cholecytitis

A Case Study

Presented to the Faculty of

The Ateneo de Davao University

College of Nursing

A Case Study on

Cholecystitis with Gallstones,

Diabetes Mellitus Type 2

Submitted by:

Kristi Ann Cabonita

Marie Allexis Campaner

Francis Thomie Caranay

Rico Janrev Castañeda

Rashed Eduard Ceniza

Joanna Paula Concepcion

Submitted to:

Loreto Deonaleth Estor, RN, MN

July 2010

TABLE OF CONTENTS

Acknowledgement………………………………………………………………….…3Introduction……………………………………………………………………………4Objectives…………………….……………………………………………………….6Patient’s Data………………………………………………………………………….8Genogram………………………………………………………………………………Health History………………………………………………………………………….9Developmental Data…………………………………………………………………...12Physical Assessment……………………….…………………………………………..17Complete Diagnosis……………………………………………………………………21Anatomy and Physiology………………………………………………………………22Etiology…………………………………………………………………………………27Symptomatology…………………………………………………………….………….32Pathophysiology…………..……………………………………………………….……35Doctor’s Order……………………………………………………………………..……49Diagnostic Examination.………………………………………………………………..58Drug Study………………………………………………………………………………74Nursing Theories…………………………………………………………………………92Nursing Care Plans……………………………………………………………………….95Discharge Planning……………………………………………………………………….107Prognosis………………………………………………………………………………….110Conclusion………………………………………………………………………………..113Recommendation………………………………………………………………………….114Bibliography……………………………………………………………………………….117

ACKNOWLEDGMENT

In accomplishing great things, we must not only think, but believe in the power of our

cognition; not only aim but make our visions tangible; and at the end of the day, not only smile

at the thought of accomplishment, but look back to where the strength to achieve such success

came from.

The proponents would like to extend their warmest gratitude to all the people who helped

make the success of this undertaking a reality.

First and foremost, to our parents, for giving us support and encouragement every day,

for making us feel loved and cared for.

To our Clinical Instructor, Mrs. Loreto Deonaleth Estor, RN, MN, for her invaluable

time and effort rendered to us; for her guidance all throughout the our ward exposure. For being

a friend and companion in the area.

And lastly, to the Almighty Father, for His unceasing love and blessings; for giving us

enough power and fortitude to face all the hardships in the making of this work. To Him be all

glory and praise!

INTRODUCTION

The gallbladder is a small pear-shaped organ which aids in the digestive process. Its

function is to store and concentrate bile - a digestive liquid continually secreted by the liver. The

bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in

the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the

gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of

the majority. The gallbladder tends to be taken for granted – ignored of the proper care and

conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a

room for gallbladder complications to occur.

This study is about cholelithiasis. Problems with the way bile is made and excreted (emptied)

from the gallbladder may cause cholelithiasis. Bile is a balanced mixture of water, cholesterol

(fat), bile salts and bilirubin (yellow pigment). Stones may be made from different bile materials.

Cholesterol stones are formed when the bile has too much cholesterol and not enough bile salts.

It is thought that liver and blood diseases, such as hepatitis and anemia, may cause pigment

stones. Gallstones may also be formed when bile does not empty from the gallbladder as fast as it

should. In an Italian study, 20% of women had stones, and 14% of men had stones. In a

Danish study, gallstone prevalence in persons aged 30 years was 1.8% for men and 4.8% for

women; gallstone prevalence in persons aged 60 years was 12.9% for men and 22.4% for

women. (http://emedicine.medscape.com/article/774352-overview). In the Philippines, there

were 131 males (18%) and 609 (82%) females, with a female ratio male 4.6:1. Benign lesions

http://emedicine.medscape.com/article/774352-overview

comprised 99% (mean age 36), mostly chronic cholelithiasis (97%) and acute cholelithiasis

which constituted 15 cases only (2%), malignant lesions comprised only 7 cases for example 1%

of all lesions (mean age 65)

(

http://www.thedoctorsdoctor.com/diseases/gallbladder_chronic_cholelithiasis.htm#epidemiology

).

The significance of studying this case is to enhance or broaden our knowledge as well as the

patient’s who are suffering this disease and also to those people who are in high risk of having

this disease for us to share our knowledge for the primary prevention and simple interventions of

the disease. Thus they are in a pursuit for knowledge to be able to impart it to others.

Furthermore, this case is quite interesting since it does not always affect only females and

elderly. It can affect everyone. It can be alarming since many people are confused and unaware

of the symptoms presented. As teen-agers living in a fast-phased world and governed by

schedules, they too are predisposed to lifestyle modification – especially diet and food

preferences which can contribute to the disease. With this study, the student nurses hope to apply

their learning in taking care not only of their patients but also of themselves.

http://www.thedoctorsdoctor.com/diseases/gallbladder_chronic_cholelithiasis.htm#epidemiology

OBJECTIVES

After 3 days of data gathering, research and analysis, the student nurse shall have devised

objectives that will guide them for the proper understanding and fair interpretation of the case of

their chosen patient.

GENERAL OBJECTIVES

Cognitive

The student nurse’s first main goal is to gain knowledge through the completion of the

case study and to impart this learning to the patient, and to those directly and indirectly involved

with the completion of this case.

Specific Objectives under Cognitive aspect

Within the 3 days span of duty, the student nurses will be able to:

- Gather significant data from the patient’s chart which includes the doctor’s order,

laboratory exams and etc. to have complete information about the patient’s current

condition.

- Research on the anatomy and physiology of the clients affected system.

- Research on the possible causes and also the symptoms the patient experienced that may

suggest the current condition of the patient.

- Research and understand the disease process of the patient’s illness.

- Determine and interpret the medical management employed including laboratory and

diagnostic procedures.

- Identify and study the drugs prescribed to the patient which affects the patient’s current

situation.

Psychomotor

- In this aspect, the student nurse’s goal is to apply all what they have learned during the

process of completing this case study to improve nursing care that will meet the patient’s

need for the improvement of his general welfare.

Specific Objectives under Psychomotor aspect


- Conduct a thorough physical assessment and to interpret the assessment in order to give

the care the patient need

- Formulate nursing care plans and apply them to satisfy the patient’s needs and give

appropriate nursing interventions.

- Make a discharge plan for the patient using M.E.T.H.O.D and validate the patient’s

prognosis according to categories.

Affective

- With the knowledge gained and through the application of this knowledge, another goal

is that the student nurses will be able to empathize with the current situation of the patient

and to gain some values like the value of patience and calmness which is important for a

them to have in order to become better nurses in the future.

Specific Objectives under Affective aspect


- Establish rapport and therapeutic communication in order to gain information about the

patient which includes the medical and family health history, expectations of his

condition, gather significant data from the patient’s chart and to his family and etc.; and

for the betterment of nursing care.

- Assume the role of being the patient’s advocate.

Patients Data

Name: Tommy

Age/sex: 59y.o/M

Address: 396 KM 5 Sampaguita St. Buhangin, Davao City

Birth date: 08/14/1950

Birthplace: Davao Oriental

Father: Francis

Mother: Marie

Date of Admission: 06-30-2010

Admitting physician: Dr. Analisa Moscoso

Chief Complaint: Right upper quadrant abdominal pain

History of Past illness:

Childhood- no previous admission or operation

Adult- hypertensive, diabetic

Injuries- none

Personal history: smoker, no food allergies , alcoholic,

History of present illness:

Patient is a known hypertensive and diabetic. 4 days PTA the patient had an onset of

abdominal pain located more on the epigastric area with lower back pain. He consulted a

physician and was again diagnosed with UTI and was given Ofloxacin.

One day prior to admission still with abdominal pain but patient verbalized it was more

on the right upper quadrant area, with fever. He was advised to have an abdominal ultrasound.

FAMILY BACKGROUND AND HEALTH HISTORY

Family Background

The patient’s parents, Francis who died with an ulcer and hypertension and Marie have 8

children. The patient is the second child among the children which is comprised by four boys and

four girls. The family used to live in Manay however in the year 1970 the couple decided to

transfer to Davao City for good together with their children. Our patient named Tommy was

already 20 years old then. In the year 1972 he met his wife Tessa whom he married in the year

1977. Until now they still live in Davao City particularly at Buhangin. Their marriage gave them

4 children with two boys and two girls. Their eldest child is already a graduate of a business

course but is jobless right now while the second child is presently working as a manager in a

private company. The third child works as a clinical instructor at the University of Immaculate

Conception. Lastly their youngest child is still a trainee at the Bureau of Fire and Protection. The

couple have their own small business which serves as their source of income. The couple usually

earns at around 30,000-40,000 a month with nata de coco production business here in Davao and

a coconut plantation in Manay. The family belongs to the middle class.

Since the family earns a decent amount of cash, they have their own private vehicle as

means of their transportation, their monthly electricity bill will range from 3,000-5,000 pesos,

their water bill is within 600-1000 pesos, their food would range at 10,000 pesos a month, and

they have their own helper.

Lifestyle and diet

Tommy wakes up at around 4:00-5:00 a.m. he then goes jogging and sometimes

biking which has been his daily routine until he got sick. Their usual meals include fish, meat

and vegetables. They also love eating fruits for desert like Durian. He also used to play

basketball regularly but stopped during his 40’s. He claims that he used to smoke 2 packs of

cigarette a day and also stated that he used to drink a bottle or two of beer with his friends every

week.

Past Health and Medical History

The patient claimed that he didn’t have a single immunization during his childhood. He

has been a hypertensive for four years, they have known this when he went for a check up in the

year 2006,he was then prescribed by the physician with a maintenance medication; Pritor 4 mg 1

tablet OD. He has also been a diabetic for three years now with a medication of Lamiperide 3 mg

OD. He has no food allergies.

Present Health and Medical History

Patient is a known hypertensive and diabetic. 4 days PTA the patient had an onset of

abdominal pain located more on the epigastric area with lower back pain. He consulted a

physician and was again diagnosed with UTI and was given Ofloxacin.

One day prior to admission still with abdominal pain but patient verbalized it was more

on the right upper quadrant area, with fever. He was advised to have an abdominal ultrasound.

Effects / Expectation of Illness

With that experience, Tommy was able to realize how important it is to have prompt

treatment to an illness. He stated the importance of a healthy balanced diet together with the

destructive effects of smoking and drinking. Because of his experience he learned to be cautious.

He and his family expect him to get well as soon as possible after the treatment and management

done to him.

DEVELOPMENTAL DATA

Erikson's Stages of Psychosocial Development

Erikson's eight stages reflect both positive and negative aspects of the critical life periods.

Erikson envisions life as a sequence of levels of achievement. Each stage signals a task that must

be achieved. The resolution of the task can be complete, partial, or unsuccessful. Erikson

believes that the greater the task achievement, the healthier the personality of the person; failure

to achieve a task influences the person's ability to achieve the next task. These developmental

tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to

the person's ego. Failure to resolve the crises is damaging to the ego.

Stage Description Result Justification

Middle

Adulthood

(25 to 65

years old)

GENERATI

VITY vs.

STAGNATI

ON

According to Erik Erikson, the

developmental task in middle adult

years is concerned for the next

generation as well as involvement

with family, friends, and

community. Generativity is the

concern of establishing and

guiding the next generation.

ACHIEVEDTommy is able to display behaviors that

are acceptable for his age that could say

that he achieved generativity. He is able

to expand his interests at this time with

his family’s support and has assumed

the responsibilities of middle –aged

person.He mostly spends his time with

his family together. Even though his

Socially-valued work and

disciplines are expressions of

generativity. Simply having or

wanting children does not in and of

itself achieve generativity.

During middle age the primary

developmental task is one of

contributing to society and helping

to guide future generations. When

a person makes a contribution

during this period, perhaps by

raising a family or working toward

the betterment of society, a sense

of generativity- a sense of

productivity and accomplishment-

results. In contrast, a person who is

self-centered and unable or

unwilling to help society move

forward develops a feeling of

stagnation- dissatisfaction with the

relative lack of productivity.

children are all grown up and busy with

their own life, they still make time for

each other and share to each other their

experiences. Their family is very open

to each other. Each family member is

able to express his/her feelings and

opinions. Tommy is a very responsible

father to his children and a father to his

wife. As a father, he has molded his

children into a better person they are

today, good and responsible person. As

a middle-aged adult, he is in to various

activities in the society in order to

maintain a good societal functioning like

participating in the development of their

own community.

Kohlberg's Stages of Moral Development

This theory specifically addresses moral development in children and adults. The

morality of an individual’s decision was not Kohlberg’s concern; rather, he focused on the

reasons an individual makes a decision.


Post-

Conventional

Stage (Social

contract

orientation)

People who exhibit

postconventional morality view

rules as useful but changeable

mechanisms—ideally rules can

maintain the general social

order and protect human rights.

Rules are not absolute dictates

that must be obeyed without

question. Contemporary

theorists often speculate that

many people may never reach

this level of abstract moral

reasoning.

The world is viewed as holding

different opinions, rights and

ACHIEVED

At this stage of Kohlberg's Moral

Development theory, the client

begins to account for the differing

values, opinions and beliefs of other

people. The patient views rules of

law are important for maintaining a

society, but members of the society

should agree upon these standards.

The family members are able to

express their feelings and thoughts.

They are very open to each other.

The patient sees to it that the

decision of the family should be

based on everybody’s opinion. They

discuss in the family if there are any

values. Such perspectives

should be mutually respected as

unique to each person or

community. Laws are regarded

as social contracts rather than

rigid edicts. Those that do not

promote the general welfare

should be changed when

necessary to meet “the greatest

good for the greatest number of

people”. This is achieved

through majority decision, and

inevitable compromise.

Democratic government is

ostensibly based on this

reasoning.

problems. Tommy sees to it that

everybody should be equal.

Freud's Model of psychosexual development

According to Freud’s theory of psychosexual development, the personality develops in

five overlapping stages from birth to adulthood. The libido changes its location of emphasis

within the body from one stage to another. Therefore, a particular area has special significance to

a client at a particular stage. If the individual does not achieve a satisfactory progression at each

stage, the personality becomes fixated at that stage.


Genital (13 years

and older)

Energy is directed

toward attaining a full

sexual maturity and

function and

development of skills

needed to cope with the

environment. This stage

involves a reactivation

of the pre-genital

impulses. These

impulses are usually

displaced, and the

individual passes to the

genital stage of

maturity. An inability to

resolve conflicts can

ACHIEVEDTommy is happily married with

Tessa and is still together and

loving each other. The couple

have four children. Although they

are not very active nowadays in

terms of their sexual drives, yet

they still manage to show their

love through a very mature way,

in loving and caring each other as

well as to their children.

According to Tommy, he did not

experience any sexual problem.

He has his family and other loved

ones who guide and help him

through the problems in life.

result in sexual

problems, such as

frigidity, impotence, and

the inability to have a

satisfactory sexual

relationship.

Physical Assessment

General Survey

Physical assessment was taken on July 6, 2010 at 11:00am, Six days 10 hours and 45

minutes after time of admission, 3 daysafter surgery. Received Sitting on bed, conscious, alert

and responsive with an on-going IVF bottle number D5LR + moriamin 2ampule at 170cc level

infusing well at a rate of 42-43 gtt/min to left metacarpal vein.

Upon entering in the room of a 59 year old male with spectacles who is watching

television with a height of 5’9’’ with a weight of 181 pounds and is wearing a dark blue colored

t-shirt and short pants. Appears clean and neat with hair combed. No noted foul body odor. Was

relaxed, fully rested with no hesitancy in changing body position. With good range of facial

expressions varying with mood. No noted pallor or other noticeable signs of illness. Is

cooperative and able to follow requests with promptness and is in a sociable mood and willing to

interact. Speech is understandable, moderate pace. Voice is fully audible, speaks at moderate

volume and has clear voice tone. Speaks clearly with coherent organization of thought, speaks in

logical sequence, makes sense and has good sense of reality with minimal vagueness and is able

to further respond to and clarify inquiries.

