Republic of the Philippines

ISABELA STATE UNIVERSITY

Echague, Isabela

COLLEGE OF NURSING

A Case Study of
LAPAROSCOPIC CHOLECYSTECTOMY
Submitted to the
Faculty and Staff of the College of Nursing

Submitted by:
Lyka C. Abitria
Aiko A. Acosta
Christianne May B. Addun
Apple Madge O. Agnes
Tsz Hay Kimberly C. Guarin
Marc Cesar A. Ramos
Laarnie Camille B. Saet
Junelie P. Tapaoan
Karl Vincent C. Uy
Vea Amor T. Verdadero

4-1 Group 4

A.Y. 2023-2024 (2nd Semester)

 Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Isabela

COLLEGE OF NURSING

TABLE OF CONTENTS

TITLE PAGE

I. OBJECTIVES OF THE STUDY

II. OVERVIEW OF THE DISEASE

III. DEMOGRAPHIC DATA AND PROFILE

IV. NURSING HISTORY

V. COURSE IN THE WARD

VI. ANATOMY OF THE SURGICAL SITE

VII. SURGICAL PROCEDURE

VIII. SURGICAL INSTRUMENTS AND FUNCTIONS

IX. NURSING CARE PLAN

X. DRUG STUDY

XI. REFERENCES

1
I. OBJECTIVES OF THE STUDY
General Objectives:
➢ This case study's primary aim is to obtain adequate knowledge,
understanding, and appropriate intervention skills about the nature of
cholelithiasis, and determine nursing concepts and theories which can
utilize in the actual clinical settings.

Specific Objectives:
➢ To Identify the risk factors, epidemiology, prognosis, etiology of acute
calculous cholecystitis including gallstone formation, and recognize its
symptoms and diagnostic methods.
➢ Evaluate the patient's medical history to extract relevant information
influencing the progression of acute calculous cholecystitis.
➢ To comprehend the treatment plan and management approach for the
patient in the ward.
➢ Describe the anatomical disruptions in the gastrointestinal systems
contributing to acute calculous cholecystitis.
➢ To comprehend and describe the surgical procedure termed laparoscopic
cholecystectomy, encompassing its indications and its procedure.
➢ To gain knowledge of the instruments being used and its functions.
➢ Develop tailored nursing care plans addressing specific patient concerns,
such as pain management and psychosocial well-being, in acute calculous
cholecystitis.
➢ Implement appropriate nursing interventions aligned with medical protocols
to alleviate symptoms anfd provide comprehensive support for patients with
acute calculous cholecystgbitis.
➢ Gain understanding of pharmaceutical interventions for acute calculous
cholecystitis, including their mechanisms of action and suitability for
individual patients.

2
II. OVERVIEW OF THE DISEASE

CHOLELITHIASIS
Cholelithiasis, are hardened deposits of digestive fluid that form in the
gallbladder. Cholelithiasis commonly results from a chemical imbalance
within the contents of the gallbladder in which the bile contains excessive
cholesterol or bilirubin Cholelithiasis is typically not characterized by any
signs or symptoms unless there is an obstruction of the cystic duct, bile
ducts, or both.
There are two types of cholelithiasis:

❖ Cholesterol gallstones.
o The most common type of gallstone, called a cholesterol
gallstone, often appears yellow in color. These gallstones are
composed mainly of undissolved cholesterol, but may contain
other components.
❖ Pigment gallstones.
o Pigment gallstones can form in the gallbladder when there’s too
much bilirubin, which is a chemical that is created when your
body breaks down red blood cells. They are called “pigment”
gallstones because they’re usually brown or black in color.
o When your body breaks down too much hemoglobin from the
blood, bilirubin is secreted at high levels and can even leak into
your bloodstream. Excess bilirubin in your bloodstream can
cause jaundice, which can cause your skin and/or eyes to have
a yellowish hue. An unhealthy liver, cirrhosis of the liver, and
sickle cell anemia are risk factors for black pigment gallstones.

3
Epidemiological Report
Worldwide
- Gallstones are common in 20 % of patients with symptomatic disease, with
wide variation in severity. In developed countries, 10–15 % of the adult
population is affected by gallstones. According to the third National Health
and Nutrition Examination Survey, 6.3 million men and 14.2 million women
aged 20 to 74 in the United States had gallbladder disease. In Europe, the
Multicenter Italian Study on Cholelithiasis (MICOL) examined nearly 33,000
subjects aged 30 to 69 years in 18 cohorts of 10 Italian regions. The overall
incidence of gallstone disease was 18.8 % in women and 9.5 % in men.
However, the prevalence of gallstone disease varies significantly between
ethnicities. Biliary colic occurs in 1 to 4 % annually. occurs in 10 to 20 % of
untreated patients. In patients discharged home without operation. the
probability of gallstone related events is 14, 19, and 29 % at 6-weeks, 12
weeks, and at 1 year, respectively. Recurrent symptoms involve biliary colic
in 70 % while biliary tract obstruction occurs in 24 % and pancreatitis in 6
%. Significant controversies remain regarding the diagnosis and
management. The 2007 and 2013 Tokyo guidelines (TG) attempted to
establish objective parameters for the diagnosis, debates continue in the
diagnostic value of single ultrasound (US) signs, as well as of laboratory
tests. Historically, the main controversies were around the timing of surgery.
The need for surgery as compared to conservative management has been
less investigated, particularly in high surgical risk patients. The other major
disagreements include: method and need to diagnose potential associated
biliary tree stones, treatment options, type of surgery, definition and
management of high surgical risk patients (with clarification of the role for
cholecystostomy). While the TG have certainly improved the understanding,
some criticisms have followed. Indeed, the references in the TG are
outdated for some recommendations; the scoring system has not been
validated and it does not distinguish between suspected gallbladder
inflammation and systemic signs. Finally, the conclusions are not clear
because all the different therapeutic options are available for the same
“severity grade”. For these reasons the World Society of Emergency
Surgery (WSES) decided to convene a consensus conference (CC) to
investigate these controversies and define its guidelines regarding
diagnosis and treatment
National
- There was no statistical data found in the Philippines but studies in pediatric
patients estimate an overall prevalence of 0.13% to 1.9 % for cholelithiasis
disease in children up to 19 years of age (Abacan and Chiong, 2017.)
CAUSES

4
 1. Gallstones (Cholelithiasis):
o The primary cause is the presence of gallstones within the
gallbladder. Gallstones are solid deposits that form from cholesterol,
bilirubin, and calcium salts in bile.
2. Cystic Duct Obstruction:
o Apart from gallstones can also be caused by other factors that
obstruct the cystic duct, such as edema, inflammation, or
compression from adjacent structures.
o Inflammatory conditions of the bile ducts or adjacent organs, such as
pancreatitis or inflammatory bowel disease, can lead to cystic duct
obstruction and subsequent cholecystitis.
3. Biliary Sludge:
o Biliary sludge refers to a mixture of particulate matter, including
cholesterol crystals, calcium salts, and mucin, suspended in bile.
Sludge may form within the gallbladder due to alterations in bile
composition or stasis.
4. Gallbladder Dysmotility:
o Impaired gallbladder motility, often associated with conditions such
as diabetes mellitus or prolonged fasting, can lead to stasis of bile
within the gallbladder.
5. Ischemia:
o In some cases, may occur due to impaired blood supply to the
gallbladder, leading to ischemia and subsequent inflammation.
6. Infection:
o Although less common, /’can be complicated by superimposed
bacterial infection, particularly in cases of prolonged cystic duct
obstruction or biliary stasis. Bacterial proliferation within the
gallbladder leads to secondary infection and exacerbates the
inflammatory response.\
Risk Factors:
- Certain risk factors including obesity, female gender, advanced age, rapid
weight loss, pregnancy, and a diet high in saturated fats.

❖ Non- Modifiable Risk Factors

a. Age: Risk increases with age, particularly after 40.
b. Gender: Females are at a higher risk, especially during their
reproductive years
c. Genetics: Family history of gallstones can increase the
likelihood of developing them.
d. Ethnicity: Certain ethnic groups, such as Native Americans
and Hispanics, have a higher risk.
❖ Modifiable Risk Factors

5
 a. Obesity: Excess body weight, particularly central obesity, is
strongly associated with gallstone formation.
b. Diet: High-fat, high-cholesterol diets can contribute to
gallstone formation.
c. Rapid weight loss: Crash diets or bariatric surgery can
increase the risk of gallstones due to changes in bile
composition and flow.
d. Sedentary lifestyle: Lack of physical activity can increase the
risk of gallstone formation.
e. Diabetes: Insulin resistance and metabolic syndrome are
associated with an increased risk of gallstones.
f. Cholesterol-lowering drugs: Some medications used to
lower cholesterol levels can increase the risk of gallstones.
CLINICAL MANIFESTATIONS
1. Pain
- Patient feel this discomfort in the center of the upper abdomen, just below
the breastbone, or in the upper right portion of the abdomen, near the
gallbladder and liver. In some people, the pain extends to the right shoulder.
Symptoms typically start after eating.
2. Fever and chills
3. Nausea and/or vomiting
4. Jaundice
- Yellowing of the skin or eyes, dark urine and pale, grayish bowel
movements. These symptoms appear when gallstones pass out of the
gallbladder and into the common bile duct, blocking the flow of bile out of
the liver.
5. Abdominal tenderness
- Palpation of the right upper quadrant may reveal tenderness
6. Murphy's sign
- Pain or halt in inspiration during deep palpation of the right upper quadrant
Elevated Inflammatory Markers:
Laboratory tests may reveal elevated inflammatory markers such as C-reactive
protein (CRP) and white blood cell count (WBC), indicating an inflammatory
response and potential infection.
Complications

• Biloma
• Intraabdominal abscess
• Small bowel injury
• Infection
• Bleeding

6
 • Injury to your liver, bile ducts or pancreas (pancreatitis).
Medical Management
a. Pain Management
o Administer analgesic medications to alleviate abdominal pain
o Utilize a combination of nonsteroidal anti-inflammatory drugs
(NSAIDs), acetaminophen, or opioids as appropriate based on
the severity of pain and patient response.
b. Antibiotic Therapy
o Initiate empirical antibiotic treatment to target bacterial
infection
o Prescribe broad-spectrum antibiotics initially, considering
the likely pathogens involved,
o Adjust therapy based on culture and sensitivity results to
optimize efficacy and minimize antibiotic resistance.
c. Intravenous Fluids
o Providing intravenous fluids to maintain hydration and
support organ function during acute illness.
o Adequate hydration is essential for optimizing circulation,
renal function, and metabolic processes.
d. Nonsteroidal Anti-inflammatory Drugs (NSAIDs):
o Using NSAIDs to reduce inflammation and relieve pain
associated with acute cholecystitis. NSAIDs help alleviate
symptoms by targeting the inflammatory processes in the
gallbladder.
e. Anti-emetics
o Administering anti-emetic medications to control nausea
and vomiting, which are common symptoms of acute
cholecystitis. This helps improve oral intake, prevent
dehydration, and enhance patient comfort.
f. C-tube
o Cholecystectomy tube or c-tube is placed after the removal
of the gallbladder and is placed in the bile duct. C-tubes are
place through the abdominal wall and into the gallbladder.
This is for patients who can’t do the surgery or are too sick
and cannot have anesthesia. It is attached to the patient for
6 weeks or until the patient is allowed to have surgery.
g. Nasogastric tube
o If the patient experiences frequent episodes of severe
nausea and vomiting, the doctor may decide to put a
nasogastric tube with GI decompression. The NG tube
aids in removing stomach contents to prevent the
gallbladder from being stimulated.

