INTRODUCTION

We, the BSN4D group 3 oI Central Luzon Doctors` Hospital-Educational

Institution, present the case oI a 67 year old male patient who was admitted at Tarlac Provincial
Hospital on November 21, 2011 at 06:00 PM, with a chieI complaint oI abdominal pain. For the
purpose oI privacy and conIidentiality, the real name oI the patient in this study is withheld and
he will be named as 'Mr. Pepito 'throughout the entire document. Mr. Pepito lives in Capas,
Tarlac. He was diagnosed initially oI having acute cholecystitis secondary to choledocholithiasis.
AIter Iurther laboratory studies done, cholecystitis with gallstones was conIirmed.
We have chosen this case because this study is signiIicant to our concept since our
concept in NCM 106 is about Care oI Clients with Problems in Cellular Aberrations, Acute
Biologic Crisis including Emergency and Disaster Nursing.
Cholecystitis is inIlammation oI the gall bladder. Usually presents as a pain in the right upper
quadrant. This is known as biliary colic. This is initially intermittent, but later usually presents as
a constant, severe pain. During the initial stages, the pain may be Ielt in an area totally separate
Irom the site oI pathology, known as reIerred pain. The pain is originally located in the right
upper quadrant but the reIerred pain may occur in the right scapula region.This may also present
with the above mentioned pain aIter eating greasy or Iatty Ioods such as pastries, pies, and Iried
Ioods. This is usually accompanied by a low-grade Iever, diarrhea, vomiting, nausea and
granulocytosis. The gallbladder may be tender and distended.More severe symptoms such as
high Iever, shock and jaundice indicate the development oI complications such as abscess
Iormation, perIoration or ascending cholangitis. Another complication,gallstone ileus, occurs iI
the gallbladder perIorates and Iorms a Iistula with the nearby small bowel, leading to symptoms
oI intestinal obstruction.
Choledocholithiasis is the presence oI a gallstone in the common bile duct. The stone may
consist oI bile pigments or calcium and cholesterol salts. This condition causes jaundice and liver
cell damage, and is a medical emergency, requiring the endoscopic retrograde
cholangiopancreatography (ERCP) procedure, it uses an endoscope in combination with
radiographic techniques to view the ductal structures oI the biliary tract. ERCP is helpIul in
evaluating jaundice , pancreatitis, pancreatic tumor, common duct stones and biliary tract
diseasor surgical treatment.
Choledocholithiasis develops in about 10-20 oI patients with gallbladder stones and the
literature suggest that at least 3-10 oI patients undergoing cholecystectomy will have common
bile duct (CBD) stones. CBD stones may be discovered preoperatively, intaoperatively or post-
operatively. Multiple modalities are available Ior assessing patients Ior choledocholithisis
including laboratory tests, ultrasounds, computed tomography scans and magnetic resonance
cholangiopancreatography.

Risk Iactors include a previous medical history oI gallstones. It can also be inherited as well
as the dietary status oI a person such as high cholesterol, low Iiber and low calorie.
Choledocholithiasis can occur in people who have had their gallbladder removed. Women are
much more likely than men to develop gallstones. At about 20 oI men have gallstones by the
time reach age 75.
The complications can lead to jaundice, elevation in alakaline phosphate, increase in
conjugated bilirubin in the blood and increase in cholesterol in the blood. It can also cause acute
pancreatitis and ascending cholangitis.
This is a serious complication and usually requires immediate treatment. The only
treatment that cures gallbladder disease is surgical removal oI the gallbladder, called
cholecystectomy. Generally, when stones are present and causing symptoms, or when the
gallbladder is inIected and inIlamed, removal oI the organ is usually necessary.

Patients who undergo surgery to remove the gallbladder usually do very well.
