Vital Signs are:

Blood Pressure: 130/100

Respiratory Rate: 18

Pulse Rate: 82

Temperature: 36.1

Neurological System

Has no noted difficulty in speaking: Is fully oriented upon interview and is able to state

the current location, time of the day, day of the week, duration of hospital stay, duration of

illness and the names of the family members. With regards to memory, is able to recall various

events of the day including time seen by the physician and visits my family members and is also

able to recall and reiterate information given early in the interview. However has problems

recalling some health details such as the grade of eyeglasses. Has good attention span with

maintained eye contact. Fully conscious with spontaneous eye opening. Good motor function

upon verbal request and is able to converse normally with good grammar, sentence structure and

showed ability to speak bilingually.

Skin

Upon inspection, skin color varies from light to deep brown. Skin is generally uniform

except in areas exposed to the sun including face and upper extremities which is of a darker tone.

Skin is generally uniform except the areas exposed to the sun. areas of lighter pigmentation

include the palms, lips and nail beds. No edema noted. Moderate amount of facial wrinkles noted

most abundant on outer canthus of the eye, under the eye and around the mouth. Minimal amount

of dark spots and moles noted in left and right side of face particularly below the eye, neck and

chest. With noted patch of dry skin approximately 3 inches in length on right inner foot proximal

to talus bone and also on right elbow. Upon palpation, skin was neither excessively dry nor

excessively moist. Skin felt generally warm on areas under the cover of clothing but cool on the

arms. With a Temperature of 36.1. Skin springs back to previous state upon light pinching of the

left forearm indicating good skin turgor.

Head

Upon inspection, the skull is normocephalic and symmetric, with frontal, parietal, and

occipital prominences and has smooth skull contour. Palpation of the skull reveals absence of

nodules and masses has symmetric facial features. Facial movements are symmetrical and is

particularly evident when showing emotions such as smiling. Head is full of hair, generally black

in color but with moderate amount of gray strands, and short, not reaching ear level in langth.

Hair is parted through the left side and does not cover the face. Has thin hair strands and dry hair.

No presence of infection or infestation was noted.

Eyes

Wears spectacles however, were removed during the time of assessment. Eyebrows are

full of hair, equally distributed and generally black in color. Eyebrows were symmetrically

aligned with equal movement. Eye lashes were equally distributed and curled slightly outward.

The skin of the eyelids were intact, no discharges and no discoloration. Lids close symmetrically

however with noted infrequent blinking with a rate of 8 blinks per minute; bilateral blinking.

Upon inspection, sclera is generally white though with some noted redness near outer canthus of

both eyes. No noted visible sclera above corneas. Palpebral conjunctiva appeared smooth and

pink. Lacrimal gland, lacrimal sac and nasal lacrimal duct had no noted edema or tearing. Has

brown colored iris. Pupils are black in color, equal in size of about 2mm. Noted bouth pupil

having a distinct cloudiness upon inspection with a penlight. Both pupils constrict when

illuminated however, noted right pupil is more briskly reactive to light. Both eyes coordinated

and move in unison. Has noted visual difficulty when not wearing spectacles. Unable to read

print writing held with a distance of approximately 14 inches from front of face. With spectacles,

is able to read but still with noted difficulty as evidenced by squinting. Noted small temporal

peripheral field of vision on the both; unable to see object coming from right periphery until an

estimated 70 degrees from central field of vision.

Ears

During inspection, the color of auricles is same as the facial skin and is symmetrical.

Auricles are aligned with the outer canthus of the eye. Upon palpation, found to be firm and not

tender; no noted pain. Pinnea recoils after it is folded. Noted dry cerumen upon inspection with a

penlight but no noted excessive discharge or blood. Upon assessment of hearing, normal voice

tones are audible. No noted difficulty in hearing.

Nose

Upon inspection, nose is wide, symmetric and straight. Upon palpation, no noted

tenderness or lesions. Able to breath freely through nares. Noted olfactory difficulties. Upon

inspection with a penlight, mucosa is pink and full of hair; no noted swelling, redness, growth or

lesions. Nasal septum is intact and in the midline between the nasal chambers.

Mouth

Upon inspection outer lips are dark pink in color; appeared soft, moist and smooth; with

symmetrical contour and has ability to purse lips. Noted slight dryness and roughness. Inner, lips

are pinkish red and uniform in color; is moist, soft and smooth. Has no teeth on his upper gums.

Gums are pink, moist with presence some noted dark patches. No noted retraction of gums.

Tongue is in central position of the mouth, light pink in color; moist; slightly rough with noted

thin whitish coating in some areas. Papillae are raised. Able to move side to side. Smooth tongue

base with prominent veins. No noted lesions or dryness. Hard palate is light pink and irregular in

texture. Uvula is positioned in midline of palate.

Neck

During inspection, neck muscles are equal in size and head is centered. Coordinated head

movement. Has noted dry wound dressing on posterior portion of neck. Head has full range of

motion except when attempting to hyper extend. Shows hesitancy when attempting to

hyperextend and unable to hyperextend head to full 60 degrees. Upon palpation, no noted

enlarged lymph nodes. Trachea is in central placement in the midline of the neck. Thyroid gland

not visible upon inspection.

Chest and lungs

Has symmetrical anterior chest expansion with a respiratory rate of 18 breaths per

minute. Spine is vertically aligned. No noted productive coughing. Upon auscultation, no noted

adventitious breath sounds. Breathing pattern rhythmic and with minimal effort during

respirations. Right and left shoulders are of the same height. Anterior chest wall is intact, no

noted tenderness or masses. Posterior chest has full and symmetric respiratory excursion. Upon

palpation of the posterior chest there is bilateral symmetry of vocal fremitus although faint

vibrations. Upon percussion of the posterior chest, sounds resonate; no noted dullness or flatness

over lung tissue. Upon auscultation of the upper chest using a stethoscope, no noted adventitious

breath sounds.

Heart

Upon auscultation, the two heart sounds are audible, the systole and diastole. Upon

palpation of the carotid artery, pulse volumes are symmetric, with full pulsations and good

thrusting quality. Thrusting quality remains the same when client breathes, turns head, and

changes from sitting to from semi-fowler’s position. Radial pulse is also symmetric in volume

along with full pulsations and good thrusting quality. Noted increased pulse rate of 82 beats per

minute. Jugular veins not visible upon inspection.

Abdomen

Abdomen round, flabby and is uniform, medium brown in color with unblemished skin.

Noted wound dressing on upper right quadrant of abdomen. With noted abdominal pain upon

sudden movement. Abdomen has rounded, symmetrical countour. No noted enlargement of liver

or spleen. Has symmetrical movements upon respiration. Upon auscultation, bowel sounds are

audible, with irregular gurgling noises at a rate of two per minute. Upon palpation, no noted

tenderness; relaxed abdomen with soft texture.

Genito-Urinary

No noted change in urinary pattern. Urine is light yellow-colored. No noted pain while

urinating. No observed hematuria.

Back and Extremities

Upon inspection upper extremities and lower extremities are grossly proportional to body

shape. Nails of upper extremities are trimmed and cleaned with capillary refill of less than 2

seconds. Toenails are trimmed and cleaned. No noted deformities or edema. Upon palpation,

muscles are firm. No noted tremors. Upper body muscles are at 100% of normal strength on each

side of the body and able to fully move against gravity and resistance. Joints in upper extremities

have good range of motion. Joints move smoothly with no noted deformities, swelling, pain,

tenderness or crepitation. Spinal column vertically aligned. Noted difficulty ambulating without

assistance. Unable to stand unassisted. Suggested functional level classification of 3. Spinal

column is straight with no noted protrusions or deformities.

DEFINITION OF COMPLETE DIAGNOSIS

CHOLELITHIASIS

The presence of gallstones in the gallbladder. The condition affects about 20% of the

population above 40 years of age and is more prevalent in women and in persons with cirrhosis

of the liver. Many patients complain of unlocalized abdominal discomfort, eructation, and

intolerance to certain foods. Others have no symptoms. In patients with severe attacks of biliary

pain associated with cholelithiasis, cholecystectomy is recommended to prevent such

complications as cholecystitis, cholangitis, and pancreatitis. Also called chololithiasis. See also

biliary calculus, cholecystitis.

Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition

Also known as gallstones, these hard masses are formed in the gallbladder or passages,

and can cause severe upper right abdominal pain radiating to the right shoulder, as a result of

blocked bile flow.

Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc.

The presence of stones or calculi (gallstones) in the gallbladder results from changes in

bile components. Gallstones are made of cholesterol, calcium bilirubinate, or a mixture of

cholesterol and bilirubin pigment. They arise during periods of sluggishness in the gallbladder

resulting from pregnancy, use of oral contraceptives, diabetes mellitus, Crohn’s disease, cirrhosis

of the liver, pancreatitis, obesity, and rapid weight loss.

Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified

CHOLECYSTITIS

Cholecystitis, an acute or chronic inflammation of the gallbladder, is usually associated

with a gallstone impacted in the cystic duct; the inflammation develops behind the obstruction.

Cholecystitis accounts for 10% to 25% of all patients requiring gallbladder surgery.

Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition

Inflammation of the gallbladder, a complication of gallstones which are formed by cholesterol

and pigment (bilirubin) in bile. (Bile is produced in the liver and stored in the gallbladder).

Cholecystitis is frequently associated with infection in the gallbladder. Risk factors for

cholesterol gallstones include age, obesity, female gender, multiple pregnancies, birth control

pills, and heredity. The most common symptom is pain in the upper abdomen.

Smeltzer, Suzzane C. and Brenda G. Bare. Medical Surgical Nursing. Volme 2. 10th

Edition. Lippincott Williams & Wilkins: Philadelphia. Copyright © 2004.

Cholecystitis is inflammation of the gallbladder, a small organ near the liver that plays a part in

digesting food. Normally, fluid called bile passes out of the gallbladder on its way to the small

intestine. If the flow of bile is blocked, it builds up inside the gallbladder, causing swelling, pain,

and possible infection.

McCance, Kathryn L. and Huether, Sue E., Pathophysiology 2 nd Edition

http://www.medterms.com/script/main/art.asp?articlekey=10456

http://www.medterms.com/script/main/art.asp?articlekey=368

DIABETES MELLITUS

Diabetes mellitus is a group of metabolic diseases in which defects in insulin secretion or

action result in high blood sugar level.

Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia

resulting from defects in insulin secretion, insulin action, or both (The American Diabetes

Association, 1997). Type II DM is formerly known as Non-insulin Dependent Diabetes Mellitus.

Type 2 diabetes usually occurs at any age but most cases occur after age 30. More than 80% of

the clients are overweight and do always experience classic symptoms.

Kowalski, M.T., Rosdahl, C.B.;Basic Nursing

Diabetes mellitus occurs when beta cells are unable to produce insulin (Type I DM) or

produce an insufficient amount of insulin (Type II DM). As a result, glucose does not enter cells

but remains in the blood.

Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified

ANATOMY AND PHYSIOLOGY

HEPATOBILLARY TREE

LIVER

A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg; lies

under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform ligament

1. Left lobe- forms about one sixth of the liver

2. Right lobe- forms about five sixths of the liver; divides into right lobe proper, caudate lobe,

and quadrate lobe

3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein extends through

the center of each lobule

C. Bile ducts

1. Small bile ducts form right and left hepatic ducts

2. Right and left hepatic ducts immediately join to form one hepatic duct

3. Hepatic duct merges with cystic duct to form the common bile duct, which opens into the

duodenum

D. Functions of the liver

1. Glucose Metabolism

-after a meal, glucose is taken up from the portal venous blood by the liver and converted into

glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to

glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of

the blood glucose.

-glucose can be synthesized by the liver through the process gluconeogenesis

2. Ammonia Conversion

-use of amino acids from protein for gluconeogenesis result in the formation of ammonia as a

byproduct. Liver converts ammonia to urea

3. Protein Metabolism

-Liver synthesizes almost all of the plasma protein including albumin, alpha and beta globulins,

blood clotting factors plasma lipoproteins

4. Fat Metabolism

-Fatty acid can be broken down for the production of energy and production of ketone bodies

5. Vitamin and Iron Storage

-stores vitamin A, D, E, K

6. Drug Metabolism

7. Bile Formation

-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium, potassium, calcium, chloride, bicarbonate,

lecithin, fatty acids, cholesterol, bile salts

-collected and stored in the gallbladder and emptied in the intestine when needed for digestion

a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny spheres called

micelles

b. Sodium bicarbonate increases pH for optimum enzyme function

c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are wastes products

excreted by the liver and eventually eliminated in the feces

GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the

body is to harbor bile and aid in the digestive process.

Anatomy

· The cystic duct connects the gall bladder to the common hepatic duct to form the common bile

duct.

· The common bile romero duct then joins the pancreatic duct, and enters through the

hepatopancreatic ampulla at the major duodenal papilla.

· The fundus of the gallbladder is the part farthest from the duct, located by the lower border of

the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy

The different layers of the gallbladder are as follows:

· The gallbladder has a simple columnar epithelial lining characterized by recesses called

Aschoff's recesses, which are pouches inside the lining.

· Under the epithelium there is a layer of connective tissue (lamina propria).

· Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in

response to cholecystokinin, a peptide hormone secreted by the duodenum.

· There is essentially no submucosa separating the connective tissue from serosa and adventitia.

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at

its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on

theundersurface of the liver’s right lobe and is attached there by areolar connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is

arranged in folds called rugae, similar in structure to those of the stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time

the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs in the

stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the

duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of

bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the

feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue

enters the blood and is deposited in the tissues. The gallbladder stores about 50 mL (1.7 US fluid

ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters

the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the

liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the

gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency

and intensifying its effect on fats. Most digestion occurs in the duodenum.

BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is formed from senescent red blood cells. In

the process of degradation, the hemoglobin from the red blood cell is broken down from

biliverdin, which is rapidly converted to free bilirubin thru biliverdin reductase. Free bilirubin,

which is not soluble in plasma, is transported in the blood attached to plasma albumin. Even

when it is bound to albumin, this bilirubin is still called free bilirubin. As it passes through the

liver, free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes.

Inside the hepatocytes, free bilirubin is converted to conjugated bilrubin thru glucoronyl

transferase, making it soluble to bile. Conjugated bilirubin is secreted as a constituents of bile,

and in this form, it passes through the bile ducts into the small intestine. In the intestine,

approximately one half of the bilirubin is converted into a highly soluble substance called

urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the portal circulation or

excreted in the feces. Most of the urobilinogen that is absorbed is returned to the liver to be re-

excreted into the bile. A small amount of urobilinogen, approximately 5% is absorbed into the

general circulation and then excreted by the kidneys. Usually, only a small amount of bilirubin is

found in the blood; the normal level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory

measurements of bilirubin usually measure the free and the conjugated bilirubin as well as the

total bilirubin. These are reported as the direct (conjugated) bilirubin and the indirect

(unconjugated or free) bilirubin.

Anatomy and Physiology of the Pancreas

The pancreas consists of two major types

of secretory tissues. This reflects its dual function as an exocrine gland that secretes digestive

juice and as an endocrine gland that releases hormones. The exocrine function of the pancreas is

localized in the acinar cells that synthesize and secrete digestive juices. The endocrine function

of the pancreas is localized in the islet cells (islets of Langerhans), which synthesize and secrete

hormones including insulin and glucagon.

The exocrine pancreas is composed of closely packed acini draining into a series of

branched ducts. The acini are composed of several wedge-shaped serous cells surrounding a

central lumen. These are typical polarized secretory cells with a spherical nucleus and a

basophilic cytoplasm. Eosinophilic secretory vesicles rich in digestive enzymes (zymogen

granules) may be seen toward the apex of each acinar cell. The base of each pyramidal acinar

cell lies on the basement membrane which surrounds each acinus. Beneath this basement

membrane is a rich capillary network.

Interspersed among the exocrine acinar glands are lightly staining, spherical clusters of

cells without ducts, acini, or obvious zymogen granules: the endocrine islets of Langerhans. At

least 4 different kinds of cells in these clusters, specialized to produce different hormones. Alpha

cells stain deep pink by H+E and produce glucagon, which stimulates glycogenolysis and

lipolysis in other tissues to raise blood glucose levels. Beta cells stain stain light pink and

produce insulin, which has many effects, such as promoting other tissues (particularly liver

muscle and adipose tissue) to take up and metabolize glucose, lowering blood sugar levels.

