Republic of the Philippines Tarlac State University College of Nursing

In partial fulfillment of the course requirements in NCM 104- Related Learning Experience In Tarlac Provincial Hospital: Surgery Ward- Charity

A Case Study on

CHOLEDOCHOLITHIASIS

BSN 3A - Group A4: Clemenete, Kevin Canaveral, Rose anne De Mayo, Juvy De Vera, Jebree Garcia, Christian King Garcia, Christine Joyce Grande, Jessa Guillermo, Michelle Nunag, Jorelle Nikolo Abilain Tuazon, RN Clinical Instructor

Dates of Rotation: November 18-19-25-26, 2010

Introduction The Gallbladder is a small pear shaped organ located beneath the liver. It stores bile; the greenish yellow digestive fluid produced by the liver. When bile is needed, the gallbladder contracts, pushing bile through the lower portion of the bile duct into the small intestine. In humans, the loss of the gallbladder is usually easily tolerated. Disorders such as gallstones and tumors can easily obstruct the flow of bile through the bile ducts. Occasionally, an injury during gallbladder surgery may cause an obstruction or the duct may be narrowed as it passes through the common bile duct into the duodenum, some stones may be too large to pass and may cause an obstruction. This condition is termed as Choledocholithiasis which is the most common digestive disease. About 15% of the population will develop stones is the common bile duct. Choledocholithiasis occurs as a result of either the primary formation of stones in the common bile duct (CBD) or the passage of gallstones from the gallbladder through the cystic duct into the CBD. (Examples of CBD stones are shown below.) Bile stasis, bactibilia, chemical imbalances, pH imbalances, increased bilirubin excretion, and the formation of sludge are among the principal factors thought to lead to the formation of these stones. Gallstones are differentiated by their chemical composition. Cholesterol stones are composed mainly of cholesterol, black pigment stones are mainly pigment, and brown pigment stones are made up of a mix of pigment and bile lipids. Obstruction of the CBD by gallstones leads to symptoms and complications that include pain, jaundice, cholangitis, pancreatitis, and sepsis. Choledocholithiasis is obstruction of the common bile duct. In choledocholithiasis, gallstones pass out of the gallbladder and lodge in the common bile duct, causing partial or complete biliary obstruction. The prognosis is good unless infection occurs. (http://www.msdlatinamerica.com/ebooks/HandbookofMedicalSurgicalNursing/sid163667.html) Choledocholithiasis may lead to cholangitis, obstructive jaundice, pancreatitis, and secondary biliary cirrhosis. Choledocholithiasis results when gallstones lodge in the common bile duct. The source of most stones found in the biliary ducts is the gallbladder. Bile stasis and infection involving the bile ducts may predispose to formation of primary bile duct calculi within the duct themselves. It may be asymptomatic and lead to rapid demise. Patients should be suspected if chills, fever, or jaundice accompanies biliary colic. Patients may notice transient darkening of urine and/or pruritis if long standing obstruction occurs. Surgery is used to remove the gallbladder and stones. ERCP and a procedure called a sphincterotomy, which makes a surgical cut into the muscle in the common bile duct. Performance of a cholecystectomy in patients with choledocholithiasis remains controversial, although most experts recommend it. However, in patients who cannot tolerate surgery well (eg, due to age, medical problems), leaving the gallbladder in situ is an option as long as the organ is asymptomatic. Cholecystectomy is not indicated for primary CBD stones. INTERNATIONAL
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The incidence rate for gallstones is 10-20%. Approximately 600,000 cholecystectomies are performed in the United States every year, and choledocholithiasis complicates 10-15% of these cases.The international incidence rate is higher, mainly because of the additional problem of primary CBD stones caused by parasitic infestation with Ascaris lumbricoides and Clonorchis sinensis.(e-medicine.com/choledocholithiasis, 2008) NATIONAL In the Philippines, there were 25,365 cases recorded in the year 2006 (Department of Health). LOCAL In November 2010, there were 6 cases of choledocholithiasis recorded in Tarlac Provincial Hospital. Reason of Choosing the Case The group chose this topic because the members would like to expand their knowledge about Choledocholithiasis. Another reason is that, it is important for us as students to learn this disease because we know that it will be useful for us in the future as nurses, to be able to share it with people in our own community and to improve their health and ways of preventing gallstones. The group would also like to know appropriate health care for choledocholithiasis so that we can provide for our patients. Studying this disease would give us benefits and broaden our knowledge to be better nurses.

IMPORTANCE OF PHYSICAL ASSESSMENT Physical assessment played a vital role in determining the different normal and abnormal findings in our patient having the disease (Choledocholithiasis). It will be a useful tool in monitoring our patient, implementing variety of nursing interventions and evaluating changes happening to our patient and it provide a baseline data in making missing actions to alleviate our patients condition. IMPORTANCE OF CASE STUDY The case study serves as a learning experience for us student nurses and to our patient as well because this will help to further understand the treatment option that can lower the serious
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complication. The importance of this study is to develop nursing actions that will surely give us a background data that will serve as a reference. We will gain more knowledge regarding this condition and also enhance our skills, and will be able to share to our colleagues in our future journey and this case study is really important especially to the patients for preventing further complications. OBJECTIVES GENERAL: To become successful in promoting and rendering effective nursing care to the patient and for the patient to maintain optimum health by cooperating on the different nursing process. SPECIFIC (NURSE CENTERED) Within the given rotation date (November 18-19, 2010) the student nurse will be able to:

Develop a trusting nurse-patient relationship. Specify current trends about choledocholithiasis Enumerate signs, symptoms and risk factor about the complication of choledocholithiasis. Enhance nursing skills through observation and practice. Evaluate all the nursing interventions that has been established and outcome of patient condition through different nursing interventions that had been done to the patient.

CLIENT CENTERED: Within the given rotation date (November 18-19, 2010) the student nurse will be able to:

Identify measures on how to improve and maintain a healthy lifestyle. Cooperate with the nursing interventions done. Maintain good physiological and emotional health through support.
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Enumerate ways of coping such as participating on the different nursing cares. Identify interventions reflecting a good adaptation to a healthier lifestyle such as diet modification after the operation through health teachings and procedures done.

