Obstructive Jaundice Secondary

to Choledocholithiasis

In Partial Fulfillment
Of the Requirements for the Course
Related Learning Experience (RLE)
Nursing Care Management (NCM) 0121
 Table of Contents

Page

I. Introduction …………………………………………………………………. 3

II. Nursing Process …………………………………………………………… 5

Personal History …………………………………………………………… 5

Family Health Illness History …………………………………………….. 9

History of Past Illness ..…………………………………………………… 10

History of Present Illness ………………………………………………… 10

Physical Examination …………………………………………………….. 11

Diagnostic and Laboratory Procedures ………………………………… 23

III. Anatomy and Physiology ………………………………………………… 42

IV. The Patient and His Illness ……………………………………………… 45

A. Pathophysiology …………………………………………………. 45

1. Book-Centered …………………………………………... 45

2. Patient-Centered ………………………………….……... 48

B. Planning (Nursing Care Plan) …………………………………… 51

C. Implementation …………………………………………………… 65

1. Medical & Surgical Management ………………………. 65

2. FDAR ……………………………………………………… 82

D. Evaluation …………………………………………………………. 83

1. Client's Daily Progress Chart …………………………… 83

2. Discharge Planning ………………………………………. 85

V. Summary of Findings ……………………………………………………… 88

VI. Conclusion …………………………………………………………………. 87

VII. Learning Derived ………………………………………………………….. 88

VIII. Recommendations ………………………………………………………… 92

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 IX. Bibliography ………………………………………………………………… 93

I. INTRODUCTION

Have you ever wondered why our liver produces bile? Have you ever wondered what will
happen if we are not able to secrete bile?
The liver is the largest organ in our body, one of its important functions is its ability to
produce bile. This substance has a yellow-green appearance and has a sticky texture which
contains different substances like bilirubin, and bile acids that break down lipid chains into fatty
acids so that it can be utilized by our body. Bile is stored inside the gallbladder which is
connected to the liver via the common bile duct (CBD). During meals, bile is released from the
gallbladder through the common bile duct which also connects the two organs to the duodenum.
However, bile can also harden and cause an obstruction in the gallbladder, or in the common
bile duct. The presence of a gallstone in the common bile duct is called Choledocholithiasis.
Since the bile contains bilirubin, it will not be able to be excreted in the feces due to the
obstruction. Therefore, there will be a buildup of bilirubin causing jaundice or the yellow
discoloration of the skin, mucous membranes, or sclera.
Choledocholithiasis can occur in up to approximately 20% of people who have
cholelithiasis (Molvar & Glaenzer, 2016). Most of the stones form in the gallbladder but some
may pass through the common bile duct causing an obstruction and generate symptoms such
as acute pain and jaundice. According to McNicoll et al (2023), choledocholithiasis has been
found in 4.6% to 18.8% of individuals undergoing cholecystectomy. The incidence of
cholelithiasis increases with age, more common in women, pregnancy, and individuals with high
serum lipid levels.
The treatment for choledocholithiasis is the removal of the stones via endoscopy. An
Endoscopic Retrograde Cholangiopancreatography (ERCP) can be done under general
anesthesia. However, endoscopic sphincterotomy during an ERCP can lead to the loss of the
sphincter’s function, and some adverse events may occur such as bleeding, perforation,
cholangitis, malignant degeneration, and recurrent choledocholithiasis. That is why
Cholangioscopy-assisted basket extraction for choledocholithiasis technique can be performed
where biliary intubation was conducted, then a covered single dumbbell-style support was
placed in the distal common bile duct, then the cholangioscope was inserted into the CBD when
a stone was found, a basket will be inserted into the CBD through the working tunnel of the
cholangioscope where it will trap the stone firmly, then by withdrawing the scope and the basket

3
together the stone may be removed from the CBD, then the support will be removed and a
plastic stent was placed in the CBD to avoid inadequate drainage of bile resulting from possible
papillary edema. (Zhang et al, 2023).
This case study presents a 63-year-old male, patient Pedro, diagnosed with Obstructive
Jaundice secondary to Choledocholithiasis. The researchers have chosen this case because
the condition has been reported to be one of the complications of poor serum lipid control,
aging, and unhealthy eating habits. Thus, the researchers wanted to investigate more about
Choledocholithiasis. This case study enabled the researchers to broaden their knowledge of the
disease condition and its management in the clinical setting. The researchers have identified
possible nursing interventions for the disease condition. This will help them become more
efficient and successful nurses in the future when caring for patients with PCAP.

Objectives
1. Student- centered
Short Term:
Within the first 1-3 days of student nurse-patient engagement, the student nurse will be
able to:
● Develop a therapeutic connection with the patient and their significant others.
● Collect all essential data and perform a cephalocaudal physical evaluation to determine
the patient’s further needs.
● Perform a thorough physical examination of the major body systems, noting any
anomalies in the patient's age.
● Examine important laboratory and diagnostic results relevant to the patient's condition.

Long Term:
Upon conducting the case study, the student nurses will be able to:
● Created an in depth pathophysiology of a patient's prognosis based on collected data
and credible sources like evidence-based journals or textbooks, including synthesizing
the ailment, precipitating/predisposing variables, and signs and symptoms.
● Implemented independent, dependent, and interdependent nursing interventions as the
nursing care plan indicates.
● Created appropriate nursing care plans based on patient evaluations, clinical findings,
and daily progress.

4
 ● Obtained evidence-based nursing care through a collaborative and cooperative
approach focused on clinical care, safety, and standards.
● Documented relevant observations, nurse actions, and the patient's reaction to therapy.
● Strengthened and achieved professional growth and progress of skills and knowledge.

Reasons for choosing the study

1. Student-Centered
○ To assess the contributing factors on why the disease process occurred.
○ To acquire more knowledge regarding Obstructive Jaundice secondary to
Choledolithiasis and its complications.
○ To ascertain the purpose of each diagnostic operation and laboratory test
performed on the patient.
○ To give the patient promotional and preventative actions to improve their health.

2. Patient- centered
● To assess the knowledge of the patient, especially significant others about the
disease condition (Obstructive Jaundice secondary to Choledolithiasis).
● To enhance their understanding especially the significant others about
Choledolithiasis.
● To help them identify the factors that have caused the condition.
● To help them identify the factors that may exacerbate the condition.
● To help them develop confidence in terms of preventing such conditions by
having a well balanced nutrition and healthy lifestyle practices.
● To increase awareness about different measures that may promote health and
prevent aggravation of condition.

3. Research- centered
● To determine any research gaps that may arise from the patient’s health
condition and health management.
● To provide evidence that may verify research information.
● To enable researchers to propose and present solutions that are evidence-based
in order to ensure the safety of patients.

5
II. NURSING PROCESS

A. Personal history

a. Demographic data
Mr. Pedro, the patient, introduced by his wife, the informant during the
interview as 63 years old, male, married, Filipino, born on December 9, 1959, in
Lubao, Pampanga, Philippines and currently live in Purok 3 Jose Abad Santos
Guagua, Pampanga. They have four living children and all currently resides in
Pampanga, Philippines. His current occupation is a tricycle driver. He has been
in this line of work for more than 30 years. At the time of interview, Mr. Pedro was
wearing a hospital gown, lying on bed, lethargic, and was not able to speak for
himself. He has black short hair with white hair strands evenly distributed on his
face, symmetrical facial features, weighing around 60 kg and around 5.4 ft tall.
He was admitted on April 1, 2023 at 2:14 pm with chief complaint of fever and
abdominal pain. His admitting diagnosis is Obstructive Jaundice secondary to
Choledocholithiasis. The patient was not discharged on the last day of nurse-
patient interaction, April 15, 2023. The patient remains admitted to the hospital
and was on his first day post-operative from his second surgery.
b. Socioeconomic and cultural factors
i. Income and expenses
Mr. Pedro has been working as a tricycle driver for more than 30 years
and as a barangay tanod for almost five years. According to the wife, the
informant during the interview, who also works in their barangay, they share their
earnings together to afford their fees. At times, the couple share some of their
extra income to their children when they need help. According to the wife, their
income exactly meet their expenses but most of the time it is insufficient,
especially during these times when a member of the family is hospitalized.

INCOME (Monthly)

Salary as Barangay Tanod 5,000

(husband)

Salary as Barangay kagawad 8,000

(wife)

6
 Earnings as a Tricycle driver 600

TOTAL: 13, 600

EXPENSES (Monthly)

Food 5,000

Electric bill 1,500

Water bill 500

Groceries 2,500

Internet / Mobile Data 1,500

Gas stove 900

TOTAL: 11,900

ii. Educational attainment

According to the wife of Mr. Pedro, the informant during the interview, Mr.
Pedro’s highest educational attainment was second year college on a technical-
vocational program. The wife of Mr. Pedro was not aware of the reason of his
husband of not pursuing a traditional four-year undergraduate program.

iii. Religious affiliation

Mr. Pedro and his family are all members of Roman Catholic Church.
They worship one and only God and made choices thoughout their lives that
were in union with the holy will of God. According to the wife of Mr. Pedro, the
informant during the interview, they often attend holy mass every Sunday and
participate in Catholic occasions, expect the past weeks when Mr. Pedro was
hospitalized.

iv. Cultural factors affecting health and family

According to the wife of Mr. Pedro health is the utmost priority in their
family. However, the family tends to cope with illness with the endurance of pain,
with the help of family and acquaintances, or by faith in God. Initially, Mr. Pedro
will resort to utilizing home remedies, such as the decoction of malunggay leaves
to strengthen his body and fight illness. When the illness was not relieved by

7
these home remedies, Mr. Pedro will try to self-medicate by buying over-the-
counter medicines. The wife reported that Mr. Pedro had been experiencing
‘pangangasim ng sikmura’ for almost a year, which he treats by drinking an oral
suspension of Gaviscon or an Efficascent oil, and Mr. Pedro reports relief of pain
afterward. The family, particularly Mr. Pedro, tends to not consult doctors unless
the situation is worse and not manageable by their traditional ways. Thus, Mr.
Pedro and his family manages their illness by self-monitoring of symptoms,
treatment by acknowledged regimen, and determining the severity and threat to
functional capacity in consideration of the financial and emotional burden to the
family.

v. Environmental Factors
Despite Mr, Pedro old age, he remained an active person. According to
his wife, Before his hospitalization, his daily routine was to wake up around 2-3
am, have a cup of coffee, do laundry, and by 6 am, his work as a tricycle driver
starts. He works until 5 pm and goes to bed around 8 pm. For Mr. Pedro meals,
he eats 3 meals a day with snacks in between meals. His usual breakfast
consists of a cup of coffee, fried meat, and one bowl of rice. At times his
breakfast is replaced by bread and eggs. According to his wife, he eats all kinds
of food and likes fried fish, chicken, and pork the most. Also, he is fond of
drinking a cup of coffee at least 3 cups per day and carbonated beverages. He
seldom eats street foods and junk foods. His wife reported that he started
smoking when he was a teenager but already stopped smoking for more than 20
years from the time of the interview. However, he occasionally drinks alcohol,
especially when there are gatherings. When ask about the condition of their
environment in the house, the wife mentioned that they value the importance of
cleanliness, which motivates them to frequently clean the inside and outside of
their house. Also, the wife briefly explained that they have adequate living space
and good ventilation in their house, which helps in reducing the concentration of
airborne contaminants whenever someone is sick among the members of the
family.

8
B. Family Health Illness History

9
 According to the wife of Mr. Pedro, she cannot recall the year and cause of death of the
grandparents of Mr. Pedro. Based on the statement of the wife, Mr. Pedro’s father died due to a
Cardiac disease. The wife cannot recall the specific cause of death and year. Mr. Pedro’s
mother was diagnosed with Type 2 Diabetes Mellitus and died due to the complications of the
disease. The wife cannot also recall the exact year of death since they were not living with
them. Mr. Pedro was the third child among his three other siblings. The firstborn is currently
alive but diagnosed with Type 2 Diabetes Mellitus. Then, the secondborn died a week before
the interview due to ischemic heart disease. The youngest is alive though the wife cannot recall
his current illness.
Based on the statement of the wife of Mr. Pedro, all of their children are alive and well.
No one in his children has a problem with liver, diabetes, or other gastrointestinal conditions.

C. History of Past Illness

According to the wife of Mr. Pedro, he was diagnosed with Gastric Ulcer twenty years
ago and was hospitalized for a day. Aside from that the wife of Mr. Pedro reported that she
cannot recall any childhood illnesses, trauma, allergies, and other serious illness.
By 2022, the wife of Mr, Pedro reported that he had been experiencing symptoms of
gastric acidity, which she describes as ‘pangangasim ng sikmura’ and sometimes accompanied
by nausea and vomiting. From 2022 to April 2023, the wife of Mr, Pedro was not entirely
attentive to his health. Despite frequently experiencing these symptoms, he remains skeptical of
consulting a doctor because he thought believes it is not something that is not serious.
Throughout this period, Mr. Pedro continued to drink caffeinated and carbonated beverages as
well as all sorts of fried meats. And whenever he starts to feel abdominal pain he treats it with
one sachet of Gaviscon or rubbing an efficascent oil, a home remedy, and reports relief of pain
after.
By the time of the interview, the wife of Mr. Pedro reported that he was vaccinated
against COVID-19 in two doses with a booster.

