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SAN PABLO COLLEGES MEDICAL CENTER
San Pablo City, Laguna
Case
Presentation

2. 2
CORTEZ, Oliver D.
DE ROXAS, Jennifer M.
GARCIA, Clarisse C.
LINATOC, Mary Rose E
PORNASDORO, Ma. Crystal M.
SERNA, John Jerome Jonathan M.
TATAD, Carizsa Armina D.
TAGLE, Angelica A.
TABLE OF CONTENTS
PAGE
TITLE PAGE 1
INTRODUCTION 3
PATIENT’S PROFILE 9
HISTORYTAKING 10
REVIEWOF SYSTEMS 11
ANATOMYAND PHYSIOLOGY 14
CHOLELITHIASIS
GROUP 2

3. 3
PATHOPHYSIOLOGY 17
MEDICALMANAGEMENT 19
LABORATORYAND DIAGNOSTIC WORKUPS 22
DRUG STUDY 30
NURSING CARE PLAN 35
CHOLELITHIASIS (Gallstones)
Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones
may be as small as a grain of sand or as large as a golf ball.
CAUSES
There are two main types of gallstones:
INTRODUCTION
REPORTER: LINATOC, MARY ROSE and TAGLE, ANGELICA A.

4. 4
 Stones made of cholesterol, which are by far the most common type.
Cholesterol gallstones have nothing to do with cholesterol levels in the blood.
 Stones made of bilirubin, which can occur when red blood cells are being
destroyed (hemolysis). This leads to too much bilirubin in the bile. These
stones are called pigment stones.
RISK FACTOR
NON MODIFIABLE MODIFIABLE
 Family history
 Genetic
 Ethnic background
 Female
 Age
 Obesity
 Rapid weight loss
 Diet
SYMPTOMS
 Pain in the right upper or middle upper abdomen (biliary colic)
o May be constant
o May be sharp, cramping, or dull
o May spread to the back or below the right shoulder blade
 Fever
 Yellowing of skin and whites of the eyes (jaundice)
Other symptoms that may occur with this disease include:
 Clay-colored stools
 Nausea and vomiting
EXAMS AND TESTS
Tests used to detect gallstones or gallbladder inflammation include:
 Abdominal ultrasound
 Abdominal CT scan
 Endoscopic retrograde cholangiopancreatography (ERCP)
 Gallbladder radionuclide scan
 Magnetic resonance cholangiopancreatography (MRCP)
 Percutaneous transhepaticcholangiogram (PTCA)
Your doctor may order the following blood tests:
 Bilirubin
 Liver function tests
 Pancreatic enzymes
TREATMENT

5. 5
SURGERY
 LAPAROSCOPIC CHOLECYSTECTOMY
 This procedure uses smaller surgical cuts, which allow for a faster
recovery. Patients are often sent home from the hospital on the same
day as surgery, or the next morning.
 OPEN CHOLECYSTECTOMY (GALLBLADDER REMOVAL)
 was the usual procedure for uncomplicated cases. However, this is
done less often now.
MEDICATION
 CHENODEOXYCHOLIC ACIDS (CDCA) OR URSODEOXYCHOLIC ACID (UDCA,
URSODIOL)
 may be given in pill form to dissolve cholesterol gallstones. However, they
may take 2 years or longer to work, and the stones may return after
treatment ends.
 LITHOTRIPSY
 Electrohydraulic shock wave lithotripsy (ESWL) of the gallbladder has
also been used for certain patients who cannot have surgery. Because
gallstones often come back in many patients, this treatment is not used
very often anymore.
POSSIBLE COMPLICATIONS
Blockage of the cystic duct or common bile duct by gallstones may cause the following
problems:
 Acute cholecystitis
 Cholangitis
 Cholecystitis - chronic
 Choledocholithiasis
 Pancreatitis
Prevention
 Increase fiber in the diet

6. 6
LAPAROSCOPIC SURGERY
Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-
choice of treatment for gallstones and inflammation of the gallbladder unless there are
contraindications to the laparoscopic approach. This is because open surgery leaves the
patient more prone to infection. Sometimes, a laparoscopic cholecystectomy will be
converted to an open cholecystectomy for technical reasons or safety.
Laparoscopic cholecystectomy requires several small incisions in the abdomen to
allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in
diameter, through which surgical instruments and a video camera are placed into the
abdominal cavity. The camera illuminates the surgical field and sends a magnified image
from inside the body to a video monitor, giving the surgeon a close-up view of the organs
and tissues. The surgeon watches the monitor and performs the operation by manipulating
the surgical instruments through the operating ports.
To begin the operation, the patient is placed in the supine position on the operating
table and anesthetized. A scalpel is used to make a small incision at the umbilicus. The
surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The
camera is placed through the umbilical port and the abdominal cavity is inspected.
Additional ports are opened inferior to the ribs at the epigastric, midclavicular, and
anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted
superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to
expose and open Calot's Triangle (the area bound by the inferior border of the liver, cystic
duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal
covering and obtain a view of the underlying structures. The cystic duct and the cystic
artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is
dissected away from the liver bed and removed through one of the ports. This type of
surgery requires meticulous surgical skill, but in straightforward cases, it can be done in
about an hour.
Recently, this procedure is performed through a single incision in the patient's
umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or
"LESS".
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut,
resulting in less pain, quicker healing, improved cosmetic results, and fewer complications
such as infection and adhesions. Most patients can be discharged on the same or following
day as the surgery, and can return to any type of occupation in about a week. Furthermore,
flexible instruments are being used in laparoscopic surgery by some surgeons.