Dysfunction or destruction of the beta cells is one of the many causes of diabetes. Excess blood

sugar (hyperglycemia) causes excretion of abnormally large volumes of urine rich in glucose.

The kinds of islet cells are less numerous and difficult to pick out without special staining

techniques. They produce several other hormones. These interspersed endocrine cells are

arranged as cords separated by a network of fenestrated capillaries. Both the endocrine cells and

the blood vessels are innervated by autonomic nerves.

ETIOLOGY AND SYMPTOMATOLOGY

A. ETIOLOGY

Predisposing

Factors

Present/ Absent Rationale Justification

Age Present According to the

Framingham Study, which

examined the risk factors

for cholelithiasis in a 10-

year follow-up study of 30-

to 59-year-old subjects, the

risk of cholelithiasis within

10 years was highest

among the 55- to 62-year-

old age group, and most of

the patients were diagnosed

with cholelithiasis in their

fifties and sixties. Although

the incidence of

The patient is aged 59

years old.

cholelithiasis in female

patients of all age groups is

more than double that of

male patients, the

difference between the

incidence in men and

women tends to shrink with

increasing age

Family History Present First-degree relatives

(parents, siblings, and

children) of individuals

with gallstones are 1 ½

times more likely to have

gallstones than if they did

not have a first-degree

relative with gallstones.

Further support comes

from twin studies that

genetic factors are

important in determining

who gets gallstones.

The patient reports of

having family

members who were

diagnosed with

cholelithiasis and

cholecystitis.

Sex Absent Women are more likely to The patient is male.

develop gallstones than

men, with a ratio of 2:1.

Race Absent Epidemiologic studies have

shown variations in the

prevalence of gallstones in

different ethnic

populations, with

particularly high rates in

Native Americans.

The patient is of

Asian Heritage.

Precipitating

Factors

Present/ Absent Rationale Justification

Obesity Absent Cholelithiasis is one of the

main diseases associated

with obesity. The

Framingham study also

confirms that cholelithiasis

patients tend to be more

obese than

noncholelithiasis patients.

The patient’s BMI is

within the normal

range.

However, there is a report

that this tendency is much

more prominent in female

than in male patients

Diabetes Mellitus Present Diabetes Mellitus accounts

for the swelling most of

the time in acalculous

cholecystitis. This is due to

the

The patient has

Diabetes Mellitus.

AIDS Absent Enlarged liver and/or

abnormal liver functions

are observed in two/thirds

of AIDS patients, some of

whom have biliary tract

disease. Ninety percent of

the patients complain of

upper abdominal pain and

have enlarged intra- and

extrahepatic bile ducts on

abdominal

ultrasonography.

Abnormal findings on

abdominal

The patient does not

have AIDS.

ultrasonography and

computed tomography are

seen in 81% and 78% of

patients, respectively.

Acalculous cholecystitis in

AIDS patients is

characterized by: (1)

younger age than in non-

AIDS patients, (2)

problems with oral

ingestion (3), right upper

abdominal pain, (4) a

marked increase in

alkaline phosphatase and a

mild increase in serum

bilirubin level, and (5)

association with

cytomegalovirus and

cryptosporidium

infections. According to a

review of abdominal

surgery for AIDS patients,

acute cholecystitis is the

most frequent reason for

performing open surgery

in AIDS patients.

Drugs Absent According to the review by

Michielsen et al.,

regarding the association

between drugs and acute

cholecystitis, 90%–95% of

acute cholecystitis cases

are caused by

cholelithiasis, and drugs

promoting the formation of

stones are indirectly

associated with a risk of

acute cholecystitis.

It is reported that women

taking oral conceptives

have a higher risk of

having gallbladder disease,

but there also is a report

The patient has not

been taking any drugs

in a long span of time,

specially those

mentioned to

contribute to stone

formation.

which denies the

association between the

disease and these drugs

(level 2a).54 Among

various drugs used for the

treatment of

hyperlipidemia, only

fibrate is shown to be

associated with gallstone

diseases (level 2b).55 One

report suggests that

thiazides induce acute

cholecystitis (level 3b),56

and another report denies

this association (level

3b).57 The administration

of a large dose of

ceftriaxone, a third-

generation cephalosporin

antimicrobial, in infants,

precipitates calcium salt in

bile and forms a sludge in

25%–45% of them, but

these effects disappear

when the medication is

discontinued (level 4).53 It

is reported that the

longterm administration of

octreotide causes

cholestasis, and that

administration for a year

causes cholelithiasis in

50% of patients (level

4).53 Hepatic artery

infusion will cause

chemical cholecystitis

(level 4).53 Erythromycin

and ampicillin are reported

to be a cause of

hypersensitive

cholecystitis (level 4).53

According to a meta-

analysis of the risk of

disease induced by

hormone replacement

therapy, the relative risks

(RRs) of cholecystitis were

1.8 (95% confidence

interval [CI], 1.6–2.0) and

2.5 (95% CI, 2.0–2.9) at

less than 5 years of

treatment and at 5 and

more years, respectively

(level 1a).58

Ascaris Absent The complications of

ascariasis include hepatic,

biliary, and pancreatic

diseases. Complications in

the biliary tract include:

(1) cholelithiasis with the

ascarid as a nidus for stone

formation, (2) acalculous

cholecystitis (3), acute

cholangitis (4), acute

pancreatitis, and (5)

hepatic abscess. Biliary

tract disease is caused by

the obstruction of the

The patient has not

been affected by any

scaris infection.

hepatic and biliary tracts

by the entry of ascarids

from the duodenum

through the papilla.

Ascarids entering the

biliary tract usually return

to the duodenum in a

week, but if they stay over

10 days there, they will die

and form a nidus for stone

formation.

Ascarid-associated biliary

diseases occur more

frequently in women

(male/female ratio, 1 : 3)

and less frequently in

infants. The risk of biliary

complications is higher in

pregnant than in non-

pregnant women. In

epidemic regions such as

China and Southeast Asia,

ascariasis is a frequent

cause of cholelithiasis.

Crohn’s Disease Absent Individuals with Crohn's

disease of the terminal

ileum are more likely to

develop gallstones.

Gallstones form because

patients with Crohn's

disease lack enough bile

acids to solubilize the

cholesterol in bile.

Normally, bile acids that

enter the small intestine

from the liver and

gallbladder are absorbed

back into the body in the

terminal ileum and are

secreted again by the liver

into bile. In other words,

the bile acids recycle. In

Crohn's disease, the

terminal ileum is diseased.

Bile acids are not absorbed

The patient doesn’t

have Crohn’s disease.

http://www.medicinenet.com/script/main/art.asp?articlekey=5512




normally, the body

becomes depleted of bile

acids, and less bile acids

are secreted in bile. There

are not enough bile acids

to keep cholesterol

dissolved in bile, and

gallstones form

High Levels of Blood

Triglycerides

Gallstones occur more

frequently in individuals

with elevated blood

triglyceride levels.

Drastic dieting /

Fasting

Absent Rapid weight loss by

whatever means, very low

calorie diets or obesity

surgery, causes cholesterol

gallstones in up to 50% of

individuals. Many of the

gallstones will disappear

after the weight is lost, but

many do not. Moreover,

The patient did not fast

nor attempted to lose

weight by drastic

measures.







until they are gone, they

may cause problems.

Fasting renders the

gallbladder less active,

thus making the bile more

concentrated.

Parity Absent Pregnancy increases the

risk for cholesterol

gallstones because during

pregnancy, bile contains

more cholesterol, and the

gallbladder does not

contract normally.

The risk of cholelithiasis in

women begins to increase

when adolescence begins

and it declines when the

menopause begins. It is

also said that the use of

oral conceptives is

The patient is male

correlated with a risk of

gallbladder disease. It is

considered, therefore, that

levels of estrogen and

progesterone are involved

in the formation of

gallstones. Cholecystitis is

the second most common

cause of acute abdomen,

following appendicitis, in

pregnant women, and

occurs in one of 1600 to 10

000 pregnant women.

Cholelithiasis is the most

frequent cause of

cholecystitis in pregnancy

and accounts for 90% or

more of all causes of

cholecystitis Routine

ultrasonography found

cholelithiasis in 3.5% of

pregnant women but it is

unknown whether

pregnancy increases the

risk of cholecystitis. The

frequency of

cholecystectomy in

pregnant women is lower

than that in non-pregnant

women. This is not

because of the lower

incidence of

cholecystectomy in

pregnant women, but

because physicians tend to

refrain from performing

any operation during

pregnancy. Though there

are few reports of patients

undergoing

cholecystectomy during

pregnancy, there is no

evidence that laparoscopic

surgery increases the

maternal or fetal risks.

B. SYMPTOMATOLOGY

Symptoms Present/Absent Rationale Justification

Biliary Colic Present Biliary colic is a very

specific type of pain,

occurring as the

primary or only

symptom in 80% of

people with gallstones

who develop

symptoms. Biliary

colic occurs when the

extrahepatic ducts-

cystic, hepatic or

common bile-are

suddenly blocked by a

gallstone. (Slowly-

progressing

The patient reported to have

experienced this symptom.

obstruction, as from a

tumor, does not cause

biliary colic.) Behind

the obstruction, fluid

accumulates and

distends the ducts and

gallbladder. In the

case of hepatic or

common bile duct

obstruction, this is

due to continued

secretion of bile by

the liver. In the case

of cystic duct

obstruction, the wall

of the gallbladder

secretes fluid into the

gallbladder. It is the

distention of the ducts

or gallbladder that

causes biliary colic.

Dyspepsia (with Present Due to the backing up The patient reported to have



abdominal bloating

and discomfort)

of bile, there is a

limited ability to

dissolve fatty

substances taken by

meals, thus causing

dyspepsia.

experienced this symptom

Flatulence Absent Patients usually have

symptoms of acute

cholecystitis in the

initial stage. (3)

emphysematous

cholecystitis, in which

air appears in the

gallbladder wall due

to infection with gas-

forming anaerobes,

including Clostridium

perfringens

The patientdid not manifest

this symptom.

Fever Present Fever is a sign of

infection and

inflammation

resulting from the

infection of

The patient reported to have

had experienced this

symptom.

microorganisms.

Increased WBC Present A high white blood

cell count suggests

inflammation, an

abscess, gangrene, or

a perforated

gallbladder.

The gallbladder wall

has white blood cells

present, with areas of

necrosis and

suppuration. In this

stage, the active repair

process of

inflammation is

evident.

The laboratory results of the

patient shows an elevation of

the patient’s WBCs

Right Upper

Quadrant Pain

Present Symptoms occur with

gallstones when the

gallbladder contracts,

often after a meal,

resulting in occlusion

The patient reported to

have had experienced

this symptom

of the cystic duct with

a stone that produces

symptoms, typically

pain. This pain may

even radiate to the

back behind the right

scapula and the right

shoulder.

Jaundice Absent Jaundice is a

condition in which

bilirubin accumulates

in the body. Bilirubin

is brownish-black but

yellow when it is not

too concentrated. A

build-up of bilirubin

in the body turns the

skin and whites of the

eye yellow. Jaundice

occurs when there is

prolonged obstruction

of the bile ducts. The

The patient did not

manifest this symptom.


obstruction may be

due to gallstones, but

it also may be due to

many other causes of

obstruction, for

example, tumors of

the bile ducts or

surrounding tissues.

Jaundice, by itself,

generally does not

cause problems.

Dark Urine Absent If people pass dark

urine and light-

colored stools, the

common bile duct is

probably blocked by a

stone, causing a

backup of bile in the

liver.

The patient did not

manifest this symptom

Clay colored stools Absent If people pass dark

urine and light-

colored stools, the

The patient did not

manifest this symptom

common bile duct is

probably blocked by a

stone, causing a

backup of bile in the

liver.

Murphy’s Sign Present Murphy's sign -

guarding in right

upper quadrant on

deep inspiration

The patient manifested

this symptom.

DOCTOR’S ORDER

DATE ORDER RATIONALE REMARKS

6/30/10

12:00

PM

Please admit patient under

the service of Dr.

Moscoso.

For close monitoring of the patient and

proper management of his condition

Admitted

Low salt and low fat,

diabetic diet, small

frequent feedings.

Low salt, low fat diet is designed to

limit the total amount of fat, salt and

cholesterol in the diet to reduce serum

lipid levels and avoid excessive sodium

retention to prevent ascites and

Patient informed

generalized edema.

Monitor Vital Signs q4

hours and record.

Vital signs are important for baseline

assessment and to monitor patients

condition which evaluates the whole

treatment course, especially the

medications he received that could be a

contributing factor in the variation

results of the vital signs

Taken and

recorded.

Laboratory tests:

Complete Blood Ccount

with Platelet

CBC with PC determines the quantity

of each quantity of blood cell in a given

specimen of blood, often including the

amount of hemoglobin, hematocrit, and

the proportion of various white blood

cells. This is done to know any

condition of the client that may affect

his medical management.

Done

Urinalysis Urinalysis is performed to screen for

urinary tract disorders, kidney

disorders, urinary neoplasm and other

medical conditions that produce

changes in the urine. This test also is

used to monitor the effects of treatment

of known renal or urinary condition.

Done

This test is also used to monitor the

effects of certain procedures done to

patient and to check if genito-urinary is

in normal state or not.

Fasting Blood Sugar A method for learning how much

glucose (sugar) there is in a blood

sample taken after an overnight fast.

The fasting blood glucose test is

commonly used in the detection

of diabetes mellitus.

Done

Serum Glutamic Pyruvic

Transaminase

SGPT is an enzyme that is normally

present in liver and heart cells. SGPT is

released into blood when the liver or

heart is damaged. The blood SGPT

levels are thus elevated with liver

damage (for example, from viral

hepatitis) or with an insult to the heart

(for example, from a heart attack).

Done

Serum Creatinine The test is done to evaluate kidney

function. Creatinine is removed from

the body entirely by the kidneys. If

kidney function is abnormal, creatinine

levels will increase in the blood

because less creatinine is released

Done

through your urine.

S. Uric acid Test is used to learn whether the body

might be breaking down cells too

quickly or not getting rid of uric acid

quickly enough.

Done

Lipid profile The lipid profile is a group of tests that

are often ordered together to determine

risk of coronary heart disease. They are

tests that have been shown to be good

indicators of whether someone is likely

to have a heart attack or stroke caused

by blockage of blood vessels or

hardening of the arteries

(atherosclerois).

Done

ECG The electrocardiogram (ECG or EKG)

is a diagnostic tool that measures and

records the electrical activity of the

heart in exquisite detail. Interpretation

of these details allows diagnosis of a

wide range of heart conditions.

Done but not

attached to chart

CXR (PA) A chest radiograph, commonly called

a chest x-ray (CXR), is a projection

radiograph of the chest used to

diagnose conditions affecting the chest,

Done

its contents, and nearby structures.

Chest radiographs are among the most

common films taken, being diagnostic

of many conditions.

Start venoclysis with

PNSS 1L @100cc/hr

(please incorporate

moriamin s2 2 amps)

Intravenous lines provide easy access

for drug administration intravenously

(IVTT). Plain normal saline solution is

isotonic to body fluid and is commonly

used for rehydration.

Moriamin s2 is an aminoacid supply

for the conditions such as malnutrition,

pre- and post-operations.

Started

Medications:

Paracetamol 500mg tab, 1 tab

q4h PRN or fever

Paracetamol is used to reduce

fever reduction.

Given

Clindamycin 300 mg IVTT

q12h (ANST)

Clindamycin is used to treat

serious infections caused by

susceptible strains of anaerobes

streptococci, staphylococci,

pnemococci , reserve use for

penicillin –a llergic patients or

when penicillin is inapprorpriate

Given

HNBB (hyoscine N-Butyl

Bromide or Hyoscine

HNBB is an antipasmodic drug. It

treats conditions associated w/

Given

ButylBromide) 1 amp now

then q8h

visceral spasms.

Lactulose 30 ml OD at bed

time

Lactulose is a laxative used to treat

constipation.

Given

I&O q shift Intake and output helps gauge

fluid balance in the body of the

patient. This would also check if

patient’s elimination pattern is

normal or impaired.