D. History of Present Illness

Before admission on March 27 of the current year, Mr. Pedro experienced abdominal
pain, vomiting, and fever with chills. After a week, Mr. Pedro manifested yellow sclera and

10
jaundiced skin. He was then admitted to the regional hospital and diagnosed with Obstructive
Jaundice Secondary to Choledocholithiasis.
Mr. Pedro underwent his first operation, held on April 5, 2023, which was an Open
Cholecystectomy, Intraoperative Cholangiography, Pyloro duodenoplasty, T-tube insertion, and
insertion of a Jackson-Pratt drain. The surgeon have noted the presence of a gangrenous
gallbladder with cholecystoduodenal fistula measuring 1.5 cm and with stone measuring 2 cm
eroding the common bile duct.
After the procedure, it was noted that there was a leakage surrounding the patient’s T-
tube. Hence, on April 14, 2023, Mr. Pedro underwent his second surgical procedure which
involved Tube Duodenostomy, T-tube reinsertion, lavage, and feeding jejunostomy.

E. Physical Examination

Admission Assessment (Lifted from the chart, done by NOD):

Admission: April 01, 2023

Vital Signs
Blood Pressure: 140/100
Temperature: 37.1 degrees Celsius
Heart Rate: 114 bpm
Respiratory Rate: 40 bpm
Oxygen Saturation: 93%

General Survey:
The client was alert, awake, (+) Jaundice, has an icteric sclera, slightly pale peripheral
conjuctiva, tachycardic, (-) murmur sounds, soft globular, non-tender abdomen, (-) edema in the
extremities; with a GCS score of 15 (E4, V5, M6).

April 14, 2023 (DAY 1 Student Nurse-Patient Interaction)

Vital Signs
Blood Pressure: 110/70
Temperature: 36 degrees Celsius
Heart Rate: 125 bpm
Respiratory Rate: 22 bpm

11
 Oxygen Saturation: 75%
GCS: 10 (E: 3 V: 2 M:5)

General Survey:
The client was seen lying on bed in a prone position, he appears weak and mostly use
body language to communicate; with a GCS score of 10 (E3, V2, M6); with an ongoing IVF #11
Lactated Ringer’s solution 80 cc/ hr infusing well on the left arm seen at 600mL, with an intact
heplock on the right hand, with a total parenteral nutrition (Kabiven) q24, no any signs of
inflammation and phlebitis; with foley catheter seen at 200mL, with O2 support via face mask at
10LPM, with Jackson Pratt Drain maintained on negative pressure, intact T-tube, and tube
duodenostomy to urine bag.

➢ Examination of the Skin

Skin was uniform skin color, jaundice, and was cold and clammy. Skin was
wrinkly and has poor skin turgor. There was a break in the skin caused by the
duodenostomy and jejunostomy. No edema noted.

➢ Examination of the Hair and Nails

Hair was black with few streaks of white hair, thick and evenly distributed. There
was no presence of dandruff and infestations noted. Fingernails and toenails were pale,
clean and trimmed. Poor capillary refill was noted.

➢ Examination of the Skull and Face

The skull was round without lesions or deformations, masses, nodules nor
depressions on the skull upon palpation. There are symmetric facial movements and
without edema. There is a supplementary O2 via face mask.

➢ Examination of the Eyes

Eyebrows are thick and symmetrically aligned with white strands and without
flakes, scars and lesions. Eyelashes are evenly distributed and slightly curled outward.
Eyelids have intact skin, has an icteric sclera. Palpebral conjunctiva is pale. There is no
tenderness over the lacrimal gland upon palpation.

➢ Examination of the Ears

12
 Auricles have the same color as the facial skin, symmetrical and are aligned with
the outer canthus of the eye. They are firm, not tender and recoil as they were folded.
Minimal cerumen was noted on both ears. No abnormal discharges were noted during
the assessment.

➢ Examination of the Nose

Nose is centrally positioned on the face, symmetrical in size and shape and has
the same color as the face. There is no discoloration, and lesion. Nasogastric Tube is
seen on the left nostril.

➢ Examination of the Mouth

Lips are dry and purplish in color but there were no cracks present.

➢ Examination of the Neck

The neck muscles are of equal size and shape. Head was in midline position.
There was no jugular vein distention noted. Patient is able to move head slowly. The
trachea is in the midline at the suprasternal notch upon inspection and palpation.

➢ Examination of the Chest (Lungs)

Skin was intact, uniform in color and temperature. No deformities noted. No signs
of difficulty breathing. No abnormal breath and lung sounds noted.

➢ Examination of the Heart

Heart rate was a little below normal. Blood pressure is 120/80mmHg. No
murmurs noted. The jugular veins are not visible and distended. Carotid pulses are
palpable and no bruits noted upon auscultation.

➢ Examination of the Abdomen

The skin is uniform in color. Abdomen is evenly rounded upon inspection. There
is no tenderness and masses noted upon palpation. Bowel sound is noted.

➢ Examination of the Genitourinary

13
 According to the significant other of the patient, there are no lesions. No
abnormal discharge on the external urethral opening was noted. The patient is with an
indwelling foley catheter.

➢ Examination of the Extremities

The upper extremities are symmetrical. Temperature is uniform with no
tenderness, swelling or deformities. Peripheral pulses are palpable and fast. Muscles are
symmetrical in size with no contractures and no tremors. With cool lower extremities, the
legs are identical in size and shape bilaterally with no swelling or atrophy.

Cranial Nerve Assessment

CRANIAL NERVE ASSESSMENT

Name, Type and TECHNIQUES NORMAL FINDING ACTUAL FINDING
Function

I. Olfactory Ask the patient to Identifies different The patient was weak
Sensory close his eyes and to mild aromas and his words are
identify different mild specifically coffee, incomprehensible
aromas such as candy and perfume hence this part of
coffee, candy and correctly by means of cranial nerve
perfume. smelling it. assessment was not
assessed.

II. Optic Ask the patient to Ability to read the The patient was weak
Sensory cover one eye at a handout 14 inches and his words are
time then instruct to away. incomprehensible
read the handout hence this part of
from 14 inches away. cranial nerve
assessment was not
assessed.

III. Oculomotor Assess direct and Follows the penlight Mr. Pedro was able to
Motor consensual response up, down, side to side follow the penlight up,
by instructing the correctly and easily. down, side to side

14
 patient to follow the For the pupils, it will easily and correctly.
penlight without constrict with light His pupils constricted
moving his head. and dilate when light when illuminated,
Assess for is removed. round and equally
accommodation by reactive to light and
using the penlight to accommodation.
see the reaction of
the pupil.

IV. Trochlear Assess for upward, Ability to follow the Mr. Pedro was able to
Motor downward and lateral movement of the pen look up, down, and
ocular movement by upward, downward, side to side without
following an object and lateral without moving his head.
without moving the moving the head.
head.

V. Trigeminal Ask the patient to Ability to open her The patient was
Sensory and Motor move the jaw while mouth and move his weak, and words are
applying resistance. jaw against incomprehensible
Use the tip of a resistance. Corneal hence this part of
cotton to swipe the reflex must be elicited cranial nerve
corneal surface of the upon touching the assessment was not
eye. cornea with a cotton assessed.
tip. Identifies if the
sensation is blunt or
sharp.

VI. Abducens Ask the patient to Ability to follow the The patient was
Motor follow the student’s student's finger from weak, and words are
finger as it moves side to side without incomprehensible
from side to side. difficulty. hence this part of
cranial nerve
assessment was not

15
 assessed.

VII. Facial Ask the patient to Ability to perform The patient was
Sensory and Motor smile, raise the movements easily weak, and words are
eyebrows, frown, puff and symmetrically. incomprehensible
cheeks and close hence this part of
eyes tightly. Ask him Identifies the specific cranial nerve
to identify varying taste (sweet and assessment was not
taste such as sugar, salty). assessed.
vinegar and salt.

VIII. Auditory/ Instruct the patient to Ability to hear the The patient was
Acoustics listen to the ticking of ticking watch and will weak, cannot stand
Sensory a wrist watch on each be able to stand erect up, and words are
ear while eyes are and will walk with incomprehensible
covered. Allow the balance. hence this part of
patient to stand with cranial nerve
feet together and assessment was not
arms on the side, first assessed.
with eyes open and
then closed.

IX. Instruct the patient to Ability to elicit upward The patient have an
Glossopharyngeal open mouth and movement of soft NG tube, was weak,
Motor and sensory protrude the tongue. palate when mouth is and words are
Place a tongue opened, gag reflex incomprehensible
depressor on the will be stimulated hence this part of
back portion of the when tongue cranial nerve
tongue. Ask the depressor is placed assessment was not
patient to drink if he on posterior portion assessed.
is able to swallow. of tongue. Ability to
swallow water without
difficulty.

16
 X. Vagus Instruct the patient to Ability to swallow and The patient have an
Sensory and Motor speak or say one speak without NG tube, was weak,
sentence. Ask the hoarseness. and words are
patient to swallow or incomprehensible
drink a glass of water. hence this part of
cranial nerve
assessment was not
assessed.

XI. Accessory Ask the patient to Ability to move his The patient was
Motor move his head side head side to side and weak, and words are
to side and downward against incomprehensible
downward against resistance. He will hence this part of
resistance. Also, ask also be able to cranial nerve
the patient to elevate elevate shoulders assessment was not
shoulders against when resistance is assessed.
resistance. applied.

XII. Hypoglossal Instruct the patient to Ability to protrude The patient have an
Motor protrude tongue at tongue at midline NG tube, was weak,
midline then move it then move it side to and words are
side to side, in and side, in and out and incomprehensible
out and up and down. up and down. hence this part of
cranial nerve
assessment was not
assessed.

April 15, 2023 (DAY 2 Student Nurse-Patient Interaction)

Vital Signs
Blood Pressure: 110/80
Temperature: 36 degrees celsius
Heart Rate: 94 bpm
Respiratory Rate: 21 bpm

17
 Oxygen Saturation: 98%
GCS: 12 (E: 4 V: 2 M:6)

General Survey:
The client was seen lying on bed in a prone position, he appears weak and mostly use
body language to communicate; with a GCS score of 10 (E3, V2, M6); with an ongoing IVF #14
Dextrose 5% in Water 60 ml/hr infusing well on the left arm seen at 300mL, with a total
parenteral nutrition (Kabiven) q24, no any signs of inflammation and phlebitis; with foley
catheter seen at 150mL, with O2 support via face mask at 10LPM, with Jackson Pratt Drain
maintained on negative pressure, intact T-tube, and tube duodenostomy to urine bag.

➢ Examination of the Skin

Skin was uniform skin color, jaundice, and was cold and clammy. Skin was
wrinkly and has poor skin turgor. There was a break in the skin caused by the
duodenostomy and jejunostomy. No edema noted.

➢ Examination of the Hair and Nails

Hair was black with few streaks of white hair, thick and evenly distributed. There
was no presence of dandruff and infestations noted. Fingernails and toenails were pale,
clean and trimmed. Poor capillary refill was noted.

➢ Examination of the Skull and Face

The skull was round without lesions or deformations, masses, nodules nor
depressions on the skull upon palpation. There are symmetric facial movements and
without edema. There is a supplementary O2 via face mask.

➢ Examination of the Eyes

Eyebrows are thick and symmetrically aligned with white strands and without
flakes, scars and lesions. Eyelashes are evenly distributed and slightly curled outward.
Eyelids have intact skin, has an icteric sclera. Palpebral conjunctiva is pale. There is no
tenderness over the lacrimal gland upon palpation.

➢ Examination of the Ears

18
 Auricles have the same color as the facial skin, symmetrical and are aligned with
the outer canthus of the eye. They are firm, not tender and recoil as they were folded.
Minimal cerumen was noted on both ears. No abnormal discharges were noted during
the assessment.

➢ Examination of the Nose

Nose is centrally positioned on the face, symmetrical in size and shape and has
the same color as the face. There is no discoloration, and lesion. Nasogastric Tube is
seen on the left nostril.

➢ Examination of the Mouth

Lips are dry and purplish in color but there were no cracks present.

➢ Examination of the Neck

The neck muscles are of equal size and shape. Head was in midline position.
There was no jugular vein distention noted. Patient is able to move head slowly. The
trachea is in the midline at the suprasternal notch upon inspection and palpation.

➢ Examination of the Chest (Lungs)

Skin was intact, uniform in color and temperature. No deformities noted. No signs
of difficulty breathing. No abnormal breath and lung sounds noted.

➢ Examination of the Heart

Heart rate was a little below normal. Blood pressure is 110/80mmHg. No
murmurs noted. The jugular veins are not visible and distended. Carotid pulses are
palpable and no bruits noted upon auscultation.

➢ Examination of the Abdomen

The skin is uniform in color. Abdomen is evenly rounded upon inspection. There
is no tenderness and masses noted upon palpation. Bowel sound is noted.

➢ Examination of the Genitourinary

19
 According to the significant other of the patient, there are no lesions. No
abnormal discharge on the external urethral opening was noted. The patient is with an
indwelling foley catheter.