7. 7
An uncommon but potentially serious complication is injury to the common bile
duct, which connects the cystic and common hepatic ducts to the duodenum. An injured
bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases
of minor injury to the common bile duct can be managed non-surgically. Major injury to the
bile duct, however, is a very serious problem and may require corrective surgery. This
surgery should be performed by an experienced biliary surgeon.
Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that
obscure vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons
to switch to the standard cholecystectomy for safe removal of the gallbladder. Adhesions
and gangrene can be serious, but converting to open surgery does not equate to a
complication.
During laparoscopic cholecystectomy, gallbladder perforation can occur due to
excessive traction during retraction or during dissection from the liver bed. It can also
occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender,
advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an
average size greater than 1.5 cm have been identified as risk factors for complications.
Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the
patient. Clear documentation of spillage and explanation to the patient is of utmost
importance, as this will enable prompt recognition and treatment of any complications.
Prevention of spillage is the best policy
Biopsy
After removal, the gallbladder should be sent for pathological examination to
confirm the diagnosis and look for an incidental cancer. If cancer is present, a reoperation
to remove part of the liver and lymph nodes will be required in most cases.

8. 8
EQUIPMENTS:
 Camera unit - (sterilizable head and cable, video control unit)
 Connector cables from camera to monitor
 Video Monitor
 Light Source
 Light transmission fibre-optic cable
 Insufflator
 Carbon Dioxide Cylinder
 Carbon dioxide pressure regulator valve (optional - see description below)
 Tubing and Luer-lock adapter for carbon dioxide to patient
 Suction irrigation apparatus (optional)
 Cautery machine with cables and foot control
 Power control equipment (Transformer/spike and surge suppresser)
 Power extension cord
 Telescope
 Trocars and cannulas- 2 x 11mm, 2 x 5.5mm, 11 to 5.5mm reducer(1), 11-
7mm reducer(optional)
 Verress Needle (optional)
 2 Atraumatic graspers
 1 toothed grasper
 1 curved dissector
 1 clip applicator with suitable clips
 1 dissection hook
 1 pair scissors
 1 suction irrigation cannula
 1 sterilization ring applicator (if sterilization is to be done)
 1 pair hook scissors (optional)
 1 cautery spatula (optional)
 1 gallstone retrieving forceps (optional)
 1 needle holder (optional)
STEPS
This is one of the most commonly performed procedures in the western world. It is
often done as a day case procedure and when correctly performed is associated with little
post-operative pain or morbidity. The following steps are generally taken:
1. General anesthesia
2. Creation of pneumoperitoneum: 1cm subumbilical (or transumbilical) incision.
Dissection to peritoneum and insertion of trocar. Insufflation using CO2 and
insertion of camera.
3. The patient is placed with their head down and tilted to the left position.
4. Placement of at least two other ports. A grasper is inserted at the top of the
gallbladder and locked into place. The camera assistant then uses the other hand to

9. 9
apply upwards traction on the gallbladder in order to maximise the surgeon’s access
to Calot’s triangle.
5. The surgeon then either uses one or two ports to dissect around Calot’s triangle
using a grasper, Pledget and hook diathermy.
6. Clips are then placed around the cystic artery and duct – two below and one above
where they will be cut.
7. Scissors are then used to cut the duct and artery.
8. The gall bladder is then dissected off the liver and a bag is used to remove it out of
the abdomen.
9. The surgeon then looks around for any bleeding or bile leak and performs washout
if necessary.
10. The ports are opened and gas stopped to remove free gas.
11. The peritoneum is closed at the umbilicus then the subcutaneous tissue and skin are
closed.
12. The rest of the ports are closed at the skin only.
13. Dressings are placed and the patient woken up.

10. 10
NAME : Mrs. Y.
ADDRESS : San Pablo City
AGE : 49 years old
CIVIL STATUS : Married
NATIONALITY : Filipino
RELIGION : Catholic
OCCUPATION : Teacher
CHIEF COMPLAINT : RUQ Abdominal Pain
ATTENDING PHYSICIAN : Dr. Gabriel Eala
ADMITTING DIAGNOSIS : Cholelithiasis
MEDICAL CASE TYPE : Surgery (Adult)
ADMISSION DATE & TIME : March 26, 2013 at 04:45 PM
ADMISSION NUMBER : 10442
CASE NUMBER : 009876
ROOM : C201
DISCHARGE DATE : March 29, 2013
FINAL DIAGNOSIS : Cholecystolithiasis
OPERATION PERFORMED : Lap Cholecystectomy
PATIENT’S PROFILE
REPORTER:LINATOC,MARYROSE

11. 11
History of Present Illness
 Three (3) months prior to admission patients was diagnosed to have
cholelithiasis given with unrecalled medications. Since then, patient was
asymptomatic for almost three (3) months but opted to undergo surgery due
to abdominal pain hence admission.
Past Medical History
 This is the fourth (4th) time the patient been hospitalized. The 1st three
hospitalizations were due to giving birth via ceasarean section. According to
the patient she has no allergies on food and medication.
Personal and Social History
 The client eats 2 cups of rice every meal and more than 1 serving of meat
(pork, chicken and beef). She doesn’t eat much vegetable. She drinks plenty
of water and no exercised activity done in her daily living. She has her normal
bowel movement ranging from 3-5 times a week and urine output of almost 8
times a day. She takes a bath every day and had 5-6 hours of sleep. She had
no enough rest in everyday due to busy schedule in her teaching lesson. She
had her annual check up
Family History
 According to the patient she has no known hereditary disease that run within
their family.
PATIENT’S HISTORY
REPORTER: LINATOC, MARY ROSE

12. 12
Patient is ambulatory, with mark of fatigue and discomfort due to abdominal pain at the
right upper quadrant rated as 7 from a scale of 0-10 as 10 being the highest.
Body Part Examined Finding Norms
HEAD
Skull
-normocephalic
-absence of masses
Proportional to the size of the
body/round/with prominence
in the frontal area and the
occipital are posteriorly
symmetrical in all planes.
Hair
-with long hair evenly
distributed
-black in color
Black evenly distributed and
covers the whole scalp, thick
shiny, free from split ends
Face
-round and symmetrical
-no pain and tenderness
-with wrinkles
Round, symmetrical. Smooth
and free from wrinkles and no
involuntary movements.
Eyes
-no discharge, lesion,
redness, and swelling
-slightly yellowish sclera
-pale conjunctiva
-pupil black and
symmetrical
Parallel, evenly placed,
symmetrical, with scant
amount of secretions, both
eyes are bright and clear.
Nose
-without discharges and
lesions
-symmetrical nares
-moist, pink mucosal walls
Symmetric straight. No
discharge or flaring. Non-
tender, no lesions.
PHYSICAL EXAMINATION
REPORTER: CORTEZ, OLIVER D.