7
 Surgical Management
❖ Laparoscopic Cholecystectomy
o Perform laparoscopic removal of the gallbladder as the
primary surgical intervention for acute calculous
cholecystitis. This minimally invasive approach offers faster
recovery, shorter hospital stays, and reduced postoperative
pain compared to open surgery, making it the preferred
choice for uncomplicated cases.
o A laparoscope, is a small, thin tube that is put into your body
through a tiny cut made just below the navel.
Pharmacological Management
❖ Analgesics
o Administering pain relief medications to alleviate abdominal
pain, which is a hallmark symptom.
o Nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen or diclofenac, and acetaminophen are commonly
used to provide symptomatic relief.
❖ Antibiotics
o Initiating antibiotic therapy to target bacterial infection in the
gallbladder.
❖ Anti-emetics
o administering anti-emetic medications to control nausea and
vomiting.
o Medications such as ondansetron or metoclopramide can help
alleviate these symptoms and improve patient comfort.
❖ Proton Pump Inhibitors (PPIs) or Histamine-2 Receptor
Antagonists
o Prescribing acid-suppressing medications to reduce
gastric acid production and minimize irritation of the
gastrointestinal tract.
o PPIs (e.g., omeprazole, pantoprazole) or H2 blockers
(e.g., ranitidine, famotidine) may be used to prevent stress-
related mucosal damage and gastrointestinal bleeding,
especially in patients with a history of peptic ulcer disease
or those requiring prolonged NSAID use.
Nutritional Management

Diet
- Patient should avoid eggs, cream, pork, fried foods, cheese and in rich in
dressing, gas- forming vegetables, and alcohol.

8
- It is important to remind the patient that fatty foods may bring on an episode
of pain
• Low-fat Diet
- Advise patients to follow a low-fat diet to minimize gallbladder stimulation
and reduce the risk of symptom exacerbation.
- Dietary modifications play a crucial role in managing acute cholecystitis by
reducing gallbladder workload.
• Hydration
- Adequate hydration is essential to prevent dehydration and maintain overall
health.
- Patients are encouraged to drink plenty of water throughout the day and
avoid sugary or caffeinated beverages that may exacerbate gastrointestinal
symptoms.
• Monitoring
- Closely monitor the patient's nutritional status during hospitalization and
recovery, assessing dietary intake, weight changes, and signs of
malnutrition or dehydration.
Nursing Management
Assessment:
- Conduct a thorough assessment of the patient's symptoms, including the
severity of abdominal pain, nausea, vomiting, fever, and any associated
complications.
- Monitor vital signs and observe for signs of dehydration or sepsis.
Pain Management:
- Administer prescribed analgesic medications to alleviate abdominal pain
and discomfort.
- Use non-pharmacological pain relief measures such as positioning,
relaxation techniques, and distraction techniques to complement
pharmacological interventions.
Monitoring:
- Monitor the patient's fluid intake and output closely to assess hydration
status.
- Keep track of intake, output, and daily weights to identify signs of
dehydration or fluid overload.
- Monitor for complications such as jaundice, sepsis, or gallbladder
perforation.
Nutritional Support:
- Collaborate with the dietitian to provide dietary counseling and ensure the
patient follows a low-fat diet to minimize gallbladder stimulation.

9
- Encourage small, frequent meals and provide education on foods to avoid,
such as fatty or fried foods.
Hygiene and Comfort:
- Assist the patient with personal hygiene and provide comfort measures such
as changing positions, providing warm blankets, and ensuring a comfortable
environment.
- Address any concerns related to pain, nausea, or discomfort promptly.
Education:
- Provide patient education on the nature of acute calculous cholecystitis,
including its causes, symptoms, and treatment options.
- Educate the patient on the importance of adherence to prescribed
medications, dietary restrictions, and follow-up care instructions.
Preoperative Preparation:
- Patient is scheduled for surgery, ensure they understand the procedure,
risks, and benefits.
- Provide preoperative instructions, including fasting guidelines and
medication management.
Emotional Support:
- Offer emotional support and reassurance to the patient and their family
members.
- Address any fears, concerns, or anxieties they may have about the
condition, treatment, or surgery.
Prognosis
- For patients with uncomplicated acute cholecystitis, the prognosis is
excellent. The mortality rates are very low. Perforation or gangrene of the
gallbladder may occur in delayed cases. Patients with acalculous
cholecystitis have high mortality varying from 20-50%.
- In severe cases of acute cholecystitis, the intense inflammation can make
surgery difficult, resulting in injury to the bile duct, which has substantial
morbidity.

III. DEMOGRAPHIC DATA AND PROFILE

Patient Y, a 33-year-old Filipino female from Balintocatoc, Santiago City,

Isabela, who is self-employed, was admitted on April 25, 2024, at 1:45
PM, with a chief complaint of right upper quadrant pain. Initially
diagnosed with cholelithiasis, subsequent tests revealed acute calculous
cholecystitis. Patient Y is Catholic and married.
10
IV. NURSING HISTORY

• History of Present Illness

Patient Y, a 33-year-old woman, residing in Santiago City, presents to the

emergency department with abdominal pain. A week prior to admission, the
patient experienced tolerable abdominal pain rated at 6 out of 10 on the pain
scale. Initially, the patient opted for rest and observed her body. However, the
following day, the abdominal pain worsened, described as a constant radiating
pain to the back, and rated at 8 out of 10. At this point, the patient treated the
discomfort at home with over-the-counter pain medication (paracetamol),
admitting to taking it twice a day until the day prior to admission. Despite this
intervention, the pain persisted, providing only temporary relief. The patient also
applied a heating pad to the affected area but admitted that she only did it twice.
Over the following days, intermittent discomfort persisted, particularly after
meals, "lalo na kapag karne ang ulam", as she verbalized. The pain was
described as sharp and cramping. After experiencing persistent symptoms for
days, the patient decided to seek medical attention.

• Past Health History

The patient lacks recall of her immunization record but denies significant
childhood illnesses. However, she has a history of S/P Arrest in 2018 and
reports no known allergies.
• Social History

The patient is a college graduate and owns a small clothing business, where
she is actively involved in all aspects of its operation. Her daily activities
primarily revolve around managing her business and attending to home
responsibilities. Because of her busy schedule, she does not engage in
much physical exercise. Stress, largely stemming from the demands of
running her business, is a significant factor in her life. She lives in Santiago
City with her spouse and three children. There are no reported
environmental exposures or occupational hazards.

• Family History

11
There is no known family history of acute calculous cholecystitis or related
gallbladder conditions.

12
V. COURSE IN THE WARD

Date and Order Interpretation / Rationale Nursing Responsibility Rationale

Time
April 25, 2024 Please admit to room ➢ This order facilitates ➢ Coordinate with the ➢ To make sure if there’s
1:45 PM of choice under the efficient and admitting officer, nurse any available room in
service of Dr. personalized care by station, and house the hospital.
BP: 110/80 Macaraeg. allowing the patient to keeping department.
PR: 74 select their preferred
RR: 20 room, promoting ➢ Assist the patient to the ➢ To make sure patient’s
Temp: 36.5 comfort and potentially room. safety.
aiding in the healing
process. Assigning the ➢ Collaborate closely with ➢ Effective collaboration
patient to Dr. Macaraeg Dr. Macaraeg to ensure with the attending
ensures continuity of seamless continuity of physician promotes
care under a specific care. This includes coordinated care
healthcare provider, discussing the patient's delivery, reduces
fostering a consistent admission details, errors, and enhances
and cohesive treatment medical history, patient safety and
approach. treatment plan, and any satisfaction throughout
specific care their hospitalization.
requirements.
Secure concent for ➢ To uphold patient ➢ Make sure to witness ➢ To verify that the patient
admission and autonomy and ensure the consent signing. and significant others
management ethical practice by ➢ Document the consent understand what is
providing individuals process in the patient's explained.
with the necessary medical record. ➢ This documentation
information to make serves as legal
informed decisions evidence that informed
about their healthcare, consent was obtained

13
 fostering trust, and and ensures
promoting patient safety compliance with
throughout their regulatory standards.
treatment and hospital Proper documentation
stay. helps protect both
patients and healthcare
providers by providing a
record of the
discussions held and
decisions made during
the consent process.
NPO post midnight ➢ Implementing NPO ➢ Educate patient ➢ Patient education helps
(nothing by mouth) post and/or their family the patient understand
midnight before surgery about the NPO the purpose of NPO
is to reduce the risk of guidelines and status and what to
aspiration during ensuring compliance expect during this time,
anesthesia. By allowing with the fasting reducing anxiety and
the stomach to empty instructions. promoting cooperation.
before surgery, the
likelihood of ➢ Regularly assess the ➢ Monitoring for signs of
regurgitation and patient for signs of hunger, thirst, or
aspiration of gastric hunger, thirst, or discomfort allows for
contents into the lungs discomfort related to prompt intervention to
is minimized, enhancing not being able to eat or address any needs or
patient safety and drink. concerns.
decreasing the potential ➢ Collaboration with the
for serious respiratory ➢ Communicate with the healthcare team
complications during healthcare team, promotes holistic care
anesthesia induction including physicians, and ensures that the
and throughout the dietitians, and other patient's nutritional and
surgical procedure. nurses, to ensure medical needs are
coordinated care and addressed

14
 appropriate appropriately during
management of the NPO status.
patient's NPO status.

IVF D5 LRS 1L ➢ D5 LRS provides ➢ Use an aseptic ➢ To minimizes the risk of

q12˚ x 2 CYCLES hydration, electrolytes technique when introducing pathogens
(sodium, potassium, inserting the IV into the bloodstream,
chloride, calcium, catheter, choose an reducing the likelihood
lactate), and glucose appropriate vein, of infection, and helps
(5% dextrose), which usually in the forearm maintain IV access
are essential for or hand, and secure integrity, ensuring
maintaining the catheter properly. continuous fluid
hemodynamic stability, delivery throughout the
preventing dehydration, ➢ Regularly assess the surgical procedure and
and supporting IV site for signs of postoperative period.
metabolic demands infiltration (fluid ➢ To detect early signs
during the perioperative leakage into of complications like
period. This fluid surrounding tissues), infiltration, phlebitis, or
therapy helps optimize phlebitis (inflammation infection. Prompt
tissue perfusion, of the vein), or intervention upon
prevent complications infection. detecting these issues
such as hypotension helps prevent further
and electrolyte complications,
disturbances, and ensuring the integrity of
facilitate postoperative IV therapy and
recovery. promoting patient
safety.