II. NURSING PROCESS A. ASSESSMENT 1. Personal Data a. Demographic data Name: Age: Sex: Civil Status: Occupation: Religion: Role in the Family: Address: Date of Birth: Place of Birth: Nationality: History Care Financing: Admitting Diagnosis: Mrs. C 64 y/o Female Married Housewife Born Again Mother Tarlac March 1946 Burot Filipino None Obstructive Jaundice secondary to Choledolithiasis Date of Admission: Place of Admission: Date of Operation: B. Environmental Status Mrs. C lives in Tarlac with her two children. According to her, their house is located near the road. Their drinking water is coming directly from the forced pump and they use pitcher as storage. November 12, 2010 Tarlac Provincial Hospital November 22, 2010

C. Lifestyle Mrs. C verbalized that she consumes salty and fatty foods almost every day. She stated that some of the salty foods she eats are: bagoong, alamang, foods with preservatives and canned goods like noodles, sardines. Fatty foods were enumerated as fried meat, eggs, and fishes. She also eats vegetables occasionally. According to her, she does not have any vices. Doing household chores is her form of exercise.

2. Family Health History of Illness Paternal Maternal

74 UNK 86 Ast

79 Ast

68 UNK 84 HPN

71 HPN

67 Ast CLD

64 HPN

62 HPN

59 HPN

56 HPN

53

Schematic Diagram Legends: - Deceased Male -Living Male - Pertains to Patient - Deceased Female - Living Female CLD Choledolithiasis HPN- Hypertension Ast- Asthma UNK- Unknown

ANALYSIS: The patient has a family history of hypertension, which is a possible contributory factor to her condition.

3. History of Past Illness Data for the history of past illness were primarily taken from the interview and Mrs. C is the main source of data. She stated that she experienced common illnesses such as measles, cough, colds, headache, diarrhea and fever. She told that her vaccination was complete; she has no known allergy to foods, drugs, insects and animals. During an earthquake in 1988, she encountered an accident caused by falling debris such as hollow blocks and she was rushed at San Miguel Clinic. 4. History of Present Illness. Three days prior to confinement, she verbalized that she experienced on and off fever, right upper quadrant pain with nausea, headache, dizziness, grayish stool and voids 3 4 times per day. These were accompanied by decreases in appetite. She took Paracetamol (Biogesic) for the fever and pain but afforded no relief. Two days prior to admission, she said, parang may mantika ang tae ko,. She stated that she experienced episodes of sharp abdominal pain (RUQ) radiating to the right part of her back usually 1 to 2 hours after meals with pain scale of 7/10. One day prior to admission, she had recurrence of right upper quadrant pain and tenderness with vomiting and fever. Due to persistent pain, she decides to consult and was admitted.

5. 13 Areas of Assessment PRE-OPERATION (November 19-20, 2010) I. Social Status According to Mrs. C, she was not socializing well with other people. She had harmonious relationships with her two daughters. She was supported by her daughters. The patient also said that she was being respected by her children, and grandchildren. In return, she also shows respect to them. Her husband was already dead. Norms: The ability to interact successfully with the people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs. The ability to interact successfully with the people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs. (Kozier 2007) Analysis She was not socializing with other people because she just wants to stay at her house. II. Mental Status General Appearance and Behavior The patient responded correctly and promptly when asked about the place where she was. Also in this manner, she was able to state her name, age, time and date when she was interviewed. Mrs. C was also able to enumerate the symptoms she experienced prior to her admission such as abdominal pain, nausea and vomiting and right upper quadrant pain. Level of Consciousness The patient responded well to the questions asked. She was able to verbalize her feelings and was coherent. Orientation The patient was able to state the time and place correctly. Speech The patient used Filipino language and kapampangan during the conversation. She spoke clearly. Intellectual Function
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The patient was able to read, write, and compute and comprehend simple mathematical problems. Educational Attainment Mrs. C was elementary graduate. Norms: The patient should be oriented to time and place, can identify past and recent memories and should be able to verbalize concrete messages. The patients ability to read and write should match his educational level. The patient should be able to respond to questions and identify all the objects presented to him. The patient should be able to evaluate and act appropriately in situation. Normal Intellectuual functions are as follows: Level 1: able to read and write Level 2: able to read,write and can solve simple mathematics Level 3:able to read,write,compute simple mathematics and comprehend Level 4: able to read,write,compute simple mathematics, comprehend, and high school graduate (Estez 2003)

Analysis: Preoperatively, the patients mental status was normal because she was oriented to the time and place where she was and able to answer promptly. She was only an elementary graduate due to financial problem. III. Emotional Status The day of interview, the patient showed poor eye contact though she answered the questions being asked, irritability was observed during the conversation. When she was asked if she was feeling nervous or not, she sated.natatakot ako sa pwedeng mangyari sa akin, she was anxious because of her upcoming operation. Norms: Emotional wellness involves the ability to recognize, accept and express feelings and to accept limitations. It is also the ability to manage stress and to express emotions appropriately. Emotional status such as sadness and depression can affect clients perceptions and can alter a clients thinking patterns and reaction time and usual safety precautions may be forgotten during periods of emotional stress. (Daniels 2007) Analysis:
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Preoperatively, the patient was able to express her feelings verbally and non-verbally. She was nervous and anxious for her upcoming operation. Poor eye contact and irritability was seen. IV. Sensory Perception Vision She said that she have difficulty reading in far distances. She had to place them near from her eyes to see them clearly. Using a penlight, the patients eyes were inspected. She could read newspaper with her eye glasses. There were no abnormalities noted and both pupils constricted well when light was introduced. Extra ocular movements were also done correctly. There was presence of icteric sclera.

