General Objective:

This case presentation aims to develop efficiency, effectiveness, and collaboration in nursing students. It is also a facilitating factor in the truthful application of the Louisian Core Values such as True Christian Living, Academic Excellence, Professional Responsibility, and Social Awareness and Involvement in the holistic quality of care being deliberately delivered. It also aims to provide a detailed discussion about the disease, as well as the findings, interventions and client’s response, that will serve as a learning foundation.

Specific Objectives:

1. Introduction To define Cholelithiasis. To enumerate and explain its signs and symptoms. To identify those that were manifested by the client. To identify and explain appropriate diagnostic examinations. To identify and carry out appropriate nursing responsibilities before, during, and after the

diagnostic examinations to be undertaken.2. Statistics To identify the number of cases of Cholelithiasis in years 2010, 2011 and 2012, through

statistical data from various health institutions such as the Cagayan Valley Medical Center, Tuguegarao City People’s General Hospital and Clinica de Leon.

To interpret and analyze statistical data for it to contribute in the provision of information about the prevalence of the disease in relation to variables such as age group and every month of the year.

3. Patient’s Profile To identify the biographic data of the patient as well as the physicians who are involved in caring

for the patient, and the diagnoses of the patient such as admitting, principal and final diagnoses.4. Nursing Health History To elaborate the past, present, social, sexual, and family histories of the client. To relate particular information that predisposes, precipitates, alleviates, and aggravates the

disease process of the client.5. Gordon’s 11 Functional Health Patterns To identify, define and elaborate the holistic functioning of the clients with the use of health

patterns.6. Physical Assessment To apply knowledge, skills and attitude to collect objective data from the client. To use the systematic method such as the cephalocaudal assessment and processes such as

inspection, palpation, percussion, and auscultation, except for the abdomen which follows, inspection, auscultation, palpation and percussion.

To differentiate actual findings from normal findings to categorize if they are normal or abnormal.

To rationalize abnormal findings in relation to the client’s disease.7. Anatomy and Physiology To identify the anatomical structures of the system affected by the disease. To explain the normal functioning of the different parts of the affected system and how these

parts function as a whole.8. Pathophysiology To identify predisposing factors, etiologic agent and precipitating factors that affect the disease

process. To discuss the disease process and emphasize those manifestations found in the patient.9. Laboratory Results To identify and analyze laboratory findings for the more detailed rationalization of occurrences

associated with the disease. To identify doctors’ orders and carry out those, with accompanied rationales.10. Nursing Care Plans To develop plans of care that are composed of interventions compatible with the client’s ability

and energy level.

11. Values To experience how to work in camaraderie with others. To apply the values of unity, love and respect of wisdom in the making of the requirement. To establish good working relationships with group mates, for better collaborative outcomes. To develop the attitude of respecting the ideas and capabilities of others. To develop the parameters to good communication such as active and attentive listening,

silence.

Introduction

Cholelithiasis

The gallbladder is a small, pear-shaped organ located beneath the liver. The gallbladder stores bile, the greenish yellow digestive fluid produced by the liver. When bile is needed, the gallbladder contracts, pushing the bile through the lower portion of the bile duct into the small intestine. Bile flows out of the liver through the left and right hepatic duct. This duct then joins with a duct connected to the gallbladder, called the cystic duct, to create the common bile duct. The common bile duct enters the small intestine at the sphincter of Oddi (a ring-shaped muscle), a few inches below the stomach. About half the bile secreted between meals is diverted through the cystic duct and into the gallbladder, where bile is stored. In the gallbladder, up to 90% of the water in the bile is absorbed into the bloodstream, making the remaining bile very concentrated. The rest of the bile produced by the liver flows directly through the common bile duct into the small intestine. When food enters the small intestine, a series of hormonal and nerve signals trigger the gallbladder to contract and the sphincter of Oddi to relax and thus open. Bile then flows from the gallbladder into the small intestine to mix with food contents and perform its digestive functions. After bile enters and passes down the small intestine, about 95% of the bile salts are reabsorbed into the bloodstream through the wall of the lower small intestine. The liver then extracts these bile salts from the blood and resecretes them back into the bile. The bile salts in the body go through this cycle about 10 to 12 times a day. Each time, small amounts of bile salts escape absorption and reach the large intestine, where they are broken down by bacteria. Some bile salts are reabsorbed in the large intestine, the rest are excreted in the stool.

Although the gallbladder is useful, it is not necessary. Thus, if the gallbladder is removed (for example in someone with cholecystitis or cholelithiasis), bile is able to move directly from the liver to small intestine.

Bile consists of bile salts, electrolytes (dissolved charged particles, such as sodium and bicarbonate), bile pigments, such as bilirubin, cholesterol, and other fats (lipids). Bile is responsible for the elimination of certain waste products from the body – particularly pigment from destroyed red blood cells and excess cholesterol- and assists in the digestion and absorption of fats. Bile salts increase the solubility of fats and fat-soluble vitamins to aid in their absorption from the intestine. Hemoglobin (the protein that carries oxygen in the blood) from destroyed red blood cells is converted into bilirubin (the main pigment in bile) and excreted in bile as a waste product.

Components of Bile

Approximate Values For Major Components of Liver and Gallbladder with Power of Hydrogen

Component Liver GallbladderSodium 150 mmol/L 300 mmol/LPotassium 4.5 mmol/L 10 mmol/LC1- 80 mmol/L 5 mmol/LBile Salts 30mmol/l 3.5mmol/LCholesterol 110mg/100mL 600mg/100mLBilirubin 100 mg/100mL 1000mg/100mLPh 7.4 6.5

Disorders of the gallbladder include gallstones, inflammatory conditions, infections, tumors, and congenital malformations. The two most common conditions are gallstones and associated cholecystitis, which is the inflammation of the gallbladder. About 98% of clients who present with symptomatic gallbladder disease have gallstones. Malignancies and congenital anomalies of the biliary tract are relatively uncommon.

Disorders such as gallstones and tumors can obstruct the flow of bile through the bile ducts. Occasionally, an injury during gallbladder surgery may cause an obstruction, or the duct may be narrowed as it passes through a chronically diseased pancreas. Rarer causes of bile duct obstruction include infection by the parasite Ascaris lumbricoides or Clonorchis sinensis.

Definition

Cholelithiasis is defined as the presence of stones in the gall bladder. It came from the Greek terms, “chol”, which means “bile”, “lith”, which means “stone” and “iasis”, which means “process”. which in turn can result in pancreatitis.

Term DefinitionChole- Pertaining to bile

Cholang- Pertaining to bile ductsCholangiography X-ray study of bile ducts

CholangitisThis term came from the Greek terms, “chol-”, which means bile, “ang”, meaning vessel, and“itis”, meaning inflammation.

Inflammation of the bile duct. It is a serious infection of the bile ducts.