13. 13
Respiratory System
Lungs: Clear and Symmetrical
Patient has a respiratory rate of 22 bpm. Slightly elevated
because of pain experienced from RUQ
Cardiovascular
Mouth
-pale lips
-tongue moves freely, -
-without difficulty in
swallowing
Soft, Pink, or Reddish
Ears
-without lesions, discharges
and discomfort
-auricles are symmetrical
Parallel, symmetrical,
proportional to the size of the
head. Bean shaped, helix is in
line with the outer canthus of
the eye
Firm cartilage.
Abdomen
-globular tender
-with right upper
quadrant pain
Pain scale: 7
No tenderness, relaxed
abdomen, with smooth
consistent tension.
Bowel sound present
Upper & lower Extremities -No lumps
-Fingers are equal in
numbers
-symmetrical
-nails are clean and well-
trimmed
Firm, equal in size, bilaterally,
equal in numbers, clean and
symmetrical. Hair distribution
is even. Equal number of digits

14. 14
Patient’s blood pressure ranges from 120/70-130/80 mmHg. Extremities are warm to touch and
peripheral pulses are present. Radial pulse is 87 bpm which is within normal range.
Genitourinary
The patient’s urine is turbid in appearance.
Musculoskeletal
The patient is ambulatory. He is able to perform flexion, extension,
abduction and adduction independently.
Integumentary
Patient’s skin is dry and warm to touch. No lesions, cracks, signs of
inflammation and bruises noted. He has short hair. Nails are clean
and well-trimmed.

15. 15
LIVER
The liver lies to the right of the stomach and overlies the gallbladder. The human
liver in adults weighs between 1.4-1.6 kilograms. It is a soft, pinkish brown, triangular
organ. It is both the largest internal organ and the largest gland in the human body.
Among the most important Liver functions are:
1. Removing and excreting of wastes and hormones as well as drugs and other foreign
substances.
2. Synthesizing plasma proteins, including those necessary for blood clotting.
3. Producing Bile to aid in digestion.
4. Excretion of bilirubin.
5. Storing certain vitamins, minerals, and sugars.
ANATOMY & PHYSIOLOGY
REPORTER: GARCIA, CLARISSE C.

16. 16
GALLBLADDER
The gallbladder is a pear or oval shaped, hollow, saclike organ that lies in shallow
depression on the inferior surface of the liver, to which connected by a connective tissue.
Its wall is composed largely of smooth muscle. The gallbladder is connected to the
common bile duct by the cystic duct. The capacity of gallbladder is 30 – 50 ml of bile.
Bile
Bile or Gall is a bitter tasting, dark green to yellowish brown fluid, produced by the
liver. It is important in digestion. It is poured into the intestine through the bile duct but the
amount varies with the diet. Normal man makes 1000-1500 cc of bile per day. Some
amount of bile entering our intestinal tract goes into the gallbladder as it comes down the
duct. About half of the bile secreted between meals flows directly through the common bile
duct into the small intestine.
Composition of Bile
1. Water and electrolytes
 Sodium
 Potassium
 Calcium
 Chloride
 Bicarbonate
2. Lecithin
3. Fatty Acids
4. Cholesterol
5. Bilirubin
6. Bile Salts

17. 17
PANCREAS
The pancreas is a gland organ located in the upper abdomen that has endocrine and
exocrine functions. The exocrine functions include secretion of pancreatic enzymes into the
gastrointestinal tract through the pancreatic duct.
The enzyme secretion includes:
1. Amylase
2. Trypsin
3. Lipase
The endocrine function consists primarily of the secretion of the two major hormones,
insulin and glucagon. Four cell types have been identified in the islets:
1. A cells produce glucagon
2. B cells produce insulin
3. D cells produce somatostatin

18. 18
PATHOPHYSIOLOGY
REPORTER:PORNASDORO,MARIACRYSTAL
Several stonesdevelop
Precipitate out of the bile
Forms small crystals into
Gallbladder’s mucosalsurface
Enlarges to grosslyvisible
stonesREPORTER:
CHOLELITHIASIS
Gallstonesin the
INT
ROD
UCT
ION
Increased Bile Cholesterol
Irritationof Gallbladder
mucosa
Surface Changes
Increased Mucus Secretion
ImpairedGallbladderemptying
Calcium Bilirubinate
Irritation of Gallbladder
mucosa
Pigment
Stones
Combines with stearic acid,
Lecithin and palmitic acid
Forms Brown
Gallstones
Bile StasisContractile functionObstruction

19. 19
Biliary Colic
Abnormal Fat
Digestion
Anorexia
Nausea
Vomiting
Weight loss
Flatulence
Diarrhea
Fat
intolerance
Bacterial
Proliferation
Gallbladder
duct infection
Rupture of
Gallbladder
Peritonitis
Jaundice
Decrease bile
flow
Biliary
Cirrhosis
Bile
accumulates
in Liver
Vit. K
absorption
Increase
Serum
Bilirubin
Prorates/Tea-
collaredUrine
Bile StasisContractile function
InjuryRUQ
Pain
Intraductal
Pressure
Obstruction
Distension
Blood flow &
Lymphatic drainage
Is compromised
Mucosal
Ischemia
Necrosis
Release of
Inflammatory
Mediators
Increase
Permeabilityof
BloodVessels
Fluid, Proteins
and Cells enter
interstitial spaces
Edema
CholecystitisInflammation of
Gallbladder
Increase WBC
Leukocytosis
Release of Pyrogens
Increased Hypothalamic
set point
Inflammation of
Gallbladder