Norms: The client who has a visual acuity of 20/20 is considered to have normal visual acuity. The eyes must be symmetrical during the six cardinal gazes test. The sclera should be white with some small blood vessels. Papillary constriction should occur when struck by light. (Estez 2003) Analysis: Before the operation, the patients vision is abnormal because she was nearsighted. Regarding the six cardinal gazes, the result was normal because she was able to move her eyes properly. Papillary constriction is normal as well because both pupils constricted as light was introduced. There was presence of icteric sclera due to presence of excess bile in the blood. Hearing The voice whisper test was used to assess the sense of hearing. The words paper and ball pen were whispered to both ears of the patient and she was asked to repeat the words. She was able to repeat the words correctly. During the interview, the patient responded promptly to the questions and no repetition was needed. The ear matches the flesh color of the patients skin and was positioned centrally and proportion to the head. There was no presence of masses, lesions, nodules and deformities. During in the palpation of the ear there was no presence of tenderness. Norms: For the auditory acuity, the patient should be able to repeat the whispered words from a distance of two feet. (Estes 2003) Analysis:
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Before the operation, the patients hearing was normal because she was able to repeat the words whispered to her correctly. Smell The nose is in midline. Nasal patency was assessed by asking the patient cover one nostril and breathes with other one and vice-versa. The patient was able to breathe properly. In assessing the sense of smell of the patient, she was instructed to close her eyes and let her smell alcohol and cologne. She was then instructed to recognize and name them. Mrs. C was able to state the names of the things correctly. Norms Nose must be symmetrical and along of the face. Each nostril must be patent and recognize the smell of an object. (Estes 2003) Analysis: Before the operation, Mrs. C sense of smell was normal because of her ability to smell and name thing correctly. Tactile In the assessment of the touch sensation of the patient, she was asked to close her eyes and let her feel things like pen and coins. She was able to answer all correctly using her both hands. Also with her eyes closed, a sharp (tip of a pencil) and a blunt (eraser of a pencil) were placed on her arm alternatively and she was asked if the object was sharp or blunt. She was able to answer correctly. Pain scale was 7/10, quality was stabbing, provoke was due to obstruction in common bile duct, it radiates to her chest and at back, and pain was felt after 30 minutes of eating fatty foods. Norms The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized touch are sent via slower sensory pathways. (Estes 2003) Analysis Pre- operatively, the patients tactile sensitivity was normal because she was able to feel and name objects correctly. Pain scale was 7/10, quality was stabbing, provoke was due to obstruction in common bile duct, it radiates to her chest and at back, and pain was felt after 30 minutes of eating fatty foods. V. Motor Stability and Gait

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During the interview the patient was in sitting position. She was able to sit, move from side to side of the bed alone in slow manner but when walking and standing she still needs assistance. She had a limited body movement. Norms: The normal range is that patient has a good posture, easily to walk, transfer from bed to chair and walk fast not just slowly. In standing position, the torso and head are upright. The head is midline and perpendicular to the horizontal line of the shoulder and the pelvis. The shoulders and hips are level, symmetry of the scapulae and iliac crests. The arms are freely from the shoulders. The feet are aligned and the toes forward. Walking in itiated in one smooth rhythmic fashion. (Estes 2003) Analysis: Before the operation, Mrs. Cs was able to sit and move from bed alone but whenever she walks she need assistance. VI. Body Temperature Date Assessed November 2010 November 2010 Time Temperature (oC) 35.8 36.8

19, 10:00 am 20, 10:00 am

Norms: Normal body temperature fluctuates with the patients activity level and the time of day. Core body temperature lowers during sleep than during waking hours, being the lowest in the early morning just before awakening from sleep and the highest in the afternoon and early evening. A 0.5C to 1.0C or a 1.0F to 2.0F, fluctuation in body temperature throughout the day is considered within normal range. The elderly are more sensitive to extremes of environmental temperature due to a decrease in thermo regulatory controls. The normal body temperature for adults is 36.7C to 37.4C (98.06F to 99.32F) by axilla. A normal range of body temperature is 36.6-37 Degree Celsius via axilla for 6 minutes (Daniels 2004) & (Estes 2007) Analysis:
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Based on the data written above, before the operation, Mrs. C body temperature was in within normal. VII. Respiratory Status The breath sound was high in pitch, loud in intensity, and with blowing quality. Date Assessed Time Respiratory Rate (cycles per minute) 22 24

November 2010 November 2010

19, 10:00 am 20, 10:00 am

Norms: A normal adult respiratory rate ranges from 1620 cpm. Average is 18 cycle per minute. In terms of pattern it must be regular and even in rhythm The normal breath sound is Bronchial which is high pitch, loud in intensity and blowing or hollow in quality, Bronchovesicular moderate in pitch, moderate intensity and combination of bronchial and vesicular in quality and Vesicular low in pitch, soft intensity and gentle rustling or breezy in quality. (Kozier,2007) Analysis: Before the operation, Mrs. C has a bronchial breath sound. Mrs. C respiratory rate were above the normal range due to the pain she felt at right upper quadrant on her abdomen. VIII. Status Circulatory Date Assessed Time Pulse Rate (bpm) 109 108 100 Blood Pressure (mmHg) 140/90 140/90 140/80

Mrs. C pulse rate was weak, thready and not easily palpable during the assessment. Her capillary refill goes back at 2 seconds.

