo and fatigue.
Nursing Precaution: e. Report sore, throat, fever, bleeding, tarry stool,
confusion.
f. Give with or without food, simultaneous
administration does not appear to reduce absorption
or serum.
g. Administer adjunctive antacid treatment 2h before or
after drug.
Generic Name: Paracetamol
Classification: Antipyretic
Dose/Frequency/Route: 600mg IVTT every 4hrs RTC
Mechanism of Action: Thought to produce analgesia by blocking pain impulses
by inhibiting synthesis of prostaglandin in the CNS or
other substances than sensitize pain receptors to
stimulation. The drug may relieve fever through central
action in the hypothalamic heat-regulation center.
Specific Indication: Mild pain and fever.
Contraindication: Contraindicated in patients hypersensitive to drug.
Use cautiously in patients with long term alcohol use
because therapeutic doses cause hepatotoxicity in these
patients.
Side Effects:  Jaundice
 Hypoglycemia

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 Rash
 Headache
 Chest pain
 Dyspnea
Nursing Precaution: a. Alert: Many OTC and prescription products
contain acetominophen; be aware of this when
calculating total daily dose.
Laboratory Results
COMPLETE BLOOD COUNT
OCTOBER 4, 2012
MRXUH LABORATORY
Test Results Reference Rationale
WBC
RBC
13.7
4.52
(4.50 – 11.0)x10^9/uL
(4.2-5.0)mm3
Indicates infection;
acute stress/trauma
Within normal
values
Hemoglobin 11.70 (12-16.)% May indicate
bleeding; acute
stress/trauma
Hematocrit
MCV
MCH
37.20
82.3
25.90
(36.0 -46.0)%
(80.0-100.0)fl
(26.10-33.30)pg
Within normal limits
Within normal
Limits
Slightly low;
indicates Vit. B12

26
MCHC
Platelet count
31.5
310
(31.0 – 37.0)g/dl
(150-390)x10^9/L
deficiency
Neutrophils 78.6 (37.00 – 72.00)% Indicates bacterial
infections;
inflammation
Lymphocytes
Monocytes
Eosinophils
Basophils
RDW- CV
15.0
5.9
0.4
0.1
15.6
(20.00 – 50.00) %
(8.00-14.00)%
(0.00-6.00)%
(0.00-1.00)%
(11.5-14.5)%
Indicates infections;
autoimmune
disorders
Low,usually not
medically
significant(repeated
low result indicate
bone marrow
failure or damage)
Indicates mixed
populations of
small and large
RBC’s
Blood Typing “AB”(+) Blood Type “AB”
it’s signifies a need
for a donor with a
blood type “AB+”,
“A+” or “B+”

27
ULTRASOUND
OCTOBER 4, 2012
Gallbladder is dilated measuring 13.33 x 4.88cms. ( LW) with thickened walls measuring
4.5 mms. High Level shadowing echoes within the urinary bladder and one with a
diameter of 1.95 cms. Is impacted in gallbladder neck. No dilated biliary ducts. Liver,
pancreas and spleen are of normal size and echo pattern with no focal masses. Right
kidney measures11.1 x 5.3 cm ( LW) with corticomedullary thickness of 1.7 cms.
Normal echo pattern with no stones nor focal masses.
No localized dilatation in the gallbladder aorta.
No echoes within the urinary bladder.
Uterus is anteverted and measures 7.7 x 4.9 x 6.9cms ( LHW) with endometrial
thickness of 9.2 mm. no adrenal mass.
CONCLUSION:
Acute Cholecystitis with multiple gallstones. Stone with a diameter of 1.95cms.
impacted in the gallbladder neck.
Normal liver, pancreas, spleen, genitor-urinary tract and abdominal aorta.
COMPLETE BLOOD COUNT
OCTOBER 5, 2012
NMMC LABORATORY
WBC
RBC
21.7
4.50
(5.00 – 10.0)x10^3/uL
(4.2-5.4)x10^6/uL
Indicates infection;
acute stress/trauma
Within normal
values
Hemoglobin 12.1 (12-16.)% Within normal limits

28
Hematocrit
MCV
MCH
MCHC
Platelet count
37.3
82.9
26.90
32.4
330
(37.0 - 47.0)%
(82.0-98.0)fl
(27.0-31.0)pg
(31.0 – 35.0)g/dl
(150-400)x10^9/L
Within normal Limits
Slightly low;
indicates Vit. B12
deficiency
Neutrophils 82.3 (43.4 – 76.2)% Indicates bacterial
infections;
inflammation
Lymphocytes
Monocytes
Eosinophils
Basophils
RDW- CV
PDW
MPV
11.6
6.0
0.1
0.0
15.9
9.1
8.9
(17.4 – 48.2) %
(4.5-10.5)%
(1.0-3.0)%
(0.00-2.00)%
(12.0-17.0)%
(9.0 – 1.0)fL
(8.0-12.0)fL
Indicates infections;
autoimmune
disorders
An occasional low
result is not
medically significant
Blood Typing “AB”(+) Blood Type “AB” it’s
signifies a need for
a donor with a blood
type “AB+”, “A+” or
“B+”

29
BLOOD CHEMISTRY RESULT
OCTOBER 5, 2012
NMMC LABORATORY
glucose
Creatinine
SGOT
SGPT
ALP
Na+
K+
Prothrombin
time
Protime
Control
I.N.R.
APTT
APTT
Control
88
0.9
18.9
29.2
252.7
135.0
3.71
13.7 sec.
11.6 sec.
1.18
28.4 sec.
27.5 sec.
(60-100)mg/dl
(0.6-1.2)mg/dl
(0.0-37.0)U/l
(0.0-42.0)u/l
(80.0-306.0)u/l
(135-148)mmol/L
(3.5-5.3)mmol/L
10.2-15.2 sec.
23.4-38.5 sec