Done

Watch out for any unusualities To closely monitor patient and

prevent any complications.

Watched out

Refer accordingly This may create a collaborative

treatment among the client and the

health care providers; thus it also

makes a good coordination on the

treatment of the client.

Referred

Additional meds: (after breakfast)

Telmisartan (Pritor plus) 40mg

/ 12.5 mg 1 tab OD

An angiotensin II receptor

antagonist, this drug is an

antihypertensive drug to treatment

for hypertension, alone or in

combination with other

antihypertensive.

Given

Glimiperide 3 mg 1 tab OD Glimiperide is an antidiabetic Given

drug. It adjunct to diet to lower

glucose level in patients with type

2 (non-insulin dependent) diabetes

mellitus

9:00 pm Nalbuphine ½ amp IVTT now An Opoid agonist –antagonist

analgesic. It relieves moderate to

severe pain. Preoperative

analgesia, as a supplement to

surgical anesthesia.

Given

07/01/10

2:00 am

IVF to follow with PNSS 1L

with 2 amp moriamin s2 to run

at 100 cc/hr

Intravenous lines provide easy

access for drug administration

intravenously (IVTT). Plain

normal saline solution is isotonic

to body fluid and is commonly

used for rehydration.

Moriamin s2 is an aminoacid

supply for the conditions such as

malnutrition, pre- and post-

operations.

Hooked

9:00 am Follow up all lab results and

attach to chart

This is done since the laboratory

results are needed in the medical

management of the patient’s

condition.

Followed up and

attached to chart

Increase IVF ro 120 cc/hr To increase intake of the patient Regulated

through intravenous; to maintain

hydration.

Essentiale forte 1 tab TID Essentiale forte is an cholagogues,

cholelitholytics & hepatic protector

drug. This is given to the patient since

the ultrasound shoes tht the patient

has gall stones.

Given

Start levofloxacin 500 mg OD

ANST IVTT

A flouroquinolone antibiotic;

bactericidal interferes with DNA

inhibiting DNA gyrase repication

is susceptible gram negative and

gram positive bacteria prevent cell

reproduction.

Started

3:55 pm Glucovance 500 mg /5 1 tab

BID

An antidibetic drug that stimulates

insulin release from functioning

beta cells in th pancreas; may

improve binding between insulin

and insulin receprtors or increase

the numbers of insulin receptor :

more potent in effect than first

generation sulfonylurea.

Given

7/2/10

7:50 am

For surgical clearance please

inform Dr. Sanchez

Surgical clearance allows patient

to be prepared for the procedure.

Dr. Sanchez

informed

For repeat CBC To determine the effect of drugs Taken

given and to evaluate progress of

the patient.

For CBG now Capillary blood glucose testing is

used for the care of people with

diabetes as a monitoring tool

giving a guide to blood glucose

levels.

Taken

Soft diet Soft diet is a diet soft in texture,

low in residue, easily digested and

well tolerated; easy to chew and

swallow providing essential

nutrients in the form of liquids and

semisolid foods. This is also to

prevent gastric irritation and

stomach upset.

Patient informed

11:00

am

HGT = 11.4

For CBG q6h (5-11-5-11) To closely monitor patient’s blood

glucose.

Done

11:17

am

Humulin R 8 “u” IVTT now An antidiabetic drug given to

patient to reduce blood glucose.

Given

Schedule for OR 2 pm today

secure consent

To perform surgery to patient that

would remove the stones seen in

his gall bladder through the

Consent secured.

Scheduled for

OR

ultrasound done. Informed consent

is the permission obtained from

the patient/guardian to perform a

specific test or procedure. This

also evaluates whether the patient

has understood the surgeon and his

or her condition. To secure the

consent of the client is important

for legal purposes.

12:45

pm

For CP clearance c/o M

Durban

Cardiopulmonary clearance

required before surgery to ensure

that the patient doesn’t have any

cardiopulmonary problems which

could interfere and complicate the

surgery.

CP not cleared

For Trop I now Troponin tests are primarily

ordered for people who have chest

pain to see if they have had a heart

attack or other damage to their

heart.

Done

1:00 pm Pre-schedule OR 4 pm if with

cp clearance

To perform surgery to patient that

would remove the stones seen in

his gall bladder through the

ultrasound done. Informed consent

Not scheduled

is the permission obtained from

the patient/guardian to perform a

specific test or procedure. This

also evaluates whether the patient

has understood the surgeon and his

or her condition. To secure the

consent of the client is important

for legal purposes.

Cardiopulmonary clearance

required before surgery to ensure

that the patient doesn’t have any

cardiopulmonary problems which

could interfere and complicate the

surgery.

2:15 pm May hold OR temporarily Operation was hold due to failure

to obtain CP clearance.

Hold

Possible rescheduling

tomorrow pending cardiac

clearance

Done to reschedule the patient for

operation.

Done. CP

cleared

Discontinue clindamycin and

levofloxacin

Antibiotics are discontinued and

shifted to another antibiotics

Discontinued

Start ampicillin – sulbactam

1.5 gms q 8h IVTT ANST

An antibiotic that treats mild to

moderate infections.

Started

Update Dr. Sanchez This creates a collaborative Dr. Sanchez





updated

IVF: PNSS to run at 120cc/h Plain normal saline solution is

isotonic to body fluid and is

commonly used for rehydration.

Hooked

Please give Glucovance pc and

Glimiperide ac

Glucovance is a combination of

two types of pills. One pill helps

your body make more insulin. The

other pill lowers the amount of

glucose made by your liver and

helps your insulin work the way it

should. Glimiperide is an

antidiabetic drug. It adjunct to diet

to lower glucose level in patients

with type 2 (non-insulin

dependent) diabetes mellitus.

Given

5:00 pm Shift present IVF to D5W to

KVO rate

5% Dextrose in Water is a type of

isotonic fluid on initial

administration, but when glucose

is metabolized, it produces free

water.This water may expand both

the ICF & ECF fluid volume, thus,

Shifted

acts as a hypotonic solution.

10:30

pm

Discontinue Glimiperide To prevent hypoglycemia Discontinued

Sitagliptin + metformin 1 tab

OD pc after lunch

Is an antidiabetic drug. It is an

adjunct to diet and exercise to

improve glycemic control in

patients with type 2 diabetes

mellitus, with other oral

antibiotics.

Given

Please give glucovance after

breakfast and after supper

Glucovance is a combination of

two types of pills. One pill helps

your body make more insulin. The

other pill lowers the amount of

glucose made by your liver and

helps your insulin work the way it

should.

Given

For CPK-MB tom am CPK-MB test is a cardiac marker

used to assist diagnoses of an

acute myocardial infarction.

Done

7/3/10

5:50 am

Give humulin R 5’u’ IVTT

now then repeat CBG 2 hrs

post prandial

Humulin R is an antidiabetic drug

given to patient to reduce blood

glucose. CBG is done to evaluate

the effect of insulin to the patient

after eating a meal.

Given

11:30 Relay CPK-MB asap pls. In order to know the result of the Relayed

test.

Please give humulin R 6’u’

now

An antidiabetic drug given to


Given

Please schedule OR this 2 pm,

Dr. Sanchez aware

Scheduling patient to OR allows

patient undergone operation.

Scheduled

Secure consent, please inform

OR

Informed consent is the permission

obtained from the patient/guardian

to perform a specific test or

procedure. This also evaluates

whether the patient has understood

the surgeon and his or her

condition. To secure the consent of

the client is important for legal

purposes.

Consent secured.

OR aware

1:30 pm Give Metoclopramide (Plasil)

1 amp now IVTT

Metoclopramide increases muscle

contractions in the upper digestive

tract. This speeds up the rate at

which the stomach empties into

the intestines.

Given

Give ranitidine 50 mg 1 amp

IVTT now

Ranitidine is an antisecretory (h2-

receptor antagonist), antiulcer

drug. Since the patient will be on

NPO status, it is important to give

Given

ranitidine to prevent ulcer.

5:00 pm NPO temporarily NPO is ordered to prepare the

gastrointestinal tract prior to

surgery. The stomach and

esophagus relaxes when anesthesia

is administered which makes it

possible for food to move up into

your mouth from where a patient

may aspirate it down to their

trachea into their lungs. Such

aspirate is usually very acidic (pH

around 1-3) and can cause severe

damage to the lungs requiring

artificial ventilation.

Patient informed

VS q 15 mins until stable Monitoring the vital signs in this

close timed-manner will verify if

the patient is experiencing post

operative complications, has

weaned out from anesthesia, and is

already stable.

Monitired and

recorded

IVF at 150 cc/hr Increasing IVF rate to 150 cc/hour

is important to prevent patient

from dehydration since patient is

Regulated

still on NPO.

IVF to follow D5NSS 150

cc/hr

5% Dextrose in normal saline

solution is a hypertonic solution.

Hypertonic solutions have tonicity

or solute concentration in ECF

greater than that of the ICF.

Therefore, it pulls fluids out of the

ICF and the cell shrinks.

(ST-) Tazocin 2.25 grams q 8 hours

IVTT ANST next dose 2 am

Piperacillin (Tazocin) is a beta-

lactam antibiotic and is mainly

bactericidal.

Given

Tramadol 300 mg + pNSS 500

cc @ 25 micro drops

Tramadol is a narcotic-like pain

reliever. Tramadol is used to treat

moderate to severe pain. Tramadol

extended-release is used to treat

moderate to severe chronic pain

when treatment is needed around

the clock. Given to patient post-op

for pain.

Given

Ketorolac 15 mg q 6 hours

IVTT

This medication is a nonsteroidal

anti-inflammatory drug that

relieves pain and reduces swelling.

It is for short-term use only (no

Given

more than 5 days).

O2 3-4 LPM This is to relieve hypoxia,

headache, nausea, as well as to

restore the ability of the cells of

the body to carry on normal

metabolic function.

Indicated

Refer accordingly This creates a collaborative





referred

7:35 pm BP 150/100 aware

+ pain at the surgical site 8/10 comfortable/ assesment 140/100

Continue BP monitoring q 15

mins until stable then q 2hrs

Monitoring the vital signs in this

close timed-manner will verify if

the patient is experiencing post

operative complications, has

weaned out from anesthesia, and is

already stable.

Monitored and

recorded

Refer for persistent increase bp

or any unusualities

To closely monitor patient for

unusualities and proper

interventions will be given

immediately.

Referred

8:40 pm May increase tramadol drop to Tramadol may be increased of Noted

100cc/hr patient complains of pain.

7/4/10 13.2 mmol

May give 5 “u” RI IVTT now An antidiabetic drug given to


Given

5:10 am Shift D5NSS 1 L to PNSS 1 L

at same rate (150 cc/hr)

IVF was shifted from hypertonic

to isotonic to maintain balance

within body. Plain normal saline

solution is isotonic to body fluid

and is commonly used for

rehydration.

Shifted

Give humulin R 4 units IVTT

now

An antidiabetic drug given to


Given

8:00 am Decrease CBG to q 12 hours To continue monitoring blood

glucose.

Carried out

Change dressing of wound

(drain site)

Maintaining wound cleanliness is

very important to prevent any

infection that can be caused by

enter of microorganisms through

the incision site.

Changed

IVTT tramadol 300 mg in 500

cc PNSS to run in 24 hours



moderate to severe pain. Tramadol

extended-release is used to treat

Given

moderate to severe chronic pain

when treatment is needed around

the clock. Given to patient post-op

for pain.

9:00 am IVF to follow PNSS 1L 150

cc/hr

Plain normal saline solution is

isotonic to body fluid and is

commonly used for rehydration.

Noted

7/5/10

5:20 am

Shift IVF to D5NSS 1L

(previously KSS) and

incorporate moriamin sr 2

amps @ 120 cc/hr







ICF and the cell shrinks.




operations.

Shifted

7:00 am IVF to follow D5NSS + 2

amps moriamin to run @

120cc/hr







Noted

ICF and the cell shrinks. Moriamin

s2 is an aminoacid supply for the

conditions such as malnutrition,


For serum Na and K deter this

am

This is done to measure the

concentration of electrolytes which

are needed for both the diagnosis

and management of renal,

endocrine, acid-base, water

balance, and many other

conditions. Their importance lies

in part with the serious

consequences that follow from the

relatively small changes that

diseases or abnormal conditions

may cause. This is done for

diagnosing dietary deficiencies,

excess loss of nutrients due to

urination, vomiting, and diarrhea,

or abnormal shifts in the location

of an electrolyte within the body.

Done

Insert 2 Dulcolax suppository

adult now

Bisacodyl is a stimulant laxative.

It acts directly on the bowels,

Done

stimulating the bowel muscles to

cause a bowel movement.

Constipation, pre operative use,

short term relief of constipation, to

prevent training, to remove

ingested poisons from th lower GI

tract.

9:45 am BP = 140/90

Increase tramadol drip to 120

cc/hr

The intensity of pain felt by the

patient increased.

Done

11:10

am

Revise tramadol drip rate to 30

micro gtts/min

Intensity of pain has decreased. Done

3:00 pm IVF to follow D5NSS 1 L + 2

amps moriamin @ 120cc/hr

t/f: PNSS 500 cc + 300 mg

tramadol to run @ 120 cc/hr




operations. It is incorporated to

D5NSS since D5NSS has

electrolyte.



moderate to severe pain. Given to

patient post-op for pain.

Noted

4:00 pm d/c tramadol drip Patient can already tolerate pain.

Celebrex is a nonsteroidal Anti-

Tramadol dip

discontinued;

start celebrex 200 mg BID to

start 6 pm tonight

inflammatory Drugs (NSAIDs) celebrex started

(+BM x1 +flatus x4) bp=150/100

May remove sitaglaptin +

metformin

Sitaglaptin + metformin may be

removed if blood glucose will be

on normal range.

Noted

May remove Telmisartan

(Pritor plus)

Telmisartan may be removed if BP

of the patient will be on normal

range.

Noted

7:30 pm May have general liquids in

small amount

A general liquid diet consists of

clear liquids, such as water, broth

and plain gelatin that are easily

digested and leave no undigested

residue in your intestinal tract.

Your doctor may prescribe a clear

liquid diet after NPO order.

Patient noted

May give Telmisartan (Pritor

plus) 40 mg/12.5 mg tab, 1 tab






antihypertensive.

Given

May have soft diet in am Diet was shifted to soft diet

because patient was already with

Patient informed

flatues. Soft diet is a diet soft in

texture, low in residue, easily

digested and well tolerated; easy to

chew and swallow providing

essential nutrients in the form of

liquids and semisolid foods.

To follow: D5NSS 1 L + 2

amps moriamon @ 120 cc/hr







ICF and the cell shrinks. Moriamin

s2 is an aminoacid supply for the

conditions such as malnutrition,


Followed up

7/6/10

8 am

C/D Ivf and Ivf meds Patient can already tolerate P.O

medications. IVF can be

discontinued since IVF is used as

an access for IVTT meds.

Consumed and

discontinued

Saltamicillin 750 mmg 1 tab q

8hrs

Sultamicillin is an antibiotic that is

indicated for perioperative

rophylaxis and post operative

Given

prophylaxis.

Soft low fat diet Soft low fat diet is a diet soft in

texture, low in residue, easily

digested and well tolerated but low

in fat content to reduce serum lipid

contents; easy to chew and

swallow providing essential

nutrients in the form of liquids and

semisolid foods.

Patient informed

Drain mobilized To drain discharges in the wound. Done

Dressing done Maintaining wound cleanliness is




the incision site.

Done

Revised celecoxib to 400 mg 1

tab OD

A Nonsteroidal Anti-inflammatory

Drugs (NSAIDs) that is intended

to relieve pain while minimizing

the gastrointestinal adverse effects.

Revised

8:25 am Dressing of wound (check

area)

Maintaining wound cleanliness is




Done

the incision site.

7/7/10 Okay for discharge if so

desired

Patient can already go home if he

wishes to do so.

Patient informed

Dressing and drain off Maintaining wound cleanliness is




the incision site.

Done

Unasyn 750 mg 1 tab q 8hr

#15

Unasyn (Ampicillin + Sulbactam)

is an antibiotic that treats mild to

moderate infections.