20. 20
DATE &TIME PROGRESS NOTE DOCTOR’S ORDER
March26,
2013
05:00PM
BP: 120/90 mmHg
T: 36.8 °C
CR: 88bpm
R: 22cpm
WEIGHT:77.5 kg
 Please admit to ROC under the serviceof
Dr. Eala
 Secure consent foradmission and
management
 DAT
 Diagnostics
 CBC withPC, Prothrombine time
 FBS, BUN, Crea, BUA, SGOT, SGPT,
Lipid Profile
 Whole abdomen UTZ
 12 lead ECG, UA
 Chest X-ray
 Meds.
 Paracetamol 500mg tablet q8H
PRN forfever ≥ 38.0⁰C.
 Schedule patient forLap chole w/p open
chole tom March 27, 2013 at 09:30am
 Dr. Gloria for C-P clearance
 Dr. Romero for Anesthesia
 Give Cefuroxime (Elixime) 750 mg TIV ( )
ANST 1 hour prior
 Monitor VS q2
 I & O q shift and record
 Inform all APs
 Refer accordingly
DR. EALA/ DRA.MEDRANO
March26,
2013
05:15PM
 NPO post midnight
 Notify Dr.Romero once C-P cleared by Dr.
Gloria
DR. ROMERO
March26,
2013
05:30PM
 Cleared for procedure
 Solucortef 250mg, give 125mg IVat 8pm
and 125mg 1 hour prior to OR.
 Inform all AP’s
DR. GLORIA
March26,
2013
08:00PM
 D5NR 1L x 12°
DR. GLORIA
MEDICAL MANAGEMENT
REPORTER: TAGLE, ANGELICA A.

21. 21
March27,
2013
12:05AM
 IVF to follow:D5NR1L x 12°
DR.GLORIA
March27,
2013
08:35AM
Pre-Op Order
 Maintain on NPO
 Pre-meds: Midazolam 2.5mg
Nalbuphine 5mg IV Cocktail
now
 To OR on call
DR. ROMERO
March27,
2013
03:15PM
Post-opOrder
 Transfer to PACU
 Monitor VS q15 minutes
 Placeon moderate back rest
 NPO
 Encourage deep breathing exercises
 Present IVF to run at 30gtts/min
 IVF TOFF-D5 NR 1L to run for 8hours
-D5 NM 1L to run for8hours
-D5 NR 1L to run for8hours
 Meds
- continue Cefuroxime 750 mg IV q
8hours
-Ranitidine 50 mg IV q 8hours
-Diclofenac Na (Dosanac) 75 mgdeep IM
(intragluteal) single dose
-Tramadol (Tramal) 100 mg IV q 8hours
PRN forsevere pain
 Specimen forhistopath
 Refer accordingly
DR. ROMERO
March27,
2013
04:00PM
 Ketorolac (Ketodol)30mg IV q 8hours for
2 doses; 1st dose at 2am tomorrow
DR.ROMERO
March27,
2013
04:00PM
BP: 120/70mmHg
T: 36.0°C
CR: 77bpm
RR: 20cpm
UrineOutput: 450cc
 To room
 VS q1°
DR.GLORIA
March28,
2013
08:00AM
 Progressive diet: genera liquid to DAT
 May remove FC
 Once on DAT, may consume IV shift
Cefuroxime to oral 500mg TID
 Daily wounddressing
 May sit up on bed
DR. R. RAYMUNDO
March28,
2013
10:00AM
Post-Anesthesia order
 If OK with Dr. Eala start Celecoxib 200mg
1cap POBID start this afternoon

22. 22
DR. ROMERO
March28,
2013
10:02AM
 Ok tocarry out orders of Dr. Romero
DR.EALA
March28,
2013
01:45PM
 No new orders
DR. R. RAYMUNDO
March29,
2013
08:10AM
Afebrile
(+) BM
 For discharge anytime notify Dr. Eala for
follow-upand meds
DR.EALA/ DR.R. RAYMUNDO
March29,
2013
10:40AM
 Ok fordischarge
DR. R. RAYMUNDO

23. 23
DIAGNOSTIC IMAGING REPORT
Date done: January 9, 2013
Ultrasound of whole abdomen:
The liver is normal in size measuring 13.7 x 9.2cm in sagittal and AP diameter, contour with mild
diffuse parenchymal echo pattern. No discrete parenchymal lesion is seen. The intrahepatic and
extrahepatic bile ducts appear normal.
The gallbladder is well visualized showing multiple shadowing echogenicities seen
intraluminally the largest is seen at the neck region measuring 2.1 cm. The wall is not
thickened. The common bile duct is not dilated measuring 0.4 cm.
The visualized spleen is normal in size measuring 7.3 x 3.6 cm, smooth contour and homogenous
echo pattern with no evidence of discrete mass lesion nor calcification.
The head, body and visualized proximal tail of the pancreas are normal in size and contour. No
lithiasis or masses are seen. The main pancreatic duct is not dilated. The aorta, periaortic and
paracaval areas are unremarkable.
The right kidney measures 10.3 cm x 4.9 cm with cortical thickness of 1.2cm and the left kidney
measures 10.5cm x 5.1cm with cortical thickness of 1.2cm. Both kidneys are normal in size.
The cortical thickness, cortical echogenicity, cortico-medullary differentiation, renal sinus
complexes and perinephric areas are unremarkable.Thepelvocalyceal systems and ureters are not
dilated.
The urinary bladder shows no evidence of reflective intraluminal echoes. Its walls are smooth and
unthickened.
Pre-void vol.= 154.8ml
Post-void vol=15.1ml
Residue in post micturation = 9.8%
The uterus is anteverted, measuring 8.3 x 5.7cm. The endometrial stripe is intact, measuring 1.0cm
The ovaries are not visualized due to overlying gas. Negative for posterior cul de sac fluid.
LABORATORY &
DIAGNOSTIC WORKUPS
REPORTER: DE ROXAS, JENNIFER M.
Legend for laboratory result:
Abnormal