30
V. ANATOMY and PHYSIOLOGY
The Gallbladder
The gallbladder is a
pear-shaped sac lying on the
undersurface of the liver,
measuring about 7.5 to 10
cm (3 to 4 inches) long. It has
a capacity of 30 to 50 ml and
stores bile, which it
concentrates by absorbing
water. The gallbladder is
divided into the fundus, the
body and the neck. The
fundus is rounded and
projects below the inferior
margin of the liver, where it comes in contact with the anterior abdominal wall at the
level of the tip of the ninth right costal cartilage. The body lies in contact with the
visceral surface of the liver and is directed upward, backward and to the left. The neck
becomes continuous with the cystic duct, which turns into the lesser omentum to join
the common hepatic duct to form the bile duct.
The peritoneum completely surrounds the fundus of the gallbladder and binds the
body and neck to the visceral surface of the liver.
Functions of the Gallbladder
The gallbladder functions as a storage depot for bile. Bile is a viscid alkaline fluid
secreted by the liver where it aids in the emulsification and absorption of fats. Human
normally produce 400-800 ml of bile daily.
When digestion is not taking place, the sphincter of Oddi remains closed and bile
accumulates in the gallbladder. The gallbladder concentrates bile; stores bile;
selectively absorbs bile salts, keeping the bile acid; excretes cholesterol and secretes

31
mucus. To aid in these functions, the mucous membrane is thrown into permanent folds
that unite with each other giving the surface a honeycomb appearance. The columnar
cells lining the surface have numerous microvilli on the free surface.
Bile is delivered to the duodenum as a result of contraction and partial emptying
of the gallbladder. This mechanism is imitated by the entrance of fatty foods into the
duodenum. The fat causes release of the hormone cholecystokinin from the mucous
membrane of the duodenum; the hormone that enters the blood, causing the gallbladder
to contract. At the same time, the smooth muscle around the distal end of the bile duct
and the ampulla is relaxed, thus allowing the passage of concentrated bile into the
duodenum. The bile salts in the bile are important in emulsifying the fat in the intestine
and in assisting with its digestion and absorption.
Functions of the Bile
1. Digestion and absorption of fats for bodily consumption
2. Serves as a means for the body to excrete waste products from the blood
3. Contains waste products from haemoglobin breakdown, known as Bilirubin, and
helps in its excretion outside of the body.
Approximately half of the bilirubin, a pigment derived from the breakdown of red
blood cells, is a component of bile. It is converted by the intestinal flora into the
urobilinogen, a highly soluble substance. Urobilinogen is either excreted in the fecs of
returned to the portal circulation, where it is re-excreted into the bile. Bilirubin has two
types. First is the unconjugated bilirubin which is insoluble in water and not excreted in
the urine. Second, is the conjugated bilirubin which is soluble in water and excreted in
the urine. About 5% of it is normally absorbed into the general circulation and then
excreted by the kidneys.
Source: Snell, Richard S. Clinical Anatomy by Regions. 8th Edition. Lipincott Williams
& Wilkins. 530 Walnut Street, PA. 2008.

32
IDEAL PATHOPHYSIOLOGY OF CHOLECYSTOLITHIASIS
Definition: The formation of one or more gallstones in the gallbladder or in the bile
ducts which results into obstruction and subsequent inflammation.
Increased
cholesterol
Increased
bilirubin
Increased calcium
carbonate
Super saturation and
precipitation of excess
cholesterol
precipitation of excess bilirubin
precipitation of excess calcium
carbonate
Increased viscosity of bile
leading to bile stasis
leading to bile stasis
leading to stasis
Solidification and aggregation of
precipitates to a calculi
CHOLESTEROL STONES PIGMENT STONES MIXED STONES
CHOLELITHIASIS
Stone dislodges and obstructs opening of
gallbladder preventing outflow of bile, thus,
leading to distention of gallbladder
PREDISPOSING FACTORS
 Advancing Age: 40 years old and above
 Gender: Female
 Family history of gallstones
 Family history of DM
PRECIPITATING FACTORS
 High fat and High Cholesterol Diet
 Pregnancy, most especially multiparity
 Use of oral contraceptives
 Excessive intake of alcohol
Imbalance ratio between bile and bile components resulting to
insolubility of bile

33
ACTUAL PATHOPHYSIOLOGY OF CHOLECYSTOLITHIASIS
(AS SEEN IN OUR PATIENT)
Definition: The formation of one or more gallstones in the gallbladder or in the bile
ducts which results into subsequent inflammation.
PREDISPOSING FACTORS
 Gender (Female)
PRECIPITATING FACTORS
 High fat and High
Cholesterol Diet
 Multiple Parity
 Obesity
 History of Smoking and
Drinking
DYSFUNCTIONAL BILE PRODUCTION IN
THE GALL BLADDER
Increased cholesterol concentration in the bile
with insufficient bile salts and lecithin
Super-saturation of bile results to progressive
dissolution of vesicles wherein cholesterol-
carrying capacity is exceeded
Increased bile viscosity leading to bile stasis
within the gallbladder and its ducts
Precipitation of cholesterol in bile forms
cholesterol monohydrate crystals which
aggregates and solidifies
CHOLELITHIASIS
Presence of gallstones, particularly
cholesterol stones in the bladder

34
Cholesterol stone dislodges into opening of
gallbladder causing obstruction
No bile outflow to the duodenum to aid in fat
digestion
Autolysis, wherein bile acid causes irritation
and damage to the Tunica mucosa of the
gallbladder’s smooth muscle wall
Prostaglandins are released by the body as
an inflammatory response to endothelial
damage
CHOLECYSTITIS
Inflammation of the gallbladder
No further complication noted since patient
was able to immediately undergo
CHOLECYSTECTOMY, or the removal of her
cholesterol stone.
S/s
-Complaints
of sudden
right upper
quadrant
pain
S/s
-Increased
WBC of
S/s
-Low grade
fever of
S/s
-Complaints of
discomfort
after
consuming
fried food
S/s
Ultrasound
result of
inflamed
gallbladder at

35
VI. NURSING ASSESSMENT
NURSING SYSTEM REVIEW CHART
Name: Mrs. G. Age: Date: October 7, 2012(pre-op)
V/S: c Temp: 36.9 C PR: 80bpm RR: 20cpm BP: 120/80mmhg
EENT:
[] impaired vision [ ] blind
[ ] pain [ ] reddened [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion [ ] teeth
Assess eyes, ears, nose, and throat
For abnormality [ x] no problem
RESPIRATORY:
[ ] asymmetric [ ] tachypnea
[ ] apnea [ ] rales [ ] cough [ ] barrel chest
[ ] bradypnea [ ] shallow [ ] rhonchi x
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopenea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotic
Assess resp.rate, rhythm, depth, and pattern
Breath sounds, comfort [x] no problem
CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain [] stong pulses
X Assess heart sounds, rate, rhythm, pulse, bp,
Circulation, fluid retention, comfort [x ] no problem
GASTRO INTESTINAL TRACT:
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] noctoria
Assess urine freq., control, color, odor, comfort /
D5lr @30
gtts/min Pain in the
abdomenwith
pain scale of
8/10
Anxiety
(moderate)
Abdominal
Gird: 46 cm

