SAN PABLO COLLEGES MEDICAL CENTER San Pablo City, Laguna

Case Presentation CHOLELITHIASIS

GROUP 2
CORTEZ, Oliver D. DE ROXAS, Jennifer M. GARCIA, Clarisse C. LINATOC, Mary Rose E PORNASDORO, Ma. Crystal M. SERNA, John Jerome Jonathan M. TATAD, Carizsa Armina D. TAGLE, Angelica A.

TABLE OF CONTENTS PAGE TITLE PAGE INTRODUCTION PATIENTS PROFILE HISTORY TAKING REVIEW OF SYSTEMS ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY MEDICAL MANAGEMENT LABORATORY AND DIAGNOSTIC WORKUPS DRUG STUDY NURSING CARE PLAN 1 3 9 10 11 14 17 19 22 30 35

INTRODUCTION
REPORTER: LINATOC, MARY ROSE and TAGLE, ANGELICA A. CHOLELITHIASIS (Gallstones) Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones may be as small as a grain of sand or as large as a golf ball. CAUSES There are two main types of gallstones: Stones made of cholesterol, which are by far the most common type. Cholesterol gallstones have nothing to do with cholesterol levels in the blood. Stones made of bilirubin, which can occur when red blood cells are being destroyed (hemolysis). This leads to too much bilirubin in the bile. These stones are called pigment stones.
RISK FACTOR NON MODIFIABLE Family history Genetic Ethnic background Female Age MODIFIABLE Obesity Rapid weight loss Diet

SYMPTOMS Pain in the right upper or middle upper abdomen (biliary colic) o May be constant o May be sharp, cramping, or dull o May spread to the back or below the right shoulder blade Fever Yellowing of skin and whites of the eyes (jaundice) Other symptoms that may occur with this disease include:

Clay-colored stools Nausea and vomiting

EXAMS AND TESTS Tests used to detect gallstones or gallbladder inflammation include: Abdominal ultrasound Abdominal CT scan 3

Endoscopic retrograde cholangiopancreatography (ERCP) Gallbladder radionuclide scan Magnetic resonance cholangiopancreatography (MRCP) Percutaneous transhepaticcholangiogram (PTCA)

Your doctor may order the following blood tests:

Bilirubin Liver function tests Pancreatic enzymes

TREATMENT SURGERY LAPAROSCOPIC CHOLECYSTECTOMY This procedure uses smaller surgical cuts, which allow for a faster recovery. Patients are often sent home from the hospital on the same day as surgery, or the next morning. OPEN CHOLECYSTECTOMY (GALLBLADDER REMOVAL) was the usual procedure for uncomplicated cases. However, this is done less often now. MEDICATION CHENODEOXYCHOLIC ACIDS (CDCA) OR URSODEOXYCHOLIC ACID (UDCA, URSODIOL) may be given in pill form to dissolve cholesterol gallstones. However, they may take 2 years or longer to work, and the stones may return after treatment ends. LITHOTRIPSY Electrohydraulic shock wave lithotripsy (ESWL) of the gallbladder has also been used for certain patients who cannot have surgery. Because gallstones often come back in many patients, this treatment is not used very often anymore. POSSIBLE COMPLICATIONS Blockage of the cystic duct or common bile duct by gallstones may cause the following problems: Acute cholecystitis Cholangitis Cholecystitis - chronic Choledocholithiasis Pancreatitis Prevention Increase fiber in the diet 4

LAPAROSCOPIC SURGERY Laparoscopic cholecystectomy has now replaced open cholecystectomy as the firstchoice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection. Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety. Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports. To begin the operation, the patient is placed in the supine position on the operating table and anesthetized. A scalpel is used to make a small incision at the umbilicus. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (the area bound by the inferior border of the liver, cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases, it can be done in about an hour. Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS". Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection and adhesions. Most patients can be discharged on the same or following day as the surgery, and can return to any type of occupation in about a week. Furthermore, flexible instruments are being used in laparoscopic surgery by some surgeons.

An uncommon but potentially serious complication is injury to the common bile duct, which connects the cystic and common hepatic ducts to the duodenum. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. This surgery should be performed by an experienced biliary surgeon. Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder. Adhesions and gangrene can be serious, but converting to open surgery does not equate to a complication. During laparoscopic cholecystectomy, gallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5 cm have been identified as risk factors for complications. Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy

Biopsy After removal, the gallbladder should be sent for pathological examination to confirm the diagnosis and look for an incidental cancer. If cancer is present, a reoperation to remove part of the liver and lymph nodes will be required in most cases.

EQUIPMENTS: STEPS This is one of the most commonly performed procedures in the western world. It is often done as a day case procedure and when correctly performed is associated with little post-operative pain or morbidity. The following steps are generally taken: 1. General anesthesia 2. Creation of pneumoperitoneum: 1cm subumbilical (or transumbilical) incision. Dissection to peritoneum and insertion of trocar. Insufflation using CO2 and insertion of camera. 3. The patient is placed with their head down and tilted to the left position. 4. Placement of at least two other ports. A grasper is inserted at the top of the gallbladder and locked into place. The camera assistant then uses the other hand to 7 Camera unit - (sterilizable head and cable, video control unit) Connector cables from camera to monitor Video Monitor Light Source Light transmission fibre-optic cable Insufflator Carbon Dioxide Cylinder Carbon dioxide pressure regulator valve (optional - see description below) Tubing and Luer-lock adapter for carbon dioxide to patient Suction irrigation apparatus (optional) Cautery machine with cables and foot control Power control equipment (Transformer/spike and surge suppresser) Power extension cord Telescope Trocars and cannulas- 2 x 11mm, 2 x 5.5mm, 11 to 5.5mm reducer(1), 117mm reducer(optional) Verress Needle (optional) 2 Atraumatic graspers 1 toothed grasper 1 curved dissector 1 clip applicator with suitable clips 1 dissection hook 1 pair scissors 1 suction irrigation cannula 1 sterilization ring applicator (if sterilization is to be done) 1 pair hook scissors (optional) 1 cautery spatula (optional) 1 gallstone retrieving forceps (optional) 1 needle holder (optional)