Nursing Health History A
Patient: Mr. Pepito
Date: 11/21/2011 Ward: Surgery Room #: 203
Age:67 y/o Sex: Male C/S: Married
Religion: Catholic
Examiner: Group 3 BSN 3D
InIormant: Mr. Pepito

I. CHIEF OF COMPLAINT: abdominal pain
II. 7 months prior to admission
III. Abdominal pain located at the right upper quadrant,
IV. aggravated by consumption oI oily and Iatty Ioods.
V. Associated with a burning epigastric pain and acid reIlux.
VI. No associated vomiting nor Iever was noted
VII. Consulted a private physician and UTZ was done which
VIII. revealed a 1.5cm stone in her gallbladder
IX. She was advised to undergo an operation but the patient
X. did not comply
XI. She was prescribed with unrecalled medications to which
XII. the patient did not comply as well.
III. HISTORY OF PRESENT ILLNESS
Four month prior to admission, the patient has abdominal pain associated with
burning epigastric pain and acid reIlux and it was treated with lomotil and herbal
medicine such as guava leaves.
Three months prior to admission his wiIe was conIined and according to him due
to Iatigue dizziness was Ielt and abdominal pain arises. He had undergone stool exam and
it was Iound out that the stool has worms, and then aIterwards he was given medications
such as anti-protozoal drugs. He discontinued taking his medications because he
experienced vomiting and epigastric pain. And because oI that, he was admitted at
emergency in Concepcion, Tarlac and he was given medications.
Three weeks prior to admission, Mr. Pepito Ielt a sudden
onset oI abdominal pain, stabbing in character and he was admitted at Tarlac
Provincial Hospital. Medications such as ranitidine and antibiotics were given.
Abdominal X-RAY revealed bilateral renal cysts and multiple gallstones and so
the patient was advised to undergo surgery
The patient undergone surgery and cholecystitis was the Iinal diagnosis.
The patient is hypertensive and was taking losartan 50mg as maintenance.


IV. PAST MEDICAL HISTORY (Include dates, complications if any)
A. Pediatric illness:
Mumps(childhood) Pertussis HPN
Measles(childhood) Rheumatic Heart
Disease

Chicken pox(childhood) Pneumonia Hepatitis
Rubella Tuberculosis Others

. Immunization/Test (the patient doesn`t remember any oI her past
immunizations)

C. Hospitalization:
Mr. Pepito was his Iirst time oI being hospitalized.

D. Injuries:
No injury/injuries noted.

E. Transfusions
None
F. Obstetrics
Not Applicable

G. Medications
The client is taking losartan 50mg OD as her maintenance Ior
hypertension.

H. Allergies
No allergies noted


IV. FAMILY HISTORY

BCG Hep B For
pneumonia

Measles DPT Others
AGE
List:
PARENTS, SPOUSE
HEALTH STATUS
Or CAUSE OF
DISEASES
PRESENT IN
THE FAMILY
L living TB Tuberculosis HPN hypertension OB obesity
D deceased DM diabetes mellitus CA cancer J
jaundice
HD Heart Disease MI mentally illness KD kidney disease O others

V. SOCIAL AND PERSONAL HISTORY

irthplace: Capas, Tarlac irthday: 10/19/1943
Education: College undergraduate Ethnic background: Kapampangan

Ages and Sexes of children (if any): 4 children, 3 sons and 1 daughter ages 48, 45, 42 and one
daughter ages 38.

Client`s position in the family: Mr. Pepito was the 7
th
oldest among his siblings in the Iamily.

Residence
Home environment:
The patient lives with a concerete, one storey house at Capas, Tarlac.
Occupation:
Nature oI present occupation: (stress, hazards, etc.)
He is a sewer.
Financial support system:
He and his wiIe is the one who support the Iamily Iinancially and earned Ior about
2,000-3,000 a month.

Habits (tobacco/alcohol use, others):
The client smokes Ior about 15 sticks/ day but doesn`t drink alcoholic beverages.

Diet (meal distribution, others)
He eats vegetables, Iish, and meat.
Physical Activity/exercise, if any:
Sewing is a Iorm oI exercise Ior him
rief Description of Average Day:
L D
69 Father oI Mr. Pepito Epigastric Pain HPN
90 Mother oI Mrs. Chole Well and Alive none
65 Husband oI Mrs. Chole Well and Alive HPN
He wakes up at 6 am to prepare and eat their breakIast and aIter that he will continue
sewing clothes.
