36
Gyn-bleeding, discharge [x] no problem
NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip
Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech
[x] No problem
MUSCULOSKELETAL & SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [] poor turgor [ ] cool [ ] deformity
[ ] wound [ ] rash [ ] skin color [ ] flushed
[ ] atrophy [ ] pain [ ] eccymosis
[ ] diaphoretic [ ] moist
Assess mobility, motion, galt, alignment, joint function/
Skin color, texture, turgor, integrity [x] no problem
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] hearing loss
[] visual changes
[] others: language
[x] denied
Comments: “wala
man pud koy problema
bahin ana.” As
verbalized.
[] glasses [] languages
[ ] contact lenses [ ] hearing aide
[ ] speech difficulties
Pupil size & reaction: 2 mm-3mm
PERRLA
(pupils equally round and reactive to
light accommodation

37
OXYGENATION:
[ ] dyspnea
[X] smoking history
[ ] cough
[ ] sputum
[ ] denied
Comments: “Oo,
gapanigarilyo ako
sauna pero wala na
sukad na
nagbreastfeed ko .” as
verbalized.
Resp. [x] regular [ ] irregular
Describe:normal breathing patterns
with respiratory rate of 20 cpm
R: Right lung is symmetrical to the
left
L:Left lung is symmetrical to the right
CIRCULATION:
[ ] chest pain
[ ] leg pain
[ ] numbness of
extremities
[x] denied
Comments:. “ wala
man pud akoy
problema bahin
ana.”as verbalized by
patient.
Heart Rhythm [x] regular [ ]
irregular
Ankle Edema none
Pulse Car Rad. AP
Fem*
R:
L:
Comments:Pulses are strong and
easy to palpate.
NUTRITION:
Diet:soft diet
[ ] N [ ] V
Character
[ ]recent change in
weight and appetite
[ ] swallowing
Difficulty
[x] denied
Comments: “maayo ra
man pud ang akong
pag-kaon.” As
verbalized by the
patient
[ ]dentures [x]none
Full Partial
Upper [ ] [ ]
Lower [ ] [ ]

38
ELIMINATION:
Usual bowel pattern
Once a day
[ ] constipation Date of
last BM
October 7, 2012
[ ] diarrhea
[ ] urinary frequency
5 times a day
[] urgency
[ ] dysuria
[ ] hematuria
[ ] incontinence
[ ] polyuria
[ ] foley in place
[x] denied
Comments:
Bowel sounds
are audible
and
normoactive
Bowelsound:
normoactive
_(20/min)____
Abdominal
Distention
Present [x] yes []
no
Urine* (color,
consistency, odor)
urine color is yellow
MGT. OF HEALTH & ILLNESS:
[x] alcohol [ ] denied
[ ] SBE Last Pap Smear:
LMP: N/A
Briefly describe the patient’s
ability to follow treatments (diet,
meds, etc.) for chronic health
problems (if present):
The patient is able to follow
treatments and medications
instructed to her.
SKIN INTEGRITY:
[ ] dry
[ ] itching
[ ] other
[x] denied
Comments:
“Mao raman japon,
wala may nabag-o
sa akong pamanit”
as verbalized..
[ ] dry [ ] cold [ ] pale
[ ] flushed [ ] warm
[ ] moist [ ] cyanotic
Rashes,ulcers,decubitus (describe
size, location,drainage) : no rashes,
ulcers, decubitus noted

39
ACTIVITY/SAFETY
[ ] drowsiness
[ ] dizziness
[ ] limited motion of joints
Limitation in
ability to
[ ] ambulate
[ ] bathe self
[x] denied
Comments: “dili
kayo ko makalihok-
lihok labi na ug
mutukar ang sakit.”
as verbalized.
[ ]LOC and orientation: client is
alert, oriented to time and place
Gait: [ ] walker [ ] cane
[ ] other [x] none
[ ]sensory and motor losses in
face or extremities: there is no
alteration in sensory & motor
function
[ ] ROM limitations: with limitations
COMFORT/SLEEP/AWAKE
[ ] pain [ ] nocturia
[x] sleep difficulties
[] denied
Comments:
“medyo alimuotan
man gud ko inig
gabie. ” as
verbalized by the
patient.
[ ] facial grimaces
[ ] guarding
[ ] other signs of pain:
[ ] side rail release form signed
[x] none
COPING
Occupation: Businesswoman
Members of household: husband, children,
mother
Most supportive person: husband
Observed non-verbal behavior:
She is very attentive and cooperative.
She entertains our every questions
and query.
The person & her phone number
that can be reached anytime:
09163894562

40
Name: Mrs. G. Age: 30 years old Date: October 8, 2012(pre-op)
V/S: Temp: 36.9 C PR: 85bpm RR: 18cpm BP: 120/80mmhg
EENT:
For abnormality [ ] no problem
RESPIRATORY:
[ ] bradypnea [ ] shallow [ ] rhonchi x
CARDIOVASCULAR:
D5lr @30
gtts/min Paininthe
abdomenwith
painscale of
5/10
Abdominal
Gird: 46 cm

41
NEURO:
[x] No problem
COMMUNICATION:
[ ] hearing loss
[] visual changes
[] others: language
[x] denied
Comments: “Wala
man pud koy problema
bahin ana.” As
verbalized.
Pupil size & reaction: 2mm-3mm
PERRLA
light accommodation

