Grand Case Cholylithiasis

7/22/2019 Grand Case Cholylithiasis

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INTRODUCTION

Choledocholithiasis (stones in common bile duct) is one of the complications of

cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis.

Typically patients with cholelithiasis present with pain in the right upper quadrant of the

abdomen with the associated symptoms of nausea and vomiting, especially after a fatty meal.

The physician can confirm the diagnosis of cholelithiasis with an abdominal ultrasound that

shows the ultrasonic shadows of the stones in the gallbladder.

The incidence rate for gallstones is 10-20%. Approximately 600,000 cholecystectomies are

performed in the United States every year, and choledocholithiasis complicates 10-15% of these

cases. In Asian populations, infestation with a lumbricoides and C sinensis may promote stasis

by either blocking the biliary ducts or by damaging the duct walls, resulting in stricture

formation. Bactibilia is also common in these instances, probably secondary to episodic portal

bacteremia. Some authors have suggested that the stones are formed because of the bactibilia

alone and that the parasites' presence is just a coincidence. Choledocholithiasis occurs more

frequently in females than in males. Patients with choledocholithiasis may be completely

asymptomatic; in approximately 7% of cases, the stones are found incidentally during

cholecystectomy. Stones are seen in 1% of autopsies performed on individuals older than 60

years who died of unrelated causes. Approximately 25-50% of asymptomatic CBD stoneseventually cause symptoms and require treatment. Symptoms occur when the stones obstruct the

CBD. The clinical presentation varies depending on the degree and level of obstruction and on

the presence or absence of biliary infection.The management of choledocholithiasis remains in

evolution since the introduction of laparoscopic cholecystectomy. If the local surgical group is

adept at laparoscopic cholecystectomy and intraoperative cholecystectomy, then a laparoscopic

cholecystectomy with cholangiography may be the best approach. However, if CBD stones are

present, laparoscopic CBD exploration and stone removal is technically challenging and only the

most proficient and skilled laparoscopist can readily accomplish this operation. Note that an

endoscopic association loaded with skilled laparoscopists performed 1 of the above-mentioned

studies. On the other hand, if you have a well-trained endoscopist, then endoscopic stone

extraction is successful 90% of the time. Alternatively, preoperative magnetic resonance

cholangiopancreatography has been recommended to look for CBD stones.


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The group chose this case because more clinical skills will be developed by experiencing the

clinical management of this disease-condition and it will enhance ones knowledge in

implementing proper nursing intervention to the patient towards recovery.

Objectives

Nurse Centered:

General:

To enhance skills, comprehension and approach in the practice of nursing and be able to

establish knowledge on the risk factors, prognosis nursing management, current trends and

incidence of the disease condition that was chosen.

Specific:

To come up with a comprehensive presentation of the disease condition by means ofcorrect presentation of the data gathered through the use of nursing process.

To present the current trends about the disease condition; the reason for choosingsuch case for presentation; and the importance of the case study.

Patient Centered:

General:

To be able for the client to fully understand and recognize the disease condition,

emphasize the importance of making appropriate action and to guide the patient towards

recovery.

Specific:

To impart knowledge about the importance of healthy lifestyle. To render proper nursing management and medical regimen needed by the patient. To identify predisposing factors that aggregate the present condition of the patient.


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II.NURSING PROCESS

A. ASSESSMENT1. Personal Data

A. Demographic Data

Name: Patient X

Sex: Male

Age: 45 y/o

Civil Status: Married

Occupation: Farmer

Religious Affiliation: Roman Catholic

Position in the Family: Father

Address: Tarlac City

Date of Birth: January, 1964

Place of Birth: Tarlac City

Nationality: Filipino

Date of Admission: September 29, 2010

Health Care Financing: Phil health

Usual Source of Medical: Health center, Clinics, Hospital Care

Admitting Diagnosis: Choledocholithiasis

B. Environmental StatusPatient X lives at a barangay in Tarlac City.. According to him, their house is made up of

wood and cement with 2 windows and 2 doors: one in front of the house and one at the back.

Their water source is a Cartesian well located outside their house with a distance of 4 meters

from their kitchen. Their toilet is located 3 yards away from their kitchen. Their house has 2


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rooms, one room is used as a store room while the other one is their bedroom.. Their front yard

has irregular elevations with a muddy and slippery pathway leading to the kitchen.

Lifestyle

The patient wakes up at around 5:00 am and drinks a cup of coffee. After that he will

immediately proceed to his owned rice field to start his daily work consisting of plowing the

field and pulling out the weeds around. He usually eats fried eggs and tinapa and drinks coffee

for breakfast. His diet is usually composed of instant noodles, fried foods, and sometimes, if their

budget enough, he stated that he also likes to eat fatty foods. He goes to sleep at 9:00 and does

not observe evening hygiene.. He spends his leisure time by taking a nap.


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3. History of Past Illness:The patient had chicken pox and measles in her childhood. She also claimed that she

completed her immunizations. Patient X stated that she does not have any allergic reaction to

drugs, animals, or any other substances.

4. History of Present Illness:

Patient X stated that one month before the admission, she started experiencing abdominal

pain located at the right upper quadrant and radiates at the back. She described the pain as

"parang dinudurog ang tiyan ko. The pain occurred twice a week during the month, but became

intolerable and occurred almost everyday during the last week before her admission. During

these days, the pain was accompanied by occasional fever, anorexia, and nausea and vomiting.

According to the patient, the pain usually occurs during the afternoon up to the evening. During

the assessment, she graded the pain intensity as 8/10 prior to her operation. Patient X tried to

alleviate the pain by applying hot compress and splinting pillows at the site where the pain

originated, yet the pain did not subside. Patient X stated that the pain occur regardless of her

activity. She stated that she had several check-ups prior to her hospital admission. She was then

prescribed medications such as ibuprofen for pain. She was then admitted at Tarlac Provincial

Hospital because of her continuous pain in her abdomen, anorexia, fever, nausea, and vomitingand advised by the physician to undergo operation.


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3. Physical Assessment

THE THIRTEEN AREAS OF ASSESSMENT

1. SOCIAL STATUS

The patient is 45 years old and currently living at Tarlac City. He has a good relationship

with his family members. They help each other whenever they are in need and work in order to

support each family member. In his age, he still continues to work to provide the needs of his

family. Each of the members of their family performed their specific roles. If one of them got

problems, members are always there to support.

Norms:Family members should perform their roles. Good communication within the family must

be maintained to obtain a healthy relationship with one another. Social support is a perception

that one has emotional and tangible resource to call on when needed, perceived social support is

being followed by the family to express the love and care to the family. Financial aspect is one of

the normal constraints in the family. (Kozier , copyright 2004).