15
Dx.: ➢ Patient education ➢ By explaining the
➢ CBC ➢ To assess the patient's involves explaining the purpose and
overall health and purpose and significance of each
identify any preexisting significance of each test, nurses empower
conditions that could test in assessing patients to actively
impact surgery or overall health and participate in their care
recovery. Specifically, it surgical readiness. and make informed
helps evaluate decisions. Patients are
hemoglobin levels to informed about the
ensure adequate fasting requirements or
oxygen-carrying other preparations
capacity during surgery. necessary to obtain
Platelet count accurate test results.
assessment is crucial to Addressing patient
identify any clotting questions and
abnormalities that might concerns helps
affect bleeding risk alleviate anxiety and
during the procedure. ensures compliance
White blood cell count with preoperative
(WBC) is important for instructions, ultimately
detecting signs of promoting a positive
infection or patient experience and
inflammation, which optimizing the quality
could impact surgical of diagnostic data
planning and obtained for surgical
postoperative planning.
management. ➢ Coordinate with the ➢ Coordinating the
laboratory or diagnostic scheduling and
➢ Measuring total bilirubin department to schedule execution of diagnostic
➢ TB1B2 (TB) and direct bilirubin CBC, TB1B2, BT, and tests ensures timely
(DB) levels helps Total Bilirubin tests assessment of the
assess liver function patient's health status

16
 and detect according to the and facilitates informed
abnormalities that may surgical timeline. decision-making by the
indicate liver disease or healthcare team.
biliary obstruction. ➢ Ensure that CBC, ➢ By monitoring test
TB1B2, BT, and Total results, nurses can
Bilirubin results are identify issues that may
➢ Total Bilirubin ➢ Total bilirubin levels are promptly received, impact surgical
measured to assess reviewed, and planning or patient
liver function and monitored for any safety, such as
evaluate for signs of abnormalities or anemia, abnormal liver
biliary obstruction or deviations from normal function, or bleeding
liver disease, which are ranges. tendencies. Effective
common indications for communication of
laparoscopic significant findings to
cholecystectomy. the healthcare team,
Elevated bilirubin levels including surgeons and
may indicate underlying anesthesia providers,
conditions such as facilitates informed
gallstones blocking the decision-making and
bile ducts or allows for timely
inflammation of the interventions to
gallbladder optimize patient
(cholecystitis). outcomes.
Monitoring total bilirubin
helps guide surgical
decision-making and
postoperative care to
optimize patient
outcomes and recovery.
➢ BT ➢ To determine the
patient's blood group
(e.g., A, B, AB, O) and

17
 Rh factor (positive or
negative). This
information is crucial for
blood transfusion
compatibility in case of
unexpected bleeding or
need for blood products
during surgery.
Tx: Verify the accuracy of the Ensuring the prescription
prescription for each accuracy helps prevent
medication, including the medication errors and
dosage, frequency, and ensures that the patient
route of administration. receives the correct doses
at the prescribed frequency
and route. This verification
process is crucial for patient
2:50 PM safety, minimizing the risk
of adverse drug events or
complications associated
with incorrect dosing or
administration.

➢ Assess pain intensity ➢ Monitoring pain

➢ Tramadol ➢ Used for postoperative using pain scales, response helps nurses
50mg / IV ad LD pain management, observe for signs of optimize pain
then 25mg/ IV 4˚ Tramadol provides pain relief or management
effective analgesia inadequate analgesia strategies, tailor
without significant after medication medication dosages as
respiratory depression, administration, and needed, and ensure
enhancing patient document findings patient comfort during
comfort following accurately in the the recovery period
surgery. following surgery.

18
 patient's medical
➢ Monowel 1g q record. ➢ This monitoring is
12˚ ANST ➢ Cefoxitin is essential to ensure
administered as ➢ Confirm negative skin patient safety and
prophylactic antibiotic test for cephalosporin facilitate early
therapy before surgery allergy in patients intervention in case of
to reduce the risk of undergoing hypersensitivity.
surgical site infections laparoscopic Administering cefoxitin
(SSIs) in patients cholecystectomy. The after a negative skin
undergoing nursing responsibility test is part of antibiotic
laparoscopic includes closely prophylaxis to target
cholecystectomy. This monitoring the patient common pathogens
procedure involves for signs of allergic encountered during
entering the abdominal reactions, such as surgery and reduce the
cavity, which increases rash, itching, swelling, risk of surgical site
the risk of bacterial or respiratory distress, infections.
contamination and particularly after the
subsequent infection. initial dose of cefoxitin.
➢ Omepron
40mg/IV at the ➢ Omepron is used to ➢ To ensure patient
OR reduce gastric acid ➢ Monitor the patient's stability during
secretion, minimizing vital signs, including medication
the risk of gastric blood pressure, heart administration and
irritation and reflux in rate, and oxygen identify any potential
patients undergoing saturation, to assess complications, such as
laparoscopic for any adverse hypotension. By
cholecystectomy, reactions or changes in closely observing the
particularly when physiological status. patient's response to
receiving pain omeprazole and
medications and promptly addressing
anesthesia. any deviations from
baseline vital signs,

19
 nurses contribute to
the safe management
of gastric acid levels,
minimizing the risk of
perioperative
complications and
optimizing patient
outcomes during
laparoscopic
cholecystectomy.

➢
For laparoscopic ➢ A laparoscopic ➢ Providing preoperative ➢ By doing so, nurses
cholecystectomy cholecystectomy is education, including an empower patients to
possible open essential for a patient understanding of the make informed
tomorrow at 7 am diagnosed with acute procedure, fasting decisions about their
calculous cholecystitis guidelines, and care and alleviate
due to the urgency of medication anxiety by addressing
this condition, alleviate instructions, ensures any fears or
severe symptoms, and compliance and uncertainties they may
prevent potential promotes safety during have. Additionally,
complications like surgery. clear communication
gallbladder perforation helps build trust
or infection. This between the patient
minimally invasive and healthcare team,
procedure offers quicker enhancing overall
recovery times and patient satisfaction and
fewer post-operative contributing to better
complications surgical outcomes
compared to open

20
 surgery, making it a ➢ Collaborate with the ➢ Collaboration ensures
suitable and timely surgical team, effective
intervention for this including the communication and
urgent condition. anesthesiologist, coordination of care,
ensuring that all which are essential for
necessary preoperative patient safety and
preparations are optimal outcomes. By
completed. working closely with the
surgical team, nurses
can confirm patient
readiness, verify
surgical consent, and
address any last-
minute concerns or
preparations. Similarly,
liaising with the
anesthesiologist helps
ensure appropriate
anesthesia
management tailored to
the patient's needs,
including preoperative
assessments and
medication
administration.
Secure consent for ➢ Upholds ethical ➢ Make sure to witness ➢ To verify that the patient
procedure principles of autonomy the consent signing. and significant others
and patient-centered understand what is
care, fostering a explained.
trusting relationship
between the patient ➢ Proper documentation
helps protect both

21
 and the healthcare ➢ Document the consent patients and healthcare
team. process in the patient'sproviders by providing a
medical record record of the
discussions held and
decisions made during
the consent process.
VS q 4˚ ➢ Monitoring vital signs at ➢ Ensure assessment of ➢ Early recognition and
100˚ F untoward regular intervals allows the patient's management of
s/sx, refer nurses to track the physiological status, abnormal vital signs
patient's physiological including temperature, contribute to optimizing
status, including blood pressure, heart patient safety and
temperature, blood rate, and respiratory reducing the risk of
pressure, heart rate, rate. perioperative
and respiratory rate. In complications,
the context of a ultimately supporting
laparoscopic positive surgical
cholecystectomy (lap outcomes.
chole), an elevated
temperature could
suggest underlying
cholecystitis or another
infectious process,
which may require
treatment or adjustment
of the surgical plan.
April 25, 2024 Hold tramadol ➢ Tramadol is not Verify the accuracy of the Ensuring the prescription
6pm typically indicated as a prescription for each accuracy helps prevent
first-line treatment for medication, including the medication errors and
headaches, especially if dosage, frequency, and ensures that the patient
+ headache the pain intensity is route of administration. receives the correct doses
with painscale severe. Instead, other at the prescribed frequency
8/10 medications or and route. This verification

22
 interventions may be process is crucial for patient
more effective and safety, minimizing the risk
appropriate for of adverse drug events or
managing headache complications associated
pain. with incorrect dosing or
administration.

Give Paracetamol ➢ It prioritizes safety and

300mg IV q4 PRN effectiveness by
for pain. providing analgesia
with a lower risk of
adverse effects
compared to opioid
medications like
tramadol. It represents
a prudent initial
approach to pain
management, with the
option to consider
additional or alternative
treatments based on
the patient's response
and specific clinical
circumstances.
Refer ➢ For further medical ➢ Inform the attending ➢ Early communication
management physician promptly with the physician
about any potential ensures that necessary
issues or abnormalities actions can be taken
that arise. promptly to address
concerns, prevent
complications, and

23
 optimize patient
outcomes.

POSTANEST To PACU AP ➢ This immediate ➢ Ensure the bed is ➢ This precaution helps
HESIA laparoscopic postoperative care locked and side rails prevent falls and
ORDER cholecystectomy setting allows for early are locked. injuries during the
under GA- LMA TIVA detection and postoperative recovery
April 26, (General Anesthesia management of period, especially when
2024 - Laryngeal Mask anesthesia-related patients may still be
Anesthesia, Total complications, airway groggy or disoriented
10 pm Intravenous stability, and effective from anesthesia.
Anesthesia) pain control, optimizing ➢ Promptly notifying the
patient recovery and ➢ Monitor patient physician of any
safety following closely and notify concerning findings
surgery. physician for further allows for timely
management. intervention and
appropriate
management, ensuring
optimal patient
outcomes and
preventing potential
deterioration or
complications.
➢ Document findings. ➢ This documentation
serves as a
communication tool
among healthcare

24
 providers, supporting
continuity of care and
facilitating appropriate
follow-up actions based
on the patient's
progress and
outcomes.
O2 Inhalation via ➢ to support respiratory ➢ Ensuring proper ➢ Proper placement
nasal cannula @ 2 function and ensure placement in the ensures effective
lpm sufficient oxygenation patient's nares, and delivery of oxygen and
during the recovery adjusting the oxygen comfort for the patient.
period following a flow rate to 2 lpm as ➢ Regular assessment
laparoscopic ordered. helps evaluate the
cholecystectomy. ➢ Continuously monitors effectiveness of oxygen
the patient's respiratory therapy and ensures
status, including SpO2 that the patient's
levels and respiratory oxygen needs are
rate. being met.