apply upwards traction on the gallbladder in order to maximise the surgeons access to Calots triangle. 5. The surgeon then either uses one or two ports to dissect around Calots triangle using a grasper, Pledget and hook diathermy. 6. Clips are then placed around the cystic artery and duct two below and one above where they will be cut. 7. Scissors are then used to cut the duct and artery. 8. The gall bladder is then dissected off the liver and a bag is used to remove it out of the abdomen. 9. The surgeon then looks around for any bleeding or bile leak and performs washout if necessary. 10. The ports are opened and gas stopped to remove free gas. 11. The peritoneum is closed at the umbilicus then the subcutaneous tissue and skin are closed. 12. The rest of the ports are closed at the skin only. 13. Dressings are placed and the patient woken up.

PATIENTS PROFILE
REPORTER: LINATOC, MARY ROSE

NAME ADDRESS AGE CIVIL STATUS NATIONALITY RELIGION OCCUPATION CHIEF COMPLAINT ATTENDING PHYSICIAN ADMITTING DIAGNOSIS MEDICAL CASE TYPE ADMISSION DATE & TIME ADMISSION NUMBER CASE NUMBER ROOM DISCHARGE DATE FINAL DIAGNOSIS OPERATION PERFORMED

: : : : : : : : : : : : : : : : : :

Mrs. Y. San Pablo City 49 years old Married Filipino Catholic Teacher RUQ Abdominal Pain Dr. Gabriel Eala Cholelithiasis Surgery (Adult) March 26, 2013 at 04:45 PM 10442 009876 C201 March 29, 2013 Cholecystolithiasis Lap Cholecystectomy

PATIENTS HISTORY
REPORTER: LINATOC, MARY ROSE

History of Present Illness Three (3) months prior to admission patients was diagnosed to have cholelithiasis given with unrecalled medications. Since then, patient was asymptomatic for almost three (3) months but opted to undergo surgery due to abdominal pain hence admission. Past Medical History This is the fourth (4th) time the patient been hospitalized. The 1st three hospitalizations were due to giving birth via ceasarean section. According to the patient she has no allergies on food and medication. Personal and Social History The client eats 2 cups of rice every meal and more than 1 serving of meat (pork, chicken and beef). She doesnt eat much vegetable. She drinks plenty of water and no exercised activity done in her daily living. She has her normal bowel movement ranging from 3-5 times a week and urine output of almost 8 times a day. She takes a bath every day and had 5-6 hours of sleep. She had no enough rest in everyday due to busy schedule in her teaching lesson. She had her annual check up Family History According to the patient she has no known hereditary disease that run within their family.

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PHYSICAL EXAMINATION
REPORTER: CORTEZ, OLIVER D.
Patient is ambulatory, with mark of fatigue and discomfort due to abdominal pain at the right upper quadrant rated as 7 from a scale of 0-10 as 10 being the highest. Body Part Examined HEAD -normocephalic -absence of masses Proportional to the size of the body/round/with prominence in the frontal area and the occipital are posteriorly symmetrical in all planes. evenly Black evenly distributed and covers the whole scalp, thick shiny, free from split ends Finding Norms

Skull -with long hair distributed -black in color Hair -round and symmetrical -no pain and tenderness -with wrinkles Face -no discharge, lesion, redness, and swelling -slightly yellowish sclera -pale conjunctiva -pupil black and symmetrical

Round, symmetrical. Smooth and free from wrinkles and no involuntary movements.

Parallel, evenly placed, symmetrical, with scant amount of secretions, both eyes are bright and clear.

Eyes

-without discharges and Symmetric straight. lesions discharge or flaring. -symmetrical nares tender, no lesions. -moist, pink mucosal walls Nose

No Non-

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-pale lips -tongue moves freely, -without difficulty swallowing Mouth

Soft, Pink, or Reddish in

Ears

-without lesions, discharges Parallel, symmetrical, and discomfort proportional to the size of the -auricles are symmetrical head. Bean shaped, helix is in line with the outer canthus of the eye Firm cartilage. -globular tender No tenderness, relaxed -with right upper abdomen, with smooth quadrant pain consistent tension. Pain scale: 7 Bowel sound present Firm, equal in size, bilaterally, equal in numbers, clean and symmetrical. Hair distribution is even. Equal number of digits

Abdomen Upper & lower Extremities -No lumps -Fingers are equal in numbers -symmetrical -nails are clean and welltrimmed

Respiratory System

Lungs: Clear and Symmetrical Patient has a respiratory rate of 22 bpm. Slightly elevated because of pain experienced from RUQ

Cardiovascular

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Patients blood pressure ranges from 120/70-130/80 mmHg. Extremities are warm to touch and peripheral pulses are present. Radial pulse is 87 bpm which is within normal range.