November 19, 10:00am 2010 3:00 pm November 19, 8:30 am 2010

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Analysis: Her pulse rate was bounding due to increase in blood pressure. Mrs. C blood pressure was above normal due to history of hypertension and her condition. IX. Nutritional Status Mrs. C diet was more on salty, fatty and fried foods, and seldom eats fruits amd vegetables. She usually eats salty products like dried fish and fatty viands. She drinks at least 6-7 glasses a day.. Her height was 5 feet and 3 inches and her weight was 61 kilograms. Body mass index measurement: Patient weight: 50kg Patient height: 5 feet 152.4 cm 1.52 = 2.31 cm2 50/2.31= 23.83 Norms: According to the Health Asian Diet Pyramid, there should be a daily intake of rice, grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly for sweets, eggs and poultry, and monthly for meat. There should be an increase intake of a wide variety of fruits and vegetables. Include in the diet foods higher in vitamins C and E, and omega-3 fatty acid rich foods. (www.webmd.com) Normal body mass index is 20-25, less than 20 is associated with heart problem, and in some people more than 7 indicates higher risk for developing heart problems. (Kozier,2007) Analysis: Mrs. C regularly eats salty and fried foods which maybe a contributory factory for her disease since increase in deposition of fat in the body can cause formation of stones. Her BMI was in normal range. X. Elimination Status Mrs. C defecates once a day and the characteristic of her stool was formed, grayish in color. She usually urinates 2-3 times a day and with moderate amount. Norms: Normal bowel movement of a person must be 1 to 2 times a day and voiding in 3 to 4 times a day with an output of 1200 to 1500 ml a day. A normal stool is brown in color and well formed, urine is clear to yellowish in color. (Kozier 2007)
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Analysis: Her bowel movement was in normal duration, and her stool was in normal form and grayish in color. She also voids in normal duration. XI. Reproductive Status Mrs. C claimed that she was about 12 years old when she had her first menstruation. Her menstrual cycle last for about 3-4 days and uses 1-2 pads per day. She had her first pregnancy when she was 21 years old. She denies using any contraceptives and claimed that they are not sexually active. Norms: First Menstruation should start from the age of 9 to 14. Sexual health is the integration of the somatic, emotional, intellectual and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. Breast on the other hand are relatively equal with slight variation depending on maturation, are round and pendiculous. Areola and nipples are supposedly pink to dark brown in color and are relatively bilaterally. Shape is characterized as round or oval and are averted, no discharges and free form lesions, rashes or ulcers. Menopause will undertake at age of 40 to 50 years old. (Brunner and Suddarth 2008) Analysis: Her menstruation was in normal range and that her first pregnancy was in normal age. She also does not use contraceptives that might be contributory factor. She was not sexually active since she was already widow.

XII. Sleep-Rest Pattern Mrs. C typically sleeps at ten oclock in the evening until six oclock in the morning and sometimes wakes up in the middle of night. During the admission her sleep pattern last for about 6 hours as verbalized.

Norms: Adults average amount of sleep per day is 7 to 8 hours. (wikipedia.org). the older adult sleeps 6 hours a night. About 20% to 25% is REM sleep. Stage IV sleeps is markedly decreased and in some instances absent. The first REM period is longer. Many elders awaken more often during the night and it often takes them longer to go back to sleep. Because of the change in Stage IV sleep, older people have less restorative sleep. (Kozier 2007) Analysis
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Mrs. C sleep was normal but some time she wakes up in the morning due to pain. She was not able to have enough sleep in admission due to environmental discomfort and also due to pain.

XIII. State of Skin and Appendages Mrs. X has a brown to yellow skin color and yellow sclera is yellow. Skin was pinch in her forearm and skin goes back at 1 second. Presence of mild sweating was noted specifically in the axilla and skin folds. Nails are untrimmed and unhygienic. Her intravenous fluid was hooked at her right hand, intact and infusing well. No redness, tenderness, inflammation and irritation seen on the intravenous site. Norms: When the skin is pinched then released, it should return to its original contour rapidly. Hair varies from dark to pale blonde based on the amount of melanin present. The body is covered in vellus hair. Terminal hair is found in the eyebrows, eyelashes, and scalp, and in the axilla and pubic areas after puberty. Native Americans, Asians, and those from the Pacific Rim may have a light distribution of hair. Skin is dry with minimum perspiration. Skin surfaces should be nontender. It should normally feel smooth, even and firm. (Estes 2007) Analysis: Mrs. C has a yellow discoloration of the skin known as jaundice caused by backflow og bile into the bloodstream and mixed with blood causing yellow colored skin.

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6. Laboratory and Diagnostic Procedures

Diagnostic/ Laboratory Procedure COMPLETE BLOOD COUNT

Date ordered/ Date done 11-16-10 / 11-16-10

Result Indication/ Purposes Gives information about the cells in a patient's blood. PRE-OP WBC 8.4 G/L (4.1-10.9 G/L) Lymphocytes 10% (10.0-58.5%) Granulocytes 69% (37-92%) Red Blood Cell 4.16 T/L (4.2-6.3 T/L) Hemoglobin 120 g/L (120-180 g/L) Hematocrit 0.354 L/L (0.370-0.510 L/L) MCV 85 fl (80-97 fl)

Analysis and Interpretation of results (related to the disease) The results of the complete blood count are normal except for the lymphocytes that are decrease probably due to an infection.

Body does not make erythropoeitin or your bone marrow does not work properly

Body does not make erythropoeitin or your bone marrow does not work properly

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MCH 28.8g (26-32g) MCHC 339g/L (310-360 g/L) Platelet 310 g/L (140-440 g/L)

URINALYSIS

10-18-10/ 10-18-10

The physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine.

pH 6.0 Specific gravity 1.010 Bilirubin +3 Color Yellow Pus cells 0-1 HPF Red cells 0.1 HPF
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Epithelial Cells Few ULTRASOUND 10-12-10/ 10-12-10 A procedure in which highfrequency sound waves create images of the pelvic organs. The sound waves are projected into the pelvis, and measure how they reflector echoback from the different tissues.

Liver- is homogenous within normal in size and echogenecity, Gall Bladder-sludge and small calculi Choledocholithiasis

BLOOD CHEMISTRY

11-14-10/ 11-14-10

A Test to assess a wide range of conditions and the function of organs

BUN- 17.24

(10-20 mg/dl)

CRE- 344.74
Na- 132.7 (135 - 145mEq/L) K- 2.61 3.5-5.0 mEq/L Cl- 102.1 97-107 mEq/L.

ELECTROLYTES

11-18-10/ 11-18-10

Low potassium levels indicate hypokalemia

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Nursing Responsibilities: Before:

Explain the purpose of the test and the procedure. Client mat experience anxiety about the procedure, especially if it is perceived as being intrusive or if they fear unknown to the result. A clear explanation will facilitate cooperation on the part of the client. Assist the client in having pelvic ultrasound test. Inform the client of the time period before the results will be available. During:

Use the correct procedure for obtaining the blood and urine. Aseptic technique should be use in collection to prevent contamination that can cause inaccurate results. Ensure correct labeling, storage and transportation of the specimen to avoid invalid test results. After:

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Report results to the appropriate health team members. Compare the previous and current test results and modifies nursing interventions as needed. Follow up results in the laboratory.