Analysis

The patient has a good social relationship with his family. If some problem arises, they

can still manage to handle it properly.

2. MENTAL STATUS

Client is oriented to time, place and person. He can identify things or names

being asked. He can recall recent and remote memories he experienced.

He can speak in Tagalog and Kapampangan .He is responsive and answers to the questions being

asked.

Norms: The patient should be oriented to time and place, can identify past and recent memories

and should be able to verbalize concrete messages. The patients ability to read and write should

match his educational level. The patient should be able to respond to questions and identify all


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the objects presented to him. (Estez, Health Assessment and Physical Examination, Third

Edition.)

Analysis: Being responsive and being able to answer questions accordingly are the

major determinants which indicate patients mental capabilities are still

functioning well.

3. EMOTIONAL SUPPORT

Prior to the procedure, client was first hesitant to communicate with the interviewer.

Although he stayed looking calm, he seemed to be anxious. When asked how he feels, he

admitted that he is quite nervous but he believed that the operation would be successful. Couple

of days after the operation, the patient talked and smiled every time he was interviewed.

Norms:

A persons emotional status depends much on his ability to cope up with the happening in

his/her life. He or she may not be in the right mood if some unnecessary things had happened.

(Nursing CEU.com, the process of human being).

Analysis

The patient has a strong confidence on himself and was able to cope up with his

condition. His emotional status was stable before and after the surgery. He had a strong belief to

survive, which made him not to worry too much during the operation.

4. SENSORY PERCEPTION

Sense of tasteThe patient is fond of eating foods. After the surgery, clients taste seems to be bitter.

However, as days passed by, he was able to taste the foods presented to him without any taste

abnormalities.

Norms


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Normal sensation would be accurate perceptions of sweet, salty, and bitter taste. (Estes,

Third Edition, Copyright 2006)

Analysis

After the operation, the patient remained NPO to prevent occurrence of aspiration. Bitter

taste he experienced after the operation is maybe mainly because of the effect of anesthesia given

to him at the time of operation.

Auditory Activity

Before the operation started, questions were repeatedly asked before the client was able

to answer. Loud voice was being introduced for him to be able to answer. Nevertheless, he was

able to answer the questions asked correctly.

Norms:

Patient should hear clearly and accurately. Ear must be free from lesions and masses.

Although there are many people that reach old age with acceptable hearing, the common

thing is for this ability to decline through time. In some old people this decline, called

presbycusis, is very strong and can originate in various physiological problems.

(http://en.latinsalud.com)

Hearing loss can start at 40 years of age in some people with hereditary preconditions. In

general, it advances slowly but progressively, until clearly manifesting at the age of 60.

(http://en.latinsalud.com)

Analysis

The clients auditory sense shows that he experiences hearing difficulty mainly because

of his age affecting his communication and social skills.

Sense of smell

The patients nostrils were symmetrically aligned. No lesions, swellings and redness were

noted.
http://en.latinsalud.com/http://en.latinsalud.com/http://en.latinsalud.com/http://en.latinsalud.com/


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Norms

Patient must be able to identify different smell. Nose should be at the midline position of

the face, free from lesions, and intact nostrils.

Analysis

The patient has a normal sense of smell.

Sense of sight

Prior to the surgery, client claimed to experience blurring of vision. He admitted of using

an eyeglass. However, he couldnt remember what hes visual acuity was. No lesions, redness,

swelling and discharges were noted from her eyes.

Norms:

The normal patient has a visual acuity of 20/20 in a Snellen chart test is considered to

have normal vision acuity. (Estes, Third Edition, Copyright 2006).

Vision loss among the elderly is a major health care problem. Approximately one person

in three has some form of vision-reducing eye disease by the age of 65. The most common

causes of vision loss among the elderly are age-related macular degeneration, glaucoma, cataract

and diabetic retinopathy. (http://www.aafp.org)

Analysis

The clients blurring of vision is associated with his age. During old age, age-related

macular degeneration may happen, thus, impairing the vision of an individual which may

decrease ones ability to perform activities of daily living.

5. MOTOR STABILITY

Prior to the operation, the patient was in bed. He can move but in minimal circumstances

only because of the pain he felt on his right abdomen. After the operation, he was in complete

bed rest, but was able to progress through more complex movements as day passed by.
http://www.aafp.org/http://www.aafp.org/


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Norms

Normal motor stability includes the ability to perform the different steps in doing range

of motion. It should be firm with smooth and coordinated movements. (Estes, Third Edition

2006)

Analysis

The patients motor stability prior to the surgery was abnormal due to the presence of

pain. Pain was associated with the said disease condition. After the procedure, the patients

motor stability corresponded to his condition postoperatively.

6. BODY TEMPERATURE

The following body temperatures were obtained:

Date Time Assessed Findings

September 29, 2010 4:10 PM 37.3 C

September 29, 2010 5:00 PM 38.4 C

5:15 PM 38.1 C

5:30 PM 37.6 C

6:00 PM 37.4 C

10:00 PM 37. 1 CSeptember 30, 2010 2:00 AM 37.0 C

6:00 AM 37.0 C

The client presented with fever during her admission until after the surgery. Her temperature

stabilized during the last 3 days of the assessment.

Norms:

36.5 to 37.5C is the normal body temperature (Kozier, Seventh edition, Copyright 2004)

Analysis

The client was febrile postoperatively because of the his bodys adaptation


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7. RESPIRATORY STATUS

The table below shows the respiratory rate of the patient.

Date Time Assessed Findings

September 29, 2010 4:10 PM 19 cpm

5:00 PM 26 cpm

5:15 PM 25 cpm

5:30 PM 23 cpm

6:00 PM 22 cpm

10:00 PM 23 cpm

September 30, 2010 2:00 AM 21 cpm

6:00 AM 20 cpm

No cyanosis, chest indrawing and use of accessory muscles was noted. The patients lung

sounds were clear upon auscultation.

Norms:

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of pattern,

normal respiration must be regular and even in rhythm. The normal depth of respiration is none

exaggerated and effortless (Health Assessment and Physical Examination 3rd

edition Mary Ellen

Zator Estes)

Analysis

The patients respiratory rate was elevated as a compensation for his fever.

8. CIRCULATORY SYSTEM

Date Time Pulse Rate Blood Pressure

September 29, 2010 4:10 PM 101 bpm 120/100

5:00 PM 98 bpm 100/70

5:15 PM 92 bpm 100/80


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5:30 PM 87 bpm 110/90

6:00 PM 89 bpm 100/90

10:00 PM 99 bpm 120/90

September 30, 2010 2:00 AM 97 bpm 120/98

6:00 AM 98 bpm 110/80

During the blanch test, the patients capillary refill was able to return in less than 2 seconds.