Cholecyst- Pertaining to gallbladderCholecystectomy Removal of gallbladder

Cholecystitis Inflammation of gallbladderCholecystography X-ray study of the gallbladderCholecystostomy Incision and drainage of gallbladder

Choledocho- Pertaining to common bile ductCholedocholithiasis

This term came from the Greek terms, “chol-“, which means bile, “docho”, which means duct, “lith”, which means stone, “iasis”, which means process.

Stones in common bile ductIt is the condition wherein gallstones migrate into

the ducts of the biliary tract. This condition is frequently associated with obstruction of the

biliary tree, which in turn can lead to acute ascending Cholangitis.

Choledochostomy Exploration of common bile ductCholelith- Pertaining to gallstones

Cholelithiasis Presence of gallstonesCholescintigraphy Radionuclide imaging of biliary system

Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to four theories, there are four possible explanations for any stone formation.

1. Bile may undergo a change in composition. Studies of subjects with cholesterol gallstones indicate that their bile is supersaturated with cholesterol but deficient in bile salts. The cholesterol saturation of bile seems to increase with age. Changes in bile composition, however, do not completely explain why gallstones form.

2. Gallbladder stasis may lead to bile stasis. Bile stasis may (1) change the composition of bile, (2) supersaturate bile with cholesterol, and (3) precipitate some bile constituents. Gallbladder stasis may result from decreased contractility and emptying of the gallbladder and spasm of the sphincter of Oddi. Circumstances in which gallbladder stasis occurs (e.g., Total Parenteral Nutrition; low-fat, weight reduction diets; spinal cord injury; pregnancy) are associated with a high rate of gallstone formation. More specifically, Total Parenteral Nutrition without oral intake for longer than 1 month is associated with gallbladder sludge formation and cholelithiasis. Delayed emptying of the gallbladder may correlate with hormonal factors. In pregnant women, the female sex hormone estrogen increases, which increases dietary uptake of cholesterol and biliary cholesterol secretion. This may explain why gallstones seem to be associated with pregnancy. In addition, one of the precautions for administering estrogen substances to postmenopausal women is gallbladder disease.

3. Infection may predispose a person to stone formation. Inflammatory debris can form a nidus (point of origin) for stone growth. The related tissue injury may alter the composition of bile by increasing reabsorption of bile salts and lecithin. Certain organisms may also play a part in stone formation by altering the composition of bile. For example, Escherichia coli increases the amount of bilirubin available for pigment stones and Streptococcus faecalis reduces bile salts.

4. Genetics and demography can affect stone formation, as shown by the higher prevalence in Pima and Chippewa Native Americans, Northern Europeans, and South Americans than in Asians.

Risks Factors for CholelithiasisPREDISPOSING FACTORS:

Age(40 and above)- most internal functions decline as one ages. Inevitably resulting an organ

degeneration which also affects the body’s metabolism of lipids. Gender

- gallstones is more frequent on woman especially who had have had multiple pregnancies or who are taking oral contraceptives. Increase level of estrogen reduces the synthesis of bile acid in women.Female sex hormones have long been suspected to have a side effect of gallstone formation by altering respective bile constituents (mainly the fat metabolism).

Ileal disease/resection- people who have disease of the terminal ileum or who have undergone resection of

the terminal ileum deplete their bile salt pool and run a greater risk of developing cholesterol gallstones.

Race- Cholesterol stones are common in Northern Europe in North and South America.

Genetics- Most clinicians have an impression that gallbladder disease characterizes some

families. Indeed, the younger sisters of women with gallstone prove to have bile more highly saturated with cholesterol than the younger sisters of women without gallstones, all of which suggests that cholelithiasis does run in families.

Inflammation and infection of the gallbladder- Inflammation or infection in the biliary structures may provide a focus for stone

formation or may alter the solubility of the constituents, fostering the development of a stone.

Hemolytic Disease and Hepatic Cirrhosis- In cirrhosis, at least two fifths of patients have gallstones. One possible mechanism

behind the appearance of pigment softness, so far unproven, is the excretion of unconjugated bilirubin directly into the bile, something that might happen in patient with hemolysis or in the cirrhotic with his high incidence of pigment stones, currently estimated at 27%.

Bile stasis- Brown pigment gallstones from when there is stasis of bile (decreased flow), for

example, when there are narrow, obstructed bile ducts.PRECIPITATING FACTORS

Faulty Diet- Excessive intake of high fat or cholesterol food such as pork meat, animal skin (e.g.

chicharon and chicken skin) can result to an increase in cholesterol level in the body, making it hard for the liver to make bile enough to metabolized the all cholesterol present. Excess cholesterol present builds up and increases the cholesterol serum level. Normal liver function would then try to compensate and excrete excess cholesterol to the bile plus the body would reabsorb water from the bile making it more concentrated. Supersaturation of cholesterol along with other constituents of the bile (bilirubin, lecithin etc.) builds up mictocrystalis. When microcrystalis aggregate it would result to gallstones.

Weight loss- Weight loss is associated with an increased risk of gallstones because weight loss

increase bile cholesterol supersaturation, enhances cholesterol crystal nucleation, and decreases gallbladder contractility.

Obesity- Obesity is a major risk factor for gallstones, especially in women. A large clinical

study showed that being even moderately overweight increases the risk for developing gallstones. The most likely reason is that obesity tends to reduce the

amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying.

Pregnancy- Altered physiology of the biliary system during pregnancy may play a role in

accelerating the formation of stones in susceptible women. Treatment with estrogen/ contraceptives

- The contraceptive pill not only promotes thrombophlebitis but points to an endocrine background of gallstones by the risk of gallstones in young women taking the pill. This is largely as a result of increased cholesterol secretion into the bile and a decreases in chenodeoxycholic acid content, along with impaired emptying of the gallbladder brought about by estrogen.

Frequent Starvation and prolonged parenteral nutrition- Starvation decreases gallbladder movement causing the bile to become over

concentrated with cholesterol. The liver also secretes extra cholesterol into bile adding to the supersaturation causing stone formation. Also fasting persons have diminished bile salt pool and lithogenic bile. Gallbladder stasis plays a key role in permitting stone formation. Defective or infrequent gallbladder emptying occurs in the settings of prolonged fasting, rapid weight loss, pregnancy, and spinal cord injury.

Clofibrate use and other antillipemic drugs- Drugs that lower the serum level of cholesterol, notably clofibrate, are associated

with an increased incidence of gallstones. Clofibrate pressurably increases the secretion of cholesterol into the bile and apparently also decreases bile acid synthesis, so increasing the cholesterol saturation of the bile. Clinical reflection of these physiologic abnormalities has been found in the overwhelming association between clofibrate therapy and gallstones.

*Health promotion activities to minimize gallstone formation include maintaining a low-fat diet, maintaining ideal body weight, and limiting the number of pregnancies. Clients receiving TPN for longer than 1 month should be monitored closely as health maintenance and restoration actions. In some male clients, regular coffee consumption may help to prevent symptomatic gallstone disease.