VI. REVIEW OF SYSTEM (Pre-operative)
General description:
Weight loss: Fatigue: Anorexia:
Night Sweats Weakness:
Skin:
Itch: Bruising:
Rash: Bleeding:
Lesions: Color Change:
Eyes:
Pain: Itch: Vision loss:
Diplopia: Blurring: Excessive tearing:

Ears:
Ear rashes: Discharge: Tinnitus: Hearing loss:
Nose:
Obstruction: Epistaxis: Discharges:
Throat and Mouth:
Sore throats: Bleeding gums: Tooth aches: Decay:
Neck:
Swelling: Dysphagia: Hoarseness:
Chest:
Cough sputum: (Amount and Character) Hemoptysis
Wheeze Pain receptions Dyspnea:
Rest/Exertion
Breast:
Lumps Pain Bleeding Discharge
CVS:
Chest pain Palpation Dyspnea on exertion Edema
PND Orthopnea Others:
GIT:
Food intolerance Heartburn Nausea Jaundice
Vomiting Pain Bloating Excessive gas
Constipation Change in BM Melena
GU:
Dysuria Nuctoria Rentention Pyloria Dribbling
Hematuria Flank pain

Extremities:
Joint pains Varicose Veins Claudication
Edema StiIIness deIormities
Neuro:
Headaches Dizziness loss Fainting
Numbness Tingling Paralysis:
Paresis:
Seizures Others:
Mental Health Status:
Anxiety Depression Insomnia
Sexual Problems Fear



VII. REVIEW OF SYSTEM (Post-operative)
General description:
Weight loss: 4kg Fatigue: Anorexia:
Night Sweats Weakness:
Skin:
Itch: Bruising:
Rash: Bleeding:
Lesions: Color Change:
Eyes:
Pain: Itch: Vision loss:
Diplopia: Blurring: Excessive tearing:

Ears:
Ear rashes: Discharge: Tinnitus: Hearing loss:
Nose:
Obstruction: Epistaxis: Discharges:
Throat and Mouth:
Sore throats: Bleeding gums: Tooth aches: Decay:
Neck:
Swelling: Dysphagia: Hoarseness:
Chest:
Cough sputum: (Amount and Character) Hemoptysis
Wheeze Pain receptions Dyspnea:
Rest/Exertion
Breast:
Lumps Pain Bleeding Discharge
CVS:
Chest pain Palpation Dyspnea on exertion Edema
PND Orthopnea Others:
GIT:
Food intolerance Heartburn Nausea Jaundice
Vomiting Pain Bloating Excessive gas
Constipation Change in BM Melena
GU:
Dysuria Nuctoria Rentention Pyloria Dribbling
Hematuria Flank pain

Extremities:
Joint pains Varicose Veins Claudication
Edema StiIIness deIormities
Neuro:
Headaches Dizziness loss Fainting
Numbness Tingling Paralysis:
Paresis:
Seizures Others:
Mental Health Status:
Anxiety Depression Insomnia
Sexual Problems Fear



. Physical Assessment
GENERAL SURVEY
Height: 5`9 Weight: 68 kg ody Makeup: mesomorphic
Communication Pattern: kapampangan
Skin: Color: Turgor: poor skin turgor ruises: none
State of Hydration: good
Eyes: Sclera: icteric sclera Pupils: Her pupils were equal within 1-2 mm diameter in
size and both have a brisk reaction to light and uniIorm
reaction to accommodation.
Respiratory: Easy reathing In distress No distress

BODY POSITIONAL ALIGNMENT
Supine Fowlers Semi-Fowlers Others:

MENTAL ACUITY
Oriented Coherent Appropriately Responsive Others:
Disoriented Incoherent Inappropriately Responsive

SENSORY/MOTOR RESTRICTIONS
Amputation DeIormity Paresis Paralysis Fracture
Gait Hearing disorder Speech Others:

EMOTIONAL STATUS:
Euphoric Depressed Apprehensive Angry/Hostile
Others:

MEDICALLY IMPOSED RESTRICTIONS:
CR w/out RP BR w/ BRP OOB-Chair Restricted Ambulation

OTHER HEALTH RELATED PATTERNS:
Fatigue Restlessness Weakness Insomnia
Coughing
Dyspnea Dizziness Pain Others:

ENVIRONMENT:
Room Temperature Adequate Inadequate
Lighting Adequate Inadequate

SAFETY:
Violations oI medical asepsis:

Violations oI saIety measures:

ACTIVITIES OF DAILY LIVING:
Can/Cannot perIorm
Feeding Brushing teeth Bathing
TransIerring Dressing Combing
Others:
VITAL SIGNS
HR: 66beats/min
Temperature: 36.3 C
RR: 22cycle/min
Bp: 120/100mmHg
GENERAL SURVEY:
(-) signs oI distress; conscious, alert and coherent; oriented to time, person and place, looks
according to age; well nourished; calm

SKIN
Skin was warm to touch, slightly dry, rough, and with good skin turgor. Neither jaundice nor
cyanosis observed. No bruises or discolorations observed. No edema noted.