Norms:

The normal pulse rate rages from 60-100 bpm, and the normal blood pressure is 120/80.

Capillary refill in 2 seconds or less is expected in a healthy adult, which denotes proper

oxygenation of the blood.

Analysis

The clients pulse rate was elevated during the preoperative period due to the presence of

fever and pain. After the surgery, however, his pulse rate returned to the normal range. His blood

pressure and capillary refill was normal.

9. NUTRITIONAL STATUS

The patient claimed that his weight was 46 kilogram before the occurrence of his present

condition. His weight after the operation was 42 kilograms. he usually eats fried eggs and tinapa

and drinks coffee for breakfast and usually eats pinakbet, dinengdeng and fried fish at lunch. He

stated that he eats three (3) times a day. He claimed that he is also fond of eating junk foods such

as tokneneng and fishball and high fat foods such as sisig, chicharon and crispy pata. He has

no known allergies to foods and allergies. His computed BMI was 17.

Computation of the clients BMI:

Weight: 42 kg

Height: 5 (60 inches)

Formula: wt (kg) / ht (m2)

Solution:

42 kg / (1.52 m2)

BMI: 18.2 kg/m2


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Norms:

BMI is a measurement that indicated body composition. The degree of overweight or

obesity as well as the degree of underweight can be determined. (Estes, Third edition, Copyright

2006)

Standard Body Mass Index for Adults:

Underweight=


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color. Urine output of an adult is usually 1200-1500mL per day. (Kozier Seventh edition,

Copyright 2004)

Analysis:

The patient has a normal defecation pattern prior to and after the operation. His urinary

status was below the normal range after her operation, but was normal prior to it.

11. REPRODUCTIVE STATUS

* * PATIENT REFUSED TO THI S AREA OF ASSESSMENT

12. STATE OF PHYSICAL REST AND COMFORT

Prior to admission, the patient slept for 8 hours a day. During his stay in the hospital, he

was unable to sleep and had his rest for only 3 hours prior to his operation due to anxiousness

and pain. After the operation, the pain on his incision site limited his to 6 hours of rest until his

third day postoperatively when he was able to sleep for 12 hours.

Norms:

A normal sleep hours of an adult per day is 6 - 8 hours without being disturbed (Kozier,

Seventh edition, Copyright 2004)

Analysis:

The patients rest and comfort status was alteredprior to the surgery due to his condition

13. STATE OF SKIN AND SKIN APPENDIGES

The hair of the patient was properly distributed, black and free from infestations. The

scalp has no flakes and free from lesions. Before the operation, the patients skin wasslightly

dry. There were noted bruises and scars on his lower right leg. After the operation, his IV line

had infiltration and had to be removed. He also had his incision at the right side of her abdomen.

There were no discharges, swelling, redness and bleeding noted at her incision site.


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Norms:

Skin varies from light to brown from ruddy pink to light pink. Generally, uniform except

in areas exposed to the sun, areas of lighter pigmentation in palms, nail beds, and lips. The hair

should be evenly distributed, thick, shiny and free from infestation. The nails should be 160 and

smooth in texture. (Kozie, Seventh edition, Copyright 2004)

Analysis:

The patients skin was abnormal due to the presence of scars and bruises. The infiltration

and the presence of the incision site were also observed as an abnormal finding because it

disrupts the integrity of the skin.


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4. DIAGNOSTIC AND LABORATORY PROCEDURESDiagnostic/

Laboratory

Procedures

Date

Ordered and

date Result/s

In

Indication/s

or Purposes

Result/s Normal

Values

(Units used

in theHospital)

Analysis and

Interpretation

of results

CBC

>WBC

>LYM

>MID

>GRAN

>RBC

September

29, 2010

Result:

September

29, 2010

CBC is used asabroadscreening test

to determinethe values of

formedelements of the

blood.10.1

2.8

0.5

6.9

2.49

4.110.9 g/dL

0.64.1

0.01.8

2.07.8

4.20 6.30T/L

Normal>No indicative

abnormalitiesnoted.

Normal> No indicativeabnormalitiesnoted


Normal> No indicativeabnormalities

noted

Decreased>There is a

markeddecreased inRBC that may

indicatehypoxia.


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>HGB

>HCT

>MCV

>MCH

>MCHC

>PLT

69

0.209

83

32.0

355

258

120180 g/dL

0.370 0.510L/L

80.097.0 fl

26.032.0 pg

310360 g/dL

140 -440 g/L

Decreased

>There is amarked

decreased in

HGB thatindicates

hypoxia.

Decreased>There is a

markeddecrease in

HCT thatindicateshypoxia


Normal> No indicative

abnormalitiesnoted

Normal

> No indicativeabnormalitiesnoted

Normal> No indicativeabnormalities

noted

NURSING RESPONSIBILITIES:

Before:

Determine the clients understanding of the procedure Determine the clients response to previous testing


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During:

Ensure clients comfort until the procedure will be doneAfter:

Document the method of testing and results on the clients record Immediately reached the blood sample on the laboratory. Follow-up result from laboratory

Diagnostic/

Laboratory

Procedures

Date

Ordered and

date Result/s

In

Indication/s

or Purposes

Result/s Normal

Values

(Units used

in the

Hospital)

Analysis and

Interpretation

of results

BLOOD

CHEMISTRYSeptember,

29, 2010

Result:

September,

29, 2010

Blood tests

are used todetermine

physiological

andbiochemical

states such as

disease,

mineralcontent, drug

effectiveness,

and organfunction

FBS:

5.34

BUN:9.0

Creatinine:41

Uric acid:

None

Cholesterol:

6.25

Triglyceride:

.92

HDL:

44.6

LDL:

FBS:

3.9-6.1mmol/L

BUN:2.9-8.2

mmol/L

Creatinine:53-106

mmol/ l

Uric acid:None

Cholesterol:3.88-6.47

mmol/L

Triglyceride:.11-

Normal

Not normalincreased

levels of BUN

may be due the

presence ofinfection

Not normaldecreased

level of

creatinine may

be due todecreased

muscle mass

Normal

Normal

Normal


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180.62

Electrolytes

Na

150

K5.1

Cl

106.5

2.15mmol/L

HDL:

30-75mmol/L

LDL:66-

178mmol/L

Na

135-145mEq/L

K3.5-5.0mEq/L

Cl

98-106mEq/L

Normal

Not normalElevated LDL

may be due to

the clientsnutritional

preference

Not normal

elevated levelsof NA may be

due to thepresence of

infection

Not normalelevated levels

of K

Not normal

elevated levelsof Cl

Nursing responsibility:

Before:

Explain the purpose of the test and the procedure for collection of blood. Client mat experienceanxiety about the procedure, especially if it is perceived as being intrusive or if they fearunknown to the result. A clear explanation will facilitate cooperation on the part of the client.