Gallstone formation involves several factors:1. Bile must become supersaturated with cholesterol or calcium.2. The solute must precipitate from solution as solid crystals.3. Crystals must come together and fuse to form stones.

Gallstones are generally of three types: (1) cholesterol, (2) pigment, and (3) mixed. Because the incidence of a pure stone formation is rare, stones are generally classified by the predominant substance.

1. Cholesterol stones- are the most common type; the incidence increases with age, and the prevalence is higher in women. Stones are usually smooth and whitish yellow to tan.

2. Pigment stones- in here, bile contains an excess of unconjugated bilirubin. They may be black (associated with hemolysis and cirrhosis) or earthy calcium bilirubinate (associated with infection of the biliary system).

3. Mixed stones- may be a combination of cholesterol and pigment stones or either of these with some other substance. Calcium carbonate, phosphates, bile salts, and palmitate make up the more common minor constituents.

Most gallstones are formed in the gallbladder, but they may also form in the common duct or hepatic ducts of the liver. The actual incidence is not known, however, because some stones do not cause manifestations and they pass through the ducts unnoticed. Once a client becomes symptomatic, treatment and follow-up are essential to prevent progression to a more severe, sometimes fatal, complication of gallbladder disease. About one third of these complications are due to free perforation, which occurs when a gangrenous area becomes necrotic and bile breaks into the peritoneal cavity. The mortality rate is about 20% the peritonitis with systemic distribution of pepsin.

Pericholecystic abscess accounts for 50% of the complications and is the least severe, with a mortality rate of approximately 15%. Abscess formation occurs while the perforation is walled off by omentum or an adjacent organ (e.g., colon, stomach, or duodenum). Much less frequently, in about 15% of clients, a fistula occurs when the gallbladder becomes attached to a portion of the gastrointestinal tract and perforates it. The duodenum, followed by the colon, is the most common site for the event.

Occasionally, a stone is discharged into the small intestine. If the stone is large enough, it can obstruct the narrow terminal ileum, causing gallstone ileus.

Clinical Manifestations

Fewer than half of the people with gallstones report any distress because gallstones cause no manifestations unless complications develop. The most specific and characteristic manifestation of gallstone disease is pain or biliary colic, which is caused by spasm of the biliary ducts as they try to dislodge the stones. This pain usually follows the temporary obstruction of the gallbladder outlet.

Characteristically, the pain starts in the upper midline area. It may radiate around to the back and right shoulder blade, although some clients complain that it passes straight through to the back and substernal areas.

The client is often restless, changing positions frequently to relieve the intensity of the pain. Pain may persist only a few hours or several days, and the interval between attacks is variable.

If the stone is blocking the cystic duct, manifestations of acute cholecystitis may occur.

Acute Calculous Cholecystitis, which appears to be caused by obstruction of the cystic duct, in turn causes distention of the gallbladder. Subsequently, (1) venous and lymphatic drainage is impaired, (2) proliferation of bacteria occurs, (3) localized cellular irritation or infiltration or both take place, and (4) areas of ischemia may develop. The inflamed gallbladder wall is edematous and thickened, it may have areas of gangrene, or necrosis may be present. The term empyema describes a gallbladder that contains pus, which is the equivalent of an intra-abdominal abscess and may be associated with severe sepsis. Recurrent episodes of acute cholecystitis cause fibrosis of the wall of the gallbladder.

Complications of untreated acute cholecystitis are usually associated with septic complications. Others are consequences of ischemia, inflammation, adhesions, and gangrene: perforation, pericholecystic abscess, and fistula. Clinical Manifestations of Acute Cholecystitis

The most common and reliable finding on physical examination is tenderness in the right upper quadrant, epigastrium or both. Although clients with chronic and acute cholecystitis may complain of the same type of pain, the distinguishing factor is the severity and persistence of the pain. Chronic cholecystitis rarely lasts more than a few hours, whereas acute cholecystitis may last several days.

Pain in acute cholecystitis may be located in the epigastric, subscapular, or right upper quadrant regions. Sometimes the pain is referred to the right scapula. The pain usually starts suddenly, increases steadily, and reaches a peak in about 30 minutes. Abdominal examination may reveal a tender abdomen with right upper quadrant guarding. Murphy’s sign may be elicited when the client is asked to take a deep breath. About 60% to 70% clients with acute cholecystitis have experienced biliary colic episodes in the past from ductal spasm when a stone moves from the gallbladder into ducts causing waves of pain (biliary colic).

In addition to pain, the following problems may be revealed in clients with acute cholecystitis:1. Nausea and vomiting occur in about 75% of clients as a result of impulses transmitted to the

vomiting center from distention of bile ducts.2. A low-grade fever is often present from the response to inflammation, but this may be absent in

older clients, immunocompromised clients, and clients receiving steroidal therapy.

3. Mild jaundice occurs in only 10% of cases.4. Right upper quadrant tenderness, fever, and leukocytosis suggest acute cholecystitis,

particularly if other assessment data support this diagnosis.

If the stone lodges in the common duct, gallstones can be complicated by cholangitis (inflammation of the bile duct) and pancreatitis. Jaundice appears only when common duct obstruction is present.

Nausea and vomiting may occur; occasionally, self-induced vomiting alleviates the manifestations. Assessment may further reveal a history of flatulence, bloating, epigastric pain, belching, intolerance of fatty foods, and vague upper abdominal sensations. Occasionally, clients who have these problems still have them after cholecystectomy. Physical findings are present only during an attack with pain, with pain being the cardinal manifestation. The right upper quadrant or epigastic area is tender to palpation with voluntary muscle guarding, but manifestations of peritonitis are absent. The gallbladder is not palpable, and the temperature is normal.

Diagnostic Examinations1. Abdominal x-ray

-it is obtained to exclude other causes of symptoms. However ,only 15 %-20% of gallstones are calcified sufficiently to be visible on such x-ray studies.

2. Ultrasonography –has replaced cholecystography as the diagnostic procedure of choice, because it is rapid and accurate and can be used with patients with liver dysfunction and jaundice. The procedure is most accurate if the patient fasts overnight so that the gallbladder is distended. Ultrasonography can detect with 95% accuracy calculi in the gallbladder or a dilated common bile duct.Blood test results are unremarkable. Ultrasound is very sensitive (>95%) and very specific (>95%) for gallbladder stones larger than 2 mm diameter. Purpose of UTZ is to cofirm cholelithiasis, diagnose acute cholecystitis, and distinguish between obstructive and nonobstructive jaundice.

PROCEDURE OF ULTRASONOGRAPHY Place patient in a supine position. Water-soluble conductive gel is applied to the face of the transducer. Transverse and longitudinal oblique scans of the gallbladder are taken at 3/8”(1 cm) intervals,

starting at the xiphoid process level and moving laterally to the right subcostal area. Longitudinal oblique scans are taken at 5 mm intervals parallel to the long axis of the gallbladder marked on the patient’s skin, beginning medial to the gallbladder and continuing through to its lateral boarder.