HEAD:
Skull size was normocephalic. Skull and Iace were symmetrical with an equal distribution oI
hair. Hair was black in color with Iair amount oI white and gray strands, short, dry, and Iine.
There was no dandruII or inIestation present. No lesions, lacerations, tenderness, masses and
depressions noted.

EYES/VISION:
Mr. Pepito uses eyeglasses Ior reading with a grade oI 300.
Eyebrows were evenly distributed and symmetrically aligned with no oI Ilakes, scars and lesions
noted. Eyelashes were evenly distributed and slightly curled outward. Lid margins were clear,
lacrimal duct openings were evident at the nasal side oI the upper and lower lids. Blinking reIlex
was present. Skin around the eyes was intact with equal movement, with no discharges and no
discolorations observed. Eyelids close symmetrically. No edema seen in the periorbital region.
Shiny smooth and pale palpebral conjunctiva noted. Eye color was dark brown. His pupils were
equal within 1-2 mm diameter in size and both have a brisk reaction to light and uniIorm reaction
to accommodation. Anicteric sclera with some superIicial blood vessels visible, Corneas is clear,
moist and shiny.

EARS/HEARING
Ears were symmetrical with same size bilaterally and color consistent with Iace. Pinnas were Iree
Irom lesions, masses, swelling, redness, tenderness, and discharges and were in line with the
eyes. External canals were clear with no cerumen seen. No inIlammation, masses, discharges and
Ioreign bodies noted. Gross hearing acuity was good. No pain on the mastoid process was
reported upon palpation.

NOSE:
The nose was symmetrical with no deIormities, skin lesions, masses present. Nasal septum is
intact and in midline. Both nares is patent, (-) swelling, bleeding, lesions, and masses. No nasal
Ilaring was observed. No discharges were present. No tenderness in his sinuses upon palpation.

MOUTH:
Mouth was proportional and symmetrical. Lips were pale and dry with no presence oI
ulcerations, sores or lesions. The patient has no dentures. Tongue was in central position and
moves Ireely with no swelling or ulcerations observed. Tonsils were not inIlamed. Halitosis was
also noted. Gums is Iirm, pink and moist.

NECK and LYMPH NODES:
Neck was symmetrical with no masses or swelling noted. No jugular vein distention was noted.
Range oI motion was normal and moves easily without discomIort upon rotation, Ilexion,
extension and hyperextension. Thyroid was not palpable. Trachea is symmetrical and in midline
without deviation.

CHEST AND LUNGS
No thorax deIormity observed. Respiratory rate was 22 cycles per minute with regular breathing
pattern. Symmetrical chest expansion was observed during respiration. No use oI accessory
muscles during breathing observed. Chest wall was intact; no tenderness and masses noted. No
adventitious breath sounds heard upon auscultation. Fremitus equal on both sides oI thorax
HEART
Apical heart beat was present upon auscultation with a point oI maximal impulse at the 5th
intercostal space leIt midclavicular line; with cardiac rate oI 66 beats per minute with a regular
rhythm. No abnormal beats, palpitations, thrills or murmurs present upon auscultation.

ADOMEN
Abdomen was slighty enlarged and globular when patient was in supine position; with slightly
soaked, intact dressing on the right upper quadrant. Pulsations were not visible. The abdomen
had hypoactive bowel sounds oI two bowel sounds per minute. Tenderness noted on the right
upper quadrant near the incision site.

MUSCULOSKELETAL
Symmetrical shoulder movement observed during respiration. Spine was located at the midline
with no discrepancies noted. Shoulders, arms, elbows and Iorearms were Iree Irom nodules,
deIormities and atrophy. Range oI motion was not limited. Neither pallor nor bone enlargements
were noted upon inspection oI the upper extremities. Upper and lower extremities were not
edematous. Radial and brachial pulses were present. Hip joint and thighs were symmetrical with
no deIormities present. No edema noted at both legs. No inIlammation noted in the lower
extremities. Range oI motion was active and not limited.