Genitourinary

The patients urine is turbid in appearance.

Musculoskeletal

The patient is ambulatory. He is able to perform flexion, extension, abduction and adduction independently.

Integumentary

Patients skin is dry and warm to touch. No lesions, cracks, signs of inflammation and bruises noted. He has short hair. Nails are clean and well-trimmed.

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ANATOMY & PHYSIOLOGY

REPORTER: GARCIA, CLARISSE C.

LIVER

The liver lies to the right of the stomach and overlies the gallbladder. The human liver in adults weighs between 1.4-1.6 kilograms. It is a soft, pinkish brown, triangular organ. It is both the largest internal organ and the largest gland in the human body. Among the most important Liver functions are: 1. Removing and excreting of wastes and hormones as well as drugs and other foreign substances. 2. Synthesizing plasma proteins, including those necessary for blood clotting. 3. Producing Bile to aid in digestion. 4. Excretion of bilirubin. 5. Storing certain vitamins, minerals, and sugars.

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GALLBLADDER

The gallbladder is a pear or oval shaped, hollow, saclike organ that lies in shallow depression on the inferior surface of the liver, to which connected by a connective tissue. Its wall is composed largely of smooth muscle. The gallbladder is connected to the common bile duct by the cystic duct. The capacity of gallbladder is 30 50 ml of bile. Bile Bile or Gall is a bitter tasting, dark green to yellowish brown fluid, produced by the liver. It is important in digestion. It is poured into the intestine through the bile duct but the amount varies with the diet. Normal man makes 1000-1500 cc of bile per day. Some amount of bile entering our intestinal tract goes into the gallbladder as it comes down the duct. About half of the bile secreted between meals flows directly through the common bile duct into the small intestine. Composition of Bile 1. Water and electrolytes Sodium Potassium Calcium Chloride Bicarbonate 2. Lecithin 3. Fatty Acids 4. Cholesterol 5. Bilirubin 6. Bile Salts

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PANCREAS

The pancreas is a gland organ located in the upper abdomen that has endocrine and exocrine functions. The exocrine functions include secretion of pancreatic enzymes into the gastrointestinal tract through the pancreatic duct. The enzyme secretion includes: 1. Amylase 2. Trypsin 3. Lipase The endocrine function consists primarily of the secretion of the two major hormones, insulin and glucagon. Four cell types have been identified in the islets: 1. A cells produce glucagon 2. B cells produce insulin 3. D cells produce somatostatin

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PATHOPHYSIOLOGY
REPORTER: PORNASDORO, MARIA CRYSTAL
CHOLELITHIASIS

Gallstones in the

Increased Bile Cholesterol

Irritation of Gallbladder mucosa Surface Changes Increased Mucus Secretion

Precipitate out of the bile

Forms small crystals into Gallbladders mucosal surface

Enlarges to grossly visible ImpairedGallbladderemptying stonesREPORTER: Several stones develop

INT ROD UCT ION

Contractile function

Calcium Bilirubinate

Irritation of Gallbladder mucosa Pigment Stones

Combines with stearic acid, Lecithin and palmitic acid Forms Brown Gallstones

Obstruction

Bile Stasis

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Obstruction

Contractile function
Bile accumulates in Liver Decrease bile flow Vit. K absorption Increase Serum Bilirubin

Bile Stasis Bacterial Proliferation Abnormal Fat Digestion Anorexia Nausea Vomiting Weight loss Flatulence Diarrhea Fat intolerance

Distension

Intraductal Pressure

RUQ Pain

Injury Release of Inflammatory Mediators Increase Permeability of Blood Vessels

Blood flow & Lymphatic drainage Is compromised Mucosal Ischemia Necrosis

Biliary Colic

Prorates/Teacollared Urine

Gallbladder duct infection Rupture of Gallbladder Peritonitis

Fluid, Proteins and Cells enter interstitial spaces

Jaundice

Biliary Cirrhosis

Edema
Inflammation of Gallbladder

Cholecystitis

Increase WBC
Leukocytosis

Release of Pyrogens

Increased Hypothalamic set point

Inflammation of Gallbladder

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MEDICAL MANAGEMENT
REPORTER: TAGLE, ANGELICA A.
DATE & TIME March 26, 2013 05:00 PM PROGRESS NOTE BP: 120/90 mmHg T: 36.8 C CR: 88bpm R: 22cpm WEIGHT: 77.5 kg DOCTORS ORDER Please admit to ROC under the service of Dr. Eala Secure consent for admission and management DAT Diagnostics CBC with PC, Prothrombine time FBS, BUN, Crea, BUA, SGOT, SGPT, Lipid Profile Whole abdomen UTZ 12 lead ECG, UA Chest X-ray Meds. Paracetamol 500mg tablet q8H PRN for fever 38.0C. Schedule patient for Lap chole w/p open chole tom March 27, 2013 at 09:30am Dr. Gloria for C-P clearance Dr. Romero for Anesthesia Give Cefuroxime (Elixime) 750 mg TIV ( ) ANST 1 hour prior Monitor VS q2 I & O q shift and record Inform all APs Refer accordingly DR. EALA/ DRA. MEDRANO NPO post midnight Notify Dr.Romero once C-P cleared by Dr. Gloria DR. ROMERO Cleared for procedure Solucortef 250mg, give 125mg IV at 8pm and 125mg 1 hour prior to OR. Inform all APs DR. GLORIA March 26, 2013 08:00 PM D5NR 1L x 12 DR. GLORIA