During each scan, the patient is asked to inhale deeply and to hold his breath. (if the gallbladder is positioned deeply under the right costal margin, a scan may be taken through the intercostals spaces while the patient holds his breath.)

The patient is placed in a left lateral decubitus position and is scanned beneath the right costal margin. (This position and scanning angle may displace and allow the detection of stones lodge in the gallbladder neck and cystic region.)

NURSING CONSIDERATIONSBefore the test:

Explain the purpose of the procedure. Lights may be lowered to help visualize the monitor. Inform patient that mineral oil or a gel, which may feel cool, will be applied to the area being

tested and that a transducer will pass over his skin, directing safe, painless, and inaudible sound waves into the area.

Instruct patient to eat a fat-free meal in the evening and then to fast for 8-12 hours before the procedure to promote bile accumulation in the gallbladder and enhance ultrasonic visualization.

Instruct the patient to remain as still as possible during the procedure and to hold his breath when requested to ensure that the gallbladder is in the same position for each scan.

After the test: Remove the conductive gel from the patient’s skin. Instruct the patient that he may resume his usual diet and medications, as ordered.

2. Gallbladder nuclear scanning/radionuclide imaging (cholescintigraphy, HIDA scanning, IDA scanning, or DISIDA scanning)

-is used successfully in the diagnosis of acute cholecystitis or blockage of a bile duct. In this procedure, a radioactive agent is administered intravenously. It is taken up by the hepatocytes and excreted rapidly through the biliary tract. The biliary tract is then scanned, and images of the gallbladder and biliary tract are obtained.

It is more expensive than ultrasonography, takes longer to perform, exposes the patient to radiation, and cannot detect gallstones. It is often used when ultrasonography is not conclusive.

NURSING CONSIDERATIONS Explain the purpose of the procedure. Obtain a history for the presence of allergies or sensitivities to iodine, contrast medium,

anesthetics or dyes. Explain that some pain may be experienced during the test. Reassure the patient that the radionuclide poses no radioactive hazard and rarely produces side

effects. Instruct patient to remove jewelry and other metallic objects from the area to be examined. Instruct to restrict food and fluids for 4-6 hours prior to the procedure. Make sure informed consent has been signed. Instruct patient to void prior to the procedure. After the procedure, instruct the patient in the care and assessment of injection site.

3. Cholecystography-it is used if ultrasound equipment is not available or if UTZ results are inconclusive.Oral cholangiography may be performed to detect gallstones and to assess the ability of the gallbladder to fill, concentrate its contents, contract and empty. An iodide-containing contrast agent that is excreted by the liver and concentrated in the gallbladder is administered to the patient. The normal gallbladder fills with this radiopaque substance. If gallstones are present, they appear as shadows on the x-ray film.The patient is asked about allergies to iodine or seafood. If no allergy is identified, the patient receives the oral form of the contrast agent the evening before the x-rays are obtained. Contrast agents include iopanoic acid( Telepaque),iodipamide meglumine ( Cholografin), and sodium ipodate( Oragrafin). These agents are administered orally 10-12 hours before the x-ray study. After the contrast agent is administered, the patient is permitted nothing by mouth, to prevent contraction and emptying of the gallbladder.Cholecystography in the obviously jaundiced patient is not useful because the liver cannot excrete the radiopaque dye into the gallbladder in the presence of jaundice. Oral cholecystography is likely to continue to be used as part of the evaluation of the few patients who have been treated with gallstone dissolution therapy or lithotripsy.

4. Endoscopic retrograde cholangiopancreatography-permits direct visualization of structures that previously could be seen only during laparotomy. The examination of the hepatobiliary system is carried out via a side-viewing flexible fiberoptic endoscope insertyed into the esophagus to the descending duodenum. Fluoroscopy and multiple x-rays are used during thisn procedure to evaluate the presence and location of ductal stones.

5. Percutaneous transhepatic cholangiography-involves injection of dye directly into the biliary tract. Because of the relatively large concentration of dye that is introduced into the biliary system, all components of the system, including the hepatic ducts within the liver, the entire length of the common bile duct, the cystic duct, and the gallbladder are outlined clearly.

This procedure can be carried out even in the presence of liver dysfunction and jaundice. It is also useful for distinguishing jaundice caused by liver disease (hepatocellular jaundice) from that caused by biliary obstruction, investigating the gastrointestinal symptoms of a patient whose gallbladder has been removed, locating stones within the bile ducts and diagnosing cancer involving the biliary system.Procedure:

A flexible needle is inserted into the liver from the right side in the midclavicular line immediately beneath the right costal margin. Successful entry of a duct is noted when bile is aspirated or on injection of a contrast agent. UTZ can be used to guide puncture of the duct . Bile is aspirated and samples are sent for bacteriology and cytology. A water soluble contrast agent is injected to fill the

biliary system. The fluoroscopy table is tilted and the patient is repositioned to allow x-rays to be taken in multiple projections.

4. Magnetic resonance cholangiopancreatography (MRCP)- is a newer diagnostic modality that implements Magnetic Resonance Imaging to evaluate the fluid-filled gallbladder and biliary and pancreatic ducts. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive procedure that is being used with increasing frequency to diagnose gallstones (cholelithiasis) and the complications that may result.

NURSING CONSIDERATIONS FOR MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY

Before the procedure: Make sure that the patient or a responsible family member has signed an informed consent. Explain to the patient the purpose of the test. Explain to the patient that MRI is painless and involves no exposure to radiation from the

scanner. Advise the patient that he’ll have to remain still for the entire procedure. If contrast media will be used, obtain a history of allergies or hypersensitivity to these agents. Instruct the patient to remove all metallic objects, including jewelry, hairpins and watches. Ask the patient if he has implanted metal devices or prostheses, such as vascular lips, shrapnel,

pacemakers, joint implants, filters and intrauterine devices. If so, the test may not be able to be performed.

Just before the procedure, have the patient urinate.During the test:

Remind patient to remain still throughout the procedure.After the test:

Tell patient that he may resume his usual activities as ordered. If the test took a long time and the patient was lying flat for an extended period, observe him for

orthostatic hypotension. Provide comfort measures and pain medication as needed.

Treatment

Medical Management1. Reduce Pain. Pain may arise from contraction of the gallbladder during transient obstruction of

the cystic duct by gallstones. Analgesics may be administered intramuscularly (IM) or intravenously (IV) on a schedule, with a patient-controlled analgesia (PCA) pump or as needed for pain. Antacids are given to neutralize gastric hyperacidity and to reduce associated pain, and antiemetics are given to minimize nausea and vomiting. Antiobiotics are administered to reduce the likelihood of infection. Nitroglycerin may reduce biliary colic as well.

2. Monitor Fluid and Electrolyte Balance. During an acute attack of biliary colic, the client remains on NPO status, with IV fluids administered to maintain hydration. The client may lose fluids if an NG tube has been inserted for symptomatic relief of vomiting or if pancreatitis is a probable diagnosis. The diet progresses according to the client’s tolerance. The client is advised to avoid foods that precipitate biliary colic. Instructions may include avoiding a fatty meal or a large meal after fasting.