Given

Celecoxib 800 mg 1 cap O.D.

# 10

A Nonsteroidal Anti-inflammatory

Drugs (NSAIDs) that is intended

to relieve pain while minimizing

the gastrointestinal adverse effects.

Given

9:20 am May go home Doctor ordered patient may

already go home

Carried out

Home med:

Sitagliptin + metformin

(Janumet) 500 mg1 tab OD

after lunch x 1 month

Is an antidiabetic drug. It is an

adjunct to diet and exercise to

improve glycemic control in

patients with type 2 diabetes

mellitus, with other oral

Patient informed

antibiotics.

Telmisartan (Pritor plus) 1 tab

OD after breakfast x 1month






antihypertensive.

Patient informed

For ultrasound of liver, fbs

after 1 month

To re-assess the liver and blood

sugar after the discharge. To

determine if there are stones left in

the gallbladder.

Patient informed

Generic Name

Moriamin Forte

Brand Name Calcium pantothenic

Classification multivitamins and minerals

Ordered Dose

Mode of Action

Indications malnutrition, protein and vitamin deficiencies, anemia,

convalescence,

restoration and maintenance of body resistance, pregnancy

and lactation,

adjuvant in the therapy of peptic ulcer and TB.

Contraindications contraindicated for patient’s with malabsorption syndrome

Drug Interactions

Side Effects and Adverse

Reactions

hypervitaminosis (large doses)

Nursing Responsibilities Assess patient for signs of vitamin deficiency before and

periodically throughout

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Paracetamol

Generic Name

acetaminophen paracetamol

Brand Name Tylenol, Tempra

Classification Non-narcotic analgesic, Antipyretic

Ordered Dose 500 mg 1 tab q 4 hours, PRN

Mode of Action Produces analgesia by unknown mechanism, but it is

centrally acting in the CNS by increasing the pain threshold

by inhibiting cyclooxygenase. Reduces fever by direct

action on hypothalamus heat-regulating center with

consequent peripheral vasodilation, sweating, and

dissipation of heat. Unlike aspirin, has little effect on

platelet aggregation, does not affect bleeding time, and

produces no gastric bleeding.

Indications Fever reduction. Temporary relief of mild to moderate pain.

Generally as substitute for aspirin when the latter is not

tolerated or is contraindicated

Contraindications Hypersensitivity to acetaminophen or phenacetin; use with

alcohol.

Drug Interactions Cholestyramine may decrease acetaminophen absorption.

With chronic coadministration, barbiturates,

carbamazepine, phenytoin, and rifampin may increase

potential for chronic hepatotoxicity. Chronic, excessive

ingestion of alcohol will increase risk of hepatotoxicity.


Reactions

Body as a Whole: Negligible with recommended dosage;

rash. Acute poisoning: Anorexia, nausea, vomiting,

dizziness, lethargy, diaphoresis, chills, epigastric or

abdominal pain, diarrhea; onset of hepatotoxicity—

elevation of serum transaminases (ALT, AST) and

bilirubin; hypoglycemia, hepatic coma, acute renal failure

(rare). Chronic ingestion: Neutropenia, pancytopenia,

leukopenia, thrombocytopenic purpura, hepatotoxicity in

alcoholics, renal damage.

Nursing Responsibilities Assessment & Drug Effects

1) Monitor for S&S of: hepatotoxicity, even with

moderate acetaminophen doses, especially in

individuals with poor nutrition or who have

ingested alcohol over prolonged periods; poisoning,

usually from accidental ingestion or suicide

attempts; potential abuse from psychological

dependence (withdrawal has been associated with

restless and excited responses).

2) Administer tablets or caplets whole or crushed and

give with fluid of patient's choice.

3) Chewable tablets should be thoroughly chewed and

wetted before they are swallowed.

4) Do not coadminister with a high carbohydrate meal;

absorption rate may be significantly retarded.

5) Store in light-resistant containers at room

temperature, preferably between 15°–30° C (59°–

86° F).

Patient & Family Education

6) Do not take other medications (e.g., cold

preparations) containing acetaminophen without

medical advice; overdosing and chronic use can

cause liver damage and other toxic effects.

7) Do not self-medicate adults for pain more than 10 d

(5 d in children) without consulting a physician.

8) Do not use this medication without medical

direction for: fever persisting longer than 3 d, fever

over 39.5° C (103° F), or recurrent fever.

9) Do not give children more than 5 doses in 24 h

unless prescribed by physician.

Generic Name

Clindamycin

Brand Name Dalacin

Classification Lincosamide Antibiotic

Ordered Dose

Mode of Action Inhibits protein synthesis in susceptible bacteria causing

cell death.

Indications Serious infections caused by susceptible strains of

anaerobes streptococci, staphylococci, pnemococci ,

reserve use for penicillin –a llergic patients or when

penicillin is inapprorpriate

Contraindications Contraindicated in patient with allergy of clindamycin

Drug Interactions Increased neuromuscular blockade with neuromuscular

blocking agent

Decreased GI absorption with kaolin,aluminum salts

Side Effects and Adverse Sideeffects

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Reactions CV:Hypotension

GI : severe colitis , vomiting,nausea ,a diarrhea,

Hematological: Neutropenia, leucopenia, agranulocytosis

Local: sterile Abcess, Thrombophlebitis

ADVERSE Effects:

Cardiac arrest

Pseuomembranous colitis

Nursing Responsibilities 1. Site infection or acne, skin color , lesions.

2. Administer drug with full glass of water

3. Do not give IM injections of more than

600mg inject deep into large muscle to

avoid complication

4. Do not use for minor bacterial or viral

infection

5. Administer with food

6. Take full oral prescribed drug .

7. Report severe or watery diarrhea, abdominal

pain and any lesions

Generic Name

Hyoscine Butylbromide

Brand Name Buscin

Classification antipasmodic

Ordered Dose

Mode of Action Relaxes the GI and GU tractsOne type of antispasmodic is

used for smooth muscle contraction, especially in tubular

organs of the gastrointestinal tract. The effect is to prevent

spasms of the stomach, intestine or urinary bladder. Both

dicyclomine and hyoscyamine are antispasmodic due to

their anticholinergic action. Both of these drugs have

general side effects and can worsen gastroesophageal

reflux disease.[3]

Indications Conditions associated w/ visceral spasms.

Contraindications Prostatic enlargement; paralytic ileus or pyloric stenosis &

ulcerative colitis; myasthenia gravis. Angle-closure

glaucoma or narrow angle between the iris & cornea.

Drug Interactions Atropine, amantadine, phenothiazine antipsychotic,

http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease

http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease

http://en.wikipedia.org/wiki/Anticholinergic

http://en.wikipedia.org/wiki/Hyoscyamine

http://en.wikipedia.org/wiki/Dicyclomine

http://en.wikipedia.org/wiki/Urinary_bladder

http://en.wikipedia.org/wiki/Intestine

http://en.wikipedia.org/wiki/Stomach

http://en.wikipedia.org/wiki/Spasm

http://en.wikipedia.org/wiki/Gastrointestinal_tract

http://en.wikipedia.org/wiki/Smooth_muscle

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tricyclic antidepressants & some antihistamines. Alcohol


Reactions

Dry mouth; difficulty in swallowing & talking, thirst.

Reduced bronchial secretions, dilatation of pupil w/ loss of

accomodation & photophobia, flushing, dry skin, transient

bradycardia followed by tachycardia w/ palpitations &

arrhythmias & difficulty in micturition; constipation

Nursing Responsibilities 1. Ensure aqequate hydration

2. Provide environmental control to prevent

hyperprexia

3. Avoid hot environments

4. Avoid alcohol serious sedation can occur

5. Take as prescribed 30-60 minutes before

meals

Generic Name

Lactulose

Brand Name lactulose

Classification

Laxative, ammonia redcuing agent

Ordered Dose

Mode of Action The drug passes unchanged in colon where bacteria break it

down to organic acids that increase the osmotic pressure in

the colon slightly acidify colonic content, resulting in an

increase stool water content, stool softening and laxative

action

Indications Treatment of constipation

Contraindications Allergy to lactulose

Drug Interactions


Reactions

GI: transient flatulence, distention. Intestinal cramps,

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belching, diarrhea , nausea,

Other: acid-base imbalance

Nursing Responsibilities 1. Do not freeze

2. Give laxative with water or fruit

juice, milk to increase palatability

3. Do not administer any laxative while

using lactulose

4. Monitor serum ammonia levels

5. Carefully monitor blood glucose in

diabetic clients

6. Do not use continuously for I week

7. Bowel movements will increase 2-4

times a day

Generic Name

Telmisartan

Brand Name Micardis

Classification Angiotensin II receptor antagonist

antihypertensive

Ordered Dose 12.5mg itab OD

Mode of Action Selectively blocks the binding angiotensin II specific tissue

receptors found in the vascular smooth muscle and adrenal

gland ; this action blocks the vasoconstriction effect of the

rennin angiotensin system, as well as the release of

aldosterone , leading to decrease BP

Indications Treatment for hypertension,alone or in combination with

other antihypertensive

Contraindications Contraindicated with hypertensitivity ti telmisartan ,

pregnancy(during the second and third trimester can cause

death to fetus

Drug Interactions Increased serum levels if combined with digoxin


Reactions

CNS: lightheadedness , headache ,dizziness, muscle

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weakness

CV: hypotension

Derma : rash , dermatitis , pruritus

GI: constipation Flatulence, vomiting, Dry mouth

GU: decrease renal function

Respiratory: Asthma, dyspnea, epistaxis, Cough

Other : back pain Gout

Nursing Responsibilities 1. Alert the surgeon if hypotension occurs

2. The blockage of RENIN-angiotensin sytem

following surgery can produce problems.

Hypotension may be reversed with volume

expansion

3. If BP does not reached desired levels, diuretics or

other hypertensice may be added to termisatan

(monitor BP of client Carefully)

4 Take drug without regards to meals

5 . Do not stop taking this drug without consulting

your doctor.

6. report fever,chills,dizziness

Generic Name

Glimiperide

Brand Name Amaryl

Classification Antidiabetic drug,Sulfonylurea

Ordered Dose 3mg 1tab OD

Mode of Action A sulfonylurea that probably stimulates insulin release

from pancreatic beta cells, reduces glucose output by the

liver, and increase peripheral sensitivity to insulin

Indications Adjunct to diet to lower glucose level in patients with type

2 (non-insulin dependent) diabetes mellitus

Contraindications Contraindicated in patients hypersensitive to drugs and in

those with diabetic ketoacidosis

Contraindicated in pregnant or breastfeeding women and as

sole therapy in type 1 diabetes.

Drug Interactions

Drug-drug : amantadine anabolic

steroids ,antibiotic ,clorampenicol, clofibrate, MAO

inhibitors,probenecid ,salicylates ,sulfonamides, Oral

anticoagulants

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May increase hypoglemic activity

Corticosteroids,glucagon,phenytoin,rifampin,thiazide

antidiuretic; may decrease hypoglemic response


Reactions

Dizziness , drowsiness, headache , nausea, constipation,

diarrhea ,leucopenia, hemolytic anemia, hypoglycemia,skin

rash, pruritus, photosensitivity

Nursing Responsibilities 1) Give immediate release tablets about 30 mins.

Before meals.

2) Some patients may attain effective control on a

once –daily regimen , whereas others respond better

with divided dosing

3) Patient may switch from immediate release dose to

extended release tablets at the nearest equivalent

total daily dose.

4) Glipizide is a second generation sulfonylurea. The

frequency of adverse reaction appears lower than

2nd generation.

5) During periods of increased stress, patient may

need insulin therapy. Monitor patient closely for

hyperglycemic in these situations.

6) Tell the patient to carry candy and other simple

sugars to treat mild low glucose episodes.

7) Instruct patient not to change drug dosage without

prescriber’s consent and to report abnormal blood

and urine glucose test result.

8) Tell the patient nit to take other drugs without

checking with prescriber.

Generic Name

Nalbuphine Hydrochloride

Brand Name Nubain

Classification Opoid agonist –antagonist analgesic

Ordered Dose

Mode of Action Nalbuphine acts as an agonist at specific opoid receptors in

the CNC to produce analgesia and sedation but also acts to

cause hallucinations and is an antagonist at mu receptors

Indications Relief of moderate to severe pain

Preoperative analgesia, as a supplement to surgical

anaesthesia and for obstetric analgesia during labor and

delivery

Contraindications Hypersensitivity ti nalbuphine

Drug Interactions Potnetiation of effects with barbiturates anesthetic or other

CNS Depressant

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Reactions

CNS: Sedation, clamsiness, sweating , headache ,

nervousness, restleness, rying confusion, dizziness,

vertigo , flushing , feeling of warmth , blurred vision,

feeling of floating

CV: hypotension hypertension, bradycardia , tachycardia

Dermatoligic: pruritus, burning , urticaria

GI; Nausea vomiting, dry mouth

Respiratory: respiratory depression , dyspnea , Asthma

Nursing Responsibilities 1. Provide safety measures

2. Check for orientation ,reflexes, vision pulse,

urine output.

3. Use cautiously to patient with history of

addiction to Nubain

4. Taper dosage when discontinuing after

prolonged used to avoid prolonge

withdrawal symptoms

5. Keep opoid antagonist and facilities for

assisted or controlled respiration in caseof

respiratory depresiion

6. Reassure patient about addiction liability

Generic Name

Essentiale Forte

Brand Name Essentiale Forte

Classification Cholagogues, Cholelitholytics & Hepatic Protectors

Ordered Dose

Mode of Action Essentiale/Forte regulates membrane permeability and

improves the exchange of substances between the intra-

and extracellular space. It activates metabolic function and

supports the energy balance of the liver. It restores enzyme

functions and promotes detoxification of the liver. Neutral

fats and cholesterol are transformed into transportable

forms and led to their physiological oxidation. Liver cell

regeneration is stimulated and the bile is stabilized.

Indications Acute and Chronic Hepatitis: Dystrophy and cirrhosis of

the liver, biliary stasis and hepatic coma.

Liver Damaged by Toxins: Fatty liver (eg, in diabetes,

tuberculosis and chronic rheumatism), prophylaxis of

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recurrent gallstones, radiation damage, nephrotic syndrome

and gestoses

Contraindications

Drug Interactions


Reactions

Nursing Responsibilities Should be taken with food

Generic Name

Levofloxacin

Brand Name Levaquin

Classification FLuroquinolone antibiotic

Ordered Dose 500mg itab

Mode of Action Bactericidal interferes with DNA inhibiting DNA gyrase

rep;ication is susceptible gram negative and gram positive

bacteria prevent cell reproduction

Indications UTIs, lower respiratory tract infections, skin and skin

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structure infections, bone and joint infections, GI infection

or infectious diarrhea, chronic bacterial prostatitis,

nosocomial pneumonia, acute sinusitis. Post-exposure

prophylaxis for anthrax.

Contraindications Known hypersensitivity to levofloxacin or other

fluoroquinolones, syphilis, viral infection; tendon

inflammation or tendon pain; pregnant women (category

C).

Drug Interactions Increased risk of CNS effects with ethanol, barbiturates,

antihistamine and other sedative drugs.


Reactions

GI: Nausea, vomiting, diarrhea, cramps, gas,

pseudomembranous colitis. Metabolic: Transient increases

in liver transaminases, alkaline phosphatase, lactic

dehydrogenase, and eosinophilia count. Musculoskeletal:

Tendon rupture, cartilage erosion. CNS: Headache, vertigo,

malaise, peripheral neuropathy, seizures (especially with

rapid IV infusion). Skin: Rash, phlebitis, pain, burning,

pruritus, and erythema at infusion site. Special Senses:

Local burning and discomfort, crystalline precipitate on

superficial portion of cornea, lid margin crusting, scales,

foreign body sensation, itching, and conjunctival

hyperemia.


1) Report tendon inflammation or pain. Drug should

be discontinued.

2) Lab tests: Culture and sensitivity tests should be

done prior to initial dose. Treatment may be

implemented pending results.

3) Monitor urine pH; it should be less than 6.8,

especially in the older adult and patients receiving

high dosages of ciprofloxacin, to reduce the risk of

crystalluria.