March 26, 2013 05:15 PM March 26, 2013 05:30 PM

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March 27, 2013 12:05 AM March 27, 2013 08:35 AM

IVF to follow: D5NR 1L x 12 DR.GLORIA Pre-Op Order Maintain on NPO Pre-meds: Midazolam 2.5mg Nalbuphine 5mg now To OR on call

IV Cocktail DR. ROMERO

March 27, 2013 03:15 PM

March 27, 2013 04:00 PM March 27, 2013 04:00 PM March 28, 2013 08:00 AM BP: 120/70mmHg T: 36.0C CR: 77bpm RR: 20cpm Urine Output: 450cc

Post-op Order Transfer to PACU Monitor VS q15 minutes Place on moderate back rest NPO Encourage deep breathing exercises Present IVF to run at 30gtts/min IVF TO FF-D5 NR 1L to run for 8hours -D5 NM 1L to run for 8hours -D5 NR 1L to run for 8hours Meds - continue Cefuroxime 750 mg IV q 8hours -Ranitidine 50 mg IV q 8hours -Diclofenac Na (Dosanac) 75 mgdeep IM (intragluteal) single dose -Tramadol (Tramal) 100 mg IV q 8hours PRN for severe pain Specimen for histopath Refer accordingly DR. ROMERO Ketorolac (Ketodol) 30mg IV q 8hours for 2 doses; 1st dose at 2am tomorrow DR.ROMERO To room VS q1 DR.GLORIA Progressive diet: genera liquid to DAT May remove FC Once on DAT, may consume IV shift Cefuroxime to oral 500mg TID Daily wound dressing May sit up on bed DR. R. RAYMUNDO

March 28, 2013 10:00 AM

Post-Anesthesia order If OK with Dr. Eala start Celecoxib 200mg 1cap PO BID start this afternoon

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March 28, 2013 10:02 AM March 28, 2013 01:45 PM March 29, 2013 08:10 AM March 29, 2013 10:40 AM

DR. ROMERO Ok to carry out orders of Dr. Romero DR.EALA No new orders DR. R. RAYMUNDO Afebrile (+) BM For discharge anytime notify Dr. Eala for follow-up and meds DR.EALA/ DR. R. RAYMUNDO Ok for discharge DR. R. RAYMUNDO

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LABORATORY & DIAGNOSTIC WORKUPS

REPORTER: DE ROXAS, JENNIFER M.
Legend for laboratory result: Abnormal

DIAGNOSTIC IMAGING REPORT

Date done: January 9, 2013
Ultrasound of whole abdomen: The liver is normal in size measuring 13.7 x 9.2cm in sagittal and AP diameter, contour with mild diffuse parenchymal echo pattern. No discrete parenchymal lesion is seen. The intrahepatic and extrahepatic bile ducts appear normal. The gallbladder is well visualized showing multiple shadowing echogenicities seen intraluminally the largest is seen at the neck region measuring 2.1 cm. The wall is not thickened. The common bile duct is not dilated measuring 0.4 cm. The visualized spleen is normal in size measuring 7.3 x 3.6 cm, smooth contour and homogenous echo pattern with no evidence of discrete mass lesion nor calcification. The head, body and visualized proximal tail of the pancreas are normal in size and contour. No lithiasis or masses are seen. The main pancreatic duct is not dilated. The aorta, periaortic and paracaval areas are unremarkable. The right kidney measures 10.3 cm x 4.9 cm with cortical thickness of 1.2cm and the left kidney measures 10.5cm x 5.1cm with cortical thickness of 1.2cm. Both kidneys are normal in size. The cortical thickness, cortical echogenicity, cortico-medullary differentiation, renal sinus complexes and perinephric areas are unremarkable.Thepelvocalyceal systems and ureters are not dilated. The urinary bladder shows no evidence of reflective intraluminal echoes. Its walls are smooth and unthickened. Pre-void vol.= 154.8ml Post-void vol=15.1ml Residue in post micturation = 9.8% The uterus is anteverted, measuring 8.3 x 5.7cm. The endometrial stripe is intact, measuring 1.0cm The ovaries are not visualized due to overlying gas. Negative for posterior cul de sac fluid.

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Interpretation:

Mild fatty infiltration of the liver Cholelithiases Normal spleen, pancreas, kidneys and urinary bladder Normal anteverted uterus Non-visualized ovaries due to overlying gas Please correlate clinically

Fatty infiltration of the liver refers to the accumulation of fat in the liver cells It could be diffuse or focal in nature. In case of diffuse fatty infiltration, there is an excessive accumulation of triglycerides in the entire liver. In case of focal fatty liver, only a part of the liver is affected and the infiltration of triglycerides is non-uniform. Other factors that may lead to fatty infiltration of liver include long-term parenteral nutrition (intravenous administration of nutrients), prolonged use of steroids or excessive endogenous production of steroids. Fatty liver can also occur during pregnancy. Fatty infiltration of liver may or may not produce any symptoms. However, symptoms may appear when accumulation of fat in the liver leads to inflammation of the liver.