25
Monitor VS q15 x 2 ➢ To promote early ➢ Monitor vital signs at ➢ helps evaluate the
detection of changes in short interval as order. effectiveness of
the patient's condition, ➢ Accurate interventions or
assess treatment documentation of vital treatments initiated to
response, and maintain signs every 15 minutes address specific
vigilant surveillance ensures issues.
during a critical period of comprehensive records ➢ This documentation
care. This proactive of the patient's serves as a
approach supports physiological status communication tool
patient safety, facilitates over time. among healthcare
timely interventions, providers, facilitating
and contributes to continuity of care and
optimal patient enabling informed
outcomes. decision-making

NPO ➢ Keeping the patient ➢ Provide oral care and ➢ Maintaining oral
NPO allows the keep the patient's hygiene and moisture
gastrointestinal tract to mouth moist during the helps alleviate
rest and recover from NPO period. discomfort and reduce
the effects of the risk of dry mouth or
anesthesia and surgery. oral complications
This reduces the risk of during the fasting
postoperative nausea, period, promoting
vomiting, and patient comfort and
complications related to overall well-being.
abdominal distension or ➢ Communicate with, ➢ Collaboration with the
bowel obstruction. dietitians and other healthcare team
nurses, to ensure promotes holistic care
coordinated care and and ensures that the
appropriate patient's nutritional and
management of the medical needs are
patient's NPO status. addressed

26
 appropriately during
NPO status.

Regulate IVF: ➢ Prescribed for ➢ Monitor the ➢ Regular monitoring

D5LRS 1L X 8 maintenance fluid intravenous infusion of ensures that the IV
therapy, to replace D5LRS closely fluid is administered
ongoing losses, or to according to the correctly and at the
support postoperative prescribed rate and appropriate rate to
recovery. duration. meet the patient's fluid
and electrolyte needs.
IVF to follow: PNSS ➢ Normal Saline (0.9% ➢ Set up and regulate ➢ Initiating and
1LX KVO NaCl) is commonly the Keep Vein Open maintaining the KVO
used for fluid rate of the Normal rate helps ensure
resuscitation, Saline (PNSS) infusion venous patency and
maintaining hydration, following completion of prevents IV catheter
and as a vehicle for the D5LRS infusion. occlusion without
medication overloading the patient
administration. The with excessive fluids
KVO rate (Keep Vein post-operatively.
Open) is a slow infusion
rate used to maintain
venous patency and
prevent clotting of the
IV catheter when the
patient is not actively
receiving fluids.
MEDICATIONS: ➢ assess the patient's ➢ Ketorolac should not
➢ Keterolac 30mg ➢ This medication is medical history, be given to patients
IV q8 x 3 doses ( commonly used for including any allergies with a history of
)ANST short-term management or history of adverse NSAID-induced
of moderate to severe reactions to NSAIDs asthma, urticaria, or
pain, such as anaphylaxis, and

27
 postoperative pain, and (nonsteroidal anti- caution should be
helps reduce inflammatory drugs). exercised in patients
inflammation. with renal impairment
➢ Paracetamol is effective to prevent toxicity.
➢ Paracetamol for mild to moderate ➢ Reassess the patient's
600g q6 x 4 pain relief and is often pain intensity after ➢ helps guide further
doses. used as part of administration to pain management
multimodal analgesia to evaluate the interventions, such as
manage postoperative effectiveness of adjusting the dosage of
pain. paracetamol in paracetamol, adding
➢ Tramadol is useful providing pain relief. additional analgesics,
➢ Tramadol 50g IV when other non-opioid or considering
q8 PRN as medications are alternative pain
needed for insufficient for pain ➢ assess the patient's management
brathing and relief, but caution is pain intensity using a strategies if needed.
pain. needed due to potential pain scale (e.g.,
side effects and risks numeric rating scale) to
associated with opioid determine the ➢ Assessing pain
use. appropriateness of intensity ensures that
➢ This medication helps opioid administration tramadol is given
➢ Omeprazole prevent gastric irritation appropriately for
40mg IV OD and ulcers, particularly moderate to severe
important in patients ➢ assess the patient's pain as needed.
receiving NSAIDs like current gastrointestinal
ketorolac to reduce the symptoms and history ➢ helps determine the
risk of gastrointestinal of gastric ulcers or necessity and
complications. gastrointestinal appropriateness of
bleeding. omeprazole
administration.
Encourage deep ➢ to optimize respiratory ➢ Provide clear ➢ Educating patients
breathing exercise function, prevent instructions and about the preventive
and early ambulation complications, and demonstrations on how aspects of deep

28
 promote faster recovery to perform deep breathing and
by actively engaging breathing exercises ambulation highlights
the patient in activities effectively. Educate the the importance of
that enhance lung patient about the these activities in
expansion and physical benefits of deep reducing the risk of
mobility. breathing and early postoperative
ambulation in complications. This
promoting recovery knowledge empowers
and preventing patients to actively
complications. participate in their own
care and supports
optimal recovery.
Refer ➢ to ensure ➢ Ensure that the referral ➢ Prevents delays in
comprehensive and is addressed in a timely accessing necessary
coordinated care for the manner. care.
patient by involving
healthcare ➢ Endorse properly.
professionals who can ➢ Facilitates continuity of
provide specialized care and minimizes
expertise or errors.
interventions that may
be necessary for
diagnosing, treating, or
managing specific
medical issues.
April 26, 2024 Give paracetamol ➢ Paracetamol is an ➢ Reassess the patient's ➢ helps guide further
10:05 am 300mg IV now effective first-line pain intensity after pain management
medication for mild to administration to interventions, such as
Pain scale moderate pain and can evaluate the adjusting the dosage of
10/10 be used as part of effectiveness of paracetamol, adding
multimodal analgesia to paracetamol in additional analgesics,
providing pain relief. or considering

29
 manage acute alternative pain
postoperative pain. management
strategies if needed.
Refer ➢ to ensure ➢ Ensure that the referral ➢ Prevents delays in
comprehensive and is addressed in a timely accessing necessary
coordinated care for the manner. care.
patient by involving
healthcare ➢ Endorse properly.
professionals who can ➢ Facilitates continuity of
provide specialized care and minimizes
expertise or errors.
interventions that may
be necessary for
diagnosing, treating, or
managing specific
medical issues.
10:30 am Liquid diet at 6pm ➢ Often initiated shortly ➢ Collaborate with the ➢ This ensures that the
after laparoscopic dietitian to obtain patient's dietary plan
cholecystectomy to guidance on the aligns with their
allow the appropriate timing and postoperative needs,
gastrointestinal system composition of diet taking into account
to gradually resume progression for the factors such as
normal function without patient. tolerance to specific
overloading it. Liquid foods, nutritional
foods are easier to requirements, and any
digest and less likely to dietary restrictions or
cause discomfort or considerations based
complications post- on the surgical
surgery. procedure.
If tolerated; low fat ➢ Allows for further ➢ Communicate the ➢ Educating the patient/
diet at 8pm progression of dietary dietitian's SO about the
intake as the patient's recommendations to importance of following

30
 tolerance improves. A the patient, providing dietary guidelines
low-fat diet reduces the clear instructions on helps promote
risk of triggering dietary progression adherence and
symptoms such as post-lapchole. understanding of
abdominal pain, nutritional goals during
diarrhea, or indigestion. recovery, minimizing
the risk of dietary-
related complications
or discomfort.

Continue Monowel ➢ Often continued Verify the accuracy of the Ensuring the prescription
q12L postoperatively to prescription for each accuracy helps prevent
provide ongoing medication, including the medication errors and
prophylaxis against dosage, frequency, and ensures that the patient
SSIs. route of administration. receives the correct doses
at the prescribed frequency
and route. This verification
process is crucial for patient
safety, minimizing the risk
of adverse drug events or
complications associated
with incorrect dosing or
administration.

1:20 pm Give ranitidine 1amp ➢ Used to prevent stress Verify the accuracy of the Ensuring the prescription
IV now ulcers, which can occur prescription for each accuracy helps prevent
in critically ill or medication, including the medication errors and
postoperative patients dosage, frequency, and ensures that the patient
due to factors such as route of administration. receives the correct doses

31
 decreased mucosal at the prescribed frequency
blood flow, increased and route. This verification
gastric acid secretion, process is crucial for patient
and physiological stress safety, minimizing the risk
➢ of adverse drug events or
complications associated
with incorrect dosing or
administration.

refer ➢ to ensure ➢ Ensure that the referral ➢ Prevents delays in

comprehensive and is addressed in a timely accessing necessary
coordinated care for the manner. care.
patient by involving
healthcare ➢ Endorse properly.
professionals who can ➢ Facilitates continuity of
provide specialized care and minimizes
expertise or errors.
interventions that may
be necessary for
diagnosing, treating, or
managing specific
medical issues.
April 27, 2024 MCH ➢ To obtain valuable ➢ Collaborate with ➢ To support quality
information about red laboratory personnel to assurance and safety
blood cell parameters facilitate accurate in laboratory
and hemoglobin specimen collection, procedures, with
content, aiding in the labeling, and handling, nurses offering
diagnosis, adhering to protocols feedback on specimen
management, and that preserve sample quality and assisting in
monitoring of various integrity. resolving discrepancies
hematological in results.
conditions.

32
DAT ➢ Patients can gradually ➢ Assess the patient's ➢ To ensure that
resume normal eating readiness to advance physiological factors
patterns, supporting their diet based on such as
nutritional intake and factors such as gastrointestinal
overall recovery while absence of nausea, function and recovery
minimizing vomiting, and progress are adequate
gastrointestinal adequate bowel to tolerate a more
discomfort and function post-surgery. varied diet, reducing
ensuring appropriate the risk of digestive
postoperative dietary complications or
management. discomfort.
➢ Provide education that ➢ This promotes self-
empower patients to care and encourages
make informed dietary patients to gradually
choices based on their reintroduce foods,
body's signals. fostering independence
in managing their
recovery.
➢ Collaborate with
dietitians

➢ to optimize dietary
recommendations and
ensure alignment with
the patient's nutritional
needs and recovery
goals.
THM: Verify the accuracy of the Ensuring the prescription
prescription for each accuracy helps prevent
➢ Antibiotic therapy post- medication, including the medication errors and
lapchole helps reduce ensures that the patient

33
➢ Ampimax the risk of surgical site dosage, frequency, and receives the correct doses
750mg tab TID x infections (SSIs) and route of administration. at the prescribed frequency
7days ensures adequate and route. This verification
➢ Coxid coverage during the process is crucial for patient
200mg/cap BID early recovery period safety, minimizing the risk
x 7days when patients are most of adverse drug events or
➢ Omepron vulnerable to infection. complications associated
40mg/cap OD x with incorrect dosing or
7days ➢ Cox-2 inhibitors are administration.
nonsteroidal anti-
inflammatory drugs
(NSAIDs) that
specifically target
inflammation and pain
by inhibiting the Cox-2
enzyme, providing
effective pain relief with
fewer gastrointestinal
side effects compared
to traditional NSAIDs.