4) Monitor I&O ratio and patterns: Patients should be

well hydrated; assess for S&S of crystalluria.

5) Monitor plasma theophylline concentrations, since

drug may interfere with half-life.

6) Administration with theophylline derivatives or

caffeine can cause CNS stimulation.

7) Assess for S&S of GI irritation (e.g., nausea,

diarrhea, vomiting, abdominal discomfort) in clients

receiving high dosages and in older adults.

8) Monitor PT and INR in patients receiving coumarin

therapy.

9) Assess for S&S of superinfections


10) Immediately report tendon inflammation or pain.

Drug should be discontinued.

11) Fluid intake of 2–3 L/d is advised, if not

contraindicated.

12) Report sudden, unexplained joint pain.

13) Restrict caffeine due to the following effects (e.g.,

nervousness, insomnia, anxiety, tachycardia).

14) Report possible toxicity. If taking theophylline

derivatives, there is potential for adverse effects.

15) Report nausea, diarrhea, vomiting, and abdominal

pain or discomfort.

16) Use caution with hazardous activities until reaction

to drug is known. Drug may cause light-headedness

Generic Name

glyburide and metformin

Brand Name Glucovance

Classification Antidiabetic drug , sulfonylurea

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Ordered Dose

Mode of Action Stimulates insulin release from functioning beta cells in th

pancreas; may improve binding between insulin and insulin

receprtors or increase the numbers of insulin receptor :

more potent in effect than first generation sulfonylurea

Indications Adjucnt to lower blood glucose level with type 2 diabetes

mellitus

Contraindications Diabetic ketoacidosis,sole therapy of type 1 DM , serious

heapatic impairement, uremia, Coma

Drug Interactions Drugs that can raise blood sugar include:

isoniazid;

diuretics (water pills);

steroids (prednisone and others);

phenothiazines (Compazine and others);

thyroid medicine (Synthroid and others);

birth control pills and other hormones;

seizure medicines (Dilantin and others); and

diet pills or medicines to treat asthma, colds or

allergies.

Drugs that can lower blood sugar include:

nonsteroidal anti-inflammatory drugs (NSAIDs);

aspirin or other salicylates (including Pepto-

Bismol);

sulfa drugs (Bactrim and others);

a monoamine oxidase inhibitor (MAOI);

beta-blockers (Tenormin and others); or

probenecid (Benemid).

ciprofloxacin (Cipro);

furosemide (Lasix);

nifedipine (Adalat, Procardia);

cimetidine (Tagamet) or ranitidine (Zantac);

amiloride (Midamor) or triamterene (Dyrenium);

digoxin (Lanoxin);

morphine (MS Contin, Kadian, Oramorph);

procainamide (Procan, Pronestyl, Procanbid);

quinidine (Cardioquin, Quinidex, Quinaglute);

trimethoprim (Proloprim, Primsol, Bactrim, Cotrim,

Septra); or

vancomycin (Vancocin, Lyphocin).


Reactions

feeling short of breath, even with mild exertion; or

swelling or rapid weight gain.

Other less serious side effects may be more likely to occur,

such as:

sneezing, runny nose, cough or other signs of a

cold;

headache;

dizziness; or

mild nausea, vomiting, diarrhea, stomach pain.

Nursing Responsibilities 1. give drug before meal

2. avoid alcohol while using this drug

3. monitor urine , blood glucose and ketones

continue treatment regimen

4. Do not use Glucovance if you have

congestive heart failure or kidney disease, or

if you are in a state of diabetic ketoacidosis

(call your doctor for treatment with insulin).

5. Before taking Glucovance, tell your doctor

if you have heart disease, liver disease, or a

history of heart attack or stroke.

6. Know the signs of low blood sugar

(hypoglycemia) and how to recognize them,

including hunger, headache, confusion,

irritability, drowsiness, weakness, dizziness,

tremors, sweating, fast heartbeat, seizure

(convulsions), fainting, or coma (severe

hypoglycemia can be fatal). Always keep a

source of sugar available in case you have

symptoms of low blood sugar.

7. Check for blood sugar before and after the

therapy

8. Glucovance is only part of a complete

program of treatment that also includes diet,

exercise, and weight control. It is important

to use this medicine regularly to get the

most benefit

Generic Name Ampicillin+ Sulbactam

Brand Name Ampimax vial

Classification Antibiotic

Ordered Dose 1.5 IVTT q8

Mode of Action Ampicillin exerts bactericidal action on both gram-positive

and gram-negative

organisms. Its spectrum includes gram-positive

organisms e.g. S pneumoniae and other

Streptococci, L monocytogenes and gram-negative

bacteria e.g. M catarrhalis, N gonorrhoea, N

meningitidis, E coli, P mirabilis, Salmonella,

Shigella, and H influenzae. Ampicillin exerts its

action by inhibiting the synthesis of bacterial cell

wall. Sulbactam inhibits β-lactamases and extends

the spectrum of ampicillin to include β-lactamase

producing pathogens.

Indications Mild to moderate infections (i.e.; skin, intra-abdominal and

gynecological infections)

Contraindications Allergy to penicillins, infectious mononucleosis

Drug Interactions Several case reports describe methotrexate toxicity in

patients

following coadministration of methotrexate and

penicillins. Penicillins may reduce the renal

clearance of methotrexate resulting in elevated

methotrexate serum concentrations and

methotrexate toxicity (e.g. renal failure,

myelosuppression, mucositis, dermatologic

abnormalities). If the combination is unavoidable,

close monitoring of methotrexate drug levels and

for signs of methotrexate toxicity is necessary.


Reactions

Side Effects: Mild diarrhea; pain, swelling, or redness at

injection site.

Adverse Effects: Pain at Inj site, thrombophlebitis,

diarrhoea, itching, nausea, vomiting,

flatulence, candidiasis, fatigue, malaise, headache,

chest pain, glossitis, abdominal distention, dysuria,

urinary retention, oedema, erythema, epistaxis,

mucosal bleeding. Fatal anaphylaxis.

Nursing Responsibilities Nursing Responsibilities:

1. Assess patient for contraindication.

2. Assess for baseline data.

3. Infuse slowly as a bolus over no less than 15 seconds.

4. Tell patient that she may experience side effects brought

upon by the drug.

5. Instruct to report intolerable side effects for prompt

intervention.

6. Instruct to report if she experiences adverse effects.

Generic Name

Sitagliptin+metformin

Brand Name Januvia

Classification Therapeutic Class: Antidiabetic

Pharmacologic Class: Dipeptidyl Peptidase IV Inhibitor

Ordered Dose

Mode of Action Slows the inactivation of the incretin hormones , increasing

these hormone levels and prolonging their activity. The

incretin hormones stimulates insulin release in response to

a meal and help to regulate glucose homeostasis

throughtout the day. This increases and prolongs insulin

release and reduces hepatic glucose production to achive

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glycemic control.

Indications Adjunct to diet and exercise to improve glycemic control

in patients with type 2 diabetes mellitus, with other oral

antibiotics

Contraindications With hypersensitivity to sitagliptin

Drug Interactions Risk of hypoglycemia when combined with other drugs or

herbal medicines known to cause hypoglycemia ; monitor

patient closely to adjust dosage as needed.


Reactions

CNS: headache

Respiratort:nasopharyngitis, URI’s

Other: hypoglycemia

Nursing Responsibilities 1. Monitor blood glucose levels before during

and after the therapy

2. Ensure patient to continue diet and exercise

program for management of type 2 diabetes

3. Ensure the patient to continue with

appropriate use of other drugs to manage

type 2 DM

4. This drug should be take n once a day with

or without food

5. Arrange periodi c monitoring of your FBS

6.

Watch out for signs of hypoglycemia

hunger, headache, confusion, irritability;

o drowsiness, weakness, dizziness, tremors;

o sweating, fast heartbeat;

o seizure (convulsions); or

o fainting, coma (severe hypoglycemia can be

fatal).

7. Report signs of infection, uncontrolled bld

glucose , severe headache and stress.

Generic Name Metoclopramide

Brand Name Octamide PFS, Reglan

Classification GI stimulant, antiemetic, dopaminergic blocker

Ordered Dose 1amp now IVTT

Mode of Action Stimulates the muscles of the gastrointestinal tract

including the muscles of the lower esophageal

sphincter, stomach, and small intestine by interacting

with receptors for acetylcholine and dopamine on

gastrointestinal muscles and nerves; decreases the

reflux of stomach acid by strengthening the muscle of

the lower esophageal sphincter; stimulates the muscles

of the stomach and thereby hastens emptying of solid

and liquid meals from the stomach and into the

intestines; interacts with the dopamine receptors in the

brain and can be effective in treating nausea.

Indications Stimulation of gastric emptying prior to surgery

Contraindications Hypersensitivity to metoclopramide, GI hemorrhage,

mechanical obstruction or perforation;

pheochromocytoma (may cause hypertensive crisis);

epilepsy

Side Effects: drowsiness, restlessness, fatigue, anxiety,

insomnia, depression, sedation, nausea, diarrhea,

urinary frequency

Drug Interactions Decreased absorption of Cefprozil, cimetidine,

digoxin from the stomach

Increased oral bioavailability or absorption of

acetaminophen, cyclosporine, ethanol, levodopa,

tetracycline

Decreased effect on gastric emptying with

anticholinergic, opioid analgesics, levodopa

Increased risk of serious adverse effects due to

excess release of neurotransmitters with MAOIs for

example, isocarboxazid (Marplan), phenelzine (Nardil),

tranylcypromine (Parnate), selegiline (Eldepryl), and

procarbazine (Matulane)


Reactions

: parkinsons-like reactions, involuntary muscle

movements, facial grimacing, dystonic reactions

resembling tetanus, transient hypertension, tardive

dyskinesia, myoclonus


1. Assess patient for contraindication.


3. Give direct IV dose slowly (over 1 to 2 minutes).

4. Monitor BP carefully during IV administration.

5. Monitor for extrapyramidal reactions, and consult

physician if they occur.

6. Keep diphenhydramine injection readily available in

case of extrapyramidal reactions.

7. Have phentolamine readily available in case of

hypertensive crisis (most likely to occur with

undiagnosed pheochromocytoma).

8. Tell patient that she may experience side effects

brought upon by the drug.

9. Instruct patient to report involuntary movement of

the face, eyes or limbs, severe depression, severe

diarrhea.

10.Provide a safe environment if restlessness,

involuntary muscle movement occur.

Generic Name

ranitidine hydrochloride

Brand Name Zantac

Classification Antisecretory (h2-receptor antagonist); Antiulcer

Ordered Dose 50 mg q 8 hours, IVTT

Mode of Action Potent anti-ulcer drug that competitively and reversibly

inhibits histamine action at H2-receptor sites on parietal

cells, thus blocking gastric acid secretion. Indirectly

reduces pepsin secretion but appears to have minimal effect

on fasting and postprandial serum gastrin concentrations or

secretion of gastric intrinsic factor or mucus.

Indications Short-term treatment of active duodenal ulcer; maintenance

therapy for duodenal ulcer patient after healing of acute

ulcer; treatment of gastroesophageal reflux disease; short-

term treatment of active, benign gastric ulcer; treatment of

pathologic GI hypersecretory conditions (e.g., Zollinger-

Ellison syndrome, systemic mastocytosis, and

postoperative hypersecretion); heartburn

Contraindications Hypersensitivity to ranitidine; acute porphyria; OTC

administration in children <12 y.

Drug Interactions May reduce absorption of cefpodoxime, cefuroxime,

delavirdine, ketoconazole, itraconazole.


Reactions

CNS: Headache, malaise, dizziness, somnolence,

insomnia, vertigo, mental confusion, agitation, depression,

hallucinations in older adults. CV: Bradycardia (with rapid

IV push). GI: Constipation, nausea, abdominal pain,

diarrhea. Skin: Rash. Hematologic: Reversible decrease in

WBC count, thrombocytopenia. Body as a Whole:

Hypersensitivity reactions, anaphylaxis (rare).


1) Potential toxicity results from decreased clearance

(elimination) and therefore prolonged action;

greatest in the older adult patients or those with

hepatic or renal dysfunction.

2) Lab tests: Periodic liver functions. Monitor

creatinine clearance if renal dysfunction is present

or suspected. When clearance is <50 mL/min,

manufacturer recommends reduction of the dose to

150 mg once q24h with cautious and gradual

reduction of the interval to q12h or less, if

necessary.

3) Be alert for early signs of hepatotoxicity (though

low and thought to be a hypersensitivity reaction):

jaundice (dark urine, pruritus, yellow sclera and

skin), elevated transaminases (especially ALT) and

LDH.

4) Long-term therapy may lead to vitamin B12

deficiency.


5) Note: Long duration of action provides ulcer pain

relief that is maintained through the night as well as

the day.

6) Be aware that even if symptomatic relief is

provided by ranitidine, this should not be

interpreted as absence of gastric malignancy.

Follow-up examinations will be scheduled after

therapy is discontinued.

7) Adhere to scheduled periodic laboratory checkups

during ranitidine treatment.

8) Do not supplement therapy with OTC remedies for

gastric distress or pain without physician's advice

(e.g., Mylanta II reduces ranitidine absorption).

9) Do not smoke; research shows smoking decreases

ranitidine efficacy and adversely affects ulcer

healing.

Generic Name

Piperacillin Sodium

Brand Name Tazocin

Classification Antibiotic, Betalactam

Ordered Dose 2.25gm q8

Mode of Action Piperacillin is a beta-lactam antibiotic and is mainly

bactericidal. It inhibits the final stage of bacterial cell

wall synthesis by preferentially binding to specific

penicillin-binding proteins (PBPs) located inside the

bacterial cell wall. This interferes with bacterial cell

wall synthesis promotes loss of membrane integrity and

leads to death of the organism.

Indications Lower respiratory tract, Intraabdominal, and bone and

joint infections; septicemia, urinary tract infections.

Also used prophylactically as empiric antiinfective

therapy in granulocytopenic patients.

Contraindications Hypersensitivity to penicillins. Use cautiously to

patient with tendencies of bleeding.

Drug Interactions Anticoagulants: may increase risk of bleeding

Probenecid: decrease elimination of piperacillin


Reactions

Coughing, systemic anaphylaxis, fever,

superinfections, Injection site reactions (pain,

inflammation, abscess, phlebitis), eosinophilia,

leukopenia, hypernatremia, bleeding, rash.

Nursing Responsibilities Assessment & Drug effect

1. Obtain history of hypersensitivity to penicillins,

cephalosporins, or other drugs prior to

administration

2. Obtain specimen for culture and sensitivity tests

vefore giving first dose.

3. Watch out for any sign of superinfection in

patient with prolonged therapy

4. Monitor patient’s sodium intake

5. Monitor hematologic and coagulation

parameters.

6. Withhold drug and report to physician if signs

of an allergic reaction develop (e.g., itching,

rash, hives).

7. Report significant, unexplained diarrhea.

8. Do not mix with other drugs


9. Tell patient or significant others to report

adverse reaction promptly

10.Advise patient or significant others to alert

nurse if discomfort occurs at I.V. site

Generic Name

tramadol hydrocholoride/paracetamol

Brand Name Dolcet

Classification Narcotic analgesic

Ordered Dose 50 mg, 1 tab PRN

Mode of Action Centrally acting opiate receptor agonist that inhibits

the uptake of norepinephrine and serotonin, suggesting

both opioid and nonopioid mechanisms of pain relief.

May produce opioid-like effects, but causes less

respiratory depression than morphine.

Indications Management of moderate to moderately severe pain.

Contraindications Hypersensitivity to tramadol or other opioid analgesics;

patients on MAO inhibitors; patients acutely

intoxicated with alcohol, hypnotics, centrally acting

analgesics, opioids, or psychotropic drugs; substance

abuse; patients on obstetric preoperative medication;

abrupt discontinuation; alcohol intoxication; pregnancy

(category C); lactation; children <16 y.

Drug Interactions Carbamazepine significantly decreases tramadol

levels (may need up to twice usual dose). Tramadol

may increase adverse effects of mao inhibitors.

tricyclic antidepressants, cyclobenzaprine,

phenothiazines, selective serotonin-reuptake inhibitors

(ssris), mao inhibitors may enhance seizure risk with

tramadol. May increase CNS adverse effects when used

with other cns depressants. Herbal: St. John's wort

may increase sedation.