➢ Examination of the Extremities

The upper extremities are symmetrical. Temperature is uniform with no
tenderness, swelling or deformities. Peripheral pulses are palpable and fast. Muscles are
symmetrical in size with no contractures and no tremors. With cool lower extremities, the
legs are identical in size and shape bilaterally with no swelling or atrophy.

Cranial Nerve Assessment

CRANIAL NERVE ASSESSMENT

Name, Type and TECHNIQUES NORMAL FINDING ACTUAL FINDING
Function

I. Olfactory Ask the patient to Identifies different The patient was weak
Sensory close his eyes and to mild aromas and his words are
identify different mild specifically coffee, incomprehensible
aromas such as candy and perfume hence this part of
coffee, candy and correctly by means of cranial nerve
perfume. smelling it. assessment was not
assessed.

II. Optic Ask the patient to Ability to read the The patient was weak
Sensory cover one eye at a handout 14 inches and his words are
time then instruct to away. incomprehensible
read the handout hence this part of
from 14 inches away. cranial nerve
assessment was not
assessed.

III. Oculomotor Assess direct and Follows the penlight Mr. Pedro was able to
Motor consensual response up, down, side to side follow the penlight up,
by instructing the correctly and easily. down, side to side

20
 patient to follow the For the pupils, it will easily and correctly.
penlight without constrict with light His pupils constricted
moving his head. and dilate when light when illuminated,
Assess for is removed. round and equally
accommodation by reactive to light and
using the penlight to accommodation.
see the reaction of
the pupil.

IV. Trochlear Assess for upward, Ability to follow the Mr. Pedro was able to
Motor downward and lateral movement of the pen look up, down, and
ocular movement by upward, downward, side to side without
following an object and lateral without moving his head.
without moving the moving the head.
head.

V. Trigeminal Ask the patient to Ability to open her The patient was
Sensory and Motor move the jaw while mouth and move his weak, and words are
applying resistance. jaw against incomprehensible
Use the tip of a resistance. Corneal hence this part of
cotton to swipe the reflex must be elicited cranial nerve
corneal surface of the upon touching the assessment was not
eye. cornea with a cotton assessed.
tip. Identifies if the
sensation is blunt or
sharp.

VI. Abducens Ask the patient to Ability to follow the The patient was
Motor follow the student’s student's finger from weak, and words are
finger as it moves side to side without incomprehensible
from side to side. difficulty. hence this part of
cranial nerve
assessment was not

21
 assessed.

VII. Facial Ask the patient to Ability to perform The patient was
Sensory and Motor smile, raise the movements easily weak, and words are
eyebrows, frown, puff and symmetrically. incomprehensible
cheeks and close hence this part of
eyes tightly. Ask him Identifies the specific cranial nerve
to identify varying taste (sweet and assessment was not
taste such as sugar, salty). assessed.
vinegar and salt.

VIII. Auditory/ Instruct the patient to Ability to hear the The patient was
Acoustics listen to the ticking of ticking watch and will weak, cannot stand
Sensory a wrist watch on each be able to stand erect up, and words are
ear while eyes are and will walk with incomprehensible
covered. Allow the balance. hence this part of
patient to stand with cranial nerve
feet together and assessment was not
arms on the side, first assessed.
with eyes open and
then closed.

IX. Instruct the patient to Ability to elicit upward The patient have an
Glossopharyngeal open mouth and movement of soft NG tube, was weak,
Motor and sensory protrude the tongue. palate when mouth is and words are
Place a tongue opened, gag reflex incomprehensible
depressor on the will be stimulated hence this part of
back portion of the when tongue cranial nerve
tongue. Ask the depressor is placed assessment was not
patient to drink if he on posterior portion assessed.
is able to swallow. of tongue. Ability to
swallow water without
difficulty.

22
X. Vagus Instruct the patient to Ability to swallow and The patient have an
Sensory and Motor speak or say one speak without NG tube, was weak,
sentence. Ask the hoarseness. and words are
patient to swallow or incomprehensible
drink a glass of water. hence this part of
cranial nerve
assessment was not
assessed.

XI. Accessory Ask the patient to Ability to move his The patient was
Motor move his head side head side to side and weak, and words are
to side and downward against incomprehensible
downward against resistance. He will hence this part of
resistance. Also, ask also be able to cranial nerve
the patient to elevate elevate shoulders assessment was not
shoulders against when resistance is assessed.
resistance. applied.

XII. Hypoglossal Instruct the patient to Ability to protrude The patient have an
Motor protrude tongue at tongue at midline NG tube, was weak,
midline then move it then move it side to and words are
side to side, in and side, in and out and incomprehensible
out and up and down. up and down. hence this part of
cranial nerve
assessment was not
assessed.

F. Diagnostic and Laboratory Procedures

CHEMISTRY

Diagnostic Date General Specific Results Normal Analysis

/ ordered Indication( Indication( Values and
Laborator s) or s) or
y Date Purposes Purposes (Units Interpretat

23
Procedure Result(s) used in ion of
s in the results
hospital) (Client
Centered)

Fasting Date A fasting To 119 mg/dL 70-105 Since the

Blood ordered blood establish a mg/dL normal
Sugar 03/30/2023 sugar test baseline range for
measures values and FBS is 70-
sugar determine 105 mg/dL,
Date (glucose) if there is a the
results in your deviation patient’s
03/30/2023 blood. It’s a from the blood
simple, normal sugar is
safe and values and higher than
common treat it the normal
way to immediatel and there
diagnose y might be a
prediabete problem
s, diabetes with his
or blood
gestational glucose
diabetes. regulation.

Cholester Date A To 235 mg/dL < 200 The results

ol ordered cholesterol establish a mg/dL show that
03/30/2023 test can baseline the patient
help values and has an
determine determine increased
Date your risk of if there is a serum
results the buildup deviation cholesterol
03/30/2023 of fatty from the levels that
deposits normal may
(plaques) values and increase

24
 in your treat it the risk for
arteries immediatel having
that can y atheroscler
lead to osis, CAD,
narrowed CVA, and
or blocked cholelithiasi
arteries s.
throughout
your body.
It is the
sum of the
blood
cholesterol
content.

Triglycerid Date To To 344 mg/dL < 150 The results

es ordered determine establish a mg/dL show that
03/30/2023 the amount baseline the patient
of excess values and has an
calories determine increased
Date that turned if there is a serum
results into fat in deviation triglyceride
03/30/2023 the blood. from the levels that
normal may
values and increase
treat it the risk for
immediatel having
y atheroscler
osis, CAD,
CVA,
cholelithiasi
s and other
related

25
 conditions.

HDL Date To To 46.5 mg/dL 36-59 The results

ordered determine establish a mg/dL shows that
03/30/2023 the levels baseline the
of the good values and patient's
cholesterol determine HDL are
Date that helps if there is a within the
results in carrying deviation normal
03/30/2023 away LDL from the levels
normal
values and
treat it
immediatel
y

LDL Date To To 119.7 66-178 The results

ordered determine establish a mg/dL mg/dL shows that
03/30/2023 the levels baseline the
of the bad values and patient's
cholesterol determine LDL are
Date that may if there is a within the
results cause deviation normal
03/30/2023 plaques in from the levels
the arteries normal
that may values and
reduce treat it
blood flow immediatel
and may y
cause
heart
attack or
stroke.

26
Creatinine Date To To 1.21 mg/dL 0.6-1.3 The results
ordered evaluate establish a mg/dL shows that
03/30/2023 the kidney baseline the
functions values and patient's
via serum determine creatinine
Date creatinine if there is a are within
results levels deviation the normal
03/30/2023 since from the levels
creatinine normal
is the most values and
sensitive treat it
indicator immediatel
for renal y
function.

Uric Acid Date To To 3.6 mg/dL 2.6-7.2 The results

ordered evaluate establish a mg/dL show that
03/30/2023 the body's baseline the
ability to values and patient's
excrete determine serum uric
Date uric acid if there is a acid is
results through deviation within the
03/30/2023 urine and from the normal
feces, or to normal levels.
evaluate if values and
there is an treat it
excessive immediatel
production y
of this
waste
product.

AST Date To To 161 U/L 5-34 U/L The results

27
 ordered evaluate establish a shows that
03/30/2023 the liver baseline the
functions values and patient’s
since AST determine AST is
Date is an if there is a elevated
results enzyme deviation meaning
03/30/2023 that helps from the that there
metabolize normal might be a
amino values and problem
acids. Like treat it with the
ALT, AST immediatel patient’s
is normally y liver
present in function
blood at due to a
low levels. damage
An brought
increase in about by
AST levels the
may obstruction
indicate in the CBD.
liver
damage,
disease or
muscle
damage.

ALT Date To To 63 U/L 5-34 U/L The results

ordered evaluate establish a shows that
03/30/2023 the liver baseline the
functions values and patient’s
since ALT determine ALT is
Date is an if there is a elevated
results enzyme deviation meaning

28
 03/30/2023 found in from the that there
the liver normal might be a
that helps values and problem
convert treat it with the
proteins immediatel patient’s
into energy y liver
for the liver function
cells. due to a
When the damage
liver is brought
damaged, about by
ALT is the
released obstruction
into the in the CBD.
bloodstrea
m and
levels
increase.

HbA1c Date The To 6.12 % 4.5 - 6.5 % The results

ordered hemoglobi establish a show that
03/30/2023 n A1C baseline the
(HbA1C) values and patient's
Date test is a determine HbA1C is
results blood test if there is a within the
03/30/2023 that shows deviation normal
what your from the range.
average normal
blood values and
sugar treat it
(glucose) immediatel
level was y
over the

29
 past two to
three
months.

Nursing Responsibilities for Obtaining Blood:

Before:
● Confirm the patient identity.
● Explain the procedure to the patient/ patient’s significant other.
● Tell the patient that the test will require a blood sample. Assure that taking blood
samples will only take about 3 minutes.
● Inform the patient’s significant other that 8 hours fasting is required.
● Inform the patient that he will be experiencing mild pain on the site where the needle
was prick.
During:
● Prepare the needed equipment for puncturing.
● Clean the venipuncture site.
● Collect 5-7mL of venous blood.
After:
● Apply direct pressure from the venipuncture site.
● Check the site for bleeding.
● Fill-up laboratory form properly and send it to the laboratory technician during the
collection of samples of the specimen.
● Document the procedure

IMMUNOLOGY AND SEROLOGY

Diagnosti Date General Specific Results Analysis

c/ ordered Indication(s) Indication(s) and
Laborator or Purposes or Purposes
y Date Interpretatio
Procedure Result(s) n of results
s in (Client
Centered)

30
 HBsAg Date Hepatitis B To determine NON-REACTIVE The result
ordered surface if the patient indicates that
03/30/2023 antigen has an active the patient
(HBsAg) is a Hepatitis B does not
protein that infection, or have a
Date appears in the to rule out the Hepatitis B
results blood when Hepatitis B infection and
03/30/2023 the patient infection from other
have a the other possible
hepatitis B possible conditions
infection. If conditions may have
there is a that may caused the
REACTIVE cause elevation of
result, the jaundice and his liver
patient has a elevation of enzymes and
Hepatitis B serum liver jaundice.
infection. enzymes.

Nursing Responsibilities for Obtaining Blood:

Before:
● Confirm the patient identity.
● Explain the procedure to the patient/ patient’s significant other.
● Tell the patient that the test will require a blood sample. Assure that taking blood
samples will only take about 3 minutes.
● Inform the patient’s significant other that 8 hours fasting is required.
● Inform the patient that he will be experiencing mild pain on the site where the needle
was prick.
During:
● Prepare the needed equipment for puncturing.
● Clean the venipuncture site.
● Collect 5-7mL of venous blood.
After:
● Apply direct pressure from the venipuncture site.

31
 ● Check the site for bleeding.
● Fill-up laboratory form properly and send it to the laboratory technician during the
collection of samples of the specimen.
● Document the procedure
URINALYSIS

Diagnost Date General Specific Results Normal Analysis

ic/ ordered Indication Indication( Values and
Laborato (s) or s) or
ry Date Purposes Purposes (Units Interpretati
Procedur Result(s) used in on of
es in the results
hospital) (Client
Centered)

Urinalysi Date Urinalysis To Color - Color - The results

s ordered is the test determine AMBER Yellow show that
03/28/202 for urine. other (light/pale/ the patient
3 used to conditions Appearance - to may have a

detect that the HAZY dark/deep UTI due to

and client may amber) its hazy

Date have and to Sp. Gravity - appearance
manage a
results rule out 1.030 Appearanc and
wide
03/28/202 other e - Clear elevated
range of
3 diagnosis pH - 6 WBC,
disorders,
related to Sp. Gravity possible
such as the Protein - (+) - 1.005- dehydration
urinary symptoms 1.025 due to an
tract shown by Glucose - elevated
infections, the patient NEGATIVE pH - 4.5-8 specific
kidney specifically gravity, a

disease jaundice. WBC - 8-12 Glucose - possible

and Negative renal

RBC - 6-10 impairment
diabetes.
Protein - due to

32
 (Negative) presence of
Epithelial protein in
Cells - RARE WBC - 0-2 the urine
hpf and
Amorphous elevated
Cells - FEW RBC - 0-2 RBC.
hpf

Nursing Responsibilities for obtaining urine specimens.