➢ This medication helps

prevent gastric irritation
and ulcers, particularly
important in patients
receiving NSAIDs like
ketorolac to reduce the
risk of gastrointestinal
complications.

34
Change dressing ➢ Help maintain a clean ➢ Assess the surgical ➢ This assessment helps
daily with betadine and sterile environment incision site daily for detect early signs of
around the surgical signs of infection, such complications and
incision site, facilitating as redness, swelling, guides appropriate
optimal healing and warmth, or discharge. wound care
minimizing the potential ➢ Cleanse the surgical interventions.
for postoperative incision site with ➢ To ensure thorough
complications such as betadine solution coverage while
surgical site infections. according to aseptic minimizing
technique. contamination risk.
➢ Document the dressing ➢ By documenting wound
change procedure in appearance, such as
the patient's medical color, size, and
record, noting any presence of drainage
findings related to or signs of infection,
wound appearance or nurses can monitor the
patient response progress of wound
healing over time. Any
changes or
abnormalities can be
promptly identified and
addressed.
Follow up on may 6, ➢ The scheduled follow- ➢ Ensure that the patient ➢ To ensure that patients
2024, Monday 10 to up allows healthcare understands the date, attend their follow-up
12nn. providers to assess the time, and purpose of appointments,
patient's recovery the follow-up facilitating continuity of
progress following the appointment, and care and supporting
Advised laparoscopic confirm their ongoing monitoring
cholecystectomy commitment to and management post-
(lapchole). This attending. laparoscopic
includes evaluating cholecystectomy
wound healing,

35
 monitoring for any signs
of complications, and
addressing any
postoperative concerns.
May gargle with ➢ Gargling with Bactidol ➢ Encourage patient to ➢ To optimize oral health,
bactidol as needed helps reduce the oral gargle with Bactidol as reduce the risk of
microbial load, needed supports their complications,
potentially decreasing recovery by promoting enhance patient
the risk of oral oral hygiene and comfort, and support
infections or reducing the risk of successful recovery
complications postoperative following laparoscopic
postoperatively. complications. cholecystectomy. T
Refer ➢ to ensure ➢ Ensure that the referral ➢ Prevents delays in
comprehensive and is addressed in a timely accessing necessary
coordinated care for the manner. care.
patient by involving
healthcare ➢ Endorse properly.
professionals who can ➢ Facilitates continuity of
provide specialized care and minimizes
expertise or errors.
interventions that may
be necessary for
diagnosing, treating, or
managing specific
medical issues.

36
VI. ANATOMY OF THE SURGICAL SITE

THE GALLBLADDER
The gallbladder is a small, pear-shaped organ
located beneath the liver. It is 7.5 to 10 cm long,
3cm broad wide and it can store 30 to 50 ml of bile.
Its primary function is to store and concentrate bile
produced by the liver until it is needed for digestion.
The gallbladder is divided into three main parts: the
fundus (the rounded bottom); it stores bile juices,
the body (the main portion), and the neck (the
narrowest part near the cystic duct).
It is connected to the liver via the hepatic duct and
to the small intestine via the cystic duct, forming the common bile duct.
The common bile duct delivers bile to the small intestine, where it aids in the digestion
of fats.

FUNCTIONS OF GALLBLADDER
Storage: The gallbladder stores bile produced by the liver between meals. This
storage allows for the accumulation of bile, ensuring that a sufficient amount is
available for digestion when needed.
Concentration: While bile is continuously produced by the liver, it is diluted. The
gallbladder concentrates bile by removing water and electrolytes from it, making it
more potent and effective for digestion.
Release of Bile: When food, especially fatty food, enters the small intestine, hormonal
signals trigger the gallbladder to contract, releasing bile into the digestive tract through
the common bile duct. This bile aids in the emulsification and digestion of fats.
Aid in Digestion: Bile plays a crucial role in the digestion and absorption of fats. It
emulsifies large fat molecules, breaking them down into smaller droplets that can be
more easily acted upon by digestive enzymes. This process increases the surface
area of fats, allowing for better digestion and absorption in the small intestine.
Neutralization: Bile also helps neutralize the acidic chyme (partially digested food)
that enters the small intestine from the stomach. This neutralization creates a more
favorable environment for the activity of digestive enzymes and protects the lining of
the small intestine from damage by stomach acid.

37
CYSTIC DUCT
The cystic duct is a small tube that connects the
gallbladder to the common bile duct. Its function is to
transport bile produced by the liver and stored in the
gallbladder to the small intestine to aid in digestion,
particularly in the breakdown of fats.

COMMON HEPATIC DUCT

It carries bile from the liver to the gallbladder or directly
to the small intestine. Its primary function is to transport
bile, which is produced by the liver, to aid in digestion,
particularly in the breakdown of fats.

COMMON BILE DUCT

The common bile duct is a duct formed by the union of the cystic duct (coming from
the gallbladder) . Its function is to transport bile from the liver and gallbladder to the
small intestine, where it aids in the digestion and absorption of fats, as well as the
neutralization of stomach acid.

BILE
Bile is produced by the liver and stored in the gallbladder. Its main function is to aid in
the digestion and absorption of fats in the small intestine. Bile salts break down fat
molecules into smaller droplets, which makes it easier for enzymes to access and
break them down further. Additionally, bile helps in the absorption of fat-soluble
vitamins like A, D, E, and K.

PROCESS WHEN FOODS ENTER

When food, especially fatty food, enters the small intestine, the hormone
cholecystokinin (CCK) is released.
CCK signals the gallbladder to contract, causing it to release bile into the small
intestine through the common bile duct.
Bile helps in the emulsification and digestion of fats, facilitating their absorption by the
small intestine.
In the absence of a gallbladder, bile drips continuously into the small intestine rather
than being stored and concentrated, which can lead to less efficient fat digestion.

38
VII. SURGICAL PROCEDURE
Pre-Operative Phase
• Witnessed, secured and verified the administration and signing of the
informed consent.
• Instructed patient to eat NPO post-midnight
• Pre-operative workups secured (CBC, HgB, Hct, Bloodtyping, Platelet, WBC)
• Pre-Operative medications given (Monowel, Omepron)
• Pre-Operative care administered
o V/S taken and recorded
o Jewelries removed
o Nail polish removed
o Skin prep/shaving done
o Pt has already voided and taken a bath
• Assisted patient in changing into OR gown
• Deep breathing technique was instructed
Intra-Operative Phase
1. POSITIONING
• Assisted and placed patient on supine position with both arms extended on the
side.
• Patient is secured with OR bed strap.
• Connected patient to a cardiac monitor
2. ANESTHESIA
• Induction of anesthesia: 7:15 am
• Type of anesthesia: General Anesthesia – Laryngeal Mask Anesthesia– Total
IV Anesthesia
• Anesthesia used: Propofol and Remifentanil
3. Abdominal Preparation and initial counting done
4. Surgeon and scrub nurse aseptically draped the patient
5. Prayer done
6. PROCEDURE PROPER
• Started 7:50 am
• Incision: Umbilicus (12mm) thru Hasson’s Technique, trocar is
inserted afterwards
• CO2 was administered (maintained at 15mmHg)
• Other 3 incisions were made at:
- Epigastric Region (11mm)
- ® MCL (5mm)
- ® AAL (5mm)
• Trocars are inserted on 3 identified ports
7. EXPLORATION
• Surgeon identifies the anatomical structure of the intra-
abdominal organs involved (liver, gallbladder).

39
8. GALLBLADDER EXPOSURE
• Retraction of the liver by grasping the fundus part of the
gallbladder and pushing it upward.

9. IDENTIFICATION AND EXPOSURE OF THE CALOT’S TRIAD

• Surgeon cauterized surrounding tissue (areolar, peritoneum)
covering the area. Incising the anterior and posterior part of
the of cystic connections using a harmonic scalpel and a blunt
dissector (Maryland). This anatomical dissection was done to
isolate the ducts and arteries from surrounding tissues.

- Complete identification of the cystic duct and cystic artery.

• Surgeon applied an infrared fluoroscopic cholangiography to confirm.

10. CLIP APPLICATION

• Division of the Cystic Artery by clipping the distal and proximal area.
• Division of Cystic Duct starting from the junction of the common bile duct.

11. DISSECTION OF THE CYSTIC DUCT AND ARTERY

12. GALLBLADDER BED DISSECTION

• Done by doing an alternating maneuver (applying the anteromedial and
anterolateral traction) to cut the peritoneum starting from retrograde
cholecystectomy to Antegrade cholecystectomy.

13. EXTRACTION OF THE GB

• GB was placed in a condom and pulled out from the
abdominal cavity through the umbilicus
• SPECIMEN OUT: 9:24 am

14. FINAL INSPECTION

• Washed and cleaned the area to make sure that no tissue fragments were left.
• Stumps of the cystic artery and cystic duct was inspected.
15. INSTRUMENTS AND TROCARS REMOVED
• JP drain is inserted afterwards

16. FINAL COUNTING OF INSTRUMENTS DONE

40
17. CLOSING OF THE INCISION SITES
• Removal of trocars
• Incision closed – Fascia: Vicryl 2/0
Skin 4/0
• Dressing Applied

18. Surgery ended at 9:32 am

19. Anesthesia ended at 9:35 am

Post-Operative Phase
• Initial assessment was done. Monitored patient for untoward reactions.
• Vital signs were taken and recorded q15 for the first 2 hours and every hour on
the succeeding hours.
• Ensured comfort and safety
• NPO instructed until stable
• Encourage moderate high back rest and do DBCE
• Once stable, brought to ward and endorsed to NOD

41
VIII. SURGICAL INSTRUMENTS AND FUNCTION
Cutting and Dissecting
Scalpel For skin
incisions,
tissue
dissection

L Hook A cautery
Cautery instrument
with a hook-
shaped tip
used for
dissecting and
coagulation of
tissues.
Laparoscopic For cutting
Metz Scissor tissues, to
coagulate
tissue with
monopolar
electrocautery

Straight Mayo For cutting

Scissor thick or tough
tissues.

42
 Hook For cutting a
Scissors secured duct
or artery

Grasping and Holding

Toothed To grasp or
Forcep pick up soft
tissue

Laparoscopic A
Wave Grasper laparoscopic
instrument
with a wave-
shaped tip for
grasping and
manipulating
tissues, to lift
and mobilize
delicate
anatomical
tissues for
better
visualization
and access
Laparoscopic For holding
DeBakey and
Forceps manipulating
delicate
tissue, to
avoid tissue
damage
during
manipulation

43
 Laparoscopic A
Maryland laparoscopic
Dissector instrument
Grasper with a
serrated tip for
grasping and
dissecting
tissues.

Bipolar To coagulate
Dissector and seal
blood vessels
and small
tissue sutures.

Laparoscopic To grasp and

Allis Forcep hold tissues

Adson To grasp
Forceps superficial
tissue

Clamping and Occluding

Laparoscopic For occluding
Clip blood vessels
Applicators or ducts.

44
 Towel Clamp For holding
towels or
drapes during
surgery.

Curved For clamping

Hemostat blood vessels.