42
OXYGENATION:
[ ] dyspnea
[X] smoking history
[ ] cough
[ ] sputum
[ ] denied
Comments: “Oo,
gapanigarilyo ako apan
wala na karon .” as
verbalized.
left
CIRCULATION:
[ ] chest pain
[ ] leg pain
[ ] numbness of
extremities
[x] denied
Comments:. “ wala
man pud akoy
problema bahin
ana.”as verbalized.
irregular
Ankle Edema none
Pulse Car Rad. AP
Fem*
R:
L:
easy to palpate.
NUTRITION:
Diet:soft diet
[ ] N [ ] V
Character
[ ]recent change in
weight and appetite
[ ] swallowing
Difficulty
[x] denied
man pud ang akong
pag-kaon.” As
verbalized by the
patient
[ ]dentures [x]none
Full Partial
Upper [ ] [ ]
Lower [ ] [ ]

43
ELIMINATION:
Usual bowel pattern
Once a day
last BM
October 9, 2012
[ ] diarrhea
5 times a day
[] urgency
[ ] dysuria
[ ] hematuria
[ ] incontinence
[ ] polyuria
[ ] foley in place
[x] denied
Comments:
Bowel sounds
are audible
and
normoactive
Bowelsound:
normoactive
_(20/min)____
Abdominal
Distention
Present [x] yes []
no
Urine* (color,
consistency, odor)
urine color is yellow
LMP: N/A
The patient is able to follow
treatments and medications
instructed to her.
SKIN INTEGRITY:
[ ] dry
[ ] itching
[ ] other
[x] denied
Comments:
“Mao raman japon,
wala may nabag-o
sa akong pamanit”
as verbalized by
the patient.

44
ACTIVITY/SAFETY
[ ] drowsiness
[ ] dizziness
[ ] limited motion of joints
Limitation in
ability to
[ ] ambulate
[ ] bathe self
[x] denied
Comments: “kaya
ra man nako
maglihok-lihok.” as
verbalized by the
patient
[ ] other [x] none
function
COMFORT/SLEEP/AWAKE
[ ] sleep difficulties
[x] denied
Comments: “Ok
raman pud akong
pagkatulog” as
verbalized.
[ ] facial grimaces
[ ] guarding
[x] none
COPING
Occupation:
mother
and query.
09163894562

45
NURSING ASSESSMENT
Name: Mrs. G. Age: 30 years old Date: October 9, 2012(post-op)
V/S: Temp: 37.5 C PR:75bpm RR: 19cpm BP: 120/80mmhg
EENT:
[x] impaired vision [ ] blind
For abnormality [ ] no problem
RESPIRATORY:
[ ] bradypnea [ ] shallow [ ] rhonchi
CARDIOVASCULAR:
[ ] tingling [ ] absent pulses [ ] pain [] strong pulses
#6 D5lr @30
gtts/min
Paininthe
surgical site
withpain
scale of 7/10
Surgical site
with
attached
Penrose
drainingtoa
deepgold
colored
drainage
C foleybag
catheter
attachedto
urobag draining
to a tea colored
urine
Epidural catheterin
frontand back
Body
weakness
Abdominal
Gird: 39 cm

46
[ ] hematuria [ ] discharge [ ] nocturia
NEURO:
[x] No problem
COMMUNICATION:
[ ] hearing loss
[] visual changes
[] others: language
[ ] denied
Comments: “mao ra
man pud gihapon
adtong bag-o siya
natulog.” As
verbalized.
PERRLA

47
light accommodation
OXYGENATION:
[ ] dyspnea
[X] smoking history
[ ] cough
[ ] sputum
[ ] denied
Comments: “Oo,
gapanigarilyo na siya
sauna” as verbalized.
left
CIRCULATION:
[ ] chest pain
[ ] leg pain
[ ] numbness of
extremities
[x] denied
Comments:. “ sakit
lang jud daw ang iyang
samad.”as verbalized
irregular
Ankle Edema none
Pulse Car Rad. AP
Fem*
R:
L:
easy to palpate.
NUTRITION:
Diet:NPO
[ ] N [ ] V
Character
[ ]recent change in
weight and appetite
[ ] swallowing
Difficulty
[x] denied
Comments: “dili sad
aw siya pakan-on
ingon ang doctor.” As
verbalized
[ ]dentures [x]none
Full Partial
Upper [ ] [ ]
Lower [ ] [ ]

48
ELIMINATION:
Usual bowel pattern
Once a day
last BM
October 10, 2012
[ ] diarrhea
5 times a day
[] urgency
[ ] dysuria
[ ] hematuria
[ ] incontinence
[ ] polyuria
[ x ] foley in place
[] denied
Comments:
Bowel sounds
are audible
and
normoactive
Bowelsound:
normoactive
_(20/min)____
Abdominal
Distention
Present [x] yes []
no
Urine* (color,
consistency, odor)
with a tea-colored
urine,aromatic
LMP: N/A
The patient was able to follow
medicationsand treatments as
prescribed to her.
SKIN INTEGRITY:
[ ] dry
[ ] itching
[ ] other
[x] denied
Comments:
“Mao raman japon,
wala may nabag-o
sa iyahang
pamanit” as
verbalized.

49
ACTIVITY/SAFETY
[ ] drowsiness
[ ] dizziness
[x ] limited motion of
joints
Limitation in
ability to
[ ] ambulate
[ ] bathe self
[] denied
Comments: “luya
lang gyud siya
karon, di sa siya
ipa.sturya,
papahulayon lang
sa jud siya.” as
verbalized.
[ ] other [x] none
function
COMFORT/SLEEP/AWAKE
[x] denied
Comments: “Ok
raman iyahang
pagkatulog” as
verbalized
[ x ] facial grimaces
[ ] guarding
[] none
COPING
Occupation: businesswoman
mother
and query.
09163894562

50
NURSING ASSESSMENT
Name: Mrs. G. Age: 30 years old Date: October 10, 2012(post-op)
V/S: Temp: 37.7 C PR:75bpm RR: 19cpm BP: 130/80mmhg
EENT:
For abnormality [x] no problem
RESPIRATORY:
[ ] bradypnea [ ] shallow [ ] rhonchi
CARDIOVASCULAR:
#7 D5lr @30
gtts/min
Paininthe
surgical site
withpain
scale of 5/10
Surgical site
with
attached
Penrose,
drainingtoa
deepgold
colored
drainage
C foleybag
catheter
attachedto
urobag draining
to a yellow
coloredurine
Limitedmovements,
bodyweakness
Epidural catheterin
frontand back
removed@10 am
Slight fever
Abdominal
Gird: 39cm