Inform the client of the time period before the results will be available.During:

Use the correct procedure for obtaining the blood. Aseptic technique should be use in collection to prevent contamination that can cause inaccurate

results. Ensure correct labeling, storage and transportation of the specimen to avoid invalid test results.

After: Report results to the appropriate health team members. Compare the previous and current test results and modifies nursing interventions as needed


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5. ANATOMY AND PHYSIOLOGY

The anatomy of the biliary tree is a little complicated, but it is important to understand. The liver's cells (hepatocytes) excrete bileinto canaliculi, which are intercellular spaces between the liver cells. These drain into the right and left hepatic ducts, after which

bile travels via the common hepatic and cystic ducts to the gallbladder. The gallbladder, which has a capacity of 50 milliliters(about 5 tablespoons), concentrates the bile 10 fold by removing water and stores it until a person eats. At this time, bile is

discharged from the gallbladder via the cystic duct into the common bile duct and then into the duodenum (the first part of thesmall intestine), where it begins to dissolve the fat in ingested food.

The liver excretes approximately 500 to 1000 milliliters (50 to 100 tablespoons) of bile each day. Most (95%) of the bile tha t hasentered the intestines is resorbed in the last part of the small intestine (known as the terminal ileum), and returned to the liver for

reuse.

The many functions of bile are best understood by knowing the composition of bile:Bile Salts (cholates, chenodeoxycholate, deoxycholate): these are produced by the liver's breakdown of cholesterol. Theyfunction in bile as detergents that dissolve dietary fat and allow it to be absorbed. Hence, disruption of bile excretion disrupts the

normal absorption of fat, a process called malabsorption. Patients develop diarrhea because the fat is not absorbed (steatorrhea) ,and develop deficiencies of the fat-soluble vitamins (A, D, E, and K).Cholesterol and phospholipids-while only 4% of bile is cholesterol, the secretion of cholesterol and its metabolites (bile salts)into bile is the body's major route of elimination of cholesterol. Phospholipids, which are components of cell membranes,

enhance the cholesterol solubilizing properties of bile salts. Inefficient excretion of cholesterol can cause an increased serumcholesterol. This predisposes to vascular disease (heart attacks, strokes, etc.)Bilirubin-while this comprises only 0.3% of bile, it is responsible for bile's yellow color. Bilirubin is a product of the body'smetabolism of hemoglobin, the carrier of oxygen in red blood cells. Disruption of the excretion of this component of bile leads to

a yellow discoloration of the eyes and skin (jaundice).

Bile production and recirculation is the main excretory function of the liver. Tumors that obstruct the flow of bile from the livercan also impair other liver functions. Therefore, it is necessary to understand these other functions to understand the symptoms

that these tumors can cause. These include:

Metabolic functions, such as the maintenance of glucose (blood sugar) levelsSynthetic functions, such as the synthesis of serum proteins such as albumin, blood clotting (coagulation) factors, and

complement (a mediator of inflammatory responses)Storage functions, such as the storage of sugar (glycogen), fat (triglycerides), iron, copper, and fat soluble vitamins (A, D, E, andK)Catabolic functions, such as the detoxification of drugs


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PATHOPHYSIOLOGY (Book-Based)

RISK AND PREDISPOSING FACTORS

Obstruction of bile outflow

alteration

MODIFIABLE

Obesity, Cigarette smoking,

Alcoholism, Hypercholesterolemia/

fats intake, pregnancy

NON - MODIFIABLE

Age, Gender, Race, Diseases like

Diabetes Mellitus

Bile Stasis

Chemical Reaction

INFLAMMATION

- Epigastric pain

- Tenderness and rigidity

of Upper Right Quadrant

Decreased blood supply

and decreased lymphatic

drainage

Distension of bile duct

Proliferation of bacteria

Elevated temperature

Nausea and vomiting

Edema

- Tachycardia- Pallor- Diaphoresis


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PATHOPHYSIOLOGY (Patient-Based)

RISK AND PREDISPOSING FACTORS

Obstruction of bile outflow

alteration

MODIFIABLE

Obesity, Cigarette smoking,

Alcoholism, Hypercholesterolemia/

fats intake, pregnancy

NON - MODIFIABLE

Age, Gender, Race, Diseases like

Diabetes Mellitus

Bile Stasis

Chemical Reaction

INFLAMMATION

- Epigastric pain

- Tenderness and rigidity

of Upper Right Quadrant

Decreased blood supply

and decreased lymphatic

drainage

Distension of bile duct

Proliferation of bacteria

Elevated temperature

Nausea and vomiting

Edema

- Tachycardia- Pallor- Diaphoresis


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Assessment Diagnosis Scientific

Explanation

Planning Implementation Rationale Evaluation

S:

O:

Presenceof incision

grimace Pale and

Weak in

appearance

Reducedbody

movement

s Mild

erythemain the

operated

site

Risk for

infectionrelated to

surgicalincision

Due to

increased riskfor being

invaded by

pathogenicorganisms

therefore

possibleinfection can

occur.Contributing

factors suchas altered

peristalsis,

tissuedestruction,

increasedenvironmenta

l exposure,

trauma andinvasive

procedure.

Within 1 hour

of propernursing

interventions,

the client willknow ways on

how to prevent

complication ofinfection

Encouragedto practicegood hand

washing and

asepticwound care.

Inspectedincision anddressings.

Notedcharacteristic

s of drainagefrom wound

Assess anddocument for

any signs andsymptoms of

infection.

Ensureproper hand

hygiene byall caregivers

duringtouching and

making of

procedure.

To prevent andminimize thespread of

microorganism.

Prevents accessor limits spreadof infecting

organisms/cross-contamination.

To identify thecause of

infection anddetermine the

appropriate

nursingintervention to

be applied.

First linedefense againsthealth care

associatedinfection.

After 1 hour of

proper nursinginterventions,

the client was

able to knowways on how to

prevent

complication ofinfection

B. PLANNING- NURSING CARE PLANS


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Instruct theclient and thefamily about

the need forgood

nutrition,

especiallyprotein and

proper rest.

Optimalnutritional

statuscontributes to

healthmaintenance

and prevention

of infection.