24. 24
Interpretation:
 Mild fatty infiltration of the liver
 Cholelithiases
 Normal spleen, pancreas, kidneys and urinary bladder
 Normal anteverted uterus
 Non-visualized ovaries due to overlying gas
 Please correlate clinically
 Fatty infiltration of the liver refers to the accumulation of fat in the liver cells
 It could be diffuse or focal in nature. In case of diffuse fatty infiltration, there is an
excessive accumulation of triglycerides in the entire liver. In case of focal fatty liver,
only a part of the liver is affected and the infiltration of triglycerides is non-uniform.
 Other factors that may lead to fatty infiltration of liver include long-term parenteral
nutrition (intravenous administration of nutrients), prolonged use of steroids or
excessive endogenous production of steroids. Fatty liver can also occur during
pregnancy.
 Fatty infiltration of liver may or may not produce any symptoms. However, symptoms
may appear when accumulation of fat in the liver leads to inflammation of the liver.

25. 25
SPECIAL EXAMINATION : PROTHROMBIN TIME (COAGULATION CHECK)
Prothrombin time (PT) is a blood test that measures the time it takes for the liquid
portion (plasma) of your blood to clot.
Date done: March 25, 2013
Normal
Value
Result
Interpretation
Indication
Nursing
Responsibilities
Prothrombin
Time
10-13
secs.
14.4secs Prolonged A prolonged PT
means that the
blood is taking
too long to form
a clot. This may
be caused by
conditions such
as liver
disease, vitamin
K deficiency, or
a coagulation
factor
deficiency
 Provide
safety
measures to
prevent
bleeding
 Prothrombin is a protein produced by your liver that helps your blood to clot. When
you bleed, a series of chemicals (clotting factors) activate in a stepwise fashion. The
end result is a clot which stops the bleeding. One step in the process is prothrombin
turning into another protein called thrombin. A prothrombin time test can be used
to check for bleeding problems. PT is also used to check whether medicine to
prevent blood clots is working.
 Increased PT may also be due to: Bile duct obstruction, liver disease, vitamin K
deficiency, etc.

26. 26
HEMATOLOGY
Date done: March 26, 2013
Normal
Values
Result Interpretion Indication
Nursing
Responsibilities
Hemoglobin M: 14-18
F:12-16 12.8 g/dl
normal
RBC M:4.5-5.0
F:4.0-4.5
4.7 x
10^12/L elevated
 May indicate
dehydration.
 Monitor for
signs of
dehydration
Hematocrit M: 40-54
F:37-47
37.1%
normal
Platelet
count
150-400 274
normal
WBC 5-10 5.8 x 10^9/ L normal
Differential
count:
Neutrophil
Segmenters
40-75 57.9 %
normal
Lymphocytes 20-45 47% Elevated  acute
bacterial and
viral
infections
 acute-phase
reactions
(observed as
a response to
acute stress).
 Assess pt.
for signs
and
symptoms
of infection
 Administer
meds as
ordered
Monocytes 2-6 4.9 % normal
 Lymphocyte is a type of white blood cell present in the blood. Approximately 15% to 40%
of white blood cells are lymphocytes. Lymphocytes help provide a specific response to
attack the invading organisms.
 Increase in lymphocytes is generally the result of acute bacterial and viral infections,
leukemias, lymphomas, ulcerative colitis, and acute-phase reactions (observed as a
response to acute stress

27. 27
CLINICAL CHEMISTRY
Date done: March 26, 2013
Normal
Values
Result Interpretion Indication Nursing
Responsibilities
GENERAL
Glucose 3.05-6.38 5.43 mmol/L normal
BUN 2.15-7.16 3.42 mmol/L normal
Creatinine 45-84 53.04mmol/
L
normal
Total
BILIRUBIN
0-18.8 19.1 µmol/L Elevated  May be due
to hemolysis
 disease of
the liver
 presence of
gall stones
in the bile
duct
 Assess patient’s
skin color
 Observe for any
untoward signs
and symptoms
LIPIDS
Cholesterol
0-5.2 6.02
mmol/L
Elevated  hyperlipide
mia
 Health teachings:
importance of
keeping the diet
low in fatty food,
especially food
containing
saturated fat, and
eat lots of fruit,
vegetables
Triglycerides 0.2.3 0.87 mmol/L normal
HDL-
cholesterol
No risk:
>1.68
Moderate
risk
Moderate
: 1.15-
1.68
1.65 mmol/L
High risk:
< 1.15
LDL-
cholesterol
0-3.37 3.02 mmol/L normal
ENZYMES
SGOT 0-145 13.0 µ/L normal
SGPT 0-31 28 µ/L normal

28. 28
 Bilirubin is a byproduct of the liver processing waste. When the liver isn't functioning
properly, bilirubin may begin to build up in the body.Causes are Liver failure, Gilbert
syndrome, gallbladder infections and certain medications such as antibiotics, pain
relievers and birth control pills, can all cause adults to have high bilirubin levels.
Pancreatic cancer, allergic reaction to a blood transfusion, hepatitis, blocked bile ducts
and sickle cell anemia can also cause high levels
 Cholesterol is a fatty substance known as a lipid and is vital for the normal functioning
of the body. It is mainly made by the liver but can also be found in some foods we eat.
 Having an excessively high level of lipids in your blood (hyperlipidemia) can have an
effect on your health. High cholesterol itself does not cause any symptoms, but it
increases your risk of serious health conditions.
 Cholesterol is carried in your blood by proteins, and when the two combine they are
called lipoproteins. There are harmful and protective lipoproteins known as LDL and
HDL, or bad and good cholesterol.
 Low-density lipoprotein (LDL): LDL carries cholesterol from your liver to the cells
that need it. If there is too much cholesterol for the cells to use, it can build up in the
artery walls, leading to disease of the arteries. For this reason, LDL cholesterol is
known as "bad cholesterol".
 High-density lipoprotein (HDL): HDL carries cholesterol away from the cells and
back to the liver, where it is either broken down or passed out of the body as a waste
product. For this reason, it is referred to as "good cholesterol" and higher levels are
better