51
NEURO:
[x] No problem
COMMUNICATION:
[ ] hearing loss
[] visual changes
[] others:
[x ] denied
man pud ko bahin ana
karon,maghinay-hinay
lang k okay sakit.” As
verbalized.
PERRLA

52
light accommodation
OXYGENATION:
[ ] dyspnea
[X] smoking history
[ ] cough
[ ] sputum
[ ] denied
Comments: “Oo,
gapanigarilyo ako
sauna .” as verbalized.
left
CIRCULATION:
[ ] chest pain
[ ] leg pain
[ ] numbness of
extremities
[x] denied
Comments:. “ sakit
lang jud dapit sakong
samad”as verbalized
by patient
irregular
Ankle Edema none
Pulse Car Rad. AP
Fem*
R:
L:
easy to palpate.
NUTRITION:
Diet:NPO
[ ] N [ ] V
Character
[ ]recent change in
weight and appetite
[ ] swallowing
Difficulty
[x] denied
Comments: “dili sa d
aw ko pakan-on ingon
ang doctor.” As
verbalized.
[ ]dentures [x]none
Full Partial
Upper [ ] [ ]
Lower [ ] [ ]

53
ELIMINATION:
Usual bowel pattern
Once a day
last BM
October 10, 2012
[ ] diarrhea
5 times a day
[] urgency
[ ] dysuria
[ ] hematuria
[ ] incontinence
[ ] polyuria
[ x ] foley in place
[] denied
Comments:
Bowel sounds
are audible
and
normoactive
Bowelsound:
normoactive
_(20/min)____
Abdominal
Distention
Present [x] yes []
no
Urine* (color,
consistency, odor)
with a yellow-
colored
urine,aromatic
LMP: N/A
The patient was able to follow
medicationsand treatments as
prescribed to her.
SKIN INTEGRITY:
[ ] dry
[ ] itching
[ ] other: rash
[x] denied
Comments:
“nagka-rashes lagi
ko tungod sa
diaper.” As
verbalized.
size, location,drainage) : rashes on
the pubic area.

54
ACTIVITY/SAFETY
[ ] drowsiness
[ ] dizziness
[x ] limited motion of
joints
Limitation in
ability to
[ ] ambulate
[ ] bathe self
[] denied
Comments: “ok
raman. Musakit
lang jud siya
pagmalabian ko ug
sturya o lihok.” as
verbalized.
[ ] other [x] none
function
[ ] ROM limitations: the patient has
some difficulty on moving
COMFORT/SLEEP/AWAKE
[x] denied
Comments: “Ok
raman,
makapahulay man
pud ko ug ayo.” as
verbalized.
[ x ] facial grimaces
[x ] guarding
[] none
COPING
Occupation: businesswoman
mother
and query.
09163894562

55
VII. NURSING MANAGEMENT
PROGRESS NOTES
FIRST DAY
We had our first assessment and visited as a group last October 7, 2012, Sunday
at exactly 1:30 in the afternoon at Northern Mindanao Medical Center, CDOC with our
chosen patient S.G. Upon arrival, patient was lying on the folding bed along the hallway
with ongoing IVF of D5LR at 850 cc regulated at 30 gtts/min. We had done our head to
toe assessment and assessed patient’s health status through inspection,auscultation,
palpation and percussion. Assessment findings included: patient suffered abdominal
pain radiating to the back with a pain scale of 8/10, verbalization of anxiety at moderate
level and she’s irritable and can’t sleep properly due some environmental stimuli
(ventilation, space and noise). The patient also suffered from activity intolerance due to
pain. We also determined the patient’s diet (Low Fat Diet) and we found out that she
has a good apetite. Vital signs are within normal range.
With the assessment presented, we prioritized problems and planned
interventions based on the existing problems manifested by the patient. Interventions
planned were focused on relieving pain and providing comfort to the patient. The
following were the interventions rendered and health teachings given:
1. Obtained and recorded vital signs.
2. Encouraged to express feelings regarding feelings toward the upcoming
operation.
3. Instructed to avoid food rich in cholesterol such fried foods and egg.
4. Encouraged adequate rest periods
5. Encouraged to do deep breathing exercise during onset of pain.
6. Placed patient to comfortable position.
7. Encouraged to do diversional activities like listening to music.
8. Instructed significant others to assist the patient in doing daily activities.
9. Emphasized compliance of prescribed medications.
SECOND DAY
We had our second assessment last October 8, 2012 Monday. Since two of our
groupmates had their duty at the surgical ward, they were assigned to take care of the

56
patient chosen for our GCP. Upon arrival, patient was lying on bed at Female ward with
the same IV infusion and rate.
The two members of our group have done their head-to-toe assessment.
Assessment findings included: verbalization of pain in the abdomen with a pain scale of
5/10, anxiety at moderate level. We also assessed patient’s diet and found out that she
has poor apetite. Vital signs are within normal range.
With the assessment presented, we prioritized problems and planned
interventions based on the existing problems manifested by the patient. Interventions
planned were focused on relieving pain, and promotion of comfort. The following were
the interventions rendered and health teachings given:
10.Obtained and recorded vital signs.
11.Elevated head of the bed.
12.Instructed to take deep breaths every after pain is felt.
13.Instructed the significant others not to leave the patient alone.
14.Encouraged adequate rest periods
15.Instructed to avoid rich in cholesterol such as fried foods and egg
16.Placed patient in a comfortable position.
17.Encouraged patient to verbalize feelings on how she’s doing
18.Cleaning and straightening beddings
THIRD DAY
We had our third assessment and visit last October 9, 2012, Tuesday. Upon
arrival, we have done head to toe assessment and found out the same problems as the
second day.
That day, she was scheduled on her operation (cholecystectomy) at 10 am. She
verbalized that she was a liitle tense and we encouraged her to express her feelings to
lessen her anxiety.
19.Obtained and recorded vital signs
20.Elevated head of the bed
21.Instructed deep breathings during onset of pain
22.Encouraged to do diversional activities
23. Nothing per orem maintained
24.Encouraged adequate rest period
25. Placed patient in desired position
26. Encouraged verbalization of feelings