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SPECIAL EXAMINATION : PROTHROMBIN TIME (COAGULATION CHECK)

Prothrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot. Date done: March 25, 2013 Normal Value Prothrombin 10-13 Time secs. Result 14.4secs Interpretation Prolonged Indication A prolonged PT means that the blood is taking too long to form a clot. This may be caused by conditions such as liver disease, vitamin K deficiency, or a coagulation factor deficiency Nursing Responsibilities Provide safety measures to prevent bleeding

Prothrombin is a protein produced by your liver that helps your blood to clot. When you bleed, a series of chemicals (clotting factors) activate in a stepwise fashion. The end result is a clot which stops the bleeding. One step in the process is prothrombin turning into another protein called thrombin. A prothrombin time test can be used to check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working. Increased PT may also be due to: Bile duct obstruction, liver disease, vitamin K deficiency, etc.

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HEMATOLOGY
Date done: March 26, 2013 Normal Values M: 14-18 F:12-16 M:4.5-5.0 F:4.0-4.5 M: 40-54 F:37-47 150-400 5-10 40-75 20-45 Result 12.8 g/dl 4.7 x 10^12/L 37.1% 274 5.8 x 10^9/ L 57.9 % 47% Interpretion normal elevated normal normal normal normal Elevated acute Assess pt. bacterial and for signs viral and infections symptoms acute-phase of infection reactions Administer (observed as meds as a response to ordered acute stress). May indicate Monitor for signs of dehydration.
dehydration

Indication

Nursing Responsibilities

Hemoglobin RBC Hematocrit Platelet count WBC Differential count: Neutrophil Segmenters Lymphocytes

Monocytes

2-6

4.9 %

normal

Lymphocyte is a type of white blood cell present in the blood. Approximately 15% to 40% of white blood cells are lymphocytes. Lymphocytes help provide a specific response to attack the invading organisms. Increase in lymphocytes is generally the result of acute bacterial and viral infections, leukemias, lymphomas, ulcerative colitis, and acute-phase reactions (observed as a response to acute stress

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CLINICAL CHEMISTRY
Normal Values GENERAL Glucose BUN Creatinine Total BILIRUBIN 3.05-6.38 2.15-7.16 45-84 0-18.8 Result 5.43 mmol/L 3.42 mmol/L 53.04mmol/ L 19.1 mol/L
Interpretion

Date done: March 26, 2013 Indication Nursing Responsibilities

normal normal normal Elevated May be due Assess patients to hemolysis skin color disease of Observe for any the liver untoward signs presence of and symptoms gall stones in the bile duct hyperlipide mia Health teachings: importance of keeping the diet low in fatty food, especially food containing saturated fat, and eat lots of fruit, vegetables

LIPIDS Cholesterol

0-5.2

6.02 mmol/L

Elevated

Triglycerides HDLcholesterol

LDLcholesterol ENZYMES SGOT SGPT

0.2.3 0.87 mmol/L No risk: >1.68 Moderate 1.65 mmol/L : 1.151.68 High risk: < 1.15 0-3.37 3.02 mmol/L 0-145 0-31 13.0 /L 28 /L

normal

Moderate risk

normal normal normal

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 Bilirubin is a byproduct of the liver processing waste. When the liver isn't functioning properly, bilirubin may begin to build up in the body.Causes are Liver failure, Gilbert syndrome, gallbladder infections and certain medications such as antibiotics, pain relievers and birth control pills, can all cause adults to have high bilirubin levels. Pancreatic cancer, allergic reaction to a blood transfusion, hepatitis, blocked bile ducts and sickle cell anemia can also cause high levels Cholesterol is a fatty substance known as a lipid and is vital for the normal functioning of the body. It is mainly made by the liver but can also be found in some foods we eat. Having an excessively high level of lipids in your blood (hyperlipidemia) can have an effect on your health. High cholesterol itself does not cause any symptoms, but it increases your risk of serious health conditions. Cholesterol is carried in your blood by proteins, and when the two combine they are called lipoproteins. There are harmful and protective lipoproteins known as LDL and HDL, or bad and good cholesterol. Low-density lipoprotein (LDL): LDL carries cholesterol from your liver to the cells that need it. If there is too much cholesterol for the cells to use, it can build up in the artery walls, leading to disease of the arteries. For this reason, LDL cholesterol is known as "bad cholesterol". High-density lipoprotein (HDL): HDL carries cholesterol away from the cells and back to the liver, where it is either broken down or passed out of the body as a waste product. For this reason, it is referred to as "good cholesterol" and higher levels are better

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X-RAY EXAMINATION
Date done: March 26, 2013 CHEST: Lung fields are clear Pulmonary vascular markings are normal Heart is not enlarged Diaphragm, sulci and bony thorax are unremarkable. Impression: NORMAL CHEST FINDINGS

CLINICAL MICROSCOPY (URINALYSIS)

Normal Values PHYSICAL Color Result Date done: March 26, 2013 Interpretion Indication Nursing Responsibilities normal bacterial infection Advice pt. for adequate hydration and personal hygiene

Varying degrees of yellow yellow clear Usually acidic 1.0001.038 Slightly turbid acidic 1.025 negative negative

Transparency

abnormal

Reaction

normal normal normal normal

Specific Gravity CHEMICAL Protein negative Sugar negative MICROSCOPIC Red blood 0-2/ hpf cells

Bladder infection Pus cells 1-3/ hpf 5-7/hpf abnormal

Epithelial cells

negative

abnormal

bladder infection

Assess for possible signs of infection Health teachings about hygiene Avoid contaminatio 28