29. 29
X-RAY EXAMINATION
Date done: March 26, 2013
CHEST:
Lung fields are clear
Pulmonary vascular markings are normal
Heart is not enlarged
Diaphragm, sulci and bony thorax are unremarkable.
Impression:
NORMAL CHEST FINDINGS
CLINICAL MICROSCOPY (URINALYSIS)
Date done: March 26, 2013
Normal
Values
Result Interpretion Indication Nursing
Responsibilities
PHYSICAL
Color
Varying
degrees of
yellow
yellow
normal
Transparency clear
Slightly
turbid
abnormal
 bacterial
infection
 Advice pt. for
adequate
hydration and
personal
hygiene
Reaction
Usually
acidic
acidic normal
Specific
Gravity
1.000-
1.038
1.025 normal
CHEMICAL
Protein negative negative normal
Sugar negative negative normal
MICROSCOPIC
Red blood
cells
0-2/ hpf
Pus cells 1-3/ hpf 5-7/hpf abnormal
 Bladder
infection
 Assess for
possible signs
of infection
 Health
teachings
about hygiene
Epithelial
cells
negative + abnormal
 bladder
infection
 Avoid
contaminatio

30. 30
n of sample
Amorphous
Urates
negative few abnormal
 uric acid
stone,urolithi
asis.
 Report the
findings to the
physician
Mucous
threads
negative few abnormal
 irritation,
inflammation,
or infection in
the urinary
tract
Bacteria negative + abnormal
 bacterial
infection
 Administer
meds as
ordered
 Urinalysis can be simply explained as the analysis of urine, which helps to detect
certain diseases. This test can provide valuable information regarding the health
condition of the person. While urinalysis is mainly conducted to find out the diseases of
the urinary system, it may also come up with some information that can point towards
other medical conditions.
 Turbid (cloudy) urine may be a symptom of bacterial infection, but can also be
caused by crystallization of salts. It is usually considered abnormal. It may be the
result of blood, pus, sperm, or bacteria present in the urine.
 Possible causes of the presence of pus cells in urine include: Kidney infection, Bladder
infection, Infection in urethra, Inflammation due to presence of bladder stones or kidney
stones, Immune disorders, Allergies or growths anywhere along the genitourinary system.
 In case of older females, parabasal squamous epithelial cells (smallest and immature
epithelial cells of the vagina) may be found in urine samples. This is mostly seen in
post-menopausal women, who have low estrogen levels. Large number of transitional
cells in the urine could be an indication of some health problem. One of the possible
causes is bladder infection.
 Amorphous Urates indicates uric acid crystals in the urine. Higher than acceptable
levels of uric acid crystals in urine can be caused by gout, Lesch-Nyhan syndrome,
cardiovascular disease, diabetes, uric acid stone, urolithiasis, and metabolic syndrome.
 Mucus threads in a urinalysis are considered to be normal in small amount of them.
They appear long, thin, and wavy ribbon like. If there is a large amount of them, it may
mean there is an irritation, inflammation, or infection in the urinary tract.
 Bacteria are common in urine specimens because of the abundant normal microbial
flora of the vagina or external urethral meatus and because of their ability to rapidly
multiply in urine standing at room temperature. Therefore, microbial organisms found
in all but the most scrupulously collected urines should be interpreted in view of clinical
symptoms.

31. 31
Name of
Drug
Action/
Classification
Indication Contraindication Side Effect Adverse Effect
Nursing
Consideration
CEFUROXIME
(elixime) 750
mg TIV
 Inhibits cell wall
synthesis promoting
osmotic instability
usually bactericidal.
 Pharyngitis,
 tonsillitis,
 otitis media,
 lower respiratory
infections,
 UTI,
 gonorrhea,
 dermatologic
infections,
 treatment of early
Lyme disease.
 Contraindicated in
patients hypersensitive
to drug or other
cephalosporin.
nausea
vomiting
stomach pain
mild diarrhea
cough
stuffy nose
musclepain
joint pain or swelling;
headache,
drowsiness
feeling restless,
irritable, or hyperactive
mild itchingor skin rash.
 Large doses can cause
cerebral irritation and
convulsions;
 nausea,
 vomiting,
 diarrhea,
 GI disturbances;
 erythema multiforme,
Stevens-Johnson
syndrome,
 epidermalnecrolysis.
 Potentially Fatal:
 Anaphylaxis,
 nephrotoxicity,
 pseudomembranous
colitis.
 Check for
history: Hepatic and
renal impairment,
lactation, pregnancy
 Check the Physical: Skin
status, LFTs, renal
function tests, culture of
affected area, sensitivity
tests
MIDOZALAM
(dormicum)2.5
mg IV
Short acting
hypnotic
 Depresses the limbic
system and reticular
formation by
increasing or
facilitating the
inhibitory
neurotransmitter
activity.
 Sedation in pre
surgical or
diagnostic
procedures,
 induction and
maintenance of
anesthesia.
 Pregnancy, glaucoma,
premature infants.
 cough,
 wheezing,
 weak or shallow
breathing
 slow heart rate
 seizure (convulsions)
 Amnesic episodes,
 nausea,
 vomiting, headache
 ,drowsiness.
 monitor drug
effectiveness
 assess for apnea,
respiratory depression
which may be increased
in elderly.
 assess degree of amnesia
 assess injection site
 ensure the availability of
resuscitation equipment,
oxygen to support
airway.
DRUGS STUDY
REPORTER: TATAD, CARISZA ARMINA