Before:
● Identify the patient
● Perform handwashing
● Wear clean gloves
● Explain the procedure to the patient.
During:
● Instruct the patient to completely retract foreskin and cleanse penis with towelettes or
cotton balls.
● Instruct the patient to void a small amount of urine into the toilet to rinse out the urethra,
void the midstream urine into the specimen cup, and the last of the stream into the toilet.
After:
● Fill out the laboratory request form completely, label the specimen container with patient
identifying information, and send it to the lab immediately.
● Discard PPE and perform hand washing.
● Document the findings.
BLOOD TYPING AND CROSS-MATCHING

Diagnosti Date General Specific Results Analysis and

c/ ordered Indication(s Indication(s)
Laborator ) or or Purposes Interpretation
y Date Purposes of results
Procedure Result(s) (Client
s in Centered)

BLOOD Date Blood To determine ABO TYPING - According to

33
TYPING ordered typing the patient’s O the results, the
AND 04/13/2023 reveals blood type and patient has an
CROSS- what type of the RH TYPING - O+ blood type
MATCHIN compatibility POSITIVE and it is
blood the
G Date of the donor’s compatible with
patient has.
results blood and his COMPATIBILI the available
This
04/13/2023 blood for TY - blood to be
depends on
transfusion. COMPATIBLE transfused.
the
presence of
certain
antigens on
your red
blood cells
(RBCs).
Antigens
are proteins
that trigger
your
immune
system to
produce
antibodies.
While
cross-
matching
involves
mixing a
sample of
the
recipient’s
serum with

34
a sample of
the donor’s
red blood
cells and
checking if
the mixture
agglutinates
, or forms
clumps.
These
clumps are
the result of
antibodies
binding the
red blood
cells
together. If
agglutinatio
n is not
obvious by
direct
vision,
blood bank
technicians
check for
agglutinatio
n with a
microscope.
If
agglutinatio
n occurs,

35
 that
particular
donor’s
blood
cannot be
transfused
to that
particular
recipient.

Nursing Responsibilities for Obtaining Blood:

Before:
● Confirm the patient identity.
● Explain the procedure to the patient/ patient’s significant other.
● Tell the patient that the test will require a blood sample. Assure that taking blood
samples will only take about 3 minutes.
● Inform the patient’s significant other that 8 hours fasting is required.
● Inform the patient that he will be experiencing mild pain on the site where the needle
was pricked.
During:
● Prepare the needed equipment for puncturing.
● Clean the venipuncture site.
● Collect 5-7mL of venous blood.
After:
● Apply direct pressure from the venipuncture site.
● Check the site for bleeding.
● Fill-up laboratory form properly and send it to the laboratory technician during the
collection of samples of the specimen.
● Document the procedure
HEMATOLOGY

Diagnosti Date General Specific Results Normal Analysis

36
 c/ ordered Indication( Indication( Values and
Laborator s) or s) or
y Date Purposes Purposes (Units Interpretati
Procedure Result(s) used in on of
s in the results
hospital) (Client
Centered)

HGB Date A To monitor 100 g/dL 120-150 According to

ordered complete the the results,
04/18/2023 blood patient’s the patient
count overall has a
(CBC) is a condition, decreased
Date blood test. such as his number of
results It's used ability to RBCs, low
to look at
04/18/2023 fight hemoglobin
overall
infection, and
HCT Date health 0.3 0.4-0.54
presence hematocrit
ordered and find a
of an levels
04/18/2023 wide
infection, indicating
range of
ability to that the
conditions
Date
, including transport patient may

anemia, oxygen to have anemia

results
infection the other which may
04/18/2023
and cells, be caused

RBC Date leukemia. ability to 3.3 x 4.5-6.2 by bleeding,

ordered form a clot 10^9/L rapid

A
04/18/2023 to heal destruction
complete
wounds or of RBCs, or
blood
injuries, decreased
count test
Date measures and number of

results the evaluate RBCs are

04/18/2023 following: the produced.

37
 WBC Date Red blood appearanc 6.9 x 4.0-10.0 The results
ordered cells, e of his red 10^9/L show that
04/18/2023 which blood cells. the patient’s
carry total WBC
oxygen. are within
Date White the normal
results blood values.
cells,
04/18/2023 However his
which
differential
Neutrophil Date fight 88.9 % 55-65
counts
s ordered infection.
indicate that
04/18/2023 Hemoglob
he has an
in, the
infection
oxygen-
carrying because of
Date
protein in the
results
red blood increased
04/18/2023
cells. neutrophils,

Lymphocy Date Hematocri 8% 25-35 decreased

tes ordered t, the lymphocytes

04/18/2023 amount of , monocytes,

red blood and
cells in eosinophils.
the blood.
Date
Platelets,
results
which
04/18/2023
help blood
Monocyte Date to clot 2.3 % 3-6
s ordered
04/18/2023

Date
results

38
 04/18/2023

Eosinophi Date 0.8 % 2-4

ls ordered
04/18/2023

Date
results
04/18/2023

Basophils Date 0.0 % 0-1

ordered
04/18/2023

Date
results
04/18/2023

Platelets Date 209 x 170-400 According to

the results,
ordered 10^9/L
the patient’s
04/18/2023 platelets are
within the
normal
range and
can
Date
compensate
results when there
is bleeding
04/18/2023
episode.

MCV Date 92.3 fl 80-100 The results

ordered indicate that
04/18/2023 the patient’s
RBCs are
normochrom
Date ic and

39
 results normocytic.
04/18/2023

MCH Date 30.9 pg 27.0-34.0

ordered
04/18/2023

Date
results
04/18/2023

MCHC Date 335 g/L 310-370

ordered
04/18/2023

Date
results
04/18/2023

Nursing Responsibilities for Obtaining Blood:

Before:
● Confirm the patient identity.
● Explain the procedure to the patient/ patient’s significant other.
● Tell the patient that the test will require a blood sample. Assure that taking blood
samples will only take about 3 minutes.
● Inform the patient’s significant other that 8 hours fasting is required.
● Inform the patient that he will be experiencing mild pain on the site where the needle
was prick.
During:
● Prepare the needed equipment for puncturing.
● Clean the venipuncture site.
● Collect 5-7mL of venous blood.

40
After:
● Apply direct pressure from the venipuncture site.
● Check the site for bleeding.
● Fill-up laboratory form properly and send it to the laboratory technician during the
collection of samples of the specimen.
● Document the procedure
SONOGRAPHY

Diagnosti Date General Specific Results Analysis

c/ ordered Indication(s) Indication(s) and
Laborator or Purposes or Purposes
y Date Interpretat
Procedure Result(s) ion of
s in results
(Client
Centered)

UPPER Date Upper To rule out CALCULOUS According

ABDOMIN ordered abdominal other related CHOLECYSTITIS to the
AL 03/30/2023 ultrasound is possible results, the
ULTRASO a diagnostic diagnosis patient has
UND test that uses such as calculous
Date sound waves hepatic cholecystiti
results to create enlargement, s. Meaning
03/30/2023 images of hepatic mass, that he
organs in the or acalculous may have
upper cholecystitis a gallstone
abdomen, through within the
such as the visualization gallbladder
liver, via ultrasound calculi
gallbladder, since it is
pancreas, dilated
spleen, and causing its
kidneys. inflammati

41
 on.

Nursing Responsibilities for Upper Abdominal Ultrasound

Before:
● Inform the patient about the process, including what to expect during the procedure, the
operation's goal, and any potential risks or complications.
● Obtain an informed consent, verify that the patient knows the surgery and its risks and
advantages.
● Confirm that the patient has an empty bladder.
During:
● Position the client on their side or on their back, Depending on the part of the abdomen
being checked.
● Reassure the patient and provide emotional support.
● Assist the healthcare professional by giving supplies or equipment.
After:
● Monitor for any difficulties or adverse responses to the procedure.
● Document the procedure, note the procedure and any pertinent results.

III. ANATOMY AND PHYSIOLOGY

BILIARY SYSTEM
The liver, gallbladder, and bile ducts are all parts of the biliary system, which control the
production, storage, and secretion of bile. Intrahepatic and extrahepatic bile ducts are different
types of bile ducts. The left and right hepatic ducts are intrahepatic bile ducts, and they combine
to produce the common hepatic duct (CHD), while the common bile duct (CBD), which is
created from the CHD and cystic duct, is extrahepatic bile ducts. Bile passes via the ampulla of
Vater, which is formed by the convergence of the CHD and pancreatic duct, the sphincter of
Oddi, and the second part of the duodenum.

Bile is first a distinct alkaline fluid (7.5 to 8.1 pH) released by hepatocytes (600–1000
mL/day), which is then further modified and purified by the epithelial cells lining the biliary
channel, before becoming acidic (5.2 to 6.0 pH) in the gallbladder. This fluid is kept in the
gallbladder, where it is concentrated and later released into the digestive system by the CBD.
The gallbladder contracts and secretes bile into the duodenum in response to stimulation

42
provided by the hormone cholecystokinin (CCK) from the intestinal tract brought on by the
presence of food in the intestinal lumen. In addition to a variety of dissolved compounds
including cholesterol, amino acids, enzymes, vitamins, heavy metals, bile salts, bilirubin, and
phospholipids, bile is mostly composed of water.

FUNCTIONS OF THE COMMON BILE DUCT

The physiological function of the common bile duct in the gastrointestinal system is to
transport bile from the gallbladder and empty it into the duodenum, which is the upper section of
the small intestine. Additionally, it is a tube that carries bile from the liver and gallbladder,
through the pancreas, and into the small intestine.

ANATOMY OF THE COMMON BILE DUCT

In general, the bile ducts are divided into intrahepatic and extrahepatic portions. The
intrahepatic ducts, portal veins, and hepatic arteries form the portal triads. The right and left
hepatic ducts are anterior to the portal vessels that are adjacent to them. The peripheral
intrahepatic ducts run parallel to and adjacent to the hepatic arteries and portal veins, but their
anterior-posterior relationship is more variable than that of the extrahepatic ducts. Intrahepatic
bile ducts are a network of small tubes that carry bile inside the liver. The smallest ducts, called
ductules, come together to form the right and left hepatic ducts, which lead out of the liver. The
two ducts join outside the liver and form the common hepatic duct. The cystic duct from the
gallbladder joins the common hepatic duct to form the common bile duct.

Extrahepatic bile ducts are small tubes that carry bile from the liver and gallbladder to
the small intestine and consist of the common hepatic duct (perihilar region), the common bile
duct (distal region), and a portion of the central right and left ducts. The common hepatic duct is
the segment that lies above the cystic duct insertion, while the common bile duct is the segment
that lies below. Thus, the common bile duct passes from the pancreas to the small intestine.
The liver produces bile, which is then stored in the gallbladder. Bile is released from the
gallbladder and transported through the pancreas to the small intestine, where it aids in the
digestion of fatty substances.

43
IV. THE PATIENT AND HIS ILLNESS

A. Pathophysiology

1. Book- centered
1. Schematic Diagram

44
2. Disease Synthesis
Biliary obstruction commonly refers to blockage of the bile duct system leading to
impaired bile flow from the liver into the intestinal tract. Bile is a substance that contains bile
salts, bilirubin, and cholesterol and is continuously synthesized in the liver hepatocytes. Biliary
obstruction can occur anywhere along this path and can lead to serious complications such as
hepatic dysfunction, renal failure, nutritional deficiencies, bleeding problems, and infections.
Disruption in the bile flow due to impairment of the intrahepatic biliary system is generally
referred to as cholestasis. Cholestasis can present as abnormalities in serum hepatic enzymes,
such as elevated bilirubin and alkaline phosphatase levels, and can lead to jaundice and
pruritus.
Choledocholithiasis is the presence of stones within the common bile duct (CBD). It is
estimated that common bile duct stones are present in anywhere from 1-15% of patients with

45
cholelithiasis. Bile stasis, bactibilia, chemical imbalances, increased bilirubin excretion, pH
imbalances, and the formation of sludge are some of the factors which lead to the formation of
these stones. Less commonly, stones are formed in the intrahepatic biliary tree, termed primary
hepatolithiasis, and may lead to choledocholithiasis. Stones that are too large to pass through
the ampulla of Vater remain in the distal common bile duct, causing obstructive jaundice that
may lead to pancreatitis, hepatitis, or cholangitis.