Nonsurgical Approaches to Eradicate Stones

1. Endoscopy. Retrograde endoscopy for stone removal is an important nonsurgical alternative. To remove a gallbladder stone from the common bile duct, the physician passes an endoscope orally into the duodenum and then passes a wire snare into the common bile duct through the ampulla of Vater, securing and removing the obstructing stone. The physician may choose to enlarge the ampulla of Vater by endoscopic papillotomy to allow passage of stones. If stones remain in the common bile duct after

cholecystectomy and a T tube is still in place, the physician may pass a stone retrieving basket or other device through the T-tube tract to remove the stone.

2. Gallstone Dissolution (Cholesterol-Dissolving Agents). The oral administration of agents for dissolving cholesterol gallstones, chenodeoxyholic acid (CDCA), or chenodiol, and ursodeoxycholic acid, or ursodiol (UDCA), may be used in selected clients who refuse cholecystectomy or who are not good candidates for surgery. The dose is 7 mg/kg daily of each or 8 to 13 mg/kg or ursodeoxycholic acid in divided doses daily. Both drugs act to reduce the amount of cholesterol in bile; however, each drug uses a different mechanism. The highest success rate occurs in clients with small floating, radiolucent gallstones. It is likely, however, that fewer than 10% of clients with manifestations of cholelithiasis are candidates for this type of treatment. In addition, stones tend to reoccur (30% to 50% over 3 to 5 years of follow-up), and taking medication for an indefinite time can be costly. Because of these disadvantages and the success of laparoscopic cholecystectomy, the use of oral cholesterol dissolving agents has largely been reduced to gallstone dissolution in clients who wish to avoid or are not candidates for elective cholecystectomy.

3. Extracorporeal Shock Wave Lithotripsy. Extracorporeal shock wave lithotripsy (ESWL) may be used as an ambulatory treatment in some cases. The client should have symptomatic cholelithiasis with fewer than four stones, each smaller than 3 cm in diameter, and no history of liver or pancreatic disease. Contraindicatiobs to the procedure are the presence of common duct stones, recent acute cholecystitis, cholangitis, and pancreatitis.

Up to 1500 shock waves are directed at the stones until they are crushed during the hour-long procedure. The minute particles are then able to travel through the biliary ductal system to be excreted via the intestine. IV conscious sedation with fentanyl citrate (Alfebta) or midazolam hydrochloride (Versed) may be used to minimize the mild discomfort that some clients experience while expelling the tiny stone fragments.

After lithotripsy, minor complications may include ecchymosis over the area of entry of the shock waves, gross or microscopic hematuria because of the proximity of the right kidney, the biliary pain when large fragments pass through the cystic duct.

Lithotripsy is used infrequently as an option for treatment because of the emergence of laparoscopic cholecystectomy as the procedure of choice for symptomatic cholelithiasis. In addition, the procedure is less an option because about 30 % of clients experience gall stones within 5 years of lithotripsy combined with medical litholytic therapy and because of the high cost of taking UDCA for a variable period after the procedure.

Monitor for Complications. Monitoring for complications of gallstone disease includes observing, most commonly, for development of manifestations of biliary colic. Conditions such as bile duct obstruction, cholangitis, pancreatitis, acute calculus, and cholecystitis may occur and cause manifestations consistent with gallbladder disease and subsequent sepsis and death. People with diabetes mellitus and gallstones are more susceptible to complications of sepsis.

Because the gallbladder is left in place in all interventions except cholecystectomy, recurrence of stones is likely. Investigation continues on long-term prevention of the recurrence of gallstones.

Self-care Management

Medications. After assessing the level of understanding and learning needs, educate the client about the purpose of oral dissolution therapy, expected responses, and possible untoward reactions. Because oral dissolution medication must be taken over a long period, help the client to devise ways to remember to take medication daily. For example, a pillbox that is divided into the days of the week clearly indicates whether the client has missed a dose. The client who is being treated medically may be sent home with oral analgesics or other medications for comfort as well as with an oral dissolution agent. Be sure that the client and his or her significant others can relate all necessary information to the nurse before discharge.

Diet Modification. Diet instructions may be necessary if ingestion of food precipitated the attack; that is, if a fatty food caused the biliary colic, inform the client about the need for a low-fat diet.

Prevent Recurrence. Advise the client about what to do if another attack occurs. The client has probably been encouraged by the physician to consider elective cholecystectomy or other surgical intervention before gallbladder disease progresses. Provide written material on gallbladder disease at this time to aid the client in understanding and in making decisions.

Surgical Management

1. Laparoscopic Cholecystectomy.Indications. It has become the treatment of choice for symptomatic gallbladder disease. The procedure is suitable for most clients, even those with acute cholecystitis, because there is minimal trauma to the abdominal wall. This makes it possible for client to go home within 24 hours after the procedure and return to work within a few days instead of a few weeks, as is the case with a cholecystectomy.

With the client under general anesthesia, carbon dioxide is used to create pneumoperitoneum through a needle inserted near the umbilicus. Near the umbilicus, an endoscope is inserted through a small incision to view the gallbladder and to determine the feasibility of success associated with this procedure. Three other small incisions are created: one for grasping the gallbladder, one for suction and irrigation, and one for discussion instruments and applying clips.

Contraindications. Laparoscopic cholecystectomy is contraindicated if stones are known to exist in the common bile duct. Laparascopic cholecystectomy does not allow exploration or removal of stones from the common duct.

Complications. Possible complications of surgery or anesthesia include damage to the biliary tract and hemorrhage. Operative cholangiography is a protective procedure for complications of cholecystectomy. Laparoscopic cholecystectomy carries a nearly twofold higher risk of major bile, vascular, or bowel complications compared with open cholecystectomy. The advantages of small scars and a short hospital stay, however, have influenced surgeons to opt for this procedure more often. Clients who undergo this procedure are at less risk because they are ambulatory sooner and usually require only oral analgesia. Because of the carbon dioxide pressing on the diaphragm, nausea, vomiting, and shoulder pain are more frequent if the client’s head and torso are elevated too soon after surgery.

Outcomes. Most clients are discharged on the day of surgery or the day after. In most cases, they can resume normal activities and return to work after 3 to 4 days.

2. Cholecystectomy

Indications. A cholecystectomy consists of excising the gallbladder from the posterior liver wall and ligating the cystic duct, vein, and artery. The surgeon usually approaches the gallbladder through a right upper paramedian or upper midline incision. If necessary, the common duct may be explored through this incision. When stones are suspected in the common duct, operative cholangiography may be performed (if it has not been ordered preoperatively). The surgeon may dilate the common duct if it is not already dilated as a result of a pathologic process. Dilation facilitates stone removal. The surgeon passes a thin instrument into the duct to collect the stones, either whole or after crushing them. After exploring the common duct, the surgeon usually inserts a T tube to ensure adequate bile drainage during duct healing (choledochostomy). The T tube also provides a route for postoperative cholangiography or stone dissolution, when appropriate.