Amorphous Urates Mucous threads

negative

few

abnormal

negative

few

abnormal

Bacteria

negative

abnormal

uric acid stone,urolithi asis. irritation, inflammation, or infection in the urinary tract bacterial Administer infection meds as ordered

n of sample Report the findings to the physician

Urinalysis can be simply explained as the analysis of urine, which helps to detect certain diseases. This test can provide valuable information regarding the health condition of the person. While urinalysis is mainly conducted to find out the diseases of the urinary system, it may also come up with some information that can point towards other medical conditions. Turbid (cloudy) urine may be a symptom of bacterial infection, but can also be caused by crystallization of salts. It is usually considered abnormal. It may be the result of blood, pus, sperm, or bacteria present in the urine. Possible causes of the presence of pus cells in urine include: Kidney infection, Bladder infection, Infection in urethra, Inflammation due to presence of bladder stones or kidney stones, Immune disorders, Allergies or growths anywhere along the genitourinary system. In case of older females, parabasal squamous epithelial cells (smallest and immature epithelial cells of the vagina) may be found in urine samples. This is mostly seen in post-menopausal women, who have low estrogen levels. Large number of transitional cells in the urine could be an indication of some health problem. One of the possible causes is bladder infection. Amorphous Urates indicates uric acid crystals in the urine. Higher than acceptable levels of uric acid crystals in urine can be caused by gout, Lesch-Nyhan syndrome, cardiovascular disease, diabetes, uric acid stone, urolithiasis, and metabolic syndrome. Mucus threads in a urinalysis are considered to be normal in small amount of them. They appear long, thin, and wavy ribbon like. If there is a large amount of them, it may mean there is an irritation, inflammation, or infection in the urinary tract. Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and because of their ability to rapidly multiply in urine standing at room temperature. Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted in view of clinical symptoms. 29

DRUGS STUDY
REPORTER: TATAD, CARISZA ARMINA

Name of Drug
CEFUROXIME (elixime) 750 mg TIV

Action/ Classification
Inhibits cell wall synthesis promoting osmotic instability usually bactericidal.

Indication
Pharyngitis, tonsillitis, otitis media, lower respiratory infections, UTI, gonorrhea, dermatologic infections, treatment of early Lyme disease.

Contraindication
Contraindicated in patients hypersensitive to drug or other cephalosporin.

Side Effect
nausea vomiting stomach pain mild diarrhea cough stuffy nose muscle pain joint pain or swelling; headache, drowsiness feeling restless, irritable, or hyperactive mild itching or skin rash.

Adverse Effect
Large doses can cause cerebral irritation and convulsions; nausea, vomiting, diarrhea, GI disturbances; erythema multiforme, Stevens-Johnson syndrome, epidermalnecrolysis. Potentially Fatal: Anaphylaxis, nephrotoxicity, pseudomembranous colitis. Amnesic episodes, nausea, vomiting, headache ,drowsiness.

Nursing Consideration
Check for history: Hepatic and renal impairment, lactation, pregnancy Check the Physical: Skin status, LFTs, renal function tests, culture of affected area, sensitivity tests

MIDOZALAM (dormicum)2.5 mg IV Short acting hypnotic

Depresses the limbic Sedation in system and reticular surgical formation by diagnostic increasing or procedures, facilitating the induction inhibitory maintenance neurotransmitter anesthesia. activity.

pre or and of

Pregnancy, glaucoma, premature infants.

cough, wheezing, weak or shallow breathing slow heart rate seizure (convulsions)

monitor drug effectiveness assess for apnea, respiratory depression which may be increased in elderly. assess degree of amnesia assess injection site ensure the availability of resuscitation equipment, oxygen to support airway.

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NALBUPHINE (nubain) 5 mg IV Analgesic

Binds with opiate Relief of moderate receptors in the to severe pain; CNS; ascending pain pre op analgesia; pathways in limbic supplement to system, thalamus, balanced midbrain, altering anesthesia; surgical perception of anesthesia; emotional response obstetrical to pain. Relieves analgesia. pain.

Hypersensitivity, pregnancy.

weak or shallow breathing; fast or slow heart rate cold, clammy skin confusion, hallucinations, unusual thoughts or behavior; severe weakness or drowsiness; feeling like you might pass out.

Sedation, drowsiness, sweating, nausea, dry mouth, dizziness, headache, vomiting.

Assess patients condition before therapy, obtain drug history. monitor vital signs especially respiratory rate. discuss with patient that dizziness, drowsiness, confusion are common. instruct patient to change position slowly and avoid getting up without assistance. Assess patients and family's knowledge of drug therapy. Teach patient that drug must be continued to prescribe time to be effective. Inform patient that drug may be taken with food or milk to prevent GI distress. Do not crush or chew drugs. Instruct patient to use caution when driving because drowsiness, dizziness may occur. Teach patient to take with full glass of water to enhance absorption. take exactly as directed. do not increase dose, mat take several days before noticeable relief. avoid alcohol follow diet as physician reccomends. use caution when driving

DICLOFENAC (dosanac) 75 mg IM (intragluteal)

single dose

Inhibits cyclooxygenase (COX), an enzyme needed for the biosynthesis of prostaglandin, subsequent decrease in prostaglandin result to the analgesic, antipyretic and anti inflammatory effects.

Relief of pain and inflammation in various conditions; joint disorders and other painful conditions following some surgical procedures.

Asthmatic patients, urticaria, acute rhinitis, peptic ulcer.

chest pain, weakness, shortness of breath, slurred speech, problems with vision or balance; black, bloody, or tarry stools coughing up blood or vomit that looks like coffee grounds swelling or rapid weight gain, urinating less than usual or not at all;

Edema, water retension, hypertension, nausea, vomiting, diarrhea, abdominal cramps, dyspepsia, anorexia, headache, dizziness, vertigo, rash.