3. Risk Factors
a. MODIFIABLE RISK FACTORS
● Lipid Profile - Cholesterol, the most prevalent substance in gallstones
(Schafmayer et al., 2006), is a type of lipid synthesized primarily in the liver, and
excreted only through the biliary system (Poynard, Lonjon, Mathurin, Naveau, &
Chaput, 1995). Cholelithiasis is difficult to treat because formation of gallstones is
so complex and multifactorial. Factors associated with cholesterol gallstone
formation include cholesterol hypersecretion and supersaturation, bile salt and
phospholipid concentrations, crystal nucleation, gallbladder dysmotility, and
gallbladder absorption and secretion functions.
● Diet - In general, diets high in cholesterol elevate biliary cholesterol saturation in
patients with or without gallstones. The Nurses’ Health Study indicates that a
history of high dietary intakes of carbohydrates with an increased glycemic load
and glycemic index increases the risk of cholelithiasis and resulting
cholecystectomies in women (Tsai et al., 2005a).
● Physical Activity - Physical activity appears to be proactive, decreasing the
possibility of developing cholelithiasis (Leitzmann et al., 1999), whereas reduced
physical activity increases the risk (Leitzmann et al., 1998). Two large cohort
studies reported that recreational physical activity was associated with an
independent reduction in risk of symptomatic gallstones and also
cholecystectomies in men and women (Leitzmann et al., 1998, 1999). Leitzmann
et al. (1998) suggested that 34% of symptomatic gallstones in men could be
prevented with 30 minutes of endurance-type exercise (e.g., running or cycling)
five times per week.
● Alcohol and Smoking - Alcohol consumption has been found to be inversely
associated with risk of gallstone disease (Katsika et al., 2007; Leitzmann et al.,

46
 2003; Volzke et al., 2005). Moderate alcohol intake may lower risk of cholesterol
gallstone disease by reducing bile cholesterol saturation and raising HDL-
cholesterol levels. Studies examining the association between smoking habits
and gallstone formation are also controversial. Stampfer et al. (1992) found that
heavy smoking (more than 35 cigarettes per day) is a strong risk factor among
women for gallstones.
b. NON-MODIFIABLE RISK FACTORS
● Age - Gallstones are ten times more likely in people aged 40 and more (Chen et
al., 1998; Festi et al., 2008; Volzke et al., 2005) due to a decline in the activity of
cholesterol 7 α -hydroxylase, the limiting enzyme for bile acid synthesis (Carulli et
al., 1980; Salen, Nicolau, Shefer, & Mosbach, 1975); as this enzymatic activity
decreases, and biliary cholesterol increases, the aging individual experiences
cholesterol saturation and decreasing mobility of gallbladder emptying. Volzke et
al. (2005) found that cholecystectomies to resolve various symptoms and
complications of cholelithiasis are more common in older people.

4. SIGNS AND SYMPTOMS

● Abdominal pain. Biliary pain occurs in episodes lasting from one to several hours,
usually after a meal. It grows for the first 20 minutes and gradually declines after that.
Most people feel it in their upper right abdomen, but it may also radiate to the right side
or shoulder blade.
● Nausea and vomiting. Biliary colic is often accompanied by nausea and vomiting.
Vomiting doesn’t relieve the pain, as it does with some other types, like migraines. If
biliary colic isn’t as intense, only notice a general lack of appetite.
● Jaundice. When bile backs up and leaks into the bloodstream, it may show up as a
yellow tint to the skin or the whites of the eyes. It may also turn the pee a darker color.
Jaundice can come and go, like biliary colic. But it’ll keep coming back until the blockage
is cleared.
● Fever. Severe inflammation in the biliary system may cause a fever. Fever may also be
a sign of an infection. When the bile ducts are blocked, bacteria aren’t flushed out as
usual.

2. Patient-centered

47
1. Schematic Diagram

2. Disease Synthesis

48
 Obstructive jaundice is a result of the obstruction of the flow of bile from the liver to the
duodenum. It is caused by several factors such as tumors of the liver, pancreas or bile duct and
Cancer of the pancreas or liver, but the most common cause of obstructive jaundice is
Choledocholithiasis. It is a disease of the gallbladder wherein there is an obstruction of the bile
ducts by gallstones which may consist of bile pigments or calcium and cholesterol salts that
become hardened due to some factors causing obstructive jaundice. The sediment solidifies at
the bottom of the gallbladder or the common bile duct. The stones develop gradually as
sediment washes over them. This takes a long time. Most gallstones develop in your gallbladder
and move into the common bile duct with the passage of bile. The majority of people will have
no symptoms from their gallstones until complications arise.
The patient has a history of choledocholithiasis, which is the presence of stones in the
common bile duct, based on the patient's findings. Prior to admission, the patient also reports
having severe abdominal pain, which is a common sign of cholecystitis, an infection of the
gallbladder brought on by gallstones obstructing the bile duct. The patient often complains of
pain in the upper right quadrant of the abdomen, which can be severe and persistent. In addition
to the discomfort, the patient's also complain of nausea, vomiting, fever, chills, and other
symptoms before being admitted.
Moreover, the patient always eats foods high in fat and cholesterol. A diet that is high in
fat and cholesterol can increase the risk of developing gallstones since the gallbladder releases
bile to help break down the fat. Since the patient's diet is consistently high in fat, his gallbladder
may not be able to empty properly, which can lead to the formation of gallstones.

3. Risk Factors
c. MODIFIABLE RISK FACTORS
● Diet - A diet high in fat and cholesterol and low in fiber may increase the risk of
gallstones.

d. NON-MODIFIABLE RISK FACTORS

● Age - Gallstones become more common as people age, with the risk increasing
after age 40.

4. SIGNS AND SYMPTOMS

● Jaundice (April 1, 2023 – Date of Admission)

49
● Vomiting, Fever, Chills, and Severe Abdominal Pain (March 27, 2023 – Prior to
Admission)

50
 B. PLANNING (NURSING CARE PLANS)

PROBLEM #1: Imbalanced nutrition, less than body requirements, related to inadequate bile secretion as evidenced by poor skin
turgor and jaundiced complexion.

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSI EXPLANATION OUTCOME
S

SUBJECTIVE Imbalanced Imbalanced SHORT INDEPENDENT: INDEPENDENT: SHORT TERM:

CUES: nutrition, Nutrition: Less TERM: 1. Assess for 1. Nonverbal After 2-4 hours of
∅ less than Than Body After 6-8 hours abdominal signs of nursing
body Requirements of nursing distention, discomfort interventions, the
OBJECTIVE requiremen develops when interventions, frequent associated with patient shall have:
CUES: ts, related an individual's the patient will: belching, impaired ● Exhibited
○ Poor skin to metabolic and ● Exhibit guarding, and digestion and improvement or
turgor inadequate nutritional improveme reluctance to pain. stabilization of
○ Jaundiced bile needs are not nt or move. nutritional
cold, secretion. satisfied stabilization 2. Encourage the 2. To identify food status. .
clammy adequately. of client to keep a intolerances
skin Clients may nutritional food diary, and nutritional LONG TERM:
○ On TPN have trouble status. estimate deficiencies After 2-3 days of
(Kabiven) absorbing fat caloric intake, and needs. nursing
q24 and fat-soluble LONG TERM: and weigh. interventions, the
vitamins A, D, After 2-3 days patient shall have:
● Vital Signs are E, and K due to of nursing DEPENDENT: DEPENDENT: ● Manifested at
as follows: reduced bile interventions, 1. Administer 1. Alternative least 3 signs of
○ T: : 36 production into the patient will: parenteral or feeding may be adequate
degrees the stomach. ● Manifest at enteral necessary due to nutrition such

51
celsius These least 3 feedings as gallbladder as good skin
deficiencies can signs of indicated. involvement, turgor, moist
result in adequate nutritional status, and pink
complications nutrition and need for mucous
such as such as gastric rest. membranes,
reduced night good skin capillary refill <
vision due to turgor, INTERDEPENDE INTERDEPENDEN 3 seconds, and
vitamin A moist and NT: T: absence of
deficiency, bone pink nausea/vomitin
disease due to mucous 1. Instruct the 1. To avoid g.
vitamin D membrane patient’s SO to complications,
deficiency, s, capillary monitor and involving the
neurological refill < 3 report any SO helps
impairment due seconds, discrepancy in identify errors
to vitamin E and the prescribed promptly,
deficiency, and absence of TPN reducing the
decreased nausea/vo risk to the
production of miting. patient's safety.
clotting proteins
in the liver due
to vitamin K
deficiency

Reference:
Doenges, M. E.,
Moorhouse, M.
F., & Murr, A. C.
(2019). Nursing
care plans:
Guidelines for
individualizing

52
client care
across the life
span. FA
Davis..

53
PROBLEM #2: Deficient fluid volume related to active fluid volume loss from the surgical wound as evidenced by cold and clammy
skin, poor skin turgor, and wound drainage

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSI EXPLANATION OUTCOME
S

SUBJECTIVE Deficient Following SHORT TERM INDEPENDENT SHORT TERM

CUES: fluid surgery, After 6-8 hours 1. Monitor vital 1. Aids in After 6-8 hours of
∅ volume patients of nursing signs noting the evaluating the nursing
related to experience interventions, presence of degree of fluid interventions, the
active fluid symptoms of the patient’s hypotension, deficit or patient’s vital signs
OBJECTIVE volume loss fluid volume vital signs will tachycardia, effectiveness of shall have
CUES: from the deficit due to remain stable, and tachypnea fluid remained stable,
○ Lethargic surgical losing a large as evidenced replacement as evidenced by
○ Cold and wound as amount of blood by the absence therapy and the absence of
clammy evidenced loss during of tachycardia, response to tachycardia,
skin by cold and surgery. Also, tachypnea, and medications tachypnea, and
○ Dry skin clammy the bile leak hypotension. hypotension.
and skin, poor from T-tube 2. Maintain 2. It reflects the
mucous skin turgor, dehiscence LONG TERM accurate I & O overall hydration LONG TERM
membran and wound caused fluid to After 1 day of and correlate status After 1 day of
es drainage be lost on nursing with daily nursing
○ Poor skin wounds interventions, weights. Include interventions, the
turgor covering more the patient will measurements/ patient shall have
○ Decrease than 75% of the demonstrate estimated demonstrated
d capillary bandage. In Improved fluid losses, such as improved fluid
refill >2 addition, the balance as drains, balance as
secs bile leak evidenced by dressings, and evidenced by
○ Wound activated the adequate urine abdominal girth adequate urine
drainage systemic output with output with normal
○ Dark reactions in the normal specific 3. Observe skin specific gravity,
yellow body, which gravity, stable and mucous 3. Hypovolemia stable vital signs,
amber made the vital signs, membrane and fluid shifts moist mucous
urine immune system moist mucous dryness and contribute to membranes, good

54
 release membranes, turgor poor skin turgor skin turgor, and
● Vital Signs are cytokines to good skin 4. Monitor and prompt capillary
as follows: fight the turgor, and change 4. To protect skin refill
infection, which prompt dressings and monitor
○ PR= 94
causes the capillary refill frequently losses for
○ RR= 21
blood vessels to replacement
dilate. The needs
● May manifest
decrease in
○ Confusio
blood volume DEPENDENT:
n
and bile 1. Administer DEPENDENT:
○ Diminish
leakage plasma/blood, 1. Replenishes
ed urine
decreases fluids, and and maintains
output
circulating fluid electrolytes as circulating
○ Hemoco
in the body indicated volume and
ncentrati
making it electrolyte
on
difficult to meet balance
the needs of the
organs and INTERDEPENDE
circulate in NT: INTERDEPENDEN
peripheral 1. Monitor T:
areas. It laboratory 1. Provides
explains why studies e.g., information
the patient has Hb/Hct, about hydration
cold clammy electrolytes, and organ
skin, poor BUN, Cr function
capillary refill,
and dry mucous
membranes.

Reference:
Tuan, T. (n.d.).
Low blood
pressure after
surgery. Vinmec
International
Hospital.

55
[Link]
[Link]/en/car
diology/health-
news/low-blood-
pressure-after-
surgery/

56
 PROBLEM #3: Impaired tissue integrity related to mechanical interruption of skin/tissues as evidenced by surgical incision, presence
of JP drain, and T-tube.

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSI EXPLANATION OUTCOME
S

SUBJECTIVE Impaired A breach in SHORT INDEPENDENT: INDEPENDENT: SHORT TERM:

CUES: tissue tissue integrity TERM: 1. Inspect 1. To prevent After 1-2 hours of
∅ integrity is normally After 1-2 hours incision complications. nursing
related to extremely well of nursing regularly, Due to interventions, the
OBJECTIVE mechanical mended by the interventions, noting decreased patient shall have:
CUES: interruption body. However, the patient will: characteristics cardiac output, ● Maintained an
● Upon of in certain cases, ● Maintain an and integrity. incisions may intact tissue
observation, skin/tissues it does not heal intact 2. Assess heal more integrity.
the patient as it at all and tissue amounts and slowly in
manifested: evidenced instead integrity. characteristics individuals with LONG TERM:
○ Cold by surgical replaces the of drainage. comorbidities After 1-2 days of
clammy incision, injured tissue LONG TERM: 3. Maintain or the elderly. nursing
skin presence of with connective After 1-2 days patency of 2. Drainage interventions, the
○ Poor skin JP drain, tissue. If tissue of nursing drainage decreases as patient shall have:
turgor and T-tube. integrity is not interventions, tubes; apply healing ● Experienced
○ Decreased addressed, it the patient will: collection bag progresses and an improved
capillary can lead to local ● Experience over drains or can lead to wound healing
refill or systemic an incisions. complications process.
○ Presence infection and, improved 4. Splint such as
of surgical eventually, wound abdominal and hemorrhage
incision necrosis. healing chest incisions and infection.
○ Intact JP process. or area with 3. Facilitates
drain Reference: pillow or pad approximation
○ Intact T- Herdman, T., & during of wound
tube Kamitsuru, S. coughing and edges; reduces

57
 (2017). NANDA movement. risk of infection
● Vital Signs are international and chemical
as follows: nursing injury to skin
○ T: : 36 diagnoses: and tissues.
degrees Definitions & 4. Equalizes
celsius classification pressure on the
○ HR: 94 bpm 2018-2020 wound reduces
○ RR: 21 bpm (11th ed.). risk of
Thieme dehiscence,
● Patient may Publishers. pp. especially
manifest 404, 406, 407, during the start
○ Redness 412, 413. of the healing
○ Warmth of process.
surrounding
tissue
○ Swelling DEPENDENT:
○ Tenderness 1. Provides
or pain DEPENDENT: additional support
○ Purulent 1. Use abdominal for high-risk
drainage binder, if indicated. incisions,
especially in obese
clients.