32. 32
NALBUPHINE
(nubain) 5 mg
IV
Analgesic
 Binds with opiate
receptors in the
CNS; ascending pain
pathways in limbic
system, thalamus,
midbrain, altering
perception of
emotional response
to pain. Relieves
pain.
 Relief of moderate
to severe pain;
 pre op analgesia;
 supplement to
balanced
anesthesia; surgical
anesthesia;
obstetrical
analgesia.
 Hypersensitivity,
pregnancy.
 weak or shallow
breathing;
 fast or slow heart rate
 cold, clammy skin
 confusion,
 hallucinations,
 unusualthoughts or
behavior;
 severe weakness or
drowsiness;
 feeling like you might
pass out.
 Sedation,
 drowsiness,
 sweating,
 nausea,
 dry mouth,
 dizziness,
 headache,
 vomiting.
 Assess patients
condition before
therapy, obtain drug
history.
 monitor vital signs
especially respiratory
rate.
 discuss with patient that
dizziness, drowsiness,
confusion are common.
 instruct patient to
change position slowly
and avoid getting up
without assistance.
DICLOFENAC
(dosanac)
75 mg IM
(intragluteal)
single dose
 Inhibits
cyclooxygenase
(COX), an enzyme
needed for the
biosynthesis of
prostaglandin,
subsequent
decrease in
prostaglandin
result to the
analgesic,
antipyretic and anti
inflammatory
effects.
 Relief of pain and
inflammation in
various
conditions; joint
disorders and
other painful
conditions
following some
surgical
procedures.
 Asthmatic patients,
 urticaria,
 acute rhinitis,
 peptic ulcer.
 chest pain,
 weakness, shortness
of breath,
 slurred speech,
 problems with vision
or balance;
 black, bloody, or tarry
stools coughing up
blood or vomit that
looks like coffee
grounds
 swelling or rapid
weight gain,
 urinating less than
usualor not at all;
 Edema,
 water retension,
 hypertension,
 nausea,
 vomiting,
 diarrhea,
 abdominal cramps,
 dyspepsia,
 anorexia,
 headache,
 dizziness,
 vertigo,
 rash.
 Assess patients and
family's knowledge of
drug therapy.
 Teach patient that drug
must be continued to
prescribe time to be
effective.
 Inform patient that drug
may be taken with food
or milk to prevent GI
distress.
 Do not crush or chew
drugs.
 Instruct patient to use
caution when driving
because drowsiness,
dizziness may occur.
 Teach patient to take
with full glass of water
to enhance absorption.
RANITIDINE
(raxide)
50 mg IV q8
 Inhibits histamine at
H2, receptor site in
the gastric parietal
cells, which inhibits
gastric acid
secretion.
 Management of
various GI
disorders like
dyspepsia, GERD,
peptic ulcer.
 Hypersensitivity. history
of acute porphyria. long
term therapy.
 constipation,
 diarrhea,
 fatigue,
 headache,
 insomnia,
 muscle pain,
 nausea,and
vomiting.
 Cardiacarrythmias,
 bradycardia,
 headache,
 fatigue,
 dizziness,
 depression,
 insomnia,
 nausea,
 take exactly as directed.
do not increase dose, mat
take several days before
 noticeable relief.
 avoid alcohol
 follow diet as physician
reccomends.
 use caution when driving

33. 33
 vomiting,
 abdominal discomfort,
 diarrhea,
 constipation
 pancreatitis.
or engaging in tasks
requiring alertness.
 report chest pain or
irregular heartbeat.
TRAMADOL
(tiamide)
100 mg IV q8
PRN for pain
 Centrally acting
analgesic not
chemically related
to opioids but binds
to mu-opioid
receptors and
inhibits reuptake of
norepinephrine and
serotonin.
 Moderate to severe
pain
 Hypersensitivity.
 acute intoxication with
alcohol,
 hypnotics,
 centrally acting
analgesics,
 opioids, or psychotropic
agents.
 agitation,
 hallucinations,
 fever,
 fast heart rate,
 overactive
reflexes,
 nausea,
 vomiting,
 diarrhea,
 loss of
coordination,
 fainting;
 seizure
(convulsions);
 a red, blistering,
peeling skin rash;
 shallow
breathing, weak
pulse.
 Vasodilatation,
 dizziness,
 headache,
 anxiety,
 confusion,
 coordination
disturbances,
nervousness,
 sleep disorder
 seizures.
 assess patients pain
 monitor input and output
ratio and check
decreasing output which
may indicate retention.
 assess patients
knowledge on drug
therapy
 advice patient to avoid
alcohol and OTC
medication without
medical advice.
 warn ambulatory
patients to be careful
when getting out of bed
or walking without
assitance.
KETOROLAC
(ketodol) 30 mg
IV q8
Analgesic
 analgesic,
 anti- inflammatory
 antipyretic.
 short term
management of
moderate to
severe acute post-
operative pain.
 active peptic ulcer
disease,
 renal impairement,
 dehydration,
 during labor or delivery,
lactation,
 history of asthma.
chest pain or heavy
feeling, pain
spreading to the arm
or shoulder, nausea,
sweating, general ill
feeling;sudden
numbness or
weakness, especially
on one side of the
body;sudden severe
headache, confusion,
problems with vision,
speech, or
balance;black,
bloody, or tarry
 ocular irritation,
 allergic reaction,
 acute renal failure,
 liver failure,
 hypertension,
 rash,
 nausea,
 diarrhea,
 headache,
 drowsiness.
 Assesspatients pain
before and 1 hour after
treatment.
 Assess for
hypersensitivity
reactions.
 Advise patient to report
persistence or worsening
of pain.
 Instruct patient to report
bleeding, bruising,
fatigue.
 Instruct patient to use
caution when driving
because drowsiness and
dizziness may occur.