A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does not allow for retrieval of a stone in the common bile duct and when the client’s physique does not allow access to the gallbladder. Occasionally, when a client is very obese, the gallbladder is not retrievable via laparoscopic instruments. Further, a surgeon may have difficulty accessing the gallbladder in an adult with a small frame and may need to perform the conventional open cholecystectomy.

Contraindications. A client’s physical condition may not be able to withstand the stress of surgery, including loss of fluid, electrolytes, and anesthesia. Cholecystectomy, incision, and drainage of the gallbladder may be performed as an alternative procedure.

Complications. After cholecystectomy, monitor the client for the usual postoperative complications, such as hemorrhage, pneumonia, thrombophlebitis, urinary retention, and ileus. The risk of bile leakage into the abdominal cavity is more applicable to surgeries involving the gallbladder. With hemorrhage and bile leakage, the client feels severe pain and tenderness in the right upper quadrant, abdominal girth increases, bile or blood may leak from the wound, blood pressure drops, and tachycardia develops.

Outcomes. Cholecystectomy results in immediate cessation of pain in most clients and prevents development of complications such as acute cholecystitis, choledolithiasis, and cholangitis. Persistence of manifestations after removal of the gallbladder indicates (1) a possible misdiagnosis or functional bowel disorder, such as esophagitis, peptic ulceration, pancreatitis, or irritable bowel syndrome; (2) a technical error; (3) a retained or recurrent common bile duct stone; or (4) spasm of the sphincter of Oddi. Clients must be hospitalized for about three days before dismissal. They may be sent home with a T tube in place for 1 to 2 weeks. When stones are present in the common bile duct, research indicates that both complications and cost can be saved if preoperative Endoscopic Retrograde Cholangiopancreatography (ERCP) performed for suspicion of uncomplicated common bile duct stones is replaced by intraoperative cholangiography (IOC).

Nursing Health History

Past Health HistoryAccording to the client, he did not have any vaccinations or immunizations. “Hindi pa uso ang bakuna noon.”, as verbalized by the client. According to him, he experienced having mumps as his childhood illness. The client does not have any chronic illnesses. The client has intolerances to “hito” and “dalag”.When he eats either “hito” or “dalag” he will just vomit it. According to client, he consumes 2 packs of cigarette per day for 15 years. When the client has fever, cough, colds, or pain, the client does not immediately take medications. He first manages these through bed rest, increased intake of water, and tepid sponge bath specifically for fever. With regards to cough and colds, the client manages them by bed rest and increased fluid intake, too. With regards to pain, the client resorts to rest and he also asks the “hilot” to massage the body part that is painful, such as stomach, head, extremity or extremities. The client said that it affects him positively since the pain is being relieved. He had a previous hospitalization when he was 27 years old, due to a vehicular accident in which he suffered from bruises and abrasions in both upper extremities and he also had a fractured right leg. According to him, he was also admitted to the Cagayan Valley Medical Center. Four days prior to admission, the client experienced fever in the late afternoon. He first managed it by resting, increasing fluid intake and tepid sponge bath. The client’s home management had relieved him. The next day or three days prior to admission, he still experienced having fever and he said that he also had tonsillitis since, he felt pain whenever he swallowed. He managed this by first increasing fluid intake, but at that day, when he can’t already bear his tonsillitis and fever, he took paracetamol and he drank warm water with salt for his sore throat. According to the client, his management for his tonsillitis and fever helped in relieving him, and he said that he no longer feels that he has a fever since when he palpated his head and neck for temperature, he was not that hot anymore. The client still has tonsillitis. Two days prior to admission, the client experienced pain in his upper abdomen up to his back. He rated the pain as 8/10.He described it as, “parang binubugbog yung tiyan ko.” He took mefenamic acid to relieve the pain. He asked the service of a “hilot”, and it relieved the pain slightly. His pain scale rate after he was massaged by the hilot and took mefenamic acid was 7/10, which the client described as slightly bearable pain. He did not bother seeking medical attention. On the next day, the pain recurred again in the afternoon at a pain scale rate of 10/10, and the client took mefenamic acid but he was not relieved and in here, the client was already brought to Cagayan Valley Medical Center by his wife with the help of their relative.

Present health history

The client was admitted in the Cagayan Valley Medical Center in the Emergency Department with a chief complaint of epigastric pain. They inserted an intravenous catheter to the client and gave him an intravenous fluid, in which the client and his significant other cannot remember even the color. They also gave him pain medications for his epigastric pain. The client rated his pain from being 10/10 to 7/10. The significant other cannot remember the pain medications given to the client. The client was then admitted and transferred to the surgery ward for further care and observation. The client was assessed by submitting him to have an ultrasound and was diagnosed to have cholelithiasis. The client was not yet scheduled for operation, because he said that according to his doctor, he was still under observation. The client was not scheduled for operation for his first four days in the hospital. On his fifth day, the client signed a discharge against medical advice, since they cannot already afford the medications prescribed for the client.

Family Health history According to the patient his father has a heart disease. There are no other hereditary diseases in his mother’s side. His children don’t have any chronic illnesses. According to the client, there was no one in their family who had cholelithiasis, even with his close relatives. In their family, his father was the only one who was hospitalized twice because of his heart disease. His wife also doesn’t have any chronic illnesses. The client is 34 years old and his wife is 32 years old and they have 4 children but their second child died due to aspiration during breastfeeding, because there had been a wrong position of the baby while breastfeeding. Their first child is male and is 9 years old and was born on January 1, 2003, second child (died) is male and is supposed to be 6 years old was born on July 24, 2006, the third child is a

female and is 5 years old was born on December 3, 2007 and their last child is a male and is 3 years old was born on December 20, 2009. His first child is in the third grade. His third child is in kindergarten. His youngest child is not yet going to school.

Social history

According to the client, he has a good relationship with his wife, children, parents, relatives, neighbors and co-workers. According to him, he wants to work hard for his family and he doesn’t want to see his family failing to satisfy their needs such as food, clothing and education for his children. When they cannot handle their problems, they ask for help from their family members and friends. According to him, he doesn’t mingle too much with his neighbors but he is in good terms with them. Regarding his co-workers, they have unity in accomplishing their tasks in the farm according to the client. Regaring his relatives, they help one another in times of need. The client usually celebrates birthdays by preparing food and inviting his parents and relatives to the said occasion. The client is not involved in any organizations in the community.

Sexual history

He had his coitarche when he was 22 years old. He has 4 children. He said that their frequency of having coitus varies. It depends on their mood and physical condition. His first child is male and is 9 years old and was born on January 1, 2003; his second child (died) is male and is supposed to be 6 years old was born on July 24, 2006; his third child is female and is 5 years old and was born on December 3, 2007; and his fourth child is male and is 3 years old was born on December 20, 2009. His first child died when it was just 24 days old because of wrong position during breastfeeding. The client does not use any contraceptives. They only engage in natural contraception. He acts according to his sexuality. They do not experience any pain in having sexual intercourse.