INTERDEPENDEN
INTERDEPENDE T:
NT: 1. Nutrition plays
1. Collaborate a vital role in
with a maintaining
nutritionist/ intact skin and
dietitian in promoting

58
wound healing.

59
 PROBLEM #4: - Risk for infection related to altered skin integrity, inadequate nutrition and fluid intake, presence of environmental
pathogens, invasive instrumentation, and immobility.

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSI EXPLANATION OUTCOME
S

SUBJECTIVE Risk for The body is SHORT INDEPENDENT: INDEPENDENT: SHORT TERM:
CUES: infection subjected to TERM: 1. Position 1. To promote After 2-3 hours of
∅ related to tremendous After 2-3 hours patient to adequate nursing
altered skin stress after of nursing maximize oxygenation to interventions, the
OBJECTIVE integrity, surgery, which interventions, ventilation the client. patient shall have:
CUES: inadequate might result in a the patient will: potential. 2. To prevent ● Maintained a
● Upon nutrition temporary ● Maintain a 2. Remove colonization of safe aseptic
observation, and fluid suppression of safe secretions by respiratory environment.
the patient intake, the immune aseptic coughing (if secretions.
manifested: presence of system. environmen the patient is 3. To avoid
○ Presence environmen Furthermore, t. conscious) or infection or LONG TERM:
of foley tal surgical suctioning. proliferation of After 1-2 days of
catheter pathogens, operations LONG TERM: 3. Administer skin microorganism nursing
O2, invasive sometimes After 1-2 days care at the s. interventions, the
Jackson instrumenta entail the use of of nursing tube or drain 4. For early patient shall have:
Pratt tion, and invasive interventions, insertion site. detection of ● Been free of
Drain, immobility. medical the patient will: 4. Monitor possible signs of
intact T- equipment, ● Be free of amount, color, infection. healthcare-
tube, and such as signs of and 5. To hasten acquired
tube catheters, which healthcare- consistency of wound healing infection.
duodenost can function as acquired drainage from and reduce
omy to a surface for infection. tube or drain. local
urine bag. germs to cling 5. Cleanse the pathogens.
to and thrive on. area around 6. This prevents
● Vital Signs are Furthermore, the incision wound

60
 as follows: anesthesia and with an contamination.
○ BP: 110/80 other drugs appropriate
○ T: 36 might impair the cleaning
degrees immune system solution.
celsius and raise the 6. Cleanse the
○ HR: 94 bpm risk of infection. area around
Healthcare any tube or
● Patient may personnel drain site last.
manifest: employ sterile
○ Purulent equipment and DEPENDENT:
drainage strict hygiene 1. Administer DEPENDENT:
○ Fever techniques, antibiotics as 1. May be given
○ Tachycardia among other prescribed by prophylactically
○ Hypotension things, to the physician. for suspected
○ Elevated prevent the infection or
WBC count entry and contamination.
(>11,000 spread of INTERDEPENDE
cells/mm3) hazardous NT: INTERDEPENDEN
bacteria. 1. Collaborate T:
Antibiotics may with medical 1. To identify
also be given technologist to presence of
prophylactically obtain cultures any pathogens.
to avoid of any
infection, and suspicious
patients are drainage
constantly
watched for
indications of
infection and
treated
appropriately if

61
 one occurs.

Reference:
Berríos-Torres,
S. I., Umscheid,
C. A., Bratzler,
D. W., Leas, B.,
Stone, E. C.,
Kelz, R. R., ... &
Healthcare
Infection
Control
Practices
Advisory
Committee.
(2017). Centers
for disease
control and
prevention
guideline for the
prevention of
surgical site
infection, 2017.
JAMA surgery,
152(8), 784-
791.

PROBLEM #5: Risk for Injury related to abnormal blood profile

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSI EXPLANATION OUTCOME

62
 S

SUBJECTIVE Risk for Risk for injury is SHORT INDEPENDENT: INDEPENDENT: SHORT TERM:
CUES: Injury the state in TERM: 1. Monitor client's 1. To identify After 2-3 hours of
∅ which an After 2-3 hours vital signs, potential risks nursing
related to
individual is at of nursing level of for injury of the interventions, the
OBJECTIVE abnormal risk for harm interventions, consciousnes, client. patient shall have:
CUES: blood because of a the patient will: and overall 2. To identify any ● Remained free
● Upon perceptual or ● Remain mobility. factors that from falls
profile
observation, physiologic free from 2. Place bed rails increase the
the patient deficit, a lack of falls and perform a risk of falls. LONG TERM:
manifested: awareness of fall risk 3. To decrease After 1-2 days of
○ Decreased hazards, or LONG TERM: assessment. the potential nursing
number of maturational After 1-2 days 3. Assist patient risk of skin interventions, the
RBCs (3.3 age. of nursing with frequent injuries. patient shall have:
x 10^9/L) In relation to the interventions, position 4. Altered mental ● Maintained
○ Low patient, the patient will: changes. status could optimal
hemoglobi abnormal blood ● Maintain 4. Monitor mental increase a mobility
n (100 studies can optimal status. patient’s risk of and
g/dL) increase the mobility injury as the function
○ Low risk of injury in and patient may not while
hematocrit clients due to function be fully aware minimizing
levels (0.3) impaired while of their the risk of
clotting minimizing surroundings falls or
● Vital Signs are mechanisms, the risk of and what is other
as follows: impaired falls or considered injuries.
○ BP: 110/80 immune other safe.
○ T: 36 system, injuries.
degrees impaired DEPENDENT: DEPENDENT:
celsius oxygen-carrying 1. Avoid the use of 1. Restraints can
○ HR: 94 bpm capacity, and physical and cause injuries such

63
○ RR: 21 bpm medication chemical as strangulation,
interactions. restraints. Obtain asphyxiation,
These a health care trauma, or head
abnormalities provider’s order if injury.
can result in restraints are
excessive needed.
bleeding, INTERDEPENDEN
susceptibility to INTERDEPENDE T:
infections, NT: 1. To increase
tissue hypoxia, 1. Coordinate mobility,
and altered with a physical preventing the
medication therapist for occurence of
metabolism and strengthening falls.
elimination, exercises and
which can gait training.
increase the
risk of injury.

Reference:
Adekhera E.
(2016). Routine
postoperative
nursing
management.
Community eye
health, 29(94),
24.

64
 C. MEDICAL & SURGICAL MANAGEMENT

A. IVFs, BT, NGT Feeding, TPN, etc.

Date Client’s
Medical General
Ordered/Given/ Indication Response to
Management Description
Changed Therapy

Nasogastric Date Ordered: Nasogastric It is used to give Mr. Pedro

(NG) feeding 04/05/23 (NG) feeding is you fluids, tolerated
where a narrow medications and intervention
Date Performed: feeding tube is liquid food without adverse
04/05/23 placed through complete with reaction
your nose down nutrients directly
Date Changed: into your into your
Still on-going stomach. It is a stomach to
(maintained special tube that patients who are
NGT open) carries food and unable to
medicine to the tolerate oral
stomach through intake,
the nose. swallowing
problems,
altered mental
status/unconscio
usness, etc.

Blood Date Ordered: Packed red Transfusion of Mr. Pedro

Transfusion 04/14/23 blood cells are pRBCs is responded well
04/15/23 what remains of indicated in the to the blood
BT #3 Packed whole blood treatment of transfusion and
Red Blood Cells Date Performed: after the plasma anemia with there were no
(PRBC) 1 unit 04/14/23 and platelets symptomatic allergic
04/15/23 have been deficits of responses such
BT#4 Packed removed. It is oxygen-carrying as anaphylaxis,
Red Blood Cells used most often capacity and hemolysis and
(PRBC) 1 unit to raise a low hemorrhagic infection
hemoglobin or shock when recorded.
hematocrit level administered
in patients with with volume
chronic anemia expanders. One
or mild unit of pRBCs
hemorrhage. should raise the
hemoglobin of
an average adult
by 1 g/dL and
the hematocrit
by 3%.

65
 PNSS (Plain Date Ordered: Plain Normal Normal Saline is Mr. Pedro
Normal Saline 04/13/23 Saline Solution a prescription responded well
Solution) [0.9% is considered as medicine used and maintained
Sodium Date Performed: isotonic fluid, for fluid and his normal fluid
Chloride 04/13/23 generally electrolyte volume, and no
Solution] indicated in replenishment manifestation of
Date Changed: expanding blood for intravenous any side effects
#10 PNSS 1L 04/14/23 volume without administration. It was seen such
changing the is indicated to as chills,
size of the cells. the patient since nausea, and
this ensures vomiting.
proper hydration.
#11 PNSS 1L Also was used Mr. Pedro
as an electrolyte responded well
replenisher to and maintained
maintain or his normal fluid
restore volume, and no
extracellular fluid manifestation of
deficits. any side effects
was seen such
as chills,
nausea, and
vomiting.

#12 PNSS 1L Mr. Pedro

responded well
and maintained
his normal fluid
volume, and no
manifestation of
any side effects
was seen such
as chills,
nausea, and
vomiting.

PLRS (Lactated Date Ordered: Ringer's lactate Lactated ringer’s Mr. Pedro
ringer’s 04/14/23 solution is a solution is responded well
solution) 04/17/23 balanced or indicated for and maintained
04/18/23 buffered isotonic patients who are his normal fluid
#11 PLRS 1L 04/20/23 crystalloid fluid in need of fluid volume, and no
that is used to resuscitation. It manifestation of
Date Performed: restore lost fluid. is also good to any side effects
04/14/23 Lactated be alternated was seen such
04/17/23 Ringer's solution with PNSS as chills,
04/18/23 is an intravenous because it nausea, and
04/20/23 fluid that doctors contains more vomiting.
use to treat electrolytes such
#12 PLRS 1L dehydration and as sodium, Mr. Pedro
responded well

66
 restore fluid potassium, and maintained
balance in the calcium and his normal fluid
body. The chloride. volume, and no
solution consists Furthermore, it manifestation of
primarily of also contains any side effects
water and bicarbonate was seen such
electrolytes. precursors that as chills,
Ringer's lactate may help nausea, and
is mostly utilized prevent acidosis. vomiting.
in aggressive Alternating
#13 PLRS 1L volume PLRS and PNSS Mr. Pedro
resuscitation is indicated for responded well
from blood loss the patient and maintained
or burn injuries. because of his his normal fluid
need of volume, and no
supportive manifestation of
nutrients; useful any side effects
to maintain was seen such
serum as chills,
potassium and nausea, and
glucose levels at vomiting.
more normal
#14 PLRS 1L levels during Mr. Pedro
surgical responded well
procedures and maintained
under general his normal fluid
anesthesia. volume, and no
manifestation of
any side effects
was seen such
as chills,
nausea, and
vomiting.

#15 PLRS 1L Mr. Pedro

responded well
and maintained
his normal fluid
volume, and no
manifestation of
any side effects
was seen such
as chills,
nausea, and
vomiting.

#16 PLRS 1L Mr. Pedro

responded well
and maintained
his normal fluid

67
 volume, and no
manifestation of
any side effects
was seen such
as chills,
nausea, and
vomiting.

#17 PLRS 1L Mr. Pedro

responded well
and maintained
his normal fluid
volume, and no
manifestation of
any side effects
was seen such
as chills,
nausea, and
vomiting.

#18 PLRS 1L Mr. Pedro

responded well
and maintained
his normal fluid
volume, and no
manifestation of
any side effects
was seen such
as chills,
nausea, and
vomiting.

#19 PLRS 1L Mr. Pedro

responded well
and maintained
his normal fluid
volume, and no
manifestation of
any side effects
was seen such
as chills,
nausea, and
vomiting.

#20 PLRS 1L Mr. Pedro

responded well
and maintained
his normal fluid
volume, and no
manifestation of

68
 any side effects
was seen such
as chills,
nausea, and
vomiting.

Dextrose 5% in Date Ordered: D5IMB is a D5W was used Mr. Pedro

Water (D5W) 04/15/23 Balanced as a diluent for tolerated
Multiple omeprazole. The intervention
#1 D5W 90cc Date Performed: Maintenance diluent helps without adverse
04/15/23 Hypertonic carry the reaction and
#2 D5W 90cc 04/18/23 Solution with 5% medicine into the consumed the
Dextrose. bloodstream IVF.
through the IV.
This helps the
caregivers inject
the medicine
slowly and more
safely into your
body.