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ANATOMY AND PHYSIOLOGY

Gastrointestinal Tract
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls. The primary purpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provide energy.

Focus: GALLBLADDER
The gallbladder is a hollow, pear-shaped sac, 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It lies on the undersurface of the livers right lobe and is attached there by areolar connective tissue. It stores about 50 mL of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food. The gallbladder stores bile by the hepatic and cystic ducts. During this time the gallbladder concentrates bile fivefold to tenfold. When digestion occurs in the stomach and intestines, the gallbladder contracts and ejects the concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum. Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach.

Biliary system
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The biliary system is made up of the ducts arising in the liver, the gall bladder and its duct and the common bile duct. Starting in the liver, the small biliary ducts converge to form the larger right and left hepatic ducts. These, in turn, join to form the common hepatic duct which joins with the cystic duct to form the common bile duct.

Hepatic ducts- drain the liver L hepatic duct from the L lobe, R hepatic duct from the R lobe of the lober Common hepatic duct- unites the L and R hepatic duct. Cystic duct- connects the gallbladder and the common bile duct Common bile duct- is formed when the common hepatic duct and the cystic duct unites. Pancreatic duct- joins the pancreas to the common bile duct

The gall bladder receives bile from the liver by way of the common hepatic duct into the cystic duct. The gall bladder stores and concentrates its contents and also excretes its bile back through the cystic duct to join the common hepatic duct to become the common bile duct which then carries the bile into the duodenum. The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver.

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8. BOOK-BASED PATHOPHYSIOLOGY Non-Modifiable Risk Factor: - Gender (Female) - Race - Fertility - Age (< 40 years old) Modifiable Risk Factor: - Diet (High Fat and Salt) - Use of contraceptives - Sedentary Lifestyle Increased digestion and deposition of fat cholesterol stimulates wall of duodenum to release cholecystokinin and release bile decreased sensitivity to cholecystokinin decreased gallbladder emptying increased secretion of bile in the gallbladder bile mixed with cholesterol Bile and cholesterol becomes supersaturated and Forms crystals or microstones More crystal formation aggregate to form macrostones Macrostones blocks the common bile duct Cholecystokinin stimulates Gallbladder to contract Spasm of the smooth muscle of gallbladder Abdominal tenderness damage in the wall Injured cells release chemical cell Mediators: bradykinin and cytokin Pain: Right Upper Quadrant Stone travels to Cystic duct or common Bile duct Stone becomes an obstruction decreased secretion of bile in duodenum bile will back flow to liver bile mixed with blood and goes to circulation yellow discoloration of skin
Decrease Increased unconjugated emulsification bilirubin; bilirubin not Of fat converted to urobilinogen by intestinal flora Excretion of fat in feces Clay colored stool 25 Fait in feces Cholestasis

bile retains in the gallbladder increased concentration of bile bile synthesize or irritate the wall of gallbladder

gallbladder sense stone as foreign object cellular response: increased Cellular response: chemotaxis of WBC site blood flow to the
Release of cytokines induction of heat (pyrogens)

Increased change Hypothalamus :in metabolic activity of the in set point

CLIENT CENTERED PATHOPHYSIOLOGY Non-Modifiable Risk Factor: - Gender (Female) - Age (64 years old) Modifiable Risk Factor: - Diet (High Fat and Salt: fried fish, meat, fish and dried fish tuyo) Increased digestion and deposition of fat cholesterol stimulates wall of duodenum to release cholecystokinin and release bile decreased sensitivity to cholecystokinin decreased gallbladder emptying increased secretion of bile in the gallbladder bile mixed with cholesterol Bile and cholesterol becomes supersaturated and Forms crystals or microstones More crystal formation aggregate to form macrostones Macrostones blocks the spincter of oddi Cholecystokinin stimulates Gallbladder to contract Spasm of the smooth muscle of gallbladder Abdominal tenderness (Nov. 19, 2010) bile retains in the gallbladder increased concentration of bile bile synthesize or irritate the wall of gallbladder damage in the wall Injured cells release chemical cell Mediators: bradykinin and cytokin Pain: Right Upper Quadrant (Nov 18-19 [pain scale: 7/10],2010) gallbladder sense stone as foreign object
Cellular response: cellular response: increased chemotaxisto the site blood flow of WBC Release of cytokines induction of heat (pyrogens) Hypothalamus : change activity of the in set point Vasoconstriction and shivering

Increased in metabolic

decreased secretion of bile in duodenum

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NURSING CARE PLAN Pre-Op NURSING CARE PLAN Assessment Subjective: Masakit ang tiyan ko Planning Within 30 minutes of proper nursing interventions, the patient pain will be lessened from 7/10- 5/10. Intervention INDEPENDEENT -Note presence and location of pain. (to assess etiology of pain) -Use pain scale appropriate for age.(0 to 10) (to evaluate patients response to pain) -Monitor vital signs. (to evaluate patients response to pain) -Encourage verbalization of feeling about pain. (to evaluate patients response to pain) -Provide diversional activities such as TV/Radio and socialization. (to assist patient to explore methods to alleviate/control pain) -Prepare client for incoming operation. (to reduce anxiety and provide information) 27 Expected Outcome After 30 minutes of proper nursing interventions, the patients pain shall be lessened as evidenced by improved body movements and pain scale of 5/10.

Pain scale:7/10
Objective:

Guarding behavior Pain duration of 30 minutes Onset of pain after eating fatty foods Limited body movements Weak in appearance Grimace noted
Diagnosis: Acute pain related to physical discomfort Scientific Explanation: Patient experience pain due to retained bile that causes irritation and damaged at the wall of the gallbladder.