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Explanation


S:

O:

dry mouth chapped

lips

withsurgical

incision atright upper

quadrant

Pale andWeak in

appearance

Restlessand

irritable

RBC HGB Na K

Risk for

fluid

volume

deficitrelated to

blood loss

Surgery

predisposesthe client to

lose massive

amounts ofblood which

predisposes

the client toshock, and

hypovolemia

Within 8 hours

of propernursing

interventions,

the client willbe able to

display

adequate fluidbalance AEB

stable vitalsigns, capillary

refill andappropriate

urine output.

Maintainedaccurate

record of

input andoutput.

Assessed skin/ mucous

membrane,peripheral

pulses andcapillary

refill.

Observe forsigns ofbleeding (e.g

hematemesis,

melena,petecchiae,

ecchymossis)

Providesinformation

about a needs

and organfunction.

Indicators ofadequacy of

circulatingvolume/perfusio

n.

Prothrombin isreduced andcoagulation

time prolonged

when bile flowis obstructed,

increased riskof

bleeding/hemor

rhage

Within 8 hours

of propernursing

interventions,

the client willbe able to

display

adequate fluidbalance AEB

stable vitalsigns, capillary

refill andappropriate

urine output.


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Provide freshwater and

oral fluids,prescribed

diet;offersnacks (e.g.

frequent

drinks, freshfruits and

fruit juice).

AdministerIV bloodproducts,

electrolytes

as indicated.

The oral routeis preferred for

maintainingfluid balance.

Maintainsadequate

circulatingvolume and aids

in imbalances

from woundlosses.


28/53


Explanation


S: Masakit yungsuagt ko with

pain scale of 8/10

O:

Facialgrimace

Guardingat incisionsite

Restlessand

irritable

Observedself-

focusingor

narrowed

focus Self-

protectivebehavior

Limitedmovementnoted

Slightlydiaphoreti

c

RR28cpm

Acute

painrelated to

obstruction / ductal

spasm

It is

accompaniedby acute

localized

pain becauseof potential

tissue

damagewhich casue

inflammation, swelling

and rednessat the site.

Within 30

minutes of

proper nursing

interventions,

the clients pain

scale will

decrease from

8/10 to 5/10

Promoteadequate restand sleep.

Assist patientin use of

distractiontechniques.

Assist patientin

comfortableposition.

Providediversionaltechniques

such astalking to the

family

members.

Encouragepatient to do

deep

breathingexercise.

Supportpatient in useof

To restore bodystrength.

To control pain.

\

To facilitatecomfort.

To maximizerelaxation and

comfort.

To promoterelaxation.

Cognitivebehavioralstrategies can

After 30

minutes of

proper nursing

interventions,

the clients pain

scale was

decreased from

8/10 to 5/10


29/53

nonpharmaco

-logicalmethods to

help contropain such as

imagery,

relaxationand

application ofheat and cold.

Administerpain

medication as

prescribed.

restore theclients sense f

self-control.

To minimizepain.


30/53


Explanation


S:Nanghihina

ako.

O:

>Pale andweak in

appearance

>Reduced

bodymovement

>Reporteddysfunctional

eating patterns

Imbalanced

nutrition:

less than

body

requirementsrelated toimpaired fat

digestion due

to obstructionof bile flow

Due to

insufficientintake of

nutrients it

causes thebody not to

meetmetabolic

demands

because ofbiological,

psychological or economic

factors.

Within 8

hours ofproper nursing

interventions,

the client willdemonstrate

behaviours /lifestyle

changes to

regain andmaintain

appropriateweight.

Work with theclient todevelop a plan

for increased

activity andenergy.

Teachstrategies for

energy

conservation

such as

limiting of

talking to

others,

increased

number of rest

periods.

Providecompanionship

at mealtime.

Emphasizeimportance ofadequate rest

and sleep.

To increasepatientsappetite.

To prevent andminimize thespread of

microorganism.

To maximizepatientsstrength.

To encouragenutritional

intake.

For energyconservation.

After 8 hours of

proper nursing

interventions,

the client was

able todemonstrate

behaviours /

lifestyle

changes to

regain and

maintain

appropriate

weight.


31/53

Encouragepatient to eat awell balanced

diet.

Encouragepatient to drinkatleast 8

glasses ofwater a day.

Offer frequentand small

quantities of

food.

To restorepatients

energy.

It is importantfor clients to

maintain intakeas much as

possible.


32/53


Explanatio

n


S: Mainit ang

pakiramdam ko

O:

flushed skinwarm to touch

movements

with minimalbody

movements

weak inappearance

T38.4C

Altered

thermoreg

ulationrelated totissue

trauma

Due totissue

trauma it

causes thebody to

compensate

such asincreasing

thetemperature.

Within 1 hour

of proper

nursing

interventions,

the clients

temperature will

decrease from

38.4C to

37.8C

Monitoredclients

temperatur

e (degreeand

pattern).

Promotedsurface

cooling bemeans of

tepidsponge

bath.

Encouraged to

increasefluid

intake.

Providedhigh

caloricdiet such

as rich in

carbohydrates and

protein.

Maintained bed rest.

Administe

To be able toknow what

interventions to

be applied.

To helpmaintain a

normal bodytemperature.

To help replacefluid loss.

To help thebody to restore

strength andbody

temperature.

To help patientto conserve

energy. To help replace

After 1 hour of

proper nursing

interventions,

the clients

temperature was

decreased from

38.4C to

37.8C


33/53

red

replaceme

nt fluidsand

electrolytes as

indicated.

Administeredmedication

s as

prescribedby the

physician.

fluid loss

To helpmaintain anormal body

temperature .


34/53


35/53

C. Implementation

1. Medical Management

i. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy etc.

Prior: Understand why the therapy is needed. determine potential outcomes for the client understand the fluid and electrolyte and acid base status of the client provide an explanation to the client and gain cooperation select the appropriate IV set

Medical

Management/Treatm

ent

Date Ordered/ Date

Taken/

GivenDate Changed/ Date

Discontinued

General Description Indication/s, Purpose/s Client's reaction to

the treatment

IV Therapy

1L LRS (isotonic) with

oxytocin regulated at

15 gtts/min

1L D5NM(hypertonic) regulated

at 30 gtts/min

1L D5LRS

(hypertonic) regulatedat 30 gtts/min

Started on September 29,

discontinued on the same

date

September 29-September30

Started on September 30

discontinued on the samedate

IV Therapy is the giving of

liquid directly into a vein.

IV Therapy is usually

performed for fluid volumemaintenance, fluid volume

replacement, medication

administration, bloodadministration, total

parenteral nutrition andserves as an emergency line

The patient did not

reported pain in theIV site


36/53

During: assess the following:

o right intravenous fluids infusingo right intravenous fluids for the cliento date on the tubingo right rate according to the rate prescribed and the clients conditiono absence of kinks in the tubing that could result in occlusion of the fluid flowo date on the intravenous access deviceo insertion site and vein access for evidence of pain, redness, warmth, or coolness, and swelling

After: Discard the administration set accordingly Document relevant data.