Oxygen Date Ordered: Oxygen therapy, Provides Mr. Pedro

facemask at 10 04/14/23 also known as adequate tolerated
lpm supplemental oxygen supply to intervention
Date Performed: oxygen, is the Mr. Pedro to without adverse
04/14/23 use of oxygen as increase his reaction and
medical oxygen demonstrated a
treatment. saturation up stable oxygen
to/above 95%. saturation

Jackson Pratt Date Ordered: The Jackson- After surgery, Mr. Pedro
Drain 04/14/23 Pratt (JP) drain there is tolerated
is a special tube continued oozing intervention
Date Performed: that prevents and shedding of without any
04/14/23 body fluid from cells and bodily complications
collecting near fluids at the such as redness,
the site of your surgical site. The swelling, or
surgery. The Jackson Pratt warmth around
drain pulls this drain removes the incision or
fluid (by suction) fluid and this tube.
into a bulb. removal of fluid
speeds healing.

Jejunostomy Date Ordered: A jejunostomy Feeding Mr. Pedro

69
 feeding 04/16/23 tube (J-tube) is a jejunostomy tolerated
soft, plastic tube refers to a intervention
Date Performed: placed through surgically without any
04/16/23 - the skin of the inserted tube, complications
ongoing abdomen into preferably in the such as ube
the midsection of proximal dislocation,
the small jejunum, to obstruction or
intestine. provide enteral migration of the
nutrition or tube, occlusion,
administer and intestinal
medications. ischemia.

Oxygen Therapy Date Ordered: Oxygen therapy, Provides Mr. Pedro

at 4 LPM via 04/18/23 also known as adequate tolerated
Nasal Cannula supplemental oxygen supply to intervention
Date Performed: oxygen, is the Mr. Pedro to without adverse
04/18/23 use of oxygen as increase his reaction and
medical oxygen demonstrated a
treatment. saturation up stable oxygen
to/above 95%. saturation

Indwelling foley Date Ordered: It is a closed A urinary Mr. Pedro

catheter 04/20/23 sterile system catheter is a tolerated
with a catheter hollow, partially intervention as
Date Performed: and retention flexible tube that evidenced by
04/20/23 balloon that is collects urine continuous/at
inserted either from the bladder regular interval
through the and leads to a bladder
urethra or drainage bag. emptying
suprapubically
to allow for
bladder
drainage.

Nursing responsibilities:
Prior:
1. Check the doctor’s order.
2. Observe Hand Hygiene Procedures
3. Gather Equipment
4. Verify if the solution is appropriate for the patient’s condition.
5. Review the chart of the patient and check if there are any special notes for her condition.
During:
1. Perform hand hygiene. Don gloves

70
 2. Prepare the site of insertion. Maintain aseptic technique
3. Catheter should be stabilized in a manner that does not interfere with visualization so
you can inspect and do your assessment later.
4. Monitor for the patient’s comfort. Monitor and observe the patient during administration.
After:
1. Label the insertion site, administration site, and solution container
2. Dispose the equipments used properly
3. Ensure appropriate infusion flow
4. Teach patients and families to recognize signs and symptoms of fluid volume overload
(isotonic fluids expand the intravascular space, patients with hypertension and heart
failure)
5. Instruct patients to notify their nurse if they have trouble breathing or notice any swelling.
Close monitoring for patients with heart failure. Because isotonic fluids expand the
intravascular space, patients with hypertension and heart failure should be carefully
monitored for signs of fluid overload.

B. Medications

Date Route,
Indication(s) or Client’s
Drug Ordered or Dosage, &
Purposes Response
Given Frequency

Generic Name: Date 900 mg IV q6 Paracetamol is an Mr. Pedro was

Paracetamol Ordered: x 4 doses analgesic and compliant and
04/14/23 antipyretic drug that responded well to
Brand Name: is used to the medication as
Amcetam Date Given: temporarily relieve evidenced by
04/14/23 mild-to-moderate absence of side
pain and fever effects, as well as
decreased pain.
Mr. Pedro was
prescribed with this
medication for
relieving
postoperative pain

Generic Name: Date 50 mg IV q8 x Tramadol is a Mr. Pedro was

Tramadol Ordered: 3 doses then strong painkiller compliant and
04/14/23 PRN for pain from a group of responded well to
Brand Name: medicines called the medication as
Tramadex Date Given: opiates, or evidenced by

71
 04/14/23 narcotics. It's used absence of side
to treat moderate to effects, as well as
severe pain, for decreased pain.
example after an
operation or a
serious injury.

Mr. Pedro was

prescribed with this
medication for
relieving
postoperative pain

Generic Name: Date 4.5 g IV + Piperacillin- Mr. Pedro was

Piperacillin Ordered: 90cc D5W for tazobactam is a compliant and
Tazobactam 04/14/23 2 hrs good choice of responded well to
treatment as the medication as
Brand Name: Date Given: monotherapy for evidenced by
Perataz 04/14/23 surgical wound absence of side
infection after effects such as
surgery for it nausea, vomiting,
reduces heartburn, fever,
postoperative and headache.
infectious
complication

Mr. Pedro was

prescribed with this
medication to avoid
and reduce
postoperative
infectious
complication

Generic Name: Date 2 g IV in 90cc Cefepime is used to Mr. Pedro was

Cefepime Ordered: D5w x 2hrs treat a wide variety compliant and
04/14/23 q8 x 3 doses of bacterial responded well to
Brand Name: then 1g OD infections. It works the medication as
Neupime Date Given: by stopping the evidenced by
04/14/23 growth of bacteria. absence of side
Its single dose is a effects such
very useful abdominal pain,
alternative to other headache, and
regimens for it diarrhea.
reduces the
incidence of
postoperative
wound infections.

Mr. Pedro was

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 prescribed this
medication to avoid
and reduce the
incidence of
postoperative
wound infections.

Generic Name: Date 0.4 cc SQ Enoxaparin is a low Mr. Pedro was

Enoxaparin Ordered: molecular weight compliant and
04/14/23 heparin used for responded well to
Brand Name: deep vein the medication as
Olxarin Date Given: thrombosis. It is evidenced by
04/14/23 usually given after absence of
surgery since there unusual bleeding,
is an increased risk easy bruising, and
of blood clots chest pain.
forming.

Mr. Pedro was

prescribed this
medication for
prevention of
symptoms of blood
clots due to
significant reduction
in mobility after
surgery.

Generic Name: Date 25 mg IV q12 Ranitidine is a Mr. Pedro was

Ranitidine Ordered: medicine that compliant and
04/14/23 50 g IV q2 reduces the amount responded well to
Brand Name: 04/15/23 of acid your the medication as
Ranipen 04/16/23 1 g + 200cc stomach makes. evidenced by
D5W to run After a surgery, absence of side
Date Given: for 2hrs q24 ranitidine alone effects such as
04/14/23 decreases pain and headache,
04/15/23 regurgitation. nausea, vomiting,
04/16/23 and stomach pain.
Mr. Pedro was
prescribed with this
medication for it
relieves pain and
regurgitation
postoperatively.

Generic Name: Date 300 mg IV Paracetamol is an Mr. Pedro was

Paracetamol Ordered: (pre BT med) analgesic and compliant and
04/15/23 antipyretic drug that responded well to
Brand Name: 1g IV q6 is used to the medication as
Amcetam Date Given: temporarily relieve evidenced by

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 04/15/23 mild-to-moderate absence of side
pain and fever effects, as well as
decreased pain.
Mr. Pedro was
prescribed with this
medication for
relieving
postoperative pain

Generic Name: Date 50 mg IV Diphenhydramine is Mr. Pedro was

Diphenhydramin Ordered: (pre BT med) an antihistamine compliant and
e 04/15/23 used to relieve responded well to
symptoms of the medication as
Brand Name: Date Given: allergy, hay fever, evidenced by
Soniphen 04/15/23 and the common absence of febrile
cold. It is a nonhemolytic
premedication to transfusion
prevent febrile reactions and
nonhemolytic minor allergic
transfusion transfusion
reactions and minor reactions.
allergic transfusion
reactions.

Mr. Pedro was

prescribed this
medication because
he will undergo
blood transfusion,
preventing any
transfusion reaction
to happen.

Generic Name: Date 50 mg IV q8 Metronidazole Mr. Pedro was

Metronidazole Ordered: injection is used to compliant and
04/15/23 treat serious responded well to
Brand Name: bacterial infections the medication as
Delexigyl Date Given: in different areas of evidenced by
04/15/23 the body. It works absence of any
by stopping the serious bacterial
growth of certain infections.
bacteria

Mr. Pedro was

prescribed this
medication because
he will undergo
blood transfusion,
preventing any
transfusion reaction

74
 or any infection
from happening.

Generic Name: Date 2g IV + 200cc

Vancomycin is used Mr. Pedro was
Vancomycin Ordered: PNSS to run to treat infections compliant and
04/15/23 for 2 hours caused by bacteria. responded well to
Brand Name: 04/18/23 then into 2 It works by killing the medication as
Mersa q12 bacteria or evidenced by
Date Given: preventing their absence of any
04/15/23 1g + 200cc growth. serious bacterial
04/18/23 PNSS x 2hrs infections.
IV q12 x 6 Mr. Pedro was
doses prescribed this
medication because
It is used for
treating severe
infections given that
he is at risk of
infection

Generic Name: Date TID Hexetidine Mr. Pedro was

Hexetidine Ordered: (Bactidol) 0.1% compliant and
04/17/23 Solution is indicatedresponded well to
Brand Name: for its antibacterialthe medication as
Bactidol Date Given: and antifungalevidenced by
04/17/23 action in daily oral absence of
hygiene. mucosa irritation
and any serious
Mr. Pedro was bacterial
prescribed this infections.
medication for his
daily oral hygiene
considering he is at
complete bed rest.

Generic Name: Date 1g + 90cc Meropenem Mr. Pedro was

Meropenem Ordered: PNSS x 2hrs injection is used to compliant and
04/19/23 q8 x 6 doses treat skin and responded well to
Brand Name: abdominal the medication as
Meromax Date Given: (stomach area) evidenced by
04/19/23 infections caused absence of side
by bacteria. effects such as
nausea, vomiting,
Mr. Pedro was and headache
prescribed this
medication to
prevent any
infection especially
on his abdominal
area.

75
 Generic Name: Date 1 tab BID Multivitamins are a Mr. Pedro was
Multivitamins Ordered: combination of compliant and
04/19/23 different vitamins responded well to
Brand Name: normally found in the medication as
Enervon Date Given: food sources. The evidenced by
04/19/23 main purpose of a absence of side
multivitamin is to fill effects such as
in nutritional gaps, constipation,
and provides only a diarrhea, and
hint of the vast upset stomach
array of healthful
nutrients and
chemicals naturally
found in food.

Mr. Pedro was

prescribed this
medication to fill in
nutritional gaps, as
well as to treat or
prevent vitamin
deficiency due to
illnesses

Generic Name: Date 40 mg IV q12 Omeprazole is a Mr. Pedro was

Omeprazole Ordered: type of medicine compliant and
04/20/23 called a proton responded well to
Brand Name: pump inhibitor the medication as
Omepron Date Given: (PPI). It's widely evidenced by
04/20/23 used to treat absence of
indigestion and headaches,
heartburn, and acid diarrhea, and
reflux. It's also stomach pain.
taken to prevent
and treat stomach
ulcers.

Mr. Pedro was

prescribed with this
medication for it will
effectively prevent
gastrointestinal
bleedings for
critically ill patients
at the intensive care
unit (ICU)

NURSING RESPONSIBILITIES:
Prior:

76
 1. Check the name of the patient and the doctor’s order.
2. Follow the 10 Rights of Medication Administration.
3. Take the patient’s vital signs as needed.
During:
1. Use at least two patient identifiers.
2. Ask the patient to identify him/herself.
3. Check the name of the medication and doctor’s order again.
4. Inform and educate the patient of the drug he/she is about to take.
5. Witness the patient taking the medication.
After:
1. Monitor patient response to the drug.
2. Monitor the patient's vital signs as needed.
3. Refer to the physician if the client manifested any unwanted effects related to the drug
that was ordered.
4. Document the patient's response.

C. Diet

Type of Date Ordered General Indication(s) Specific Client's

Diet
Date Description or Purposes foods taken response
Performed and/or rxn to
Date Changed the diet

NPO Date Ordered: The After an None Mr. Pedro

(Nothing instruction operation, the complied with
04/05/23
Per Orem) to withhold patient the diet as
04/14/23
fluids and should be evidenced by
Date solid foods initially kept no food or
Performed: from a NPO. After water intake
person. surgery
04/05/23
intestines can
04/14/23 shut down.
Date It's called an
ileus and it
Changed:
basically
Still on-going means that
the intestines

77
 aren't actively
moving food
forward

NURSING RESPONSIBILITIES:
Before
1. Verify physician’s order.
2. Educate about the importance and purpose of the diet to his condition.
3. Assess vital signs
During
1. Monitor if patient was compliant with the prescribed diet
2. Instructed patient to follow the diet for safety purposes prior the surgery
After
1. Monitor for patient’s reaction, vital signs, and compliance with the diet
2. Inform patient to call for assistance if there are any concerns
3. Document essential data into the chart.