-Perform comfort measure to promote relaxation, such as massage, bathing, repositioning and relaxation technique (these measures reduce muscle tension or spasm, redisturb pressure on body parts, and help patient focus on non pain related matters) -Help patient into a comfortable position and use pillow to splint or support painful areas (to reduce muscle tension or spasm, redisturb pressure on body parts, and help patient focus on non pain related matters.) DEPENDENT/COLLABORATIV E -Collaborate with patient in administering prescribed analgesics when alternative methods of pain control are inadequate. (Gaining patients trust and involvement helps ensure compliance and may reduce medication intake.) -Administer analgesics as ordered. (to reduce pain) 28

29

Assessment Subjective: Kinakabahan ako Objective: Difficulty concentrating Poor eye contact Irritable Hypertensive (BP: 160/90) Tachypneic: (RR: 24)

Planning Within 6 hours of proper nursing intervention, the patient will verbalize diminished feeling of anxiety.

Intervention -Observe patients behaviors which denote anxiety. (for baseline data) - establish therapeutic communication (to decrease anxiety) -Monitor vital signs. (to have baseline data) (to assess level of anxiety) -Identify patients perception of the threat represented by the situation. (to identify clients response) -Have patient state what kinds of activities promote feelings of comfort and encourage patient to perform them. (this gives patient a sense of control) -Listen attentively; allow patient to express feelings verbally. (This may allow patient to identify anxious behaviors and discover source anxiety.)

Expected Outcome After 6 hour of appropriate nursing intervention, the patient will be able to diminish feeling of anxiety as evidenced by her verbalization of the preparation measures for in the incoming operation.

Diagnosis: Anxiety related to upcoming operation. Scientific Explantion: Patient experience anxiety as an emotion triggered by the anticipation of potential danger due to upcoming operation.

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-Give patient clear, concise explanation about to occur. -Make no demand on patient. (to provide information and decrease anxiety) -Support SO in coping with patients anxious behavior. (Involving family members in process of reassurance and explanation allays patients anxiety as well as their own.)

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Assessment Subjective: Nahihirapan akong kumilos Objective:

Planning Within 4-5 hours of proper nursing intervention patient will demonstrate techniques to improve mobility.

Intervention -Identify factors that may block desired level of activity. (to identify causative factors) -Monitor vital signs. (to assist patient in managing limited and appropriate activities) -Determine current activity level. (to have baseline data) -Establish realistic goal for improving the patients activity level, taking into account the patients physical limitations and energy level. (to help improve the patients quality of life) -Assist patient in repositioning. (to promote comfort and prevent other problems) -Demonstrate and teach the patient on proper

Expected Outcome After 4-5 hours of proper nursing intervention patient will able to demonstrate techniques to improve mobility.

Inability to reposition body independently Difficulty moving up in bed Weak in appearance Tachypneic (RR: 24cpm) Irritable at times Grimace noted
Diagnosis: Activity intolerance related to physical condition. Scientific Explanation: Activity is a natural process and a vigorous motion of action. When one manifested insufficient physiologic and psychologic functional changes he endure a simple task this resulted to activity

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intolerance.

repositioning of the body. (to provide information) -Provide encouragement if the patient achieve even small improvements in his activity level. (to help restore self confidence) -Teach the patient about good nutrition and the importance of getting adequate rest. (to improve health practices and promote wellness)

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SOAPIE PRE OP November 18-19,2010

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SUBJECTIVE
Masakit ang tiyan ko

Pain scale:7/10

OBJECTIVE Guarding behavior Pain duration of 30 minutes Onset of pain after eating fatty foods Limited body movements Weak in appearance Grimace noted

ANALYSIS
Acute pain related to physical discomfort

PLANNING
Within 30 minutes of proper nursing interventions, the patient pain will be lessened from 7/105/10.

INTERVENTION
INDEPENDEENT -Noted presence and location of pain. -Used pain scale appropriate for age.(0 to 10) -Monitor vital signs. -Encouraged verbalization of feeling about pain. -Provided diversional activities such as TV/Radio and socialization. -Prepared client for incoming operation. -Performed comfort measure to promote relaxation, such as massage, bathing, repositioning and relaxation technique -Helped patient into a comfortable position and use pillow to splint or support painful DEPENDENT/COLLABORATIV E -Collaborated with patient in administering prescribed analgesics when alternative methods of pain control are inadequate. -Administered analgesics as ordered.

EVALUATION
After 30 minutes of proper nursing interventions, the patients pain was lessened as evidenced by improved body movements and pain scale of 5/10.

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SUBJECTIVE
Kinakabahan ako

OBJECTIVE
Difficulty concentrati ng Poor eye contact Irritable Hypertensi ve (BP: 160/90) Tachypneic : (RR: 24)

ANALYSIS
Anxiety related to upcoming operation.

PLANNING
Within 6 hours of proper nursing intervention, the patient will verbalize diminished feeling of anxiety.

INTERVENTION
-Observed patients behaviors which denote anxiety. - established therapeutic communication -Monitored vital signs. -Identified patients perception of the threat represented by the situation. -Had patient state what kinds of activities promote feelings of comfort and encourage patient to perform them. -Listened attentively; allow patient to express feelings verbally. -Given patient clear, concise explanation about to occur. -Made no demand on patient. -Supported SO in coping with patients anxious behavior.

EVALUATION
After 6 hour of appropriate nursing intervention, the patient was able to diminish feeling of anxiety as evidenced by her verbalization of the preparation measures for in the incoming operation.

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37

SUBJECTIVE
Nahihirapan akong kumilos

OBJECTIVE Inability to reposition body independentl y Difficulty moving up in bed Weak in appearance Tachypneic (RR: 24cpm) Irritable at times Grimace noted

ANALYSIS
Activity intolerance related to physical condition.

PLANNING
Within 4-5 hours of proper nursing intervention patient will demonstrate techniques to improve mobility.

INTERVENTION
-Identified factors that may block desired level of activity. -Monitored vital signs. -Determined current activity level. -Established realistic goal for improving the patients activity level, taking into account the patients physical limitations and energy level. -Assisted patient in repositioning. -Demonstrated and taught the patient on proper repositioning of the body. -Provided encouragement if the patient achieve even small improvements in his activity level. -Taught the patient about good nutrition and the importance of getting adequate rest.