Reactions

CNS: Drowsiness, dizziness, vertigo, fatigue,

headache, somnolence, restlessness, euphoria,

confusion, anxiety, coordination disturbance, sleep

disturbances, seizures. CV: Palpitations, vasodilation.

GI: Nausea, constipation, vomiting, xerostomia,

dyspepsia, diarrhea, abdominal pain, anorexia,

flatulence. Body as a Whole: Sweating, anaphylactic

reaction (even with first dose), withdrawal syndrome

(anxiety, sweating, nausea, tremors, diarrhea,

piloerection, panic attacks, paresthesia, hallucinations)

with abrupt discontinuation. Skin: Rash. Special

Senses: Visual disturbances. Urogenital: Urinary

retention/frequency, menopausal symptoms.

Nursing Responsibilities 1) Assess for level of pain relief and administer

prn dose as needed but not to exceed the

recommended total daily dose.

2) Monitor vital signs and assess for orthostatic

hypotension or signs of CNS depression.

3) Discontinue drug and notify physician if S&S

of hypersensitivity occur.

4) Assess bowel and bladder function; report

urinary frequency or retention.

5) Use seizure precautions for patients who have a

history of seizures or who are concurrently

using drugs that lower the seizure threshold.

6) Monitor ambulation and take appropriate safety

precautions.

7) Exercise caution with potentially hazardous

activities until response to drug is known.

8) Understand potential adverse effects and report

problems with bowel and bladder function,

CNS impairment, and any other bothersome

adverse effects to physician.

Generic Name

Ketorolac

Brand Name Toradol

Classification NSAID

Ordered Dose

Mode of Action Ketorolac tromethamine is a nonsteroidal anti-

inflammatory drug (NSAID) that exhibits analgesic

activity in animal models. The mechanism of action of

ketorolac, like that of other NSAIDs, is not completely

understood but may be related to prostaglandin

synthetase inhibition. The biological activity of

ketorolac tromethamine is associated with the S-form.

Ketorolac tromethamine possesses no sedative or

anxiolytic properties.

Indications TORADOLORAL (ketorolac tromethamine), a

nonsteroidal anti-inflammatory drug (NSAID), is

indicated for the short-term (up to 5 days in adults),

management of moderately severe acute pain that

requires analgesia at the opioid level and only as

continuation treatment following IV or IM dosing of

ketorolac tromethamine, if necessary. The total

combined duration of use of TORADOLORAL and

ketorolac tromethamine should not exceed 5 days.

Contraindications GASTROINTESTINAL RISK

CARDIOVASCULAR RISK

RENAL RISK

Drug Interactions Aspirin

When TORADOL is administered with aspirin, its

protein binding is reduced, although the clearance of

free TORADOL is not altered. The clinical significance

of this interaction is not known; however, as with other

NSAIDs, concomitant administration of ketorolac

tromethamine and aspirin is not generally

recommended because of the potential of increased

adverse effects.

Diuretics

Clinical studies, as well as postmarketing observations,

have shown that TORADOL can reduce the natriuretic

effect of furosemide and thiazides in some patients.

This response has been attributed to inhibition of renal

prostaglandin synthesis. During concomitant therapy

with NSAIDs, the patient should be observed closely

for signs of renal failure.

ACE Inhibitors/Angiotension II Receptor

Antagonists

Concomitant use of ACE inhibitors and/or angiotension

II receptor antagonists may increase the risk of renal

impairment, particularly in volume-depleted patients.

Reports suggest that NSAIDs may diminish the

antihypertensive effect of ACE inhibitors and/or

angiotension II receptor antagonists. This interaction

should be given consideration in patients taking

NSAIDs concomitantly with ACE inhibitors and/or

angiotension II receptor antagonists.


Reactions

Body as a Whole: fever, infections, sepsis

Cardiovascular: congestive heart failure,

palpitation, pallor, tachycardia, syncope

Dermatologic: alopecia, photosensitivity,

urticaria

Gastrointestinal: anorexia, dry mouth,

eructation, esophagitis, excessive thirst,

gastritis, glossitis, hematemesis, hepatitis,

increased appetite, jaundice, melena, rectal

bleeding

Hemic and Lymphatic: ecchymosis,

eosinophilia, epistaxis, leukopenia,

thrombocytopenia

Metabolic and Nutritional: weight change

Nervous System: abnormal dreams, abnormal

thinking, anxiety, asthenia, confusion,

depression, euphoria, extrapyramidal

symptoms, hallucinations, hyperkinesis,

inability to concentrate, insomnia, nervousness,

paresthesia, somnolence, stupor, tremors,

vertigo, malaise

Reproductive, female: infertility

Respiratory: asthma, cough, dyspnea,

pulmonary edema, rhinitis

Special Senses: abnormal taste, abnormal

vision, blurred vision, hearing loss

Urogenital: cystitis, dysuria, hematuria,

increased urinary frequency, interstitial

nephritis, oliguria/polyuria, proteinuria, renal

failure, urinary retention

Nursing Responsibilities

1. Oral formulation should not be given as an

initial dose

2. Use minimum effective dose for the individual

patient

3. Do not shorten dosing interval of 4 to 6 hours

4. Total duration of treatment in adult patients:

the combined duration of use of IV or IM

dosing of ketorolac tromethamine and

TORADOLORAL is not to exceed 5 days.

5. TORADOL is a potent NSAID and may cause

serious side effects such as gastrointestinal

bleeding or kidney failure, which may result in

hospitalization and even fatal outcome.

6. TORADOL, like other NSAIDs, can cause GI

discomfort and rarely, serious GI side effects,

such as ulcers and bleeding, which may result

in hospitalization and even death.

7. TORADOL, like other NSAIDs, may cause

serious CV side effects, such as MI or stroke,

which may result in hospitalization and even

death.

8. Patients should promptly report signs or

symptoms of unexplained weight gain or

edema to their physicians.

9. Patients should be informed of the signs of an

anaphylactoid reaction (eg, difficulty

breathing, swelling of the face or throat). If

these occur, patients should be instructed to

seek immediate emergency help.

Generic Name

Bisacodyl

Brand Name Dulcolax

Classification Laxative

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Ordered Dose

Mode of Action Relieving occasional constipation and irregularity. It may

also be used for other conditions as determined by your

doctor.

Bisacodyl is a stimulant laxative. It acts directly on the

bowels, stimulating the bowel muscles to cause a bowel

movement.

Indications Constipation, pre operative use ,short term relief of

constipation, to prevent training, to remove ingested

poisons from th lower GI tract

Contraindications you are allergic to any ingredient in Bisacodyl

you have severe stomach pain; appendicitis; severe

constipation; stomach, intestinal, or rectal bleeding;

or intestinal blockage

you cannot swallow without chewing

you are having abdominal surgery

Drug Interactions


Reactions

Cramps; faintness; stomach discomfort.

Seek medical attention right away if any of these SEVERE

side effects occur:

Severe allergic reactions (rash; hives; itching; difficulty

breathing; tightness in the chest; swelling of the mouth,

face, lips, or tongue).

Nursing Responsibilities 1. Take Bisacodyl by mouth with or without food.

2. Take Bisacodyl with a full glass of water (8 oz/240

mL).

3. Drinking extra fluids while you are taking

Bisacodyl is recommended. Check with your doctor

for instructions.

4. Swallow Bisacodyl whole. Do not break, crush, or

chew before swallowing.

5. Do not take Bisacodyl within 1 hour after taking an

antacid or milk.

6. If you miss a dose of Bisacodyl and are taking it

regularly, take it as soon as possible. If it is almost

time for your next dose, skip the missed dose and

go back to your regular dosing schedule. Do not

take 2 doses at once.

7. Do not use for longer than 1 week without checking

with your doctor. Using Bisacodyl for a long time

may result in loss of normal bowel function.

8. Do not take additional laxatives or stool softeners

with Bisacodyl unless directed by your doctor.

9. Rectal bleeding or failure to have a bowel

movement within 12 hours after use of a laxative

may be a sign of a serious condition. Stop use and

contact your doctor.

10. If you develop nausea, vomiting, or stomach pain,

stop using Bisacodyl and check with your doctor.

11. If you notice a sudden change in bowel habits that

lasts for 2 weeks or more, do not continue using

Bisacodyl. Instead, check with your doctor.

12. Use Bisacodyl with caution in the ELDERLY; they

may be more sensitive to its effects.

13. Bisacodyl should not be used in CHILDREN

younger than 6 years old; safety and effectiveness

in these children have not been confirmed.

Generic Name Celecoxib

Brand Name Celebrex

Classification Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Ordered Dose .

Mode of Action The mechanism of action of Celebrex is believed to be due

to the inhibition of

prostaglandin synthesis, primarily via inhibition of

cyclooxygenase-2 (COX-2), and at therapeutic

concentrations in humans, Celebrex does not inhibit

the cyclooxygenase-1 (COX-1) isoenzyme.

Indications It is intended to relieve pain while minimizing the

gastrointestinal adverse effects

usually seen with conventional NSAIDs. In

practice, its primary indication is in patients who

need regular and long term pain relief: there is

probably no advantage to using celecoxib for short

term or acute pain relief over conventional

NSAIDs.

Contraindications Patients with known hypersensitivity to celecoxib and

those who have

demonstrated allergic-type reactions to

sulfonamides. Celebrex should not be given to

patients who have experienced asthma, urticaria or

allergic-type reactions after taking aspirin or other

NSAIDs. Severe, rarely fatal, anaphylactic-like

reactions to NSAIDs have been reported in such

patients (see Warnings and Precautions). Celebrex

is contraindicated for the treatment of perioperative

pain in the setting of coronary artery bypass graft

(CABG) surgery

Drug Interactions Fluconazole & other CYP2C9 inhibitors. Warfarin & other

anticoagulant. Non aspirin NSAID. ACE inhibitor,

angiotensin II antagonist, diuretics, lithium.


Reactions

C Anaphylactic reactions, renal toxicity. Hallucination,

ageusia, anosmia, aseptic

menlugitis, vasculitis, GI hemorrhage. Hepatitis,

liver failure, interstitial nephritis. photosensitivity

reaction, exfoliative dermatitis, erythema

multiforme, Stevens-Johnson syndrome, toxic

epidermal necrolysis & menstrual disorder.

Cerebral hemorrhage, fulminant hepatitis, liver

necrosis, hyponatremia, conjunctivitis.

cough; fever; skin rash; sneezing; sore throat; swelling

of face, fingers, feet,

and/or lower legs; Back pain; dizziness; gas;

headache; heartburn ; inability to sleep; nausea ;

pain or burning in throat; stomach pain; stuffy or

runny nose

Nursing Responsibilities 1. Inform the patient regarding that doses can be

given without regard to timing of meals.

2. Patients should be informed of the signs and

symptoms of an anaphylactoid reaction (e.g.,

difficulty breathing, swelling of the face or

throat). Patients should be instructed to seek

immediate emergency assistance if they develop

any of these signs and symptoms

3. Check with your doctor as soon as possible if

any of the following side effects occur:

Bloody or black tarry stools; burning feeling in

chest or stomach; chills; congestion in chest;

cough; diarrhea; fatigue; fever; loss of appetite;

muscle aches and pains; nausea; shortness of

breath; stomach pain (severe); tenderness in

stomach area; unusual weight gain; vomiting of

blood or material that looks like coffee grounds;

weakness

4. Assess for contraindication.



that are brought about by the drug.

7. Instruct her to report intolerable side effects so

management can be done.

Generic Name sultamicillin

Brand Name Sulmicil

Classification Antibiotic

Ordered Dose

Mode of Action Sultamicillin inhibits β-lactamases in penicillin-resistant

microorganisms and it

acts against sensitive organisms during the stage of active

multiplication by inhibiting biosynthesis of cell wall

mucopeptide

Indications Perioperative prophylaxis; Post operative prophylaxis

Contraindications Hypersensitivity.

Drug Interactions : Concurrent use increases risk of bleeding with warfarin

and

methotrexate toxicity; decreases efficacy of

oestrgen-containing oral contraceptives. Excretion

of ampicillin is reduced when used with probencid.


Reactions

Side Effects: Diarrhoea, nausea, vomiting, rashes, pruritus,

dizziness

Adverse Effects: Diarrhoea, nausea, vomiting, rashes,

pruritus, blood dyscrasias,

superinfections, dizziness, dyspnoea. Anaphylaxis.


1.Assess for contraindication.



that are

brought about by the drug.

4. Instruct her to report intolerable side effects so

management can be done.

5. Instruct her to eat frequent small meals

6. Instruct patient to avoid alcohol because severe

reactions could occur.

7.Tell patient to report any adverse effects that she

may experience.

Generic Name

Regular Insulin

Brand Name Humulin R, Novolin R, Actrapid,

Classification Antidiabetic Drug

Ordered Dose 6 “U’, 10 “U” subcutaneous

Mode of Action Increases Glucose transport across muscle and fat cells

membranes to reduce glucose level . Promotes conversion

of glucose to its storage from , glycogen : triggers amino

http://www.medicinenet.com/insulin/article.htm

acid uptake and conversion to protein in muscle cells and

inhibits protein degradation; stimulates triglyceride

formation and inhibits release of free fatty acids from

adipose tissue ; stimulates lipoprotein lipase activity ;

which converts circulating lipoproteins to fatty acid.

Indications Moderate to severe diabetic ketoacidosis or hperos-

molar hyperglycemia

Mild diabetic ketoacidosis

Newly diagnosed diabetes mellitus

Control of hyperglycemia

hyperkalemia

Contraindications Contraindicated during episodes of hypoglycemia

Drug Interactions

Several drugs augment the action of insulin and may lower

blood glucose to a dangerous level (hypoglycemia). To

prevent hypoglycemia when these drugs are used, the dose

of insulin may need to be reduced. Such drugs include

alcohol, MAO inhibitors like phenelzine (Nardil), beta-

blockers like propranolol (Inderal), salicylates like aspirin

(Bayer) or salsalate (Disalcid), and anabolic steroids like

methyltestosterone (Android).

There are other drugs that augment the blood glucose-

lowering effect of insulin, but they are less likely to interact

with insulin or have less of an effect. Such drugs include

tetracycline antibiotics like doxycycline (Vibramycin),

guanethidine (Ismelin), oral hypoglycemic drugs like

glyburide (Diabeta), sulfa antibiotics like sulfadiazine, and

ACE inhibitors like captopril (Capoten).

There also are drugs that decrease the effect of insulin.

Interactions are less likely and/or less serious. These drugs

include diltiazem (Cardizem), niacin, corticosteroids like

prednisone, estrogens, oral contraceptives, thyroid

hormones like levothyroxine (Synthroid), isoniazid,

epinephrine, thiazide diuretics like hydrochlorothiazide,

and furosemide (Lasix).


Reactions

Insulin may cause minor and usually temporary side effects

such as rash, irritation or redness at the injection site. To

help prevent hypoglycemia, eat meals on a regular

schedule. Too much insulin can cause low blood sugar

(hypoglycemia). The symptoms include cold sweat,

shaking, rapid heart rate, weakness, headache and fainting

Nursing Responsibilities 1) monitor patient closely for symptoms of

hypoglycemia

2) use only syringes calibrated for the

particular concentration of insulin given

3) press but don’t rub the injection site after

administration

4) Rotate injections sites to avoid overuse of

one area.Diabetic patients may achieve

better control if injection site is rotated

within the same anatomic region

5) Don’t use insulin that changes color or

becomes clumped or granular in appearance

6) Check expiration date on vial before using

contents

7) Make sure patient knows that drug relieves

symptoms but don’t cure disease

8) Monitor patient for hyperglycemia

NURSING THEORIES

Faye Glenn Abdellah’s 21 Nursing Problems

Faye Glenn Abdellah emphasized that nursing should always be patient-focused. What

she meant by patient-focused is that nurses should be able to identify the detectable conditions

ailing the patient and provide a nursing intervention in order to better the condition of the patient.