D. Activity/Exercise

Type of Date Ordered General Indication(s) or Client's

Exercise/Activit
Date Performed Description Purposes response
y

Complete Bed Date Ordered: This is the most Bed rest was Mr. Pedro was
Rest
04/14/23 extreme form of indicated for the compliant with
Date bed rest and patient since he the said activity
Performed: involves staying is under as evidenced by
04/14/23 in bed most of monitoring. This staying in bed.
the day (either in also aids to
the hospital or at decrease the
home). In some stress and
cases, you may worsen the
use a bedpan (to patient’s
pee) and not

78
 leave your bed condition.

Head of bed Date Ordered: The Semi- This is indicated Mr. Pedro was
elevated at
04/17/23 Fowler's position to promote lung compliant and
30-45
degrees Date is a position in expansion. In responded well
Performed: which a patient, the semi- with the
04/17/23 typically in a Fowler's prescribed
hospital, is position, these activity as
positioned on changes can evidenced by
their back with improve absence of
the head and oxygenation and shortness of
trunk raised to increase oxygen breath, and use
between 15 and saturation. of accessory
45 degrees, muscle.
although 30
degrees is the
most frequently
used bed angle.

Nursing responsibilities to Complete bed rest:

Prior:
1. Check the doctor’s order
2. Educate the patient and family about the purpose and significance of the ordered activity
During:
1. Ensure that the patient is following the ordered activity
2. Monitor for any significant reactions from the ordered activity
After:
1. Document essential data into the chart
2. Inform patient to call for assistance if there are any concerns

SURGICAL MANAGEMENT

79
 Type of Date Ordered General Indication(s) or Client's
Surgical
Date Performed Description Purposes response
Management

Emergency tube Date Ordered: Tube Tube Mr. Pedro was

duodenostomy
04/14/23 duodenostomy duodenostomy compliant and
Date Performed: involves has been responded well
04/14/23 insertion of a described as a with the
small feeding useful technique performed
tube through the in the surgery as
duodenal stump management of evidenced by
to encourage difficult absence of
formation of a duodenum postoperative
controlled arising from a complications.
duodenal variety of
cutaneous pathologies. The
fistula. emergency
surgery was due
to duodenal
repair leak.

T-tube Date Ordered: A T-tube is a T- It provides Mr. Pedro was

reinsertion 04/14/23
shaped tube external drainage compliant and
Date Performed:
placed in the of bile into a responded well
04/14/23
common bile controlled route with the
duct following while the healing performed
procedures process of his surgery as
involving the past surgery is evidenced by
duct, such as maturing and the absence of
after original postoperative
choledochotomy pathology is complications.
. T-tubes resolving.
provide external
drainage of bile

80
 via a controlled
route the
original
pathology is
resolving

Jejunostomy Date Ordered: A jejunostomy Feeding Mr. Pedro

(Feeding 04/14/23 tube (J-tube) is jejunostomy tolerated
Jejunostomy) a soft, plastic refers to a intervention
Date Performed:
tube placed surgically without any
04/14/23
through the skin inserted tube, complications
of the abdomen preferably in the such as ube
into the proximal dislocation,
midsection of jejunum, to obstruction or
the small provide enteral migration of the
intestine. nutrition or tube, occlusion,
administer and intestinal
medications. ischemia.

NURSING RESPONSIBILITIES:
Before Operation
1. Assess and monitor the patient's vital signs
2. Review the patient's medical history, including any allergies and current medications.
3. Verify the informed consent form has been signed and ensure the patient understands the
risks and benefits of the procedure.
4. Ensure the patient has followed the fasting protocol.
5. Administer medications as ordered, including prophylactic antibiotics.

During
1. Monitor the patient's vital signs, cardiac output, and oxygen saturation continuously.
2. Ensure that the patient is in the correct position and properly draped.
3. Administer medications as ordered, including anesthesia and any additional medications
necessary to maintain hemodynamic stability.
4. Monitor for any adverse reactions to medications and report any changes in the patient's
condition to the surgeon.
After Operation
1. Monitor the patient's vital signs, cardiac function, and level of consciousness.

81
 2. Assess and manage pain levels, as appropriate.
3. Provide emotional support and encourage the patient to participate in their recovery
process.
4. Ensure that the patient is following post-operative instructions, including activity limitations
and medication management.
5. Prepare the patient for discharge, including providing education on wound care, activity
limitations, and follow-up appointments.
6. As the patient recovers, your role is to continue to provide education, monitor for potential
complications, and provide support as necessary.

NURSING MANAGEMENT
F-DAR (FOCUS CHARTING)

● Day 1 (04/14/23)

DATE/TIME FOCUS D - DATA A - ACTION R - RESPONSE

04/14/2023 Deficient fluid D> Received Patient lying on bed lethargic. With an on going PLRS
10:00AM volume 1L x 80cc/hr at level of 850 cc and a PNSS 1L x KVO at level of 700
cc; with a TPN; nasogastric tube intact; with an oxygen via
facemask at 10 lpm; with a bilateral Jackson Pratt drainage
maintained on a negative pressure; Upon assessment, the patient
has jaundice, cold clammy skin and poor skin turgor; Vital Signs
are: Temp- 37.0 PR- 87 RR-20 and BP-110/70; GCS score of 8/15
A> Assessed patient’s appearance and status
> Monitor Vital signs
> Assess color and amount of urine
> Monitor active fluid loss from drainages and tubes
> Assess and maintain the patency of IV line and flow rate
R> Vital signs maintained within normal and demonstrated an
improved skin turgor.

● Day 2 (04/15/23)

DATE/TIME FOCUS D - DATA A - ACTION R - RESPONSE

04/15/2023 Risk for infection D> Received patient lying on bed awake and coherent. With an on
going PLRS 1L x 80cc/hr at level of 850 cc and a PNSS 1L x KVO
at level of 700 cc; with a TPN; nasogastric tube intact; with an

82
 oxygen via facemask at 10 lpm; with a bilateral Jackson Pratt
drainage maintained on a negative pressure; Upon assessment, the
patient has cold clammy skin, poor skin turgor and presence of
surgical incision; Vital Signs are: Temp- 36.8 PR- 91 RR-20 and BP-
110/70; GCS score of 15/15
A> Assess general appearance
>Monitor vital signs
> Assess for the presence of infection processes in the skin or
mucous membranes such as swelling, redness or foul drainage.
> Maintain aseptic technique in cleaning incision site and dressing
change.
> Maintained a calm environment and promote rest
R> Vital signs within normal range and maintained incision site
intact.

D. EVALUATION

1. CLIENT’S DAILY PROGRESS CHART

1ST NPI 2ND NPI

ADMISSION DAY 1 DAY 2
DAYS 04/14/23 04/15/23
NURSING PROBLEMS
Acute Pain ●
Imbalanced nutrition, ● ● ●
less than body
requirements
Deficient fluid volume ●
Impaired tissue ● ● ●
integrity
Risk for infection ● ● ●
Risk for Injury ● ● ●

VITAL SIGNS
Temperature via 37.1 37.0 36.8
axilla (°C)
Pulse Rate (bpm) 110 94 91

83
 Respiratory Rate 40 21 20
(cpm)
Blood Pressure 140/110 110/70 110/70
(mmHg)
Oxygen Saturation 93 95 98
(%)
DIAGNOSTIC AND LABORATORY PROCEDURES
- - - -
MEDICAL MANAGEMENT
1. Intravenous ● ● ●
Fluid Therapy

● PNSS (Plain
Normal
Saline
Solution)
[0.9% Sodium
Chloride
Solution]

● PLRS
(Lactated
ringer’s
solution)

● Dextrose 5%
in Water
(D5W)
2. Nasogastric ● ● ●
(NG) feeding
3. Oxygen ● ●
facemask at
10 lpm

4. Jackson Pratt ●
Drain

MEDICATIONS
Paracetamol ● ●
Ranitidine ● ●

Diphenhydramine ●
Metronidazole ●

84
Vancomycin ●
Tramadol ●
Piperacillin ●
Tazobactam
Cefepime ●
Enoxaparin ●

DIET
Nothing Per Orem ● ● ●
(NPO)

ACTIVITIES OR EXERCISES

Complete Bed Rest ● ●

2. Discharge planning (METHOD)

MEDICATIONS ● Vitamin K - to manage the itching, jaundice, and bleeding

tenderness due to VItamin K deficiency
● Antibiotics - to treat infection
● Pain relievers

- Provide the patient and the significant other with knowledge and
information about the prescribed medications
- Encourage the patient to take his medications exactly as prescribed by
his healthcare practitioner

EXERCISE/ ● Encourage the patient to refrain from driving.

ENVIRONMENT ● Inform the client to avoid strenuous activity and not lift anything
heavy that would cause pain or pull at the incision site.
● Motivate the patient to take good care of himself by sleeping for at
least 7 to 9 hours per night and learning ways to manage stress

TREATMENT ● Advise the patient and the significant other to take the medications
exactly as ordered and not to miss any doses.
● Encourage the patient and significant other to follow the advised
lifestyle changes and food restrictions to prevent further
complications.

HEALTH ● Provide the patient and the significant other an information about
TEACHINGS the disease process, prognosis, and treatment
● Instruct the client to read food labels and ensure that the food the
client chooses is low fat.

85
 ● To relieve discomfort and protect his incision, remind the patient to
place a pillow over his incision whenever he coughs or sneezes

OPD or FOLLOW- ● Emphasize the significance of follow up check-up and sticking to

UP MONITORING the provided schedule based on the client’s doctor.
● Remind the patient and the family of the importance of participating
in health promotion activities and recommended health screening.

DIET ● Eat a low-fat diet. Fatty foods can cause the gallbladder to release
bile to help digest the fats.
● Limit fatty dairy foods, animal fats, and vegetable oils.
● Drink more liquids as directed - liquids can help the client stay
hydrated and urinate more. This will help prevent harm to the
kidneys.

V. SUMMARY

Most gallstones originate in the gallbladder; however, some travel through the common
bile duct and cause severe pain and jaundice. 4.6%–18.8% of cholecystectomy patients had
choledocholithiasis, according to McNicoll et al. (2023). Cholelithiasis is more frequent in older
people, pregnant women, and people with high blood lipid levels. The primary risk factor of the
patient’s condition is his diet. The patient always eats fatty foods and foods high in cholesterol.
Since the gallbladder produces bile to break down fat, a high-fat, high-cholesterol diet can
increase gallstone risk. As the patient entered the facility, a chief complaint of fever and
abdominal pain was reported, and an initial assessment and examination were performed in
order to facilitate appropriate interventions intended for the patient’s condition.
Imbalanced nutrition, less than body requirements is the main concern caused by
inadequate bile secretion. Throughout the patient’s stay, proper assessment and evaluation are
important, for this will determine the intervention’s appropriateness and effectiveness for the
patient’s condition. Assessment and interventions, including vital signs monitoring,
administration of medications, parenteral or enteral feedings as ordered, promotion of rest, and
other interventions that will help in relieving the patient’s symptoms. Through proper
assessment and laboratory and imaging reports, a diagnosis of Obstructive Jaundice secondary
to Choledocholithiasis was identified. The patient’s lifestyle or diet may be the main factor that

86
increased his susceptibility to choledocholithiasis, along with his age, since his body is
undergoing the effects of aging, making him prone to certain disease conditions.

VI. CONCLUSION

Choledocholithiasis can occur in as many as 20% of cholelithiasis patients (Molvar &

Glaenzer, 2016). Some stones may travel through the common bile duct, causing an obstruction
and producing symptoms such as severe pain and jaundice. A high-fat and high-cholesterol diet
are the most common causes of choledocholithiasis in the elderly. Patients with
choledocholithiasis will generally need surgery to immediately resolve their signs and
symptoms, thus requiring hospitalizations. The decision whether to proceed with the surgery is
based on factors such as the patient's ability to cope with the stress brought by the operation,
the patient's age, and the risk of complications.
With all of the observed symptoms, physical examination findings, and laboratory
results, a number of nursing problems were identified. Included in these nursing problems are
imbalanced nutrition, less than body requirements; deficient fluid volume; impaired tissue
integrity; risk for infection; and risk for injury. These nursing problems were prioritized and
placed at the center of the nursing care plans developed to address the underlying causes of
the patient’s discomfort and health problems. As nurses, it is essential to conduct a
comprehensive assessment to record all pertinent information that will aid in the diagnosis of the
patient’s condition and the formulation of nursing problems to be used in the development of
individualized nursing care plans to address the patient’s health issues. Critical care nursing
entails paying close attention to the patient’s symptoms and monitoring their vital signs, as this
enables the timely administration of treatments and management of their condition.
The patient's family plays a significant role in their overall recovery, particularly with
regard to emotional and psychological issues, in addition to the medical professionals' care.
Nursing education teaches prospective nurses that holistic nursing care takes into account more
than just physical considerations. The presence of loved ones at the hospital is crucial for
psychological and emotional support. Thus, doctors and nursing staff should notify the family
about the patient's health and treatment progress. Knowing what to expect reduces anxiety and
builds trust in nursing and medical services.

87