EVALUATION
After 4-5 hours of proper nursing intervention patient was able to demonstrate techniques to improve mobility.

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39

DRUG STUDY The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and to maintain nutritional status. Standard Nursing Responsibilities in Administering Drugs: 1. Observe the 10 Rights of drug administration : *right patient identify patient by: Checking ID Band, asking him to state his name *right drug read label three times *right route- check the route of administration *right dosage- calculate the correct amount *right time *right documentation- sign medication sheet *right approach, *right attitude, *patients right to be informed, *right to refuse 2. Practice asepsis. Practice proper hand washing. 3. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications. 4. The nurse who prepares the drug administers it. DO not accept endorsement of medications.

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DRUG STUDY Name of Drug Date Administere d Cefuroxime 11-19-2010 Route, Dosage, Frequency of Administration IVP, 750 mg, 2 Inhibits bacterial hours PTOR
wall synthesis, rendering cell wall osmotically unstable, leading to cell death by binding to cell wall membrane

General Action, Mechanics Action

Indication/Purpose

Client Response to Medicine

It is used for surgical prophylaxis, reducing or eliminating infection

No response noted

Nursing Responsibilities: Check pt. for allergy to drug Protect drug vials form light Administer every 5 hours to maintain serum level and control pain Report if there is fever, rash, and etc.

Name of Drug

Date Administere d

Route, Dosage, Frequency of Administration PO, 15 mg/tab tab at HS then tab 2 hours PTOR

General Action, Mechanics Action

Indication/Purpose

Client Response to Medicine

Midazolam

11-19-2010

Acts at many levels of the CNS to produce generalized CNS depression

For reduction of anxiety

No response noted

Preprocedura l sedation.

Nursing Responsibilities: Check pt. for hypersensitivity to drug Give drug with food to decrease GI upset Discontinue if hypersensitivity occurs 41

You may experience side effects such as: stomach upset and diarrhea

Name of Drug

Date Administere d

Route, Dosage, Frequency of Administration IVP, 4mg, 1 hour PTOR

General Action, Mechanics Action

Indication/Purpose

Client Response to Medicine

Dexamethaso ne

11-19-2010

Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell reproduction.

is used to treat many different conditions such as allergic disorders, skin conditions, ulcerative colitis, arthritis, lupus, psoriasis, or breathing disorders.

No response assessed

Nursing Responsibilities: Check pt. for hypersensitivity to drug Give drug with food to decrease GI upset Discontinue if hypersensitivity occurs You may experience side effects such as: stomach upset and diarrhea

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Medical Management

Date Ordered

Medical Management General Description

Indication & Purpose

Client Response to Treatment

D5LRS 1L 30gtts/min

November 13, 2010

5% dextrose in lactated ringers Solution (Osmolarity of 527hyprtonic, pH of 4.9) -provides calories and free water, provides electrolytes. Also contains sodium lactate which is used

administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirement with minimal carbohydrates calories and to correct or replace fluid losses due to change in the patients diet (NPO)

The patient responded well with no signs of irritation and adverse reactions.

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in treating mild to moderate metabolic acidosis. Nursing Responsibilities: Check the doctors order Explain the procedure to the patient Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion Check and monitor IVF regulation and level of fluid Check if there is a need for removal and replacement of fluid Check if the tube is in the vein and signs of edema Check if there is a back-flow of blood Check if there is bubbles present in the tube Always Monitor V/S. Medical Management Date Ordered General Description Indication & Purpose Client Response to Treatment

PNSS 1L 30gtts/min

November 19, 2010

a sterile solution of sodium chloride (NaCl, more commonly known as salt) in water but is only sterile

it is isotonic, ( same osmolarity as our body fluids and can be used to replace fluids in dehydration, go with blood transfusions, hyponatremia, and

The patient responded well with no signs of irritation and adverse reactions.

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when it is to be placed intravenously, otherwise, a saline solution is a salt water solution. The sterile solution is typically used for intravenous infusion, rinsing contact lenses, nasal irrigation

burn victims

Nursing Responsibilities: Check the doctors order Explain the procedure to the patient Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion Check and monitor IVF regulation and level of fluid Check if there is a need for removal and replacement of fluid Check if the tube is in the vein and signs of edema Check if there is a back-flow of blood Check if there is bubbles present in the tube Always Monitor V/S.

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TYPE OF DIET

DATE ORDERED, STARTED & CHANGED November 12, 2010

GENERAL DESCRIPTION Low salt diet provides food which are low in sodium content, to manage individual with hypertension Low fat diet provides foods which are low in density lipoprotein, to manage individual with hypertension

INDICATIONS

SPECIFIC FOOD TAKEN High in fiber food, vegetables and fruits

CLIENTS RESPONSE Client was able to maintain proper diet

Low sodium Diet

Indicated to pt. with high blood pressure.

Low Cholesterol Diet

November 12, 2010

Indicated to patient with high blood pressure

High in fiber food, vegetables and fruits

Client was able to maintain proper diet

Nursing Responsibility: 1. Explain the purpose of diet. Perform ways to increase patients appetite and compliance to diet.

TYPE OF EXERCISE

GENERAL DESCRIPTION

Purpose

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Passive ROM exercise

Exercises are done for a person by a helper. The helper does the range of motion exercises because the person cannot do them by herself.

To maintain joints and muscle healthy

Deep Breathing Exercise

The pt. either sits in a chair or sits upright in bed inhales, pushing the abdomen out to force maximum amounts of air into the lungs

Deep breathing helps expand the lungs and force better distribution of the air into sections of the lungs.

Nursing Responsibility 1. Assess the patients stamina and response to exercise to gauge the degree of gradual activity progression. 2. Assess vital signs before and after exercise. 3. Encourage a gradual increase in activity within the limits of the patients condition.