RANITIDINE (raxide)
50 mg IV q8

Inhibits histamine at Management of H2, receptor site in various GI the gastric parietal disorders like cells, which inhibits dyspepsia, GERD, gastric acid peptic ulcer. secretion.

Hypersensitivity. history of acute porphyria. long term therapy.

constipation, diarrhea, fatigue, headache, insomnia, muscle pain, nausea, and vomiting.

Cardiacarrythmias, bradycardia, headache, fatigue, dizziness, depression, insomnia, nausea,

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TRAMADOL (tiamide) 100 mg IV q8 PRN for pain

Centrally acting Moderate to severe analgesic not pain chemically related to opioids but binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin.

Hypersensitivity. acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic agents.

KETOROLAC (ketodol) 30 mg IV q8 Analgesic

analgesic, anti- inflammatory antipyretic.

short term management of moderate to severe acute postoperative pain.

active peptic ulcer disease, renal impairement, dehydration, during labor or delivery, lactation, history of asthma.

agitation, hallucinations, fever, fast heart rate, overactive reflexes, nausea, vomiting, diarrhea, loss of coordination, fainting; seizure (convulsions); a red, blistering, peeling skin rash; shallow breathing, weak pulse. chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;sudden numbness or weakness, especially on one side of the body;sudden severe headache, confusion, problems with vision, speech, or balance;black, bloody, or tarry

vomiting, abdominal discomfort, diarrhea, constipation pancreatitis. Vasodilatation, dizziness, headache, anxiety, confusion, coordination disturbances, nervousness, sleep disorder seizures.

or engaging in tasks requiring alertness. report chest pain or irregular heartbeat.

assess patients pain monitor input and output ratio and check decreasing output which may indicate retention. assess patients knowledge on drug therapy advice patient to avoid alcohol and OTC medication without medical advice. warn ambulatory patients to be careful when getting out of bed or walking without assitance.

ocular irritation, allergic reaction, acute renal failure, liver failure, hypertension, rash, nausea, diarrhea, headache, drowsiness.

Assesspatients pain before and 1 hour after treatment. Assess for hypersensitivity reactions. Advise patient to report persistence or worsening of pain. Instruct patient to report bleeding, bruising, fatigue. Instruct patient to use caution when driving because drowsiness and dizziness may occur.

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stools; coughing up blood or vomit that looks like coffee grounds;slow heart rate; HYDRO CORTISONE (solucortef) 250 mg, 125 mg IV and 125 mg 1 hour prior to OR Adrenal corticosteroid
glucocorticoid with anti- inflammatory effect because of its ability to inhibit prostaglandin synthesis. it can also cause the reversal of increases capillary permeability. treatment of primary or secondary adrenal cortex insufficiency, rheumatic disorders, collagen diseases, dermatologic disease, allergic states, hematologic disorders. fungal infections, psychosis, acute glomerulonephritis, amebiasis, nonasthmaticbrochial disease; children less than 2 years old, AIDS, TB.

problems with your vision;swellin g, rapid weight gain, feeling short of breath;severe depression, unusual thoughts or behavior, seizure (convulsions); bloody or tarry stools, coughing up blood;
rashes shortness of breath low numbers of white blood cells (leucopenia)

Depression, Flushing, sweating, headache, mood changes, hypertension, circulatory collapse, thrombophlebitis, embolism, tachycardia, edema, fungal infections, blurred vision, diarrhea, nausea, abdominal distension. Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure renal failure, rash, urticaria, cyanosis, anemia, jaundice.

Warn patient receiving long term therapy about Cushingoid symptoms. Advise patient to wear/carry emergency ID as steroid user. Instruct patient to notify physician of decreased therapeautic response for proper dose adjustment. Instruct patient to monitor and report signs of infection.

PARACETAMOL

Decrease fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its

Relief of mild to moderate pain; treatment of fever.

Hypersensitivity; intolerance to tartrazine, alcohol, table sugar, saccharin.

Assess patients fever or pain. Advise patient to avoid alcohol Teach patient to recognize signs of chronic overdose. Tell patient to notify physician for pain or fever lasting for more than 3 days.

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minimal effect on peripheral prostaglandin synthesis.

ISOFLURANE (Forane) 50 ml

Inhibits neurotransmitt er release

Induction and maintenance of general anesthesia.

Hypersensitivity to isoflurane or to other halogenated agents, history of malignant hyperpyrexia; susceptibility to malignant hyperthermia.

malignant hyperthermia shivering respiratory depression hypotension, arrhythmias, hepatic dysfunction, hepatitis, nausea, vomiting.

Arrhythmias, elevation of WBC counts, hypotension, respiratory depression, shivering, nausea, and vomiting during post operative period.

Monitor pts. Vital signs before, during, and after the course of therapy. Explain to the pt. the reason and process of procedure. Inform patient of post operative side effects such as shivering, nausea and vomiting.