ETREMITIES
Symmetrical to rest oI the body
Nails are dirty and protracted, with normal capillary reIill and skin turgor
(-) edema










PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

























Mod|f|ab|e Iactors
LlfesLyle such as fond of eaLlng faLLy foods
Nonmod|f|ab|e Iactors
age 67 y/o
CrysLals come
LogeLher and fuse
Lo form sLones
1he soluLe preclplLaLe from
soluLlon as solld crysLals
8lle become
supersaLuraLed wlLh
cholesLerol
CallsLones
CbsLrucLlon of Lhe cysLlc ducL and common blle
ducL
Sharp pa|n |n the r|ght part
of abdomen
Icter|c sc|era
Nausea Vom|t|ng
Const|pat|on
C|ay co|ored stoo|
1ea co|ored ur|ne
Cho|edocho||th|as|s
ulsLenslon of Lhe gall bladder
rollferaLlon of bacLerla Locallzed cellular
lrrlLaLlon/lnfllLraLlon or boLh
Lake place
lnflammaLlon of gall bladder
CnCLLCS1I1IS
MEDICAL MANAGEMENT
LAORATOTY TESTS
11/23/11
lood chemistry

FBS(3.9-6.1mmol/L)------------------------------------------------5.26mmol/L
Cholesterol(3.88-6.47mmol/L)-------------------------------------2.56mmol/L
Triglyceride(0.11-2.15mmol/L)-------------------------------------1.11mmol/L
HDL(30-75mg/dl)-------------------------------------------------------45.7mg/dl
LDL(66-178mg/dl)-------------------------------------------------------33.2mg/dl

ADOMINAL -RAY
Impression
O Bilateral renal cysts
O Multiple gall stones

11-24-11
PROTHROMIN TIME TEST





11/24/11
ENZYME

RESULT
PATIENT 12.4
CONTROL 9
ACTIVITY 90.1
INR 1.03
ISI 1.03
ALK. PHOSPHATE(20/30 U/L) 18.1

Date: 11-23-11
Time: 3:15 PM
URINALYSIS
CHEMICAL PHYSICAL MICROSCOPIC
Leukocytes: large Color: dark yellow Pus Cells: 16-20
Nitrites: negative Transparency: S. turbid Red Cells: 3-5
Urobilinogen: normal OTHER TESTS Epithelial Cells:
Protein: trace Pregnancy: A Urates /Phosphates: Few
pH: 7-0 KOH: Mucus Threads: Few
lood Cells: negative OTHERS acteria:
Specific Gravity: 1.015 Crystals: Calcium oxalate
moderate
Ketone: trace
Cast/s ilirubin: 2
Glucose: negative
LOOD CHEMISTRY









BUN(2.9-8.2 mmol/L) 3.09
Ceatinine (53-
106mmol/L)
61.88
NURSING MANAGEMENT
POSTOPERATIVE
Monitored VS
Monitored Input and output
Assessed patient's incision site.
Maintained Flat on bed
Assisted patient in turning sides to sides.
Encouraged deep breathing exercises
Encourage to cough eIIectively while splinting the incision site.
Instruct patient to have low carbohydrate diet.
Provided comIort and saIety
DRUG STUDY
Drug name ClassiIication action Indication Contraindication Side eIIect Nursing
management
Generic:
hyoscine

Brand: buscopan

Dosage:
Anti cholinergic/
anti spasmodic



Inhibits
acetylcholine at
receptor sites in
ANS which
controls
secretions, Iree
acid in the
stomach: blocks
central
muscunaric
receptors which
decrease
involuntary
movement.
RelieI oI smooth
muscle spasm oI
the GI and in the
genitourinary
system
~glaucoma

~myasthenia
gravis

~paralytic ileus

~pyloric stenosis

~prostatic
enlargement

~porphyria
Side eIIect
includes
constipation,
dry mouth,
photophobia,
Ilushing, skin
rash.
Buscopan may
also cause
urinary
urgency and
urinary
retention. Less
common side
eIIect includes
conIusion,
nausea,
vomiting and
dizziness.
~assess Ior eye
pain. Discontinue
medication

~assess Ior
parkinsonism,
extra pyramidal
symptoms.