57
FOURTH DAY
We had fourth assessment and fourth visit last October 10, 2012, Wednesday at exactly
6 in the evening. Upon arrival, we had witnessed is
FIFTH DAY
We had our fifth day of assessment and visit last October 11, 2012, Thursday at 2:30 in
the afternoon. Upon arrival, patient was sitting in the bed alone. Foley Bag Catheter was
already removed.
We assessed from head to toe. Patient verbalized feeling of improvement in her
condition, she said that it pain is lessen and cited that pain scale is 2 out of 10 even
without taking the pain relivers.
Patient is already trying to stand and move in her own without anybody’s help.
Monitored vital signs don’t show any signs of complications.
The dressing doesn’t show any signs of infections.
With the assessment presented, we prioritized problems and planned interventions
based on the existing problems manifested by the patient. Interventions planned were
focused on relieving pain, and promotion of comfort. The following were the
interventions rendered and health teachings given:

58
A. IDEAL NURSING MANAGEMENT
Nursing Diagnosis Nursing Interventions Rationale
Anxiety (Moderate) related to
Hyper Metabollic State (CNS
Stimulation)
Independent:
Observe behaviour indicative
of level of anxiety.
Monitor physical responses
noting palpitations, repetitive
movements, hyperventilation,
and insomnia.
Stay with patient, maintaining
calm manner.
Acknowledge fear and allow
patient’s behaviour to belong
to patient.
-Mild anxiety may be
displayed by irritability and
insomnia. Severe Anxiety
progressing to panic state
may produce feelings of
impending doom, terror,
inability to speak or move,
shouting/swearing.
-Increase number of beta
adrenergic receptor sites,
coupled with effects of
excess thyroid hormones,
produces clinical
manifestations of
catecholamine excess even
with normal levels of
norepinephrine exists.
-Affirms to patient that
although patient feels out of
control, environment is safe.
-Avoiding personal
responses to inappropriate
remarks or actions prevents
conflicts/overreaction to

59
Describe/Explain procedures,
surrounding environment, or
sounds that may heard by
the patient.
Speak in brief statements,
using simple words.
Reduce external stimuli.
Place in quiet room; provide
soft, soothing music; reduce
bright light; reduce number of
persons contacting patient.
Discuss with patient reasons
for emotional ability/psychotic
reaction.
Reinforce expectation that
emotional control should
return as drug therapy
process.
stressful situation.
-Provides accurate
information, which reduces
distortion/misinterpretations
that can contribute to
anxiety/fear reactions.
-Attention span may be
shortened, concentration
reduced, limiting ability to
assimilate information.
-Creates a therapeutic
environment; shows
recognition that unit
activity/personnel may
increase patient’s anxiety.
-Understanding that
behaviour is physically based
enhances acceptance of
situation and encourages
different
responses/approaches.
-Provides information and
reassures patient that the
situation is temporary and
will improve in treatment.

60
Collaborative:
Administer anti-anxiety
agents or sedatives and
monitor effects.
Refer to support systems as
needed, e.g., counselling,
social services, pastoral
care.
-May be used in conjunction
with medical regimen to
reduce effects of
hyperthyroid secretion.
-Ongoing therapy support
may be desired/ required by
patient/SO if crisis
precipitates lifestyle
alterations.

61
Diagnosis Nursing Interventions Rationale
Ineffective Breathing
Pattern related to Pain
Independent:
Observe respiratory
rate/depth
Auscultate breath sounds.
Assist patient to turn, cough
and deep breathe
periodically. Show patient
how to splint incision.
Instruct in effective
breathing techniques.
Elevate head of bed;
maintain Low-Fowler’s
position. Support abdomen
when coughing,
ambulating.
Collaborative:
Assist with respiratory
treatments, e.g. Incentive
spirometer.
-Shallow breathing,
splinting with respirations,
holding breath may result in
hypoventilation/atelectasis.
-Areas of decreased/absent
breath sounds suggest
atelectasis, whereas
adventitious sounds reflect
congestion.
-Promotes ventilation of all
lung segments and
mobilization and
expectoration of secretions.
-Facilitates lung expansion.
Splinting provides incisional
support/decreases muscle
tension to promote
cooperation with
therapeutic regimen.
-Maximizes expansion of
lungs to prevent/ resolve
atelectasis.

62
Administer analgesics
before breathing
treatments/therapeutic
activities.
-Facilitates more effective
coughing, deep breathing
and activities.

63
Diagnosis Nursing Interventions Rationale
Impaired Skin Integrity
related to surgical incision
Independent:
Observe the color and
character of the drainage.
Change dressings as often
as necessary. Clean the
skin with soap and water.
Use sterile petroleum jelly
gauze, zinc oxide, or
karaya powder around the
incision.
Apply montgomery straps
Place patient in low- or
semi-Fowler’s position.
Check the T-tube and
incisional drains; make sure
that they are free flowing.
-Initially, drainage may
contain blood and
bloodstained fluid, normally
changing to greenish brown
(bile color) after several
hours.
-Keeps the skin around the
incision clean and provides
a barrier to protect skin
from excoriation.
-Facilitates frequent
dressing changes and
minimizes skin trauma.
-Facilitates drainage of bile
-T-tube may remain in
common bile duct for 7-10
days to remove retained
stones. Incision site drains
are used to remove any
accumulated fluid and bile.

64
Maintain T-tube in closed
collection system.
Collaborative:
Administer antibiotics as
indicated.
Monitor laboratory studies,
e.g., WBC.
Correct positioning
prevents backup of the bile
in the operative area.
-Prevents skin irritation and
facilitates measurement of
output. Reduces risk of
contamination.
-Necessary for treatment of
abscess/infection.
-Leukocytosis reflects
inflammatory process.,
abscess
formation/peritonitis.
Nursing Diagnosis Interventions Rationale
Risk for Infection
Independent:
Stress proper hygiene by all
caregivers between
therapies and client
Use gloves when caring for
open lesions
Maintain adequate
hydration stand or sit to
void
-First line defense against
healthcare associated
infections (HAI’s)
-To minimize
autoinoculation or
transmission of viral
diseases
-To avoid bladder distention
and urinary stasis