Retracting and Exposing

Army-Navy Used to hold
Retractor back tissues
and provide
exposure
during
surgery.
Hasson S Used for
Retractor laparoscopic
surgery to
stabilize and
retract the
abdominal
wall.

Suturing and Stapling

Mayo-Hegar To hold suture
Needle Holder needles

45
 Suture For facilitating
wound closure
and creating
an optimal
setting for
wound healing

Others
Trocar A sharp
instrument
used to create
access ports
in the
abdominal
wall for
inserting
laparoscopic
instruments.
Telescope Used to light up
and magnify
the structures of
the abdominal
cavity.

JP Drain A surgical
suction drain
that gently
draws fluid
from a wound
to help you
recover after
surgery.

46
Video Camera Used to
produce the
image and
provides
zooming and
focusing
capabilities

Laparoscopic Used for

Aspiration aspirating
Needle fluids or gas
during
laparoscopic
procedures.

Suction Used for

Irrigator suctioning
fluids and
irrigating the
surgical site.

Cardiac Device used

Monitor for monitoring
the patient's
cardiac
activity during
surgery.

Cautery Equipment
Machine used for
providing
electrocautery
to coagulate
tissues and

47
 control
bleeding.

Suction Device used

Machine for suctioning
fluids or
secretions
from the
surgical field.

Gauze Sterile cotton

fabric used for
various
purposes
during
surgery, such
as cleaning or
packing
wounds.

48
IX. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Anxiety related to Within 30 mins to 1 Independent Independent After 30mins to 1
“Hindi ko maiwasang Impending hour of nursing 1. Provide education about 1. Offering clear, hour of nursing
mag-isip baka may Surgery as intervention the surgical procedures. detailed information
intervention the
mangyaring hindi Evidenced by patient will about the surgical
goal is met. The
maganda habang Increased experience reduced procedure, including what patient showed
inooperahan ako. Respiration, anxiety related to to expect before, during, reduced anxiety
Hindi ko Pulse Rate and the impending and after surgery, helps related to the
maipaliwanag ang Tension. surgery. alleviate anxiety by
impending surgery
nararamdaman ko” reducing uncertainty and as evidenced by the
as verbalized by the fear of the unknown. patient being
patient. relaxed and aware
2. Offer Emotional 2. To provide emotional of their expectations
Objective: Support and Reassurance. support and reassurance in the surgery.
to the patient
• Vital Signs taken demonstrates empathy,
as follows: validates their feelings,
Temp: 36.8 °C and fosters a sense of
PR: 125 trust in the healthcare
RR: 25 team, helping to reduce
BP: 130/80 mmHg anxiety and increase
feelings of comfort and
• Pale looking security.
• Facial tension 3. Teach relaxation
• Increased techniques 3. Teaching relaxation
tension techniques such as deep
breathing exercises,
progressive muscle
relaxation, or guided
imagery empowers the
patient to actively
manage their anxiety,
49
 promoting a sense of
control and relaxation in
the face of impending
4. Encourage expression surgery.
of feelings and concerns.
4. To encourage the
patient to express their
feelings and concerns
openly provides an
opportunity for catharsis
and validation of
emotions, helping to
reduce anxiety and
promote psychological
Dependent well-being.
1. Collaborate with the
Healthcare Team for Dependent
Pharmacological 1. Collaboration with the
Interventions healthcare team,
including physicians and
anesthesiologists, may
be necessary to consider
pharmacological
interventions such as
anxiolytic medications for
anxiety management,
especially in cases of
severe anxiety or when
non-pharmacological
interventions alone are
insufficient.
Collaborative
1. Involve the members or
support personnel Collaborative

50
 1. Involving family
members or support
personnel in the care
process can provide
additional emotional
support and reassurance
to the patient, helping to
reduce anxiety and
increase feelings of
comfort and security.

PRE-OPERATIVE NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain Within 30 minutes Independent Independent Goal met. After 30
“Minsan masakit po related to to 1 hour of Nursing 1. Monitor vital signs 1. This will serve as a minutes to 1 hour of
yung tiyan ko, Obstruction as Intervention, the especially the pain; baseline data. Nursing
minsan hindi. evidenced by patient will report observe and document Assists in Interventions, the
Pabalik-balik po Right Upper relief or control of location, severity, and differentiating causes patient reports relief
yung sakit” as Quadrant Pain, Pain. character of pain. of pain, and provides or control of Pain as
verbalized by the Reports of Pain 2. Note the response to information about evidenced by a pain
patient. and Guarding medication, and report disease progression scale of 2/10.
Behavior. to the physician if the and resolution,
• Right Upper pain is not being development of
Quadrant Pain relieved. complications, and
• Pain Scale of 3. Promote bed rest, effectiveness of
8/10 allowing the patient to interventions.
assume a position of 2. Severe pain not
Objective: comfort. relieved by routine
• Vital Signs taken 4. Encourage the use of measures may
as follows: relaxation techniques. indicate developing
complications or a
51
Temp: 36.5°C Provide diversional need for further
BP: 100/70 mmHg activities. intervention.
PR: 72 bpm 5. Encourage 3. Bed rest in low-
RR: 20 cpm verbalization of Fowler’s position
SpO2: 99% feelings about pain. reduces intra-
abdominal pressure;
• Guarding Dependent however, the patient
Behavior 1. Administer will naturally assume
• Positioning to medications as the least painful
ease Pain prescribed. position.
4. Promotes rest, and
redirecting attention
may enhance coping.
5. Discussing any
changes in the pain
(getting better, worse,
different) helps track
its progression and
the effectiveness of
treatment.

Dependent
1. Medications should
only be given upon
doctor’s order.

52
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Disturbed Sleep Within 8 hours of Independent Independent Goal met. After 8
“Nahihirapan akong Pattern related to proper nursing 1. Establish a consistent 1. Establish a consistent hours of nursing
matulog lalo na Discomfort, as intervention, patient bedtime routine, bedtime routine, intervention, patient
kapag madalingevidenced by will achieve at least including activities that including activities achieved at least 6
araw.” as verbalizedReports of 6 hours of address both physical that address both hours of
by the patient. Difficulty uninterrupted sleep comfort and emotional physical comfort and uninterrupted sleep
Sleeping and per night within the relaxation, such as emotional relaxation, addressing both
Objective: Observable Signs next week, the reading or listening to such as reading or pain and anxiety.
• Vital Signs taken of Restlessness patient will report calming music. listening to calming Patient reported
as follows: feeling more rested music. feeling more rested
Temp: 36.5°C and refreshed. 2. Provide information and refreshed upon
BP: 100/70 mmHg about the importance 2. Provide information waking. And patient
PR: 72 bpm of a comfortable sleep about the importance demonstrated
RR: 20 cpm environment, of a comfortable sleep effective use of
SpO2: 99% considering both environment, relaxation
• Dark under eyes physical comfort and considering both techniques which
• Observations of emotional physical comfort and promoted better
Restlessness reassurance. emotional sleep.
• Tired reassurance.
Appearance 3. Explore the use of non-
pharmacological 3. Explore the use of
interventions for sleep, non-pharmacological
such as guided interventions for
imagery or progressive sleep, such as guided
muscle relaxation, to imagery or
manage pain and progressive muscle
anxiety without relaxation, to manage
medical reliance. pain and anxiety
without medical
Collaborative: reliance.

53
1. Collaborate with the Collaborative:
healthcare team to 1. Collaborate with the
assess and manage healthcare team to
pain, discomfort, and assess and manage
anxiety related to the pain, discomfort, and
upcoming anxiety related to the
laparoscopic upcoming
cholecystectomy. laparoscopic
cholecystectomy.

54
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for Injury All throughout the Independent Independent Goal Met.
N/A related to surgical procedure, 1. Assist with patient 1. Proper positioning All throughout the
minimally the patient will positioning. ensures the surgical procedure,
Objective: invasive maintain injury free surgical team has the patient has
• Vital Signs taken procedure and during the optimal access to maintained injury
as follows: potential procedure. the surgical site free during the
Temp: 36.5°C complications while minimizing procedure.
BP: 100/70 mmHg during the the risk of injury to
PR: 72 bpm procedure the patient, such
RR: 20 cpm as nerve damage
SpO2: 99% or pressure
2. Maintain aseptic ulcers.
technique. 2. Strict adherence
to aseptic
technique
reduces the risk of
surgical site
infection, which is
crucial for patient
safety and
successful
3. Monitor vital signs. surgical
outcomes.
3. Continuous
monitoring of vital
signs allows for
early detection of
any physiological

55
 changes or
complications,
enabling prompt
intervention and
preventing
adverse events
such as
hypotension,
hypoxia, or
cardiac
4. Provide surgical arrhythmias.
team support. 4. Supporting the
surgical team by
anticipating their
needs and
maintaining a
clear surgical field
enhances
efficiency and
safety during the
procedure,
reducing the risk
of errors or
5. Monitor for complications.
complications. 5. Vigilant
monitoring for
intraoperative
complications
allows for early
identification and
intervention,
potentially
preventing
serious adverse
outcomes such as
56
 hemorrhage,
organ injury, or
anesthesia-
6. Document and related
communicate. complications.
6. Accurate
documentation
and effective
communication
ensure continuity
of care and
promote patient
safety by
providing
essential
information to all
members of the
healthcare team,
facilitating
coordinated
efforts and timely
interventions as
needed.
INTRA-OPERATIVE NURSING CARE PLAN

57
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for Altered All throughout the Independent Independent Goal Met.
N/A Thermoregulation surgical procedure, 1. Initiate pre- 1. Pre-warming All throughout the
related to the patient will warming measures helps to reduce surgical procedure,
Objective: exposure to cool maintain a core using forced-air the temperature the patient has
-Low Temperature operating room body temperature warming blankets gradient between maintained a core
Operating Room temperatures and within the normal or heated blankets the patient’s body body temperature
-Insufficient Clothing impaired ability to range. before induction of and the operating within the normal
Coverage shiver due to anesthesia. room range.
-Under General anesthesia environment,
Anesthesia minimizing heat
loss and reducing
• Vital Signs taken the risk of
as follows: perioperative
Temp: 35.8°C hypothermia.
BP: 100/70 mmHg 2. Continuously 2. Regular
PR: 72 bpm monitor the temperature
RR: 20 cpm patient’s core monitoring
SpO2: 99% temperature using enables early
intraoperative detection of any
temperature deviations from
monitoring the normal range,
devices. allowing prompt
intervention to
maintain
normothermia.
3. Ensure that the 3. Maintaining a
operating room warmer
temperature is set environment
at a higher level to reduces the risk of
minimize heat loss hypothermia by
decreasing the
58
 from the patient’s temperature
body. gradient between
the patient and
the surrounding
environment.
4. These devices
4. Employ help to actively
intraoperative maintain the
warming devices patient’s body
such as warmed temperature and
intravenous fluids counteract heat
and forced-air loss during the
warming systems. surgical
procedure.
5. Reducing the time
5. Minimize the of exposure to
duration of cold environments
exposure to cold by helps prevent
ensuring efficient excessive heat
surgical loss and
techniques and maintains the
minimizing patient's core
unnecessary temperature
exposure of body within the normal
surfaces. range.
6. Monitoring for
6. Continuously shivering allows
assess the patient for early
for signs of recognition of
shivering during thermoregulatory
the surgery. disturbances,
prompting timely
interventions to
prevent further
heat loss and
59
 maintain
normothermia.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for Infection All throughout the Independent Independent Goal Met.
N/A related to surgical surgical procedure, 1. Ensure proper 1. Maintaining a All throughout the
site the patient will draping of the sterile field helps surgical procedure,
Objective: contamination as remain free of patient and prevent the patient has
• Vital Signs taken evidence by infection, as maintenance of a contamination of remained free of
as follows: ongoing surgical evidenced by sterile field the surgical site infection, as
Temp: 36.5°C procedure normal vital signs throughout the by minimizing the evidenced by
BP: 100/70 mmHg and the absence of surgical procedure. introduction of normal vital signs
PR: 72 bpm signs or symptoms microorganisms and the absence of
RR: 20 cpm of infection. from the signs or symptoms
SpO2: 99% surrounding of infection.
environment.
2. Strictly adhere to 2. Aseptic technique
aseptic technique reduces the risk of
when handling introducing
instruments, pathogens into
equipment, and the surgical field,
surgical supplies. thus minimizing
the potential for
surgical site
contamination
and subsequent
infection.