She professed that a nurse must first identify a problem of the patient and through the use of

critical thinking, subsequently solve the problem.

Abdellah’s Metaparadigm

Although she did not clearly provide a definition for each major concept, abdellah did

refer to individuals and/or families as “recipients of care.” Her description of health is the “total

health needs” of a person and “a healthy state of mind and body.” She includes society in the

planning for optimum health on local, state and international levels but emphasizes that nursing

service is primarily for the individual. Nursing for Abdellah is a comprehenseive service that is

based on an art and science and aims to help people, sick or well, cope with their health needs.

In order to aid nurses in identification and solving, Abdellah formulated a typology called

the 21 nursing problems. These problems were based on the physical, social and emotional needs

of the patient, the types of interpersonal relationshops between the nurse and the patient and the

common elements of patient care.

Abdellah’s Typology of the 21 Nursing Problems are as follows:

1.To promote good hygiene and physical comfort

2. To promote optimal activity, exercise, rest, and sleep

3. To promote safety through prevention of accidents, injury, or other trauma and through the

prevention of the spread of infection

4. To maintain good body mechanics and prevent and correct deformities

5. To facilitate the maintenance of a supply of oxygen to all body cells

6. To facilitate the maintenance of nutrition of all body cells

7. To facilitate the maintenance of elimination

8. To facilitate the maintenance of fluid and electrolyte balance

9. To recognize the physiologic responses of the body to disease conditions

10. To facilitate the maintenance of regulatory mechanisms and functions

11. To facilitate the maintenance of sensory function

12. To identify and accept positive and negative expressions, feelings, and reactions

13. To identify and accept the interrelatedness of emotions and organic illness

14. To facilitate the maintenance of effective verbal and nonverbal communication

15. To promote the development of productive interpersonal relationships

16. To facilitate progress toward achievement of personal spiritual goals

17. To create and maintain a therapeutic environment

18. To facilitate awareness of self as an individual with varying physical, emotional, and

developmental needs

19. To accept the optimum possible goals in light of physical and emotional limitations

20. To use community resources as an aid in resolving problems arising from illness

21. To understand the role of social problems as influencing factors in the cause of illness

Summary

Abdellah’s 21 nursing problems are especially useful in the case of our patient since our

patient has several of these nursing problems. Our verbalized that although he does try to get

some exercise he is no longer able to do it as often as he used to. He no longer plays sports or

jogs and the morning and has reduced his biking regimen to only less than three times per week

at a distance significantly lesser than what he had done before. Taking into consideration the

patients age and physical limitations, we addressed this problem by suggesting exercise in the

form of long, moderately paced walks after his legs regain full strength to provide a good

cardiovascular workout without straining the body too much. The patient at the time of the

interview had difficulty ambulating as well as poor eyesight thus would be prone to accidents

and injury. We provided intervention to counter this problem through assisting the patient when

ambulating, removed objects that were lying on the floor that could cause the patient to slip as

well as raising the bed rails when sleeping. As a post-operative patient, the threat of infection

will be ever-present until the wound can completely heal. Thus we provided strict monitoring of

the wound dressing and any signs of a possible infection that manifests in the client. Since the

client had a cholecystectomy, it would mean that the nutritional balance to his cells as well as the

maintenance of elimination may be affected due to the decrease of the body’s ability to emulsify

fat hence we advised the client to minimize his intake of fatty foods in order to facilitate better

digestion and absorption of nutrients.

Some of Abdellah’s 21 nursing problems were already present in the patient upon

receiving him and we forsee that several more may present as time goes by considering his

condition, thus proper intervention by the nurse must be conducted in order to adequately

facilitate good health. Abdellah’s theory is an indispensible part of the nursing practice since it

provides a road map as to how we can provide precise, patient focused care.

Imogene King’s Goal Attainment Theory

In the heart of Imogene King’s theory is the belief that the patient and the nurse can work

together to define and reach a mutually agreed upon goal. King suggests that human beings have

three fundamental needs. These are the need for the health information, the need for care with an

emphasis on the prevention of illness, and the need for care when human beings are unable to

help themselves. This theory suggests that the focus of nursing is the care of the human being,

which King believes is an open system that is constantly interacting with their environment. The

nurse can act as environmental stimuli through interaction and together with the patient, can

perceive, judge and act together and ultimately put together a set of goals and a plan to which

subsequent action will be taken.

King’s Metaparadigm

King defines health as “dynamic life experiences of a human being, which implies

continuous adjustment to stressors in the internal and external environment through optimum use

of one’s resources to achieve maximum potential for daily living.” Enviornment is defined as “ a

function of balance between internal and external interactions”. Nursing according to orem, is “a

process of action, reaction and interaction whereby nurse and client share information about their

perceptions in the nursing situation .

Summary

In our patient’s case we made extensive use of Imogene King’s goal attainment theory,

especially when it came to post-operative care and interventions and also in the management of

his diabetes. We made use of this theory most especially in the assessment phase of the nursing

process since it is only the client alone that is able to identify the subjective cues. We worked

with the client and established with him to watch out for signs of infection. This is an application

of King’s theory in that we as student nurses gave the information to the signs of infection and

agreed with the client to mutually monitor his wound with a similar goal of early detection. We

also worked with the client for diet modification with a goal of increasing his protein and vitamin

c intake to facilitate faster wound healing. Another objective set with the client is to improve his

exercise habits with gradual increase in difficulty to allow a stable return of his ambulating

abilities and overall cardiovascular health. The application of King’s theory is however, most

evident and detailed in our discharge plan since upon discussing it with the client, we set a goal

to achieve all of the specified instruction in the discharge plan and to return to the physician for a

follow-up assessment

King’s theory is unique and invaluable to a student nurse in that it teaches both the nurse

and the patient that the nursing process isn’t just about the nurses efforts and interventions but

the collaboration of both parties to achieve a single, realistic goal for the betterment of the

patient.

Myra Levine’s Conservation Model

Levine’s conservation model is a nursing theory that focuses on the promotion of

adaption and the maintenance of the perceived “wholeness” of the individual. This is done

through the use of the four principles of conservation. Levine defines adaptation as “the life

process by which, over time, people maintain their wholeness or integrity as they respond to

environmental challenges” (George, Julia B. RN Nursing Theories, The base for Professional

Nursing Practice Fourth Edition). There are two types of environment that an individual can

adapt to namely the internal environment and the external environment.

The internal environment is a combination of the physiological and pathophysiological

aspect of an individual that is persistently under the influence and challenged by the external

environment.

The external environment are the factors that are not within a persons’ direct biological

process but rather influence it. There are three components of the external environment. These

are the perceptual environment, the operational environment and the conceptual environment.

The perceptual environment refers to the part of the environment in which a person responds to

with their sensory organs such as light, temperature, sound, taste and smell. The operational

environment is the portion of the environment that interacts with living tissue even if the

organism does not have any way of sensing its presence. There include radiation,

microorganisms and pollutants. The conceptual environment is the more humanistic part of the

external environment which includes language, culture, ideas, symbols.

When adaptation occurs the product is conservation. Conservation is a universal concept,

a natural law, that deals with defense of wholeness and system integrity. “Conservation defends

the wholeness of living systems by ensuring their ability to confront change appropriately and

retain the unique identity” (George, Julia B. RN Nursing Theories, The base for Professional

Nursing Practice Fourth Edition.)

Conservation has four basic principles to which it adheres to and can therefore be

achieved. These are:

1. The conservation of energy of the individual.

This refers to the balancing of energy input and output to avoid excessive fatigue and

facilitate recovery. This can be achieved through rest and the limitation of strenuous activities as

well as the maintenance of proper nutrition.

2. The conservation of the structural integrity of the individual

This focuses on the healing process since Levine believed that “healing the defense of

wholeness”. This refers to the maintenance and restoration of the body to prevent physical

breakdown and promote healing.

3. The conservation of the personal integrity of the individual.

Refers to the sense of self of the individual. This can be preserved by

recognizing the individual as one who strives for recognition, respect, self awareness, selfhood

and self determination.

4. The conservation of the social integrity of the individual.

This refers to the conservation of an individual’s place within a society as not to become

isolated due to his/her condition.

A nurse’s role in the four principles of conservation is to assist he person with the process of

retaining wholeness through the lease expense of effort. As such we must assist the client in

conserving all integrity.

Summary

This theory is important since our patient is a post-operative patient also with diabetes

mellitus both of which would have an undeniable affect on his physical well being especially

with regards to the energy and structural integrity of the individual. It is important to maintain

the energy since these diseases will make him especially susceptible to physical stress which

could lead to worsening of the conditions. The structural integrity is also at risk since the

condition may eventually lead to the physical breakdown of the patient if not maintained. Being

in this condition also leaves the risk of the patient developing poor self-concept since his body is

currently in a weakened state and thus has to rely extensively on other people. This may lead to

the patient viewing himself as a burden. As nurses, we can use the conservation model to help

him maintain his personal integrity by introducing methods to which he can take care of herself

and showing him the respect he deserves. Social integrity also needs to be persevered because as

of the moment, the patient is still recovering and is not able to fully return to his normal roles in

society. The duration of the recovery time may vary on how well the wound is healing a time

which he may develop a sense of isolation. We can use Levine’s theory to suggest to the family

to support the patient through these tough times and, if needed, educate them on the condition to

avoid alteration of views.

DISCHARGE PLAN

MEDICATIONS:

Instruct the patient to comply with the medications ordered by the physician.

Home medication, must be strictly followed for fast recovery. Encourage to take food

supplements such as vitamin and minerals to boost up patients immunity.

Explain why the medication is given and the importance of taking it up.

EXERCISE:

The patient should be encouraged to resume his activities of daily living at home to

promote independence and for timely recovery.

Regular exercise should also be encouraged to promote good blood circulation in the

body.

TREATMENT:

The patient should be encouraged to cooperate with the treatment and procedure ordered

by the physician for his timely recovery.

Instruct patient to take Janumet 500 mg one tablet once a day for one month

Instruct patient to take pritor plus once a day after breakfast for one month.

HEALTH-TEACHINGS:

The patient should be instructed to have sleep early at night and rest during the day.

The patient should avoid places where environmental sanitation is poor .

Encourage patient to comply with the medications.

Instruct client in techniques to protect the integrity of skin, care or dressing.

OUT-PATIENT

Any odd signs such as fever, wound infection, recurrence of fever, etc. must be immedi-

ately reported to the physician.

Instruct the patient to come back after a week or so for a follow-up check up.

DIET

A well- balanced diet is necessary for good wound healing and recovery. Instruct the pa-

tient to eat foods that are from the four basic food groups: dairy products, meat, vegeta-

bles and fruits.

Encourage the patient to increase fluid intake.

Encourage patient to avoid fatty and salty foods.

Discourage patient from vices such as smoking and drinking

PROGNOSIS

GOOD FAIR POOR JUSTIFICATION

Onset of the

illness

√ The onset of cholelithiasis takes time. It takes time

for the stone to form. Moreover, unlike diseases

that has sudden onset like heartatack, the onset of

cholecystitis is not sudden therefore it can still be

treated while it is still at early stage.

Duration of illness √ Cholecystitis is a slow progressing disease. There

is still time to treat the patient with medicines and

treatments like surgery. The patient also do

something regarding his illness while it is still

early and did not disregard it.

Precipitating

factors

√ The precipitating factor present in the patient is

diabetes mellitus. Diabetes mellitus is a metabolic

diseases that is characterized by high blood sugar

(glucose) levels, that result from defects in insulin

secretion, or action, or both. This disease is

lifetime disease. However there are a lot of ways a

person can do to prevent any complications. One

of which is constant monitoring of blood glucose.

The patient is also very compliant with his

maintenance drug for diabetes which is

Glimiperide. Therefore, this factor can be modified

but with strict compliance to it.

Willingness to

take medications

√ The patient has maintenance medications which

are Pritor plus and glimiperide. The patient

and treatment complies with the medications strictly. Moreover,

the patient is very willing to take the medications

prescribed to him by the doctor. He is also willing

to undergone treatment and surgery that would be

good for his health.

Age √ The age of the patient is 59. He is already in the

middle age. He is in the age bracket that were

susceptible to illnesses. Unlike young adults who

have strong immune system and recover fast,

middle aged adults recover slowly and their

immune systems are deteriorating. However, he is

physically fit and he maintains healthy body.

Environmental

factors

√ The client’s home as reported is conducive for rest

and sleep. The patient lives in a therapeutic

environment. There are smaller chances of

pollution and noise. It can be said that the

environment as well was generally peaceful and

calm is very favorable for rest and promotes better

health. Moreover, the hospital is also clean and

conducive for healing.

Family Support √ The family has been very supportive throughout.

His sons and daughters were supportive. His two

daughters who are nurses are taking good care of

him. His two sons were supporting him especially

watching over him while he is in the hospital.

Total 3 3 1

Computation:

Poor: (0*1)/7 = 0/7

Fair: (2*2)/7 = 4/7

Good: (5*3)/7 = 15/7

Total: 2.71

General Prognosis:

1-1.6 = POOR

1.7-2.3 = FAIR

2.4-3.0 = GOOD

Rationale for a Good Prognosis

As shown by the calculated prognosis in relation to the different factors involved,

the patient has a good chance of survival. The factors presented in relation to prognosis shows

that patient can cope up after being discharged. The precipitating factor present in the patient is

diabetes mellitus. Diabetes mellitus is a metabolic disease that is characterized by high blood

sugar (glucose) levels that result from defects in insulin secretion, or action, or both. This disease

is lifetime disease. However there are a lot of ways a person can do to prevent any

complications. One of which is constant monitoring of blood glucose. The patient is also very

compliant with his maintenance drug for diabetes which is Glimiperide. Therefore, this factor

can be modified but with strict compliance to it. Moreover, The age of the patient is 59. He is

already in the middle age. He is in the age bracket that was susceptible to illnesses. Unlike young

adults who have strong immune system and recover fast, middle aged adults recover slowly and

their immune systems are deteriorating. However, he is physically fit and he maintains healthy

body.

However, on the other hand, the onset of cholelithiasis takes time. It takes time for the

stone to form. Moreover, unlike diseases that has sudden onset like heart attack, the onset of

cholecystitis is not sudden therefore it can still be treated while it is still at early stage.

Cholecystitis is a slow progressing disease. There is still time to treat the patient with medicines

and treatments like surgery. The patient also does something regarding his illness while it is still

early and did not disregard it. The patient has maintenance medications which are Pritor plus and

glimiperide. The patient complies with the medications strictly. Moreover, the patient is very

willing to take the medications prescribed to him by the doctor. He is also willing to undergone

treatment and surgery that would be good for his health. The client’s home as reported is

conducive for rest and sleep. The patient lives in a therapeutic environment. There are smaller

chances of pollution and noise. It can be said that the environment as well was generally peaceful

and calm is very favorable for rest and promotes better health. Moreover, the hospital is also

clean and conducive for healing. The family has been very supportive throughout. His sons and

daughters were supportive. His two daughters who are nurses are taking good care of him. His

two sons were supporting him especially watching over him while he is in the hospital.

RECOMMENDATION

With this case presentation, as a group we’ve acquired a lot of knowledge and

experiences that could really help us to become an efficient and competent nurse in the near

future. We’ve also seen our strengths and realized the weakness and flaws we have as a group.

With this, we have formulated recommendations for the betterment of the majority, for the

patient and his family, for the institution, for the school and lastly, for the group.

For the patient, we recommend that he should comply with the doctor’s order and eat

nutritious food more often. He should religiously comply with the home medicatios and check-

ups instructed to him. Furthermore the family should be there to support their loved one in times

of ups and downs. Each member of the family should not neglect their health. They should

promote a good diet and healthy lifestyle for the betterment of the patient. They should not

hesitate to seek medical help whenever needed. Instead they should practice seeing a medical

professional before an illness worsens.

The medical institution should continue their optimal medical service to all patients.

Their quality service should be maintained for the better of all patients.

For our group, the commendable group work and cooperation should be continued

throughout, improve on the things where we committed mishaps. And for Ateneo De Davao

University’s College of Nursing, we recommend that everyone in the faculty and staff continue

to mold student nurses to be the best future registered nurses that they can be.

cholecytitis

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