Prior: Determine the need for oxygen therapy, and verify the order for the therapy. Perform a respiratory assessment to develop baseline data if not already available. inform the client and support people about the safety precautions connected with oxygen use such as:

Avoiding materials that generate static electricity, such as woolen blankets and synthetic fabrics. Avoiding the use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone. Provide an explanation to the client and gain cooperation.

Assist the client to a semi-Fowlers position.

Medical

Management/Treatm

ent

Date Ordered/ Date

Taken/

Given

Date Changed/ Date

Discontinued

General Description Indication/s, Purpose/s Client's reaction to

the treatment

Oxygen Therapy

2 L/min for 3 hoursvia nasal prong

September 29-30 Oxygen therapy is any

procedure in which oxygen is

administered to a patient torelieve hypoxia.

Clients who have difficulty

ventilating all areas of their

lungs, those whose gasexchange is impaired, or

people who have heartfailure may require oxygen

therapy to prevent hypoxia.

The patient tolerated

the administered

oxygen andverbalized relief from

DOB


37/53

set up the oxygen equipment and the humidifierDuring: Check that the oxygen is flowing freely from the tubing. There should be no kinks in the tubing, and the connections should be

airtight. There should be bubbles in the humidifier as the oxygen flows through. Feel the oxygen at the outlets of the cannula.

Monitor the level of water in the humidifier. Set the oxygen at the flow rate ordered. if the cannula will not stay in place, tape it at the sides of the face

After: report significant deviation such as tracheal irritation and coughing, dyspnea, and decreased pulmonary ventilation

Medical

Management/Treatm

ent

Date Ordered/ Date

Taken/

Given

Date Changed/ Date

Discontinued

General Description Indication/s, Purpose/s Client's reaction tothe treatment

UrinaryCatheterization

September 29-30 Urinary Catheterizationis the introduction of a

catheter through the

urethra into the urinarybladder

Indications of urinarycatheterization includes relief

from discomfort due to bladder

distention or to provide gradualdecompression of a distended

bladder, to empty the bladdercompletely prior to surgery, to

facilitate accurate measurementof urinary output for critically

ill clients whose outputs need

to be monitored hourly, toprevent urine from contacting

an incision after perineal

surgery.

The client didntverbalize any

discomfort and have

adequate (>30cc/hr),amber colored urine

output.


38/53

Prior: Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as

total amount of urine to be removed and size of catheter to be used. Use an indwelling catheter if the bladder must remain empty or continuous urine measurements/collection is needed. Assess the clients overall condition. Determine if the client is able to cooperate and hold still during the procedure and if the

client can be positioned supine with head relatively flat. Determine when the client last voided or was last catheterized. Percuss the bladder to check for fullness or distention.

During:

Ensure that there are no obstructions in the drainage. Check that there are no kinks in the tubing, the client is not lying on thetubing, and the tubing is not clogged with mucus or blood.

Check that there is no tension on the catheter or tubing, that the catheter is securely taped to the thigh, and that the tubing isfastened appropriately to the bedclothes.

Ensure that gravity drainage is maintained. Make sure that there are no loops in the tubing below its entry to the drainagereceptacle and that the drainage receptacle is below the level of the clients bladder.

Ensure that the drainage system is well-sealed or closed. Check that there are no leaks at the connection sites in open systems.Apply water proof tape around the connection site of the catheter and tubing.

Observe the flow of the urine every 2-3 hours, and note color, odor and any abnormal constituents. If sediments are present,check the catheter more frequently to ascertain whether it is plugged.

After:

Conduct appropriate follow-up such as notifying the primary care provider the catheterization results. Performed a detailed follow-up based on findings that deviated from normal for the client. Relate findings to previous assessment data if available


39/53

ii. Drugs

Name/s of drugs

(generic and brand

name)

Date ordered/

Date taken/

Date changed

Route of

administration &

dosage &

frequency of

administration

Mechanism of

action

Indication/s

Purpose/s

Clients response

to medication with

actual side effect

Generic Name:

Cefuroxime Sodium

September 29, 2010 750 mg, IVF q 8hours

It is a anti- infectivedrug and its main

action is combat the

preset bacteria and

inhibit increased

growth.

Low respiratoryinfections,

Pharyngitis or

tonsillitis

The client did notexhibit any adverse

reactions from the

drug

Before: Check the expiration date of the drug Check the doctor's order Assess the client's understanding about the drug Assess for skin allergies

During: Reconstitute the drug with 8 ml of sterile water. Slowly inject the drug over 3 to 5 mins.

After: Evaluate the client for adverse effect. Report lack of response, persistent diarrhea or signs ad symptoms of Anemia.


40/53

Name/s of drugs

(generic and brand

name)

Date ordered/

Date taken/

Date changed

Route of

administration &

dosage &

frequency of

administration

Mechanism of

action

Indication/s

Purpose/s

Clients response

to medication with

actual side effect

Generic Name:

KetorolacTromethamine

September 29, 2010 30 mg, IVF q 6

hours X 6 doses

Possesses anti-

inflammatory,

analgesics ad

antipyretic.

Completely

absorbed following

IM use.

Use for

management of

moderate ad severe

acute pain.

The client did not

exhibit any adverse

reactions from the

drug

Before:

Check the expiration date of the drug Check the doctor's order Assess the client's understanding about the drug

During: Do not mix IV ketorolac in a small volume with morphine sulfate. The IV bolus must be given over o less than 15 sec.

After: Monitor for adverse effect. Report any unusual bruising or bleeding, weight gain, swelling of feet/ ankles, increased joint pain, change in urine patterns.


41/53

Name/s of drugs

(generic and brand

name)

Date ordered/

Date taken/

Date changed

Route of

administration &

dosage &

frequency of

administration

Mechanism of

action

Indication/s

Purpose/s

Clients response

to medication with

actual side effect

Generic Name:

Omeprazole

September 29, 2010 Q 12 hours X 2

doses

Hough to be a

gastric pump

inhibitor and that it

blocks the final step

of acid production.

By inhibiting the

Hydrogen/

Potassium ATP-ase

system at te

secretory surface of

the gastric parietal

cell.

Use for

management of

active duodenal

ulcer, gastric ulcer,

erosive esophagitis

and heartburn

The client did not

exhibit any adverse

reactions from the

drug

Before: Check the expiration date of the drug Check the doctor's order Assess the client's understanding about the drug

During: The capsule should be taken 30 minutes before eating and is to be swallowed whole. Antacid can be administered with Omeprazole.