60
3. Monitor the 3. Regular
surgical team’s monitoring
compliance with ensures that all
hand hygiene members of the
protocols and surgical team
sterile technique maintain proper
throughout the hygiene practices,
procedure. reducing the risk
of contaminating
the surgical site.
4. Ensure appropriate 4. Optimizing
ventilation and environmental
environmental controls helps
controls in the maintain a clean
operating room to and sterile
minimize the surgical
presence of environment,
airborne reducing the risk
contaminants. of surgical site
contamination.
5. Perform 5. Preoperative skin
preoperative skin preparation
preparation at the reduces the
surgical site using microbial load on
antiseptic solutions the skin,
according to minimizing the
established risk of introducing
protocols. pathogens into
the surgical
incision during the
procedure.
6. Ensure proper 6. Proper handling of
cleaning, instruments and
sterilization, and equipment helps
handling of surgical prevent
61
 instruments and contamination of
equipment before the surgical site
and during the and reduces the
procedure. risk of
postoperative
Dependent infection.
1. Administer
prophylactic 1. Prophylactic
antibiotics antibiotics help
according to reduce the risk of
established surgical site
guidelines and infection by
protocols before preventing the
the surgical growth of bacteria
incision is made. introduced during
the procedure.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain Within 2-4 hours of Independent Independent After 2-4 hours of
N/A related to surgical nursing intervention 1. Positioning and 1. Proper positioning nursing intervention
incision as the patient will Immobilization and immobilization of the the goal is met. The
Objective: evidenced by experience relief patient’s body part can patient will
reports of pain at from pain within a reduce tension on the experience relief
• Vital signs taken the surgical site, tolerable level. surgical incision, from pain within a
as follows: facial grimacing, minimizing pain and tolerable level.
Temp:37.5 °C increased heart promoting comfort.
RR: 18 rate, elevated
PR: 125 blood pressure. 2. Proper comfort 2. applying cold packs or
Sp02: 98% measures. heat therapy as
62
BP: 140/80 mm Hg appropriate can help
Pain scale: 8/10 alleviate pain by reducing
inflammation and
• Facial grimace promoting relaxation of
surrounding muscles.

3. Encourage deep 3. Deep breathing

breathing and relaxation exercises and relaxation
techniques. techniques such as
guided imagery or
progressive muscle
relaxation can help
distract the patient from
pain, reduce muscle
tension, and promote
overall relaxation.
4. Monitoring Vital Sings.
4. Continuously monitor
the patient’s vital signs,
including heart rate and
blood pressure, to assess
the effectiveness of pain
management
interventions and detect
any complications.
5. Provide health teaching
to the patient and family. 5. Provide through
education to the patient
and their caregivers
about the expected
course of post-surgical
pain, proper medication
administration, and when
to seek medical attention

63
 if pain worsens or is not
adequately controlled.
Dependent
1. Administer pain Dependent
medication as prescribed 1. Administering
analgesic medications as
prescribed by the
healthcare provider helps
alleviate pain and
discomfort associated
with the surgical incision
and inflammation.
2. Collaborate with the
healthcare provider to 2. Collaboration with the
adjusry pain medication. healthcare provider is
essential to assess the
effectiveness of current
pain management
strategies and adjust
medications as needed to
ensure optimal pain relief
while minimizing side
effects.
3. Implement orders for
non-pharmacological pain 3. Some patients may
relief modalities. benefit from additional
pain relief modalities such
as nerve blocks or
patient-controlled
analgesia (PCA), which
require orders from the
healthcare provider.
Collaborative
1. Consultation with wound Collaborative
care specialist
64
 1. Collaboration with
wound care specialists
can ensure proper
assessment and
management of the
surgical incision,
including appropriate
wound care techniques
and interventions to
promote optimal healing
2. Physical therapy and minimize pain
consultation
2. Collaboration with
physical therapists can
help develop
individualized exercise
programs aimed at
promoting mobility,
strengthening muscles,
and improving overall
function, which can
indirectly alleviate pain
and promote healing.
POST OPERATIVE NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

65
Subjective: Risk for Infection Within 4-6 hours of Independent Independent After 4-6 hours of
N/A related to surgical nursing intervention 1. Implement strict aseptic 1. By maintaining a nursing intervention
site as evidenced the patient will be technique during wound sterile environment thw goal is met. The
Objective: by presence of able remain free care during wound care, the patient will be able
surgical incision, from infection risk of introducing to remain free
• Vital signs taken invasive during the microorganisms into the from infection
as follows: procedure, postoperative surgical site is minimized, during the
Temp:37.6 °C compromised period. reducing the likelihood of postoperative
RR: 20 immune system. infection. period.
PR: 87
BP: 130/90 mm Hg 2. Promote proper hand 2. performing hand
hygiene hygiene is a fundamental
• Post-surgical aspect of infection
Incision prevention. By promoting
• Clean and Intact proper hand hygiene
Abdominal practices among
Dressing healthcare personnel and
patients, the transmission
of pathogens to the
surgical site can be
minimized.

3. Promote adequate 3. to advocate for well-

nutrition and hydration balanced diet and
adequate fluid intake to
support the body’s
immune system and
promote wound healing
4. Encourage early
ambulation and 4. Early ambulation and
mobilization mobilization promote
circulation and tissue
perfusion, which can
enhance wound healing
and reduce the risk of
66
 infection by preventing
stasis of blood and fluids
at the surgical site
5. Monitor Vital Signs
5. Regularly monitor the
patient’s vital signs,
including temperature,
hear rate, and respiratory
rate, to detect early signs
of infection.
6. Provide education on
signs and symptoms of 6. Educating patients and
infection their families about the
signs and symptoms of
infection empowers them
to recognize and report
early indications of a
potential surgical site
infection, facilitating
prompt intervention and
treatment.
Dependent
1. Performing wound Dependent
assessment and dressing 1. Regular assessment
changes of the surgical site allows
for early detection of
signs of infection, such as
redness, swelling, or
drainage. Proper wound
care, including timely
dressing changes, helps
maintain a clean and
protected environment
conducive to wound
healing.
67
2. Administer prophylactic
antibiotics 2. Prophylactic
antibiotics are prescribed
by the healthcare
provider to prevent
surgical site infections by
targeting potential
pathogens. Administering
antibiotics requires a
prescription from a
healthcare provider.
Collaborative
1. consult with infection Collaborative
disease specialist 1. Collaboration with
infectious disease
specialists may be
necessary in cases of
suspected or confirmed
surgical site infections to
guide appropriate
antibiotic therapy and
management strategies.

68
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for Fluid Within 4-6 hours of Independent Independent After 4-6 hour of
N/A Volume Deficit nursing intervention 1. Monitor intake and 1. Regular monitoring of nursing intervention
related to the patient will output the patient’s fluid intake the goal is met. The
Objective: preoperative maintain fluid and output helps identify patient maintains
fasting, surgical balance within fluid deficits or fluid balance within
• Vital signs taken losses, and normal parameters imbalances early, normal parameters
as follows: decreased oral during the allowing for timely during the
Temp:36.5 °C intake. postoperative intervention to prevent postoperative
RR: 23 period. dehydration. period.
PR: 91
BP: 100/80 mm Hg 2. Encourage early oral 2. Early initiation of oral
intake intake postoperatively,
• Flush skin, warm starting with clear fluids
to touch and advancing as
• Vaguely weak in tolerated, helps prevent
appearance dehydration and
promotes restoration of
fluid balance.

3. Educate the patient and 3. Providing education

family on hydration. on the importance of
adequate fluid intake,
signs of dehydration, and
strategies to maintain
hydration empowers the
patient and family to
actively participate in
preventing fluid volume
deficit.

4. Regular assessment
4. Assess vital signs and of vital signs, including
fluid status. blood pressure, heart
69
 rate, and orthostatic
changes, as well as
physical assessment for
signs of dehydration (e.g.,
dry mucous membranes,
decreased skin turgor),
helps detect fluid volume
deficits early.

5. encourage the patient

5. Encourage Oral Intake to resume oral intake as
soon as allowed by the
healthcare provider after
surgery, starting with
clear fluids and
advancing to a regular
diet as tolerated.

Dependent
Dependent 1. IV fluids may be
1. Administer IV fluid as necessary to replace fluid
prescribed. losses and maintain
hydration in patients
unable to tolerate oral
intake adequately.
Administration of IV fluids
requires a healthcare
provider’s prescription

Collaborative
1. Collaboration with the
Collaborative healthcare provider is
1. Consult with the essential to determine the
healthcare provider for appropriate type and rate
fluid management. of IV fluid administration
70
 based on the patient’s
fluid status, electrolyte
balance, and surgical
requirements.

2. Collaboration with a
dietitian can help develop
2. Collaborate with individualized dietary
dietitian. plans that promote
adequate hydration and
optimize nutritional
intake.

3. Collaboration with
physical therapists can
facilitate early
3. Involve physical therapy mobilization and activity,
which can help prevent
fluid shifts and promote
fluid balance by
enhancing circulation and
muscle pump activity.