Gordon’s 11 Functional Patterns

Health Pattern Before Illness During Illness1. Health Perception-

Health Management Pattern

Purpose: To determine how the client perceives his or her health. The client’s ability to perceive the relationship between activities of daily living and health is also determined.

When the client was asked to describe health, he verbalized, “Bago ako maospital, para sa akin ang kalusugan ang importante, kasi ito yung kailangan para magawa yung trabaho ng maayos.” He said that before he was hospitalized, he can actively do his work in the farm such as plowing, harvesting, carrying heavy loads of sacks and taking care of animals such as goats, carabaos, and horses. He even participates in the accomplishment of house chores such as cooking and washing of clothes. He rated his health as 9/10. Whenever the client has fever, cough, and colds, he manages them by resting, increased fluid intake and tepid sponge bath specifically for fever. The client does not immediately take medications or seek medical attention. He said that as long as he can manage his condition, he will not do so. When the client experiences pain, he also rests, and he asks for the service of a “hilot” to massage the aching part of his body like his stomach, head, back and his extremities. He said that this gives his body a positive effect, since it relieves the pain and makes the pain bearable. The client also takes Lagundi as a herbal medicine for cough. It was the only herbal medicine the client already used for managing an illness. He also takes paracetamol, antibiotics and mefenamic acid when his management is not enough. The client also uses medications such paracetamol for fever, antibiotics for cough, neozep for colds and mefenamic acid for pain. When we asked the client about self-examination, he said that, “nu matagenu ko ngana tu egga y mataki ta baggi, inna ku yari sunuka e furyatak ku penu nawawan y taki na.“Pero amme nga ugali nga innan y baggi nu ammu tu awan tu taki na.” When we asked the client if there are community health nurses who offer health services to them

The client describes health as, “nguri awan tu matageno mu tu taki na baggim.” He considers his current health condition as a hindrance to his work, because he already lost a lot of time because of the length of time he had been staying in the hospital. Another reason that it is a hindrance is that, it requires him to adjust his workload according to his physical abilities, and he expects that he will be less productive. He rated his health as 5/10. Regarding his health management, the client said that he believes in the quality of care the doctors and nurses are rendering him, and he said that their management of his condition relieves him. When the client was admitted, they inserted an intravenous line and gave him medications such as pain reliever, but he cannot remember the name of the pain medication and he cannot also remember the other drugs given to him in the emergency room. The pain medication given to him relieved the pain he is feeling. He said that his pain scale that time became 7/10. The client said that during his first four days in the hospital, he and his wife are compliant on the prescriptions but, he became less compliant of the treatment regimen because they have financial constraints. The client believes that his personal management such as having “lakas ng loob” will help him in his recovery. Even if he is under the care of the medical team, he still believes in “hilots”. Regarding the client’s activities in the hospital, the client is having a hard time ambulating since he feels weak.

in their place, the client said that he asks community health nurses who pass by to take his blood pressure, though this happens rarely according to the client. The client can’t remember the last time when he got his blood pressure measured outside the health care facility. Regarding the health promotion practices of the client, he said that he considers his work as his exercise, as well as his accomplishment of some house chores such as cooking and washing of clothes.

2. Nutritional-Metabolic Pattern

The client said that he usually eats approximately 3 cups of rice a day, approximately 1 cup per meal of the day. This amount is not the constant intake of the client. His intake depends on his workload for the day. The more things he does during the day, the more intake of rice he has. The client’s usual diet is composed of vegetables, meat specifically pork and carabeef, fish except “hito” and “dalag” from which the client is allergic. The client first experienced his allergic reactions to these foods when he was 25-30 years old. The client also includes the adipose part of meat when he eats. The client eats three times a day. He eats breakfast at 6AM, lunch at 10 or 11AM, and supper for 5 PM. The client’s food preferences include the following: for meat he favors “adobo” specifically pork, for vegetables he favors “agaya”, for rice, he favors “sinangag”. The client also favors sweet foods such as, “fried camote fruit dipped in sugar”, and banana cue. The client also eats snacks if they have enough financial resources. In snacks, he usually eats bread and coffee or fried camote, or banana cue. The client said that he is not choosy in the foods he eats, “basta egga y makan e ok ngana yari. Kesa awan tu makan. Mas makkafi nga nu amme nga kuman”. The client does not take in multi-vitamins. Regarding the client’s fluid intake, he drinks approximately 7-10 glasses of water a day. The client also drinks soft drinks. The client favors coffee

The client said that when he was hospitalized, he was instructed not to eat or drink anything. He complied with this prescribed diet and had been inserted with an intravenous fluid, which is D5LRS as main line and multivitamins + glucose or Bitagen as side drip line. The D5LRS is regulated at 30-31 gtts/min and the Bitagen is regulated at 5 gtts/min. The client was 4 days under the diet of nothing per orem. On July 25, 2012, the physician ordered the client to be on a general liquid diet, so the client ate a cup of soup and drank approximately 500 ml of water. The client has 24 teeth. His two incisors in upper part in front are damaged (presence of cavities), and he lost 3 molars in the left lower part, 2 molars in the right lower part, 2 molars in the left upper part and 1 molar in the right upper part. The client does not remember the instances when he lost his teeth. He only recalls that 3 of those teeth were removed by the dentist due to damage. The client rarely goes to the dentist, approximately once every year, and he visits only for the reason of removal of a damaged tooth or damaged teeth. The client’s current weight is 64.8 kg, and his height is 5 feet and 6 inches. He has a Body Mass Index of 23.06 which is considered normal.

that is very sweet. The client is alcoholic wherein he can drink 1 bottle of gin, and 3 bottles of red horses. The client also smokes and can finish 2 packs per day. The client has no problems in chewing and swallowing. The client’s weight was 68 kilograms and his height was 5 feet and 6 inches. He has a Body Mass Index of 24.1, which is considered normal. Three days prior admission, the client developed tonsillitis, which made it difficult for him to swallow. He also experienced nausea and vomiting, and he said that these occurred after he felt epigastric pain two days prior to admission. These instances affected his diet largely, because whenever he takes something in, he vomits it. With these, the client confined himself in chewing ice cubes. He did not immediately seek medical attention nor did he take any medications when he felt these symptoms, instead, he managed them at home. Besides from ice cubes, he also confined himself to clear broth.