~assess Ior urinary
hesitancy,
retention, palpate
bladder oI
retention occurs

~assess Ior
constipation

~assess Ior
tolerance over long
therapy

~assess Ior mental
status

~instruct patient to
avoid alcohol
because it may
increase central
nervous
depression.

Drug Dosage Action Indication Contraindication Adverse
Effect
Nursing
Responsibilities

Omeprazole
(losec)

40mg
TIV, OD

Gastric acid-
pump inhibitor;
Suppresses
gastric acid
secretion by
speciIic
inhibition
oI the hydrogen-
potassium
ATPase enzyme
system at the
secretory surIace
oI the gastric
parietal cells;
Blocks the Iinal
step oI acid
production.

Short-term
treatment oI
active duodenal
ulcer;
First-line therapy
in treatment oI
heartburn or
symptoms oI
gastroesophageal
reIlux disease
(GERD);
Short-term
treatment oI
active benign
gastric ulcer;
GERD, severe
erosive
esophagitis,
poorly
responsive
symptomatic
GERD;

Long-term
therapy:
Treatment oI
pathologic
hypersecretory

Contraindicated
with
hypersensitivity
to omeprazole or
its components;
Use cautiously
with pregnancy
lactation.

CNS:
~Headache
~Dizziness
~Asthenia
~Vertigo
~Insomnia
~Apathy
~Anxiety
~Paresthesias
~Dream
abnormalities

Dermatologic:
~Rash
~InIlammation
~Uritacaria
~Pruritus
~Alopecia
~Dry skin

GI:
~Diarrhea
~Abdominal
pain
~Nausea
~Vomiting
~Constipation
~Dry mouth

~Assessment
History:

Hypersensitvityto
omeprazole or any
oI its components;
pregnancy,
lactation.

Physical:
Skin lesions;
reIlexes, aIIect;
urinary output,
abdominal exam;
respiratory a us
cultation
interventions

~Administer
beIore meals.
Caution patient to
swallow capsules
whole, not to open,
chew, or crush
them.

conditions
(Zollinger-
Ellison
syndrome,
multiple
adenomas,
systemic
mastocytosis);
Eradication oI H.
pylori with
amoxicillin or
metronidazole
and
clarithromycin;
Prilose OTC:
Treatment oI
Irequent
heartburn (2 or
more
days/week);
Unlabeled use:
Posterior
laryngitis;
enhance eIIicacy
oI pancreatin Ior
the treatment oI
steatorrhea in
cystic Iibrosis.
~Tongue
atrophy

Respiratory:
~URI
symptoms,
cough,
epistaxis

Other:
~Cancer in
preclinical
studies
~Back pain
~Fever


Drug name ClassiIication Dosage Indication Contraindication Side eIIect Nursing
management
CeIuroxime Antibiotic;
Cephalosporin
(second
generation)
750mg Oral
(cefuroximeaxetil)
~Pharyngitis, tonsillitis
caused by
Streptococcus pyogenes

~Otitis media caused
by
Streptococcus pneumoniae,
S. pyogenes ,Haemophilus
inIluenzae, Moraxella
catarrhalis

~Lower respiratory
inIections caused by
S. pneumonia.
Haemophilus para
inIluenzae,

~UTIs caused by
E. coli,
Klebsiella pneumonia

~Uncomplicated
gonorrhea(urethral and
endocervical)

~Contraindicated
with allergy to
cephalosporin or
penicillin.


~Use cautiously
with renal
Iailure.

ody as a Whole
:Thrombophlebitis
(IV site); pain,
burning, cellulitis
(IM site); super
inIections,
positive Coomb`s
test.

GI: Diarrhea,
nausea, antibiotic-
associated colitis.

Skin: Rash,
pruritus, urticaria.

Urogenital:
Increased serum
creatinine and
BUN, decreased
creatinine
clearance.

~Culture inIection,
and arrange
Ior sensitivity tests
beIore and during
therapy iI expected
response is not
seen.
~Give oral drug
with Iood to
decrease GI upset
and enhance
absorption.
~Have with Vit K
available in case
hypo
prothrombinemia
occurs.
~Discontinue
iI hypersensitivity
reaction occurs.
~Determine history
oI hypersensitivity
reactions to
cephalosporin,
penicillin, and
history oI allergies,
particularly to
~Skin and skin
structure inIections,
including impetigo
caused by
Streptococcus aureus,
S, pyogenes

~Treatment oI early
Lyme disease
drugs, beIore
therapy is initiated.
~Inspect IM and
IV injection sites
Irequently Ior signs
oI phlebitis.
~Report onset
oI loose stools or
diarrhea. Although
pseudo
membranouscolitis.
~Monitor I &
Orates and pattern:
Especially
important in
severely ill
patients` receiving
high doses. Report
any signiIicant
changes.