71
 I. DRUG STUDY
Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Coxib (COX-2 Selectively inhibits Indication: Side effects: 1. Assess pain
Inhibitor) cyclooxygenase-2 Relief of signs and intensity and
Coxtin GI upset, peripheral
(COX-2), reducing symptoms of edema, headache, underlying
inflammation, pain, osteoarthritis, condition.
dizziness. 2. Monitor for
and fever without rheumatoid arthritis,
Generic Name: signs of GI
affecting COX-1- and acute pain
bleeding or
Coxid mediated gastric conditions. Adverse effect: renal
protection. Increased risk of impairment.
cardiovascular 3. Educate
Stock Dose: Contraindication: events, patient X on the
200 mg, 400 mg Hypersensitivity to gastrointestinal risk of
tablets coxibs, history of bleeding cardiovascular
and
asthma, urticaria, or events
allergic-type ulceration, renal associated with
Frequency: reactions to aspirin impairment. long-term use of
or other NSAIDs. coxibs.
Every 8 hours or as
directed

Route:
Oral

72
Actual Order:
Coxid 200mg/cap
BID x 7days

73
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Nonsteroidal Anti- Inhibits Indication: Side effects: 1. Assess pain
inflammatory Drug prostaglandin Short-term GI ulceration, intensity and
Taradol
(NSAID). synthesis, primarily management of bleeding, renal underlying
by blocking impairment, condition.
moderate to severe 2. Monitor for
cyclooxygenase-1 pain. headache,
Generic Name: signs of GI
and -2 enzymes, dizziness.
Ketorolac bleeding or
resulting in
Adverse effect: renal
analgesic, anti- Contraindicated: GI bleeding, renal impairment.
inflammatory, and Hypersensitivity to 3. Educate
failure,
Frequency: antipyretic effects. patients on the
ketorolac, active bronchospasm.
Every 6 hours as short-term use
peptic ulcer
needed and potential
disease, history of
gastrointestinal risks of NSAIDs.
bleeding or
Stock Dose: perforation,
10 mg tablets; 30 advanced renal
mg/mL injection impairment, peri-
operative pain in
coronary artery
Route: bypass graft
surgery.
Oral, IM, IV

74
Actual Order:
Keterolac 30mg IV
q8 x 3 doses
( )ANST

75
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Proton Pump Inhibits the H+/K+ Indication: Side effects: 1. Assess for
Inhibitor (PPI) ATPase enzyme Treatment of Headache, symptoms of
Losec
system in the duodenal and diarrhea, ulcers or GERD.
gastric parietal gastric ulcers, abdominal pain, 2. Monitor for signs
cells, suppressing GERD, erosive nausea. of
Generic Name: hypomagnesemia
gastric acid esophagitis,
Omeprazole and osteoporosis
secretion. Zollinger-Ellison
in prolonged
syndrome. Adverse effect: therapy.
Increased risk of 3. Instruct patients
Stock Dose: Clostridium difficile- to swallow
10 mg, 20 mg, 40 Contraindicated: associated capsules whole
mg capsules Hypersensitivity to diarrhea, and not crush or
omeprazole, hypomagnesemia, chew.
concurrent use with osteoporosis-
Frequency: rilpivirine- related fractures.
Once daily before containing
breakfast products.

Route:

Actual Order:
Omeprazole 40mg
IV OD

76
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Proton Pump Irreversibly inhibits Indication: Side effects: 1. Assess for
Inhibitor (PPI) the H+/K+ ATPase Gastroesophageal Headache, symptoms of
Monotrex
enzyme system in reflux disease diarrhea, GERD or peptic
the gastric parietal (GERD), peptic abdominal pain, ulcer disease.
cells, reducing acid ulcer disease, nausea. 2. Monitor for signs
Generic Name: of
secretion. erosive
Omepron hypomagnesemia
esophagitis,
and osteoporosis
Zollinger-Ellison Adverse effects: in long-term use.
syndrome. Increased risk of 3. Instruct Patient X
Stock Dose: Clostridium difficile- to swallow
20 mg, 40 mg associated capsules whole
capsules Contraindicated: diarrhea, and not crush or
Hypersensitivity to hypomagnesemia, chew.
omeprazole, osteoporosis-
concurrent use with related fractures.
Frequency:
Once daily before rilpivirine-
breakfast containing
products.

Route:
Oral

Actual Order:
Omepron 40g/IV at
the OR

77
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Non-opioid Inhibits Indication: Side effects: 1. Assess pain
Analgesic, prostaglandin Mild to moderate Rare at intensity and
Panadol
Antipyretic synthesis pain relief, fever therapeutic fever, monitor
primarily in the doses; may liver function
reduction.
CNS, reducing include rash, tests in long-
Generic Name: term use or
pain and fever. nausea, and
Paracetamol overdose
Contraindicated: allergic reactions.
situations.
Hypersensitivity to 2. Educate
paracetamol, Patient X on
Stock Dose: severe hepatic Adverse effect: proper dosing
500 mg, 650 mg tablets; impairment, Hepatotoxicity (in and the
160 mg/5 mL syrup chronic overdose), renal importance of
alcoholism. tubular necrosis not exceeding
(in overdose). recommended
doses.
Frequency:
Every 4-6 hours as needed

Route:
Oral, Rectal, IV
Actual Order:
o Paracetamol 300mg IV
q4 PRN for pain
o Paracetamol 600g q6
x 4 doses
78
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: H2 Receptor Blocks H2 Indication: Side effects: 1. Assess for
Antagonist receptors on the Treatment of Headache, symptoms of
Zantac
gastric parietal duodenal ulcers, constipation, ulcers or
cells, reducing gastric ulcers, diarrhea, dizziness. GERD, monitor
gastric acid GERD, erosive liver function in
Generic Name: patients with
secretion. esophagitis,
Ranitidine hepatic
Zollinger-Ellison Adverse effect:
impairment.
Stock Dose: syndrome. Rare, but may 2. Educate patient
include X on dietary
75 mg, 150 mg bradycardia, and lifestyle
tablets; 25mg/mL Contraindicated: arrhythmias, modifications to
injection Hypersensitivity to agranulocytosis. reduce gastric
ranitidine. acid secretion.

Frequency:
Twice daily or as
directed

Route:
Oral, Intravenous
Actual Order:
Give ranitidine 1amp
IV now

79
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Binds to mu-opioid Indication: Side effects: 1. Assess pain
receptors in the Moderate to severe Nausea, vomiting, intensity before
Tranal Opioid Analgesic and after
central nervous pain management. constipation,
system, inhibiting dizziness, sedation, administration.
the reuptake of headache. 2. Monitor for
Generic Name: Contraindicated: signs of
norepinephrine and
Hypersensitivity to respiratory
Tramadol serotonin, thereby
tramadol, severe depression,
modulating pain Adverse effect: assess bowel
transmission. respiratory Respiratory function.
Stock Dose: depression, acute depression, 3. Educate patient
intoxication with serotonin about the risk of
50 mg, 100 mg, alcohol, opioids, syndrome, dependence
200 mg tablets; 50 hypnotics, or seizures. and withdrawal
mg/mL injection psychotropic drugs. symptoms.
4. Administer with
food to minimize
Frequency: GI upset.

Every 4-6 hours as

needed

Route:
Oral, IM, IV

80
Actual Order:
o Tramadol 50g
IV q8 PRN as
needed for
brathing
and pain
o Tramadol 50mg
/ IV as a LD
then 25mg/ IV
4˚

81
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Antibiotic (Penicillin Inhibits bacterial Indication: Side effects: 1. Monitor for
derivative) cell wall synthesis Respiratory tract Diarrhea, nausea, allergic
Ampimax
(Ampicillin) and infections, urinary vomiting, skin rash reactions,
Generic Name: beta-lactamase tract infections, especially in
inhibitor intra-abdominal patients with a
Sultamicillin history of
(Sulbactam) infections, Adverse effect:
skin
Severe allergic penicillin allergy.
infections, and reactions, 2. Ensure proper
Stock Dose: gonococcal dosage
Clostridium difficile-
infections. adjustment in
375, 750 mg associated diarrhea
patients with
tablets renal
Contraindicated: impairment.
Hypersensitivity to 3. Educate the
Frequency: penicillins or any patient on
Typically twice completing the
component of the
full course of
daily, adjusted formulation. therapy to
based on infection prevent
severity resistance.
Route:
Oral

Actual Order:
Ampimax 750mg
tab TID x 7days
82
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Second-generation Inhibits bacterial Indication: Side effects: 1. Monitor patient
cephalosporin cell wall synthesis Surgical Injection site X for allergic
Cefoxitin
antibiotic prophylaxis, intra- reactions, rash, reactions.
abdominal diarrhea 2. Ensure proper
infections, urinary dosing
Generic Name: especially in
tract infections,
Monowel renal
septicemia, skin Adverse effect:
impairment.
and soft tissue Anaphylaxis, 3. Monitor for
infections. Clostridioides signs of
Stock Dose: difficile-associated superinfection.
1 g vial diarrhea 4. Educate patient
Contraindicated: X on the
importance of
Allergy to
Frequency: completing the
Every 6-8 hours cephalosporins full course of
(QID or TID) therapy.

Route:
IV

Actual Order:
Monowel 1g q 12˚
ANST

83
 Drug Name Drug Mechanism of Indication and Adverse Effect Nursing
Classification Action Contraindication and Side Effect Responsibilities
Brand Name: Antiseptic Antimicrobial action Indication: Side effects: 1. Instruct the
by disrupting cell Oral infections, Staining of teeth patient to gargle
Bactidol and not swallow
membranes and sore throat, and tongue, taste
inhibiting enzyme gingivitis alteration the solution.
activity 2. Monitor for
Generic Name: signs of oral
Hexetidine mucosal
Contraindicated: Adverse effect:
irritation.
Hypersensitivity to Rare, but can 3. Educate on
hexetidine include localized proper oral
Stock Dose: irritation hygiene
0.1% solution practices in
conjunction with
using the
Frequency: mouthwash.

Twice daily

Route:
Oral Rinse

Actual Order:
May gargle with
bactidol as needed

84
X. REFERENCES

Dubois F, Icard P, Berthelot G, Levard H: Coelioscopic cholecystectomy. Preliminary

report of 36 cases. Ann Surg 213:60, Jan 1991.
Peters JH, Ellison Ec, Innes JT, et al: Safety and efficacy of laparoscopic
cholecystectomy. A prospective analysis of 100 initial patients. Ann Surg 213:3,
Jan 1991.
Phillips E, Carroll B, DayKhovsky L, et al: Laparoscopically guided cholecystectomy.
Scientific Program: A-131, Digestive Disease Week, New Orleans, Louisiana, May
19-21, 1991.
Schirner B, Dix J: Cost-effectiveness of laparoscopic cholecystectomy. Scientific
Program: A-242, Digestive Disease Week, New Orleans, Louisiana, May 19-21, 1991.
Larson GM, Casey J, Evans J, et al: Multipractice analysis of laparoscopic
cholecystectomy in 1351 patients. Scientific Program: A-68, Digestive Disease Week,
New Orleans, Louisiana, May 19-21, 1991.
Kozarek R, Gannan R, Baerg R, et al: Bile leak following laparoscopic
cholecystectomy: Diagnostic and therapeutic application of ERCP. Scientific Program:
A-390, Digestive Disease Week, New Orleans, Louisiana, May 19-21, 1991.

85