After: Monitor for adverse effect. Report to the physician if chest pain, abdominal pain and fecal discoloration occurred


42/53

iii. Diet

Type of Diet

Date ordered/

Date taken/

Date changed

General

Description

Indication/s

Purpose/s

Specific foods

Taken

Clients response

to medication with

actual side effect

NPO (nothing by

mouth)

September 29 A patient care

instruction advising

that the patient is

prohibited from

ingesting food,

beverages, or

medicine.

It is usually ordered

whenever the

patient wills

undergoes surgery

or other diagnostic

procedure requiring

that the digestive

tract be empty.

Foods, beverages

and medicine are

prohibited.

The client complied

with the prescribed

diet.

Before:

Explain to the client and significant others the purpose, indication and the duration of the diet. Assist the clients compliance ability to the diet.

During:

Advise the client to avoid foods. Provide frequent oral hygiene Monitor the compliance of the patient to the diet.

After:

Evaluate the effect of the diet to the client. Report excessive weight loss. Assess any nutritional disturbances and notify the physician.


43/53

Type of Diet Date ordered, Date

started, Date

changed

General

description

Indication/s

Purpose/s

Specific Foods

Taken

Client s response

and/or response to

the diet

Clear liquid diet September 30, 2010 This client provides

the client with fluid

and carbohydrate

but does not supply

adequate protein,

vitamins, minerals,

or calories

This diet is

indicated for post

operative patients

first feeding when it

is necessary to fully

ascertain return of

gastrointestinal

function

Crackers

Sips of water and

tea

The client complied

with the prescribed

diet.

Prior:

Assess ability to feed self and prepare meals Determine need for special drinking cups, plates, or feeding utensils Explain the purpose of the diet Discussed allowed and prohibited foods

During: Assist the client to a comfortable position in bed or in a chair, whichever is appropriate Provide assistance of the client is unable to handle eating utensils or to open containers and packages Always allow ample time for the client to chew and swallow the food before offering more

After: After the client has completed the meal, observe how much the client has eaten and the amount of fluid taken, record the fluid

intake and calorie count as required

Provide hygiene measures after feeding Record any pain, fatigue or nausea experienced by client


44/53

Type of Diet

Date ordered/

Date taken/

Date changed

General Description Indication/s

Purpose/s

Specific foods

Taken

Clients response

to medication with

actual side effect

Soft Diet October 1, 2010 A diet that is soft in

texture, low in residue,

easily digested and

well tolerated.

It provides nutrition

to the client who

has just undergone

surgery and client

who cannot tolerate

hard foods.

Sips of water, tea,

crackers

The client complied

with the prescribed

diet.

Before: Explain to the client and significant others the purpose, indication and the duration of the diet. Assist the clients compliance ability to the diet.

During: Position the client in a sitting or high or fowler position. Advise the client to consume foods that are easily digested. Monitor the compliance of the patient to the diet.

After: Evaluate the effect of the diet to the client. Assess any nutritional disturbances and notify the physician.


45/53

Type of Diet Date ordered, Date

started, Date

changed

General

description

Indication/s

Purpose/s

Specific Foods

Taken

Client s response

and/or response to

the diet

Diet as tolerated

(DAT)

October 2, 2010 The patient can eat

any food as long as

tolerated

To increase rate of

healing

Rice

VegetablesCrackers

Eggs

Chicken

The client complied

with the prescribed

diet.

Prior

Caution patient to avoid food such as eggs, nuts, milk, sulfites, fish and chocolate that can trigger asthma attack.During:

Advise client to properly chew the food.After:

Advise patient to report any allergic reaction to the food taken.

iv. Activity / Exercise


46/53

Type of

exercise

Date Ordered

Date Started

Date Changed

General Description Indications or

Purposes

Specific

exercise/activity

Clients response and/or

reaction to

the diet

Flat on bed

September 29

It is type of exercise

done after the surgical

procedure; the client

must be in a supine

position without using a

pillow. After 8 hours the

client must be able to

use pillow already.

To prevent

spinal

headache.

Complete bed

rest within 8

hours.

The client complied to the

ordered exercise

Turn from side

to sideSeptember 29

Patient will turn on the

right side then rotate to

the opposite side after 2

hours

To increase

blood

circulation and

preventpressure ulcer

Turn from side

to side every 2

hours

Patient was able to tolerate the

exercise but with a little

discomfort due to surgical

incision

Sitting on bed

October 01,

2010

It is a type of exercise

done after the client able

to turn side to side, and

the back of the client is

unsupported and legs

hanging freely

To increase

blood

circulation

Sitting on the

bed without

assistance




incision

Standing beside

the bedOctober 02,

It is a type of exercise

when the client is able to

stand by her own and no

To increase

blood

Standing in the

side of the bed

without





47/53

Prior:

Learn passive ROM exercises from the person's caregiver. Practice the exercises with the caregiver first. The caregiver canmake sure you are doing the exercises right.

Raise the person's bed to a height that is comfortable for you. This will help keep you from hurting your back or other muscles.

Make sure the wheels of the bed or wheelchair are locked before you start the exercises.During

Do all ROM exercises smoothly and gently. Never force, jerk, or over-stretch a muscle. This can hurt the muscle or jointinstead of helping.

Move the joint slowly. This is especially important if the person has muscle spasms (tightening). Move the joint only to thepoint of resistance. This is the point where you cannot bend the joint any further. Put slow, steady pressure on the joint untilthe muscle relaxes.

Stop ROM exercises if the person feels pain. Ask the person to tell you right away if he feels any pain. Watch for signs of painif the person is unable to talk. The exercises should never cause pain or go beyond the normal movement of that joint

2010 significant others

assisted to her.

circulation assistance incision

Ambulation

October 03,

2010

Patient will walk

unaided on the side of

the bed and on the

hallway

To increase

blood

circulation

Walking on the

side of the bed

without

assistance




incision

ROM (Range ofMotion) October 01,

2010

A body action involvingthe muscles, joints, and

natural movements such

as abduction,

adduction, flexion,

extension, pronation,

supination, and

rotation.

Theseexercises

reduce stiffness

and help keepyour joints

flexible.

The clientparticipated in

the activity.

Patient was able to tolerate theexercise but with a little


incision


48/53

After:

Make ROM exercises a part of the person's daily routine. Follow the caregiver's orders. The person's caregiver will tell you how many times per day you should do ROM exercises. The

caregiver will tell you how many repetitions (number of times) you should do exercises on each joint.