NURSING CARE PLAN
Cues
Nursing
diagnosis
ScientiIic
Explanation

Planning Nursing intervention Rationale Evaluation

Subjective:
'masakit ang tiyan
ko as verbalized by
the patient.

Objective:
O Guarding
behavior
O Facial
grimace
noted
O Irritable
O Pain scale oI
7/10










Acute pain
related to
inIlammatory
process

Nociceptors are
the receptors
Ior pain. These
are activated by
chemicals such
as
prostaglandin,
serotonin,
hiastamine,
acetlycholine
and bradykinin.
Prostaglandins
produced at the
site oI injury
act to Iurther
enhance the
nociceptive
response to
inIlammation
by lowering the
threshold to
noxious
stimulation.

AIter 15-30
mins oI
nursing
intervention
the patient will
be able to
verbalize
lessened pain
Irom a pain
scale oI 7/10
to 5/10.

1. Assess level
and location oI
pain

2. Provide
comIort such
as restIul
environment

3. Promote bed
rest, allowing
to assume
position oI
comIort

4. Implement the
use oI
relaxation
techniques
such as deep
breathing
exercise


Intensity oI
pain
indentiIies
need Ior
pain
medication

Promote
relaxation,
reduces
muscle
tension

Bed rest in
semi
Iowler`s
position
reduces
pressure

Reduces
muscle
tension and

AIter 15-30
mins oI
nursing
intervention
the patient was
able to
verbalize
lessened pain
Irom a pain
scale oI 7/10
to 5/10.











Chronic
inIlammation
with
nociceptive
stimulation is
the source oI
pain.
5. Provide
diversional
activities such
as reading

6. Turn side to
side at
intervals


DEPENDENT:

7. Administer
medication as
prescribed:
Analgesics




Anticholinergics








promote
non-
pharmocolo
gic pain
managemen
t

To divert or
reIocus
attention







Relieves
pain and
enhances
circulation

Relieves
reIlex
spasm or
smooth
muscle
contraction
and assist

Narcotics
with pain
managemen
t.

Given to
reduce
severe pain.














Assessment Diagnosis ScientiIic
explanation
Planning Intervention Rationale Evaluation
S~O
O~presence oI
surgical incision
right upper
quadrant oI the
abdomen.
~with slightly
soak and intact
dressing.
Risk Ior
inIection related
to inadequate
primary deIense
secondary to
Cholecystectomy
Client`s
undergone
surgical
procedure that
impairs the
body Iirst line
oI deIense
thereby
increasing the
risk oI being
invaded by
pathogenic
organisms.
Within 2hrs oI
proper nursing
intervention, the
patient will be
able to identiIy
interventions to
prevent or
reduce risk Ior
inIection.
~monitor vital sign


~observe Ior
localized sign oI
inIection at insertion
site oI invasive
lines, sutures,
surgical incision and
wounds

~change wound
dressing as indicated
using proper
technique Ior
changing or
disposing oI
contaminated
materials.

~emphasize the
importance oI
proper hygiene


~instruct patient in
techniques to protect
~elevation in
rate may
indicate
inIection

~assessing the
patient helps
determine
prioritization oI
care.




~sterile
technique
prevent
contamination
and reduce risk
Ior inIection




~may reduce the
risk oI inIection
and spread oI
Within 2hrs oI
proper nursing
intervention, the
patient was able
to identiIy
interventions to
prevent or
reduce risk Ior
inIection.
the integrity oI skin.

~encourage patient
to verbalize any
changes noted on
the operative site,
such as redness,
swelling and
unusual odor
changes.

COLLABORATIVE
~administer
penicillin G sodium
microorganism

~to avoid other
complication.



~to allow
continuous
monitoring and
assessment oI
patient
condition.






~serves as
prophylactic
treatment and
prevent bacteria
to harbor on
operative site.