3. Elimination Pattern The client usually voids 6-10 times a day. His urine has a color of yellow. He urinates without pain or discomfort. When we asked the client to tell us the approximated amount of urine he has in a day, he said that he urinates 1 liter to 1 and ¼ ml or 1000-1250 ml per day, since the client used 1 liter bottle to do an approximate measurement. Regarding the frequency of defecation, the client defecates once a day, with brown- colored stools. According to the client, his stools are soft and moist. At times, the client said that he observes that there are remains of what he ate in his stools like pechay and malunggay. He rarely experiences constipation and diarrhea. The client said that he also observed that his stools varied in color, from being brownish, his stools became blackish to grayish in color. The stools of the client are foul-smelling. Regarding the client’s urine, he described it as “gitta na danum”. The client cannot exactly

For the client’s stay in the hospital, the he said that he urinates 3-8 times a day. The color of his urine is dark yellow. It is approximately 500-1200 ml. He urinates without pain or discomfort. Regarding the defecation of the client, he told us that when he was in the hospital he defecated for two times throughout his confinement including the day when we interviewed him. He described his stools as grayish to blackish in color. His stools are foul-smelling. He said that he didn’t experience constipation and diarrhea.

remember when these changes started, what he can remember is that it can possibly be 1 month ago.

4. Activity-Exercise Pattern

The client’s activities of daily living include plowing the field, accomplishments of house chores such as washing of clothes, cleaning their house and surroundings and cooking, and taking care of farm animals. He considers these activities of daily living as his exercise. He said that his work in the farm affected him both positively and negatively. The positive effect is that it is already his exercise and the negative effect is that the he is exposed to the sun’s heat which gives him sunburn at times of prolonged exposure. Prior to hospitalization, when the client had fever, tonsillitis and pain in the upper abdomen, he was not able to do his activities of daily living. He just rested all day and his activities were just directed on managing himself. This occurred for four days.

The client said that his activities in the hospital were restricted. The client stays in bed almost all of the time, unless he will urinate or defecate wherein he needs to go to the bathroom. The client said that he rarely ambulates.

5. Sexuality-Reproduction Pattern

The client was a male. He was circumcised when he was 5 years old. He is married. He had his coitarche when he was 22 years old. He has 4 children. He said that their frequency of having coitus varies. It depends on their mood and physical condition. His first child is male and is 9 years old and was born on January 1, 2003; his second child is male and is supposed to be 6 years old and was born on July 24, 2006; his third child is female and is 5 years old and was born on December 3, 2007; and his fourth child is male and is 3 years old and was born on December 20, 2009. His second child died when it was just 24 days old because of wrong position during breastfeeding. The client does not use any contraceptives. They only engage in natural contraception.

The client said that his sexual life was affected by his hospitalization since, in the hospital, he was not able to do the physical activities that pertain to his gender, and he does not have the privacy to express his feelings to his wife.

6. Sleep-Rest Pattern The client usually sleeps at 9 pm and wakes up at 4 or 5 am. The client sleeps for 7-8 hours. He described his sleep as continuous, without disturbances. He also sleeps in the afternoon for 1-2 hours. The client considers his

The client sleeps for 5-6 hours a day. He described his sleep as always being distracted by the noise in the ward and the performance of procedures like vital signs taking and administration of medication. He

sleeping time enough for him to be considered rested and have his effort regained in the next day for his daily work. The client usually rests in periods in between his time frame for work if he already feels tired.

considers his sleep time as deficient for him to be considered rested.

7. Cognitive-Perceptual Pattern

The client’s educational attainment was Grade 5. He is the one who decides for their family. He solves problems by asking assistance to his wife. When the client felt pain before he was hospitalized, he rated the pain as 10/10. The pain he felt was located in the upper part of his abdomen and he feels that it also radiates in his back directly. The client can speak Ibanag, Ilokano, and Tagalog.

When they gave the client pain medications, the client’s pain scale rate was 7/10. The client has no knowledge about the disease process, since he cannot define the disease in a simple way and he does not know the manifestations of the disease that he is experiencing.

8. Role-Relationship Pattern

The client is a husband, son, and father of four children. He has a good relationship with his family and parents. His children respect and love him as their father. His wife is very loving and faithful to him, which makes their relationship better. His first and third children are already going to school. His first child is in the third grade. His third child is in kindergarten. They also have misunderstandings at times, but they consider those things as challenges to surpass, that will make their relationship stronger. The client has also a good relationship with his parents. He visits them during weekends when he has enough time and means to visit them. He is also in good relationship with his neighbors and relatives. The client said that he does not frequently talk to them, but in times of need, they mutually help one another. Regarding his co-workers, he is also in good relationship with them, since they work with one another and they help one another in times of need.

The client’s role as a father to his children was affected by his condition, since he focused on his management of his illness and somehow had deficiencies in his role as a father, financially and emotionally. His relationship with his children was strengthened by his condition. Their relationship as husband and wife was also affected, but in a positive way. It enhanced his wife’s support to him. His relationship with his neighbors was also affected since, his neighbors and relatives helped him in his financial needs in his hospitalization. His relationship with his co-workers was affected since he had been absent from work for quite a long time and this affected their productivity as farmers.

9. Self-perception-Self-concept Pattern

The client perceives himself as a hardworking, kind-hearted, understanding and loving person. He is a loving husband and father to his children. He does all things just to satisfy the needs of his family. He is also a loving son, neighbor, relative and co-worker. The client considers himself as skilled in farming and taking care of

The client perceives himself as sick and a person who needs the help of others. He still considers himself as kind-hearted, understanding, and loving. He said that he may not be hardworking in action by now, but he misses to work in the field and he misses his times of hard work. His skill in being a farmer and caretaker of animals

animals. The client loves his work, because he believes that it is the way where he can satisfy the needs of his family. He treasures the foundation of his family.

was affected by his condition. His love for work was affected since he misses his work as a farmer and he is worried about his losses of opportunity costs in his work.

10. Coping-Stress Tolerance Pattern

The client perceives stressful events as challenges in his way of managing life. Their financial problems are his main stressors in life, because it affects how they will be able to manage their needs in all aspects. The client copes to stress through asking the help of his relatives as well as the advice of his parents. He also prays to GOD for him to cope up, since he becomes enlightened through prayer. Prior to hospitalization, the client had been stressed with his health condition.

The client is stressed with his illness. He is anxious about his present condition. He is also stressed with their financial state. He manages his stress regarding his illness through complying with interventions of the doctors and nurses. Their problem regarding financial aspect was managed by asking the help of their relatives.

11. Value-Belief Pattern The client is a Roman Catholic. The client grew up with Filipino values of blessing to parents before going away from home and after arriving at home. He was also oriented by his parents to greet people even if he does not know them personally. He believes in quack doctors. He also believes in the power of spirits to cause disease. He also believes that faith in GOD will help in every trial in life he will encounter.

The client’s faith in GOD was strengthened when he was hospitalized. He prays the rosary in the hospital to ask GOD’s guidance in his present health condition. The values he learned from his parents were also affected by his illness since he became irritable and sensitive. He still believes in quack doctors. He believes that the soul of his first child is one of the causes of his illness, because he believes that his child is displeased that they did not prepared foods for his birthday. The client said, “parang pag pipikit ako parang nakikita ko yung anak ko”.