65
Maintain sterile techniques
for all invasive procedures
Maintain adequate nutrition,
rest, and appropriate
exercise program
-To avoid cross
contamination
-For proper nutrition
Nursing Diagnosis Interventions Rationale
Acute pain related to
the incision site
Independent:
Note for pain, including
location, characteristics,
onset and frequency
Monitor skin color,
temperature and vital signs
Provide comfort measures
such as touch, repositioning,
quiet environment
Instruct in and encourage use
of relaxation techniques such
as focused breathing
Dependent:
Administer
NSAIDS(Ibuprofen) as
prescribed by the physician
-To rule out worsening of
underlying condition or
development of complications.
-This are usually altered in
acute pain.
-To promote non
pharmacological pain
management
-To distract attention and
reduce tension
.
-Relief of mild to moderate pain

66
B. ACTUAL NURSING MANAGEMENT
S “Sakit kaayo akong tibook likod ug tiyan” as verbalized by the patient.
O  Facial grimace
 Pain Scale of 8/10, spasmic pain all over the abdominal area
 Guarding on the abdominal area
 Self focusing; narrowed focused
A Acute Pain related to obstruction in the bile duct
P Long Term: At the end of 1 hour, patient will demonstrate techniques
to alleviate or control pain.
Short Term: At the end of 30 minutes nursing interventions, patient
will be able to relieved from pain felt.
I  Promoted bed rest and in low fowler’s position
 Use soft cotton linens, cool or moist compress as indicated
 Control environmental temperature
 Encouraged use of relaxaton techniques like deep breathing
exercises
 Administered medication as prescribed (Tramadol 50 mg slow
IVTT, q8 x 3 doses then PRN)
E Long Term: After 1 hour of nursing interventions, the patient was able
to demonstrate techniques to alleviate pain like deep breathing
exercise.
After 30 minutes nursing interventions, patient’s was relieved from
pain after administration of analgesic.

67
S “maglisod ko ug tulog kay igang kaayo” as verbalized by the patient.
O  Change in normal sleep pattern
 Restless
 Irritable
A Disturbed Sleep Pattern related to environmental factors( noise,
ambient temperature)
P Long term: At the end of 1 day nursing intervention, the patient will be
able to report improve sleep and increase sense of well-being.
Short term: At the end of 4 hours of nursing intervention the patient will
be able to identify interventions to promote sleep.
I  Provided a quiet environment
 Provided comfort measures (touch therapy, cleaning and
straightening beddings)
 Use of sleep aids (personal pillows)
 Instructed to establish routine bed time and arising, think
relaxing thoughts when in bed, do not nap in the daytime
 Adequate rest provided
E Long term: After 1 day of nursing intervention, patient have been able to
improved sleep and increased sense of well-being.
Short term: After 4 hours of nursing intervention, the patient was able to
identify interventions to promote sleep.

68
S “Dili kaayo ko kalihok maam kay sakitan ko” as verbalized by the patient.
O ● facial grimace
●guarding
●sleep disturbance
A Activity Intolerance related to decreased range of motion and pain on movement
P Long term: After 2 days of nursing interventions, the patient will be able report
measurable increase in activity tolerance
Short term: After 1day of nursing interventions, the patient will to identify
techniques to enhance activity tolerance
I  Properly position the patient to avoid straining affected areas in the body
 Engaged ROM exercises, as tolerated, to reduce muscle stiffness and
numbness
 Assisted ADL’s to help reduce discomfort and avoid too much energy
exertion
 Encouraged frequent position changes (side-lying to supine) when on bed
rest
 Encouraged bed rest

69
S “Gakakulbaan ko sa akong operasyon karon kay last nako nga opera, gi-
intubate man gud ko ” as verbalized by the patient.
O  Verbalize awareness of feelings
 Anxious
 Restlessness
 Preoccupied from her last operation experience
A Anxiety related to threat of death or change in health status
P Long term: After 1 day of nursing interventions, the patient will appear
relaxed and report anxiety reduced to a manageable level.
Short term: After 6 hours of nursing interventions, the patient will
verbalize awareness of feelings of anxiety
I  Established a therapeutic relationship, conveying empathy and
unconditional positive regard.
 Be available to client for listening and talking
 Encouraged client to acknowledge and to express feelings
 Provided information regarding disease process and anticipated
treatment
 Provided comfort measures(e.g., calm/quiet environment,
therapeutic touch)
 Provided adequate rest
 Instructed in ways to use positive talk, e.g., “I can handle this”
E Long term: After 1 day of nursing interventions, the patient appeared
relaxed and reported reduced anxiety manifested by socialization
engagement(talking with other patients and laughing with them).
Short term: After 6 hours of nursing interventions, the patient was able to
verbalize understanding of her present health status that lessened her
anxiety.

70
S “gasakit akong tahi kung mulihok ko” as verbalized by patient
O • (+) Facial grimace
• Pain scale of 5 out of 10,
• Self-focusing; narrowed focus
A Acute pain related to post op surgical incision
P Long term: After 8 hours of nursing interventions, the patient will
demonstrate techniques to alleviate/control pain.
Short term: After 30 minutes of nursing interventions, the patient will
report relief of pain
I • Positioned client to where she is comfortable
• Taught client diversional activities like watching television
• Encouraged use of relaxation techniques like focused breathing
• Have the patient splint incision when moving
• Provided adequate rest periods
• Provided a calm, quiet environment
• Administered analgesic (ketorolac 300 mg IVTT,q6 x 4 doses)
E Long term: The patient was able to demonstrate techniques to alleviate
pain
Short term: The patient reported that the pain was lessened

71
S “gasakit akong tahi kung mulihok ko” as verbalized by patient
O • Sugical dressing on RUQ
• Disruption of the skin surface
• Injury on the skin layers
A Impaired skin integrity related to surgical incision
P Long term: After 2 days of nursing interventions, the patient will achieve
timely wound healing without complications
Short term: After 1 day of nursing interventions, the patient will
demonstrate behaviors to promote healing/prevent skin breakdown
I • Observed the color and character of the drainage
• Changed dressings and do wound care as often as necessary
• Placed patient in low- or semi-Fowler’s position
• Maintained T-tube in closed collection system
• Administered antibiotics (cefuroxime 350 mg, IVTT q8).
E Long term: After 2 days of nursing intervention, the patient was able to
maintained the wound intact and free from complications
Short term: After 1 day of nursing intervention, the patient verbalized
understanding of proper wound care and demonstrated the proper way
to do it.