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CONCLUSION

Gallstones are a common condition of the biliary tract of the digestive system. Gallstones are hard deposits that are similar to pebbles or stones that can develop in the gallbladder. They can be tiny, like a grain of sand, to quite large in size, such as a golf ball. Sometimes gallstones can remain in the gallbladder or pass through the cystic duct and the common bile duct with causing any symptoms of problems. Gallstones can also become lodged within a duct and cause pain, illness and possibly complications. The gallbladder is an organ that is a part of the digestive system and is located in the upper right side of the abdomen under the liver. The pear-shaped gallbladder is a hollow sac that concentrates and stores the digestive substance bile, which is produced by the liver. Bile flows from the liver into the gallbladder for storage. When food is eaten, the gallbladder squeezes the stored bile into the cystic duct and down the common bile duct into the duodenum of the small intestine where bile works to help digest food.When a gallstone or gallstones in the gallbladder cause inflammation or passes out of the gallbladder and becomes trapped or stuck in the cystic duct, it is called cholecystitis. When a gallstone or gallstones passes out of the gallbladder and becomes trapped or stuck in the common bile duct, it is called choledocholithiasis. Gallstones that cause these conditions can result such symptoms as severe epigastric pain, abdominal pain, ride sided abdominal pain, and/or pain that radiates around the right rib cage and into the back. A commonly used general term used for the pain caused by gallstones is biliary colic. Other typical symptoms include nausea and vomiting. Some people with gallstones may have no symptoms or problems at all. However, in some cases, gallstones can result in serious, even life-threatening complications, such as pancreatitis, biliary cirrhosis, peritonitis and cholangitis. As a student nurse, it is our responsibility to be knowledgeable enough about the disease our patients have. This is very important to understand their condition and to know why they experience such circumstances. Enough information about diseases will help us to know the proper interventions we can provide to our patients. Learn to care and love the patients we are handling, this will help us lessen the pressure and tiredness especially during toxic days of duty. We should also keep our experiences with every patient, because we might encounter the same case in the future.

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RECOMMENDATION

A. Student Nurse

As a student nurse, to enhance our skills and knowledge is important thats why we doing a research about a particular disease is important for us. Searching for a particular disease such as choledocholithiasis may lead us to expand our ideas about the condition of the disease. Through this, we can encourage our co-student nurse to gather more information for them to broaden their knowledge by sharing of gathered data especially about the cause and effect of this disease together about the health teachings on how to avoid a certain illness, so that they can allocate it to other individuals to prevent diseases and to promote health.

B. Community

For the community, having knowledge about choledocholithiasis is important. The community must be aware for the signs and symptoms of disease. They must determine the cause and effect of the disease. So as a community, they may help each other to prevent its cause such as alleviating eating salty foods, eating fatty foods so that the community may take action to avert risk factors for the health of the whole community. The community should also participate in the programs that are related for the promotion of health.

C. Patient

Patient health condition will be better if she follows the recommendation that we have given to her, such as preventing eating foods that are high in salt and cholesterol.. To promote 49

health, Mrs. C should maintain a healthy lifestyle; Mrs. C should stop eating foods that are high in sodium and fats for the sake of his condition. Mrs. C should have proper exercise everyday for the good circulation of blood. Mrs. C should also monitor his intake of food and prevent foods that contains low dense lipoprotein such as fatty meats, instead take foods contain high dense lipoprotein such as fruits and vegetables, to promote a healthy diet

D. Health Workers

Health providers must broaden their knowledge in order to promote healthy conditions of the client. They must be responsible for the improvement of clients health by teaching the client on how to properly manage his condition. Health teachings are important to prevent risk factors. Promoting health must be developing in the community, and most especially in the hospital which is the most essential role of the health care providers. They must enhance more of their knowledge, such as research and studies, to have capability to impart right health teachings for individuals, family and community.

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V. REVIEW OF RELATED LITERATURE Research indicates that acute hepatocellular injury in cholelithiasis and cholecystitis without choledocholithiasis is mild and transient Acute hepatocellular injury is a commonly encountered phenomenon in patients with cholelithiasis and concomitant common bile duct (CBD) stones. However, in clinical practice, it seemed to occur also in cholelithiasis patients without evidence of CBD stones. Its incidence and final outcome necessitated clarification. A research article to be published on August 14, 2009 in the World Journal ofGastroenterology addresses this question. The research team, led by Dr. Shou-Chuan Shih from Mackay Memorial Hospital (Taiwan, China) investigated acute transient hepatocellular injury in patients with cholelithiasis and cholecystitis but no evidence of choledocholithiasis. The medical records of patients with cholelithiasis who underwent cholecystectomy between July 2003 and June 2007 were retrospectively reviewed. Imaging studies to detect CBD stones were performed in 186 patients, who constituted the study population. Biochemical liver tests before and after surgery, and with the presence or absence of CBD stones were analyzed. They found that, in 96 patients with cholelithiasis and cholecystitis without evidence of CBD stones, 49 (51.0%) had an alanine aminotransferase level elevated to 2-3 times the upper limit of normal, and 40 (41.2%) had an elevated aspartate aminotransferase level. Similar manifestations of hepatocellular injury were, as would be expected, even more obvious in the 90 patients with CBD stones. These markers of hepatocellular injury resolved almost completely within 2 week to

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1 moth after cholecystectomy. Compared to 59 patients with histologically less severe cholecystitis. The result indicated that acute hepatocellular injury in cholelithiasis and cholecystitis without choledocholithiasis is mild and transient . Hyperbilirubinemia and leukocytosis may predict severe inflammatory changes in the gallbladder. Dr. Smith, World Journal of Gastroenterology, 2010

VI. BIBLIOGRAPHY A. PUBLISHED MATERIALS

Doenges, M. (2004) Nurses pocket guide diagnoses: intervention and rationale. Ackley.(2006), Nursing diagnosis handbook: A guide to planning. Mosby (2006), Mosbys pocket dictionary of medicine, nursing health Estes, M. (2006). Health assessment and physical examination Venable, (2007). Springhouse nurses drug guide Kozier, (2004). Fundamentals of nursing; Concepts, Process, Practices, 7th edition

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B. UNPUBLISHED MATERIAL

www.Scribd.com/ cholelithiasis www.Wikipedia.com/cholelithiasis www.Emedhealth.com/approach to gallstones World Health Organization/cholelithiasis Tarlac Provincial Hospital Medical Records Department of health

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