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NURSING CARE PLAN

REPORTER: SERNA, JEROME and CORTEZ, OLIVER ASSESSMENT SUBJECTIVE: >giniginaw ako as verbalized by the patient OBJECTIVE: > Temperature of 36C >With presence of Chills NURSING DIAGNOSIS Ineffective thermoregulation due to surgical environment and use of anesthetic agents PLANNING Within 2- 3 hours of nursing intervention at the PACU, the patients temperature will improve from 36C to 37.5C INTERVENTION >Vital signs monitored and recorded especially temperature >Placed under blanket >Placed under droplight >Placed under thermal blanket RATIONALE >To have baseline data in assessing the progress of the patient >to help maintain temperature >To provide warmth >It will help to regulate the heat coming from the droplight >To help improve patients temperature EVALUATION Goal partially met as manifested by latest temperature of 37C

>Room temperature adjusted

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ASSESSMENT OBJECTIVE: -with sterile dressing on post-op site

NURSING DIAGNOSIS Impaired skin integrity related to surgical incision

PLANNING There will be no untoward signs & symptoms observed such as discoloration, foul odor and excessive bleeding at the incision site after the operation and within the stay in PACU.

INTERVENTION >Assessed for any untoward signs and symptoms >Changed dressing as required with proper aseptic technique

RATIONALE >To determine the condition of the patient >To promote easy drying of wound and to prevent infection

EVALUATION After the operation and within the stay in PACU, the patient was properly assessed with no untoward signs & symptoms such as discoloration, foul odor and excessive bleeding at the incision site.

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ASSESSMENT SUBJECTIVE: parang di ko pa maigalaw ang katawan ko as verbalized by the patient. OBJECTIVE: -needs assistance when moving -unable to perform full range of motion by command - unable to turn to sides without assistance

NURSING DIAGNOSIS Activity intolerance related to generalized muscle relaxation due to remaining effect of the anesthesia used in the surgery

PLANNING After 2-3 hours of nursing intervention at the PACU the patient will manifest improvement of activity within her limitations

INTERVENTION >Established rapport

RATIONALE >To gain trust and cooperation >To know if the effect of the anesthetic agent is exceeding the normal range of duration used in the patient >For general assessment of patient including the effects in accordance with the duration of the anesthetic agents used >To establish baseline data

EVALUATION Within 2-3 hours of nursing intervention at the PACU the patient was able to practice simple range of motion exercise such as light stretching with assistance and precautions.

>Assessed for any untoward manifestations related to fading effects of anesthesia such as jerking and drooling noted >Assessed and assisted patient in light ROM

>Vital signs monitored and recorded >Adequate rest provided

>To prevent fatigue and to conserve energy 37

ASSESSMENT OBJECTIVE -reduced level of consciousness -depressed cough and gag reflex -impaired swallowing

NURSING DIAGNOSIS Risk for aspiration related to depressed gag & cough reflex secondary to induction of general anesthesia

PLANNING After 2-3 hours of nursing intervention at the PACU, the patient will be able to maintain safety and demonstrate behaviours of return of reflexes

INTERVENTION >Vital signs monitored and recorded >Encouraged deep breathing and coughing reflex

RATIONALE >For baseline data

>To assess reflexes altered by anesthesia used in the patient, prevent atelectasis and improve pulmonary functions and breathing pattern >Airway obstruction impedes ventilation and to avoid aspiration. >To prevent aspiration and to promote lung expansion.

EXPECTED OUTCOME The patient did not show any signs of fluid accumulation like crackles and was maintained on NPO status

>Patent airway maintained by suctioning as necessary

>Positioned the patient on moderate back rest

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>Lung fields auscultated

>To assess if there are accumulation of secretions and assess the need for suctioning. >To prevent aspiration until the gag reflex returns

>Maintained on NPO status

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ASSESSMENT Objective -Decreased level of consciousness (Lethargic) -Slightly pale in color

NURSING DIAGNOSIS Risk for injury related to decrease level of consciousness secondary to administration of preoperational medications

PLANNING The patient will not experience any physical injury from perioperative up to post-operative state.

INTERVENTION >Raised side rails while transferring to operating room.

>Positioned patient properly on the operating room table with proper transferring techniques. >Proper restraints attached to the patient while on the operating room table >Proper grounding pads placed

EXPECTED OUTCOME >To protect and There are no prevent the patient physical injuries from fall out of the seen to patient stretcher such as bruises or fractures >To assure safety related to fall of the patient & from avoid further perioperative up injury such as cto postspine fracture. operative state.

RATIONALE

>To prevent the patients arm and body to move and so to prevent fall. >To prevent burns

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ASSESSMENT OBJECTIVE: -with sterile dressing on post-op site.

NURSING DIAGNOSIS Risk for infection related to inadequate primary defense mechanism as manifested by post operative incision

PLANNING Prevent patient from having infection throughout the operation and 2-3 hours of stay at the PACU

INTERVENTION >performed proper hand washing technique and surgical hand scrub by all surgical team of the client

RATIONALE >A first-line defense against nosocomial infection/crosscontamination, on the operative wound by bacteria on the hands and arms. >breaking sterility inside the operating room while in surgical operation may lead to further complication and high risk for infection >To prevent possible contamination of sterile field

EXPECTED OUTCOME The patient tolerated the procedure and did not show any signs of infection like fever and chills

>Surgical team practiced strict sterility within the operating room upon assisting in surgery

>Checked for any break in the sterility such as tear of packaging and expiration date of equipment that will be used in the

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operation >Vital signs monitored and recorded >To have baseline data in assessing the progress of the patient

>Kept incision site dry >soaked dressing and intact at all times can harbor bacteria causing further infection and complication to the patient >Medications administered as prescribed by the physician >For prophylaxis and to prevent infection

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