72
VII. REFERRAL AND FOLLOW-UP
HEALTH TEACHINGS
MEDICATION
The medications prescribed by the doctor were
thoroughly explained including its indication, possible
adverse effects, contraindication, precautions to be taken
and patient’s response. And to take it on right time, dose,
and route
 Celecoxib 200mg TID 1cap
 Cefuroxime 500mg 1tab TID times 5 days.
EXERCISE
Encouraged to ambulate every morning for 30 minutes to
promote rehabilitation of body’s energy.
Taught to do Range of motion exercises.
Gradually, encouraged to do normal daily activities.
TREATMENT
Taught the importance of proper hygiene and hand
washing
Encouraged to change the dressing everyday
Encouraged to apply povidine iodine (Betadine) to the
wound before changing the dressing
Encouraged to schedule rest periods and sleep periods.
OUTPATIENT
(check-up)
Advised to have follow-up check up on October 19, 20012
at the Outpatient Department, Northern Mindanao
Medical Center.
DIET
Encouraged to eat low fat, low salt diet.
Taught about the importance of her diet modification.
• They lose weight.
• Their health usually improves.
• Their risk of developing cardiovascular disease may
decrease.
• They get relief from unpleasant gastrointestinal
symptoms.

73
Encouraged to increase protein intake
 Cheese
 Mature (Large) Beans
 Lean Veal and Beef
 Lean Meats (Chicken, Lamb, Pork, Turkey)
 Lobster and Crab
 Peanuts
 Fish
Encourage to increase fluid intake at least 10-12 glasses
per day.
Intake of vitamin C like orange, mango fruit.

74
PROGNOSIS
Score Legend:
1 – Poor Prognosis
2 – Good Prognosis
3 – Very Good Prognosis
CRITERIA SCORE ANAYSIS/IMPLICATION
A.ONSET OF ILLNESS 1
2 days prior to admission,
onset of epigastric pain,
grouping, 7/10 in patient
scale, radiating to lower
back, associated with
shortness of breath no
consult, no medication
given.
B. DURATION OF
ILLNESS 1
Detection of the disease
condition was delayed for
attaining prevention.
Manifestation showed up by
mean of pain on the upper
quadrant of the abdomen
radiating to lower back two
days prior to admission.
C. PRECIPITATING
AND PREDISPOSING
FACTOR
3
The increasing age of the
patient, the gender and her
diet which is mostly rich in
salty and high in cholesterol
diet predisposed her and
put her at risk for obtaining

75
such condition. Such factor
manifest by the patient
cannot already be altered
and prevented.
Unfortunately,
manifestations showed up
but were diagnosed too late
for her to prevent from the
condition. Thus strictly
following the treatment
regimen would help her
prevent from further
complication and faster
recovery
D. ATTITUDE &
WILLINGNESS TO
TAKE TREATMENT
3
The patient’s admission
and adherence medication
regimen may somehow
proved that the patient is
very willing to follow
treatment that she even
had a surgery in order for
her to recover the stated
condition.
E. FINANCIAL
CAPABILITY
3
Patient is financially
capable for her was able to
pay the entire medical and
hospital bills by the help of
family member and phil.
Health.

76
F. POST-OPERATIVE
RECOVERY 3
Sign of progressive were
visible that she was able to
stand up and walk around
the area with assistance
on the first day of post
operatively.
G.PAIN MANAGEMENT
2
A daily progressive sign of
relief from a surgical
procedure especially on
the incisions showed a
good prognosis that she
had recovered from the
surgical procedure done.
H. FAMILY SUPPORT
3
Her family was very
supportive that her
husband was the one who
supported the operation
and hospital bills and she
was always accompanied
by either her husband or
her children during
admission.
This is why patient’s prognosis is very important for patient having such condition vary
greatly on the health, the extent of damage, the regimen given and the patient’s
adherence to it, and most importantly the detection of the disease. Most noted
prognosis in the chart shows good prognosis but the detection of the symptoms were
too late for her to prevent and to be able treated that may lead to life threatening
complication.

77
IX. EVALUATION
At the end of the study the presenters were able to attain the goal that we have set from
the start of her study. Thorough gathering of data by means of physical assessment
were met and through the gathered data we were able to identify some health problems
and we’re able to skilfully formulate nursing care plan that we had applied to our patient
in actual. By means of reviewing, discussing and elaborating the affected anatomy and
physiology of the body enabled us to create interventions that could alleviate pain and
any discomfort experienced by the patient. With the help of the patient family, we were
able to explore part of the patient’s personality that also helped us increasing
interventions appropriate for her. Through the interventions we imparted there was a
progress in patients health status such as regained his activity of daily living.
The presenters also imparted health teachings not only the patient but to her family as
well, in order to lower the risk of having this kind of condition. Choosing the right diet
was also elaborated for them to be aware of the precise choice of foods and nutrition
right for preventing the disease like avoiding food that is salty, fatty and especially those
highly seasoned foods which always pertained to the food we were eating, we should
still be conscious with our health especially if we want to live longer. Avoid that life
threatening disease which not only shorten our life but caused us some financial
problem too.
Lastly, the presenters were also grateful for having the opportunity to have the case
study for they not only gain knowledge but also enhanced their skills in the field of
nursing by means of planning interventions and rendering care to the patient. The
researches were hoping that the readers would be more conscious and be more careful
in taking of their health to prevent conditions to persist.

78
X. DOCUMENTATION
BIBLIOGRAPHY
 BOOKS
 “DRUG HANDBOOK” Lippincott Williams & Wilkins Nursing 2004 24th
edition.
 “MIMS” PHILIPPINES. 123rd edition 2012, Philipine Index Of Medical
Specialties Establishment. 1968 Ben Yeo,
 “Lippincott Manulal of Nursing” 8th edition, Lipincott Williams & Wilkins
 “PATHOPHYSIOLOGY” Lippincott Williams &Wilkins A2-in-1 reference for
nurses.
 Fundamentals of nursing Concepts. Process and Practices” 11th edition.
Upper Saddle, Kozier, B. etal New Jersey, 2007.
 “Nursing Care Plans, Nursing Diagnosis and Intervention” 6th edition, by
Gulanick/Myers
 WEBSITES
 WWW.MEDICINENET.COM/CHOLE/ARTICLE.HM
 www.who.int/topics/chole
 www.mursingcribs.com
 www.youtube.com
 www.google.com
 www.MIMS.com
 www.PIMS.com

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