2. Surgical Management

Name ofProcedure

Date Performed Brief Description Indication/Purpose Clients response to theoperation

Cholecystectomy,

IOC, CBDE, T-

tube

Choledochostomy

September 29,

2010

Cholecystectomy is the

surgical removal of the

gallbladder.Despite the

development of non-

surgical techniques, it is

the most common method

for treating symptomatic

gallstones.

Intraoperative

cholangiography (IOC) -

The doctor places a small

tube called a catheter into

the cystic duct, which

drains bile from the

gallbladder into the

common bile duct.A dye

that blocks X-rays is

injected into the common

bile duct, and then X-rays

will be taken.

A cholecystectomy is

performed to treat

cholelithiasis and

cholecystitis.

Intraoperative

cholangiography (IOC)

may decreasethe risk of

common bile duct (CBD)

injury during

cholecystectomyby

helping to avoid

misidentification of the

CBD.

Common Bile Duct

Exploration is used to

remove large stones during

or after some gallbladder

operations when stones are

detected.

Choledochostomy is the

The patient complained of

difficulty of breathing and

reported little sensation on the

lower extremities upon

discharge from the PACU. It

was observed that the patient

was also drowsy.
http://en.wikipedia.org/wiki/Gallbladderhttp://en.wikipedia.org/wiki/Gallstonehttp://www.revolutionhealth.com/articles?id=stc123726http://www.revolutionhealth.com/articles?id=stc123726http://en.wikipedia.org/wiki/Gallstonehttp://en.wikipedia.org/wiki/Gallbladder


49/53

A common bile duct

exploration is a procedure

used to see if a stone is

blocking the flow of bile

from the liver and

gallbladder to the intestine.

Choledochostomy:

Surgical formation of anopening (stoma) into the

COMMON BILE DUCT

for drainage or for direct

communication with a site

in the small intestine,

primarily the

DUODENUM or

JEJUNUM.

creation of an opening into

the common bile duct for

drainage.

Prior:

Always check to see if the informed consent has been given and that a signed form documents it. Ask the woman when she last had anything to eat or drink. Frequently, an antacid is given before surgery to reduce the risk of aspiration while the woman is under the effects of

anesthesia.

Ensure that an intravenous fluid is in place with a large bore catheter Ensure that an abdominal shave preparation is done immediately before surgery Ensure that a Foley catheter is in place Ensure that laboratory studies ordered are completed

During
http://www.wrongdiagnosis.com/medical/common_bile_duct.htmhttp://www.wrongdiagnosis.com/medical/duodenum.htmhttp://www.wrongdiagnosis.com/medical/jejunum.htmhttp://www.wrongdiagnosis.com/medical/jejunum.htmhttp://www.wrongdiagnosis.com/medical/duodenum.htmhttp://www.wrongdiagnosis.com/medical/common_bile_duct.htm


50/53

The nurse supports the woman so that her back remains in a c-shaped curve during placement or a regional anesthesia by theanesthesiologist

The nurse assists the woman to the supine position on the O.R table The nurse places a wedge under one hip, and then places a warm blanket and safety strap on the womans legs Ensure that a sterile abdominal preparation with alcohol or Betadine is performed and a sterile drape is provided The nurse performs the second O.R count

After:

The nurse transfers the woman from the operative suite to the PACU Ensures connection of monitoring devices that will record the electrocardiogram, blood pressure, pulse, and oxygen saturation

of the blood Monitor vital signs and pulse oximetry reading every 5 minutes until the readings are stable, and then 15 to 30 minutes until

the patient has met predetermined criteria Monitor the patients urinary output to make certain it is at least 30 cc/hour


51/53

D. EvaluationDischarge Planning

a. General condition of the client upon dischargeUpon clients discharge (October 04, 2010), the client appeared neatly dressed with no

apparent body odor. He was afebrile. He was able tolerate minimal levels of activity such as

walking, moving from place to place and transferring from sitting to standing position without

dizziness. He was able to take any food tolerated. He also does not perspire excessively or show

signs of emotional distress such as nail biting or avoidance of eye contact.

III. Conclusion

This case served as a realization for the group. It required thorough investigation about clients

condition against both theory and the large comparative environment. In this study, objectives

are important. Formulating objectives before conducting the study of Choledocholithiasis was

very challenging because it was very unfamiliar.

After doing this case study, the group attained the formulated nurse-centered objectives. They

were able to come up with a comprehensive presentation of the disease condition by means of

correct presentation of the data gathered through the use of nursing process. They were also ableto present the current trends about the disease condition, the reason for choosing such case for

presentation, and the importance of the case study.

By means of proper education rendered during the period of assessment and care, the client was

able to fully understand and recognize the disease condition. The client learned the importance of

healthy lifestyle and identified the predisposing factors that aggravated her condition.

IV. Recommendation

The group would like to convey the following recommendations that would enable to

facilitate the greater accumulation of knowledge and would improve the greater understanding of

the disease condition.


52/53

To the Tarlac Province Health Divisions: Improve the awareness of disease in its towns and barangays, the common causes of it,

the clinical manifestations.

To the Nurses and Student - Nurses:

Complete assessment of the disease. Improve the knowledge of the client regarding disease condition

To the next researchers:

Continue establishing useful and latest trends about CHOLEDOCHOLITHIASIS. Validate the data found here with the latest studies

V. Bibliography

http://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).html

http://en.wikipedia.org/wiki/Cholecystectomy http://jama.ama-assn.org/cgi/content/abstract/289/13/1639 http://www.med.umich.edu/1libr/aha/aha_commbd_crs.htm Kozier & Erbs Fundamentals of Nursing Michelle Zator Estez Health Assessment and Physical Examination Mosbys Drug Guide for Nurses 2009 Edition Mosbys Nurses Pocket Guide 11thEdition Mosbys Pocket Dictionary of Medicine, Nursing and Health Professions 5thedition Holes Essentials of Human Anatomy and Physiology
http://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).htmlhttp://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).htmlhttp://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).htmlhttp://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).htmlhttp://www.med.umich.edu/1libr/aha/aha_commbd_crs.htmhttp://www.med.umich.edu/1libr/aha/aha_commbd_crs.htmhttp://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).htmlhttp://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).html


53/53

Republic of the Philippines

Collegio De Dagupan

College of Nursing

CASE STUDY

ON CHOLEDOCHOLITHIASIS

In Partial Fulfillment of the Requirements

Of the Course Nursing Care Management 102

Presented by:

Mallaca Angelica

Mostoles RobelynMurao Eden jane

Ordanza Marcelino Jr.

Paragna John Cristopher

Parayno Debbie

Pascua Deo Alfred

Pascua Rhodalyn

Pacis Arvelyn

Perido Jenica

February 09, 2012

Documents

Grand Case Cholylithiasis