34. 34
stools;
coughing up blood
or vomit that looks
like coffee
grounds;slow heart
rate;
HYDRO
CORTISONE
(solucortef) 250
mg, 125 mg IV
and 125 mg 1
hour prior to OR
Adrenal
corticosteroid
 glucocorticoid with
anti- inflammatory
effect because of its
ability to inhibit
prostaglandin
synthesis. it can also
cause the reversal of
increases capillary
permeability.
 treatment of
primary or
secondary
adrenal cortex
insufficiency,
 rheumatic
disorders,
 collagen
diseases,
 dermatologic
disease,
 allergic states,
 hematologic
disorders.
 fungal infections,
 psychosis,
 acute
glomerulonephritis,
 amebiasis,
 nonasthmaticbrochial
disease;
 children less than 2
years old,
 AIDS,
 TB.
problems with
your
vision;swellin
g, rapid
weight gain,
feeling short
of
breath;severe
depression,
unusual
thoughts or
behavior,
seizure
(convulsions);
bloody or
tarry stools,
coughing up
blood;
 Depression,
 Flushing,
 sweating,
 headache,
 mood changes,
 hypertension,
 circulatory collapse,
 thrombophlebitis,
 embolism,
 tachycardia,
 edema,
 fungal infections,
 blurred vision,
 diarrhea,
 nausea,
 abdominal
distension.
 Warn patient receiving
long term therapy about
Cushingoid symptoms.
 Advise patient to
wear/carry emergency
ID as steroid user.
 Instruct patient to notify
physician of decreased
therapeautic response
for proper dose
adjustment.
 Instruct patient to
monitor and report signs
of infection.
PARACETAMOL  Decrease fever by
inhibiting the effects
of pyrogens on the
hypothalamic heat
regulating centers
and by
hypothalamic action
leading to sweating
and vasodilation.
Relieves pain by
inhibiting
prostaglandin
synthesis at the CNS
but does not have
anti-inflammatory
action because of its
 Relief of mild to
moderate pain;
 treatment of
fever.
 Hypersensitivity;
intolerance to
tartrazine, alcohol, table
sugar, saccharin.
 rashes
 shortness of breath
 low numbers ofwhite
blood cells
(leucopenia)
 Stimulation,
 drowsiness,
 nausea,
 vomiting,
 abdominal pain,
 hepatotoxicity,
 hepatic seizure
 renal failure,
 rash,
 urticaria,
 cyanosis,
 anemia,
 jaundice.
 Assess patients fever or
pain.
 Advise patient to avoid
alcohol
 Teach patient to
recognize signs of
chronic overdose.
 Tell patient to notify
physician for pain or
fever lasting for more
than 3 days.

35. 35
minimal effect on
peripheral
prostaglandin
synthesis.
ISOFLURANE
(Forane)
50 ml
 Inhibits
neurotransmitt
er release
 Inductionand
maintenance
of general
anesthesia.
 Hypersensitivityto
isoflurane orto
otherhalogenated
agents,historyof
malignant
hyperpyrexia;
susceptibilityto
malignant
hyperthermia.
 malignant
hyperthermia
shivering
 respiratory
depression
 hypotension,
 arrhythmias,
 hepatic
dysfunction,
 hepatitis,
 nausea,
 vomiting.
 Arrhythmias,
elevationof WBC
counts,
hypotension,
respiratory
depression,
shivering,
nausea,and
vomitingduring
postoperative
period.
 Monitorpts. Vital
signsbefore,
during,andafter
the course of
therapy.
 Explaintothe pt.
the reasonand
processof
procedure.
 Informpatientof
postoperative side
effectssuchas
shivering,nausea
and vomiting.

36. 36
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
>”giniginaw
ako” as
verbalized by
the patient
OBJECTIVE:
> Temperature
of 36⁰C
>With presence
of Chills
Ineffective
thermoregulation due
to surgical
environment and
use of anesthetic
agents
Within 2- 3 hours
of nursing
intervention at
the PACU, the
patient’s
temperature will
improve from
36⁰C to 37.5⁰C
>Vital signs
monitored and
recorded especially
temperature
>Placed under
blanket
>Placed under
droplight
>Placed under
thermal blanket
>Room temperature
adjusted
>To have baseline
data in assessing
the progress of the
patient
>to help maintain
temperature
>To provide
warmth
>It will help to
regulate the heat
coming from the
droplight
>To help improve
patient’s
temperature
Goal partially
met as
manifested by
latest
temperature of
37⁰C
NURSING CARE PLAN
REPORTER: SERNA, JEROME and CORTEZ, OLIVER

37. 37
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
OBJECTIVE:
-with sterile
dressing on
post-op site
Impaired skin integrity
related to surgical
incision
There will be no
untoward signs &
symptoms
observed such as
discoloration,
foul odor and
excessive
bleeding at the
incision site after
the operation and
within the stay in
PACU.
>Assessed for any
untoward signs and
symptoms
>Changed dressing as
required with proper
aseptic technique
>To determine the
condition of the
patient
>To promote easy
drying of wound
and to prevent
infection
After the
operation and
within the stay
in PACU, the
patient was
properly
assessed with
no untoward
signs &
symptoms such
as discoloration,
foul odor and
excessive
bleeding at the
incision site.

38. 38
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
“parang di ko pa
maigalaw ang
katawan ko” as
verbalized by
the patient.
OBJECTIVE:
-needs
assistance when
moving
-unable to
perform full
range of motion
by command
- unable to turn
to sides without
assistance
Activity intolerance
related to generalized
muscle relaxation due
to remaining effect of
the anesthesia used in
the surgery
After 2-3 hours of
nursing
intervention at
the PACU the
patient will
manifest
improvement of
activity within
her limitations
>Established rapport
>Assessed for any
untoward
manifestations
related to fading
effects of anesthesia
such as jerking and
drooling noted
>Assessed and
assisted patient in
light ROM
>Vital signs
monitored and
recorded
>Adequate rest
provided
>To gain trust and
cooperation
>To know if the
effect of the
anesthetic agent is
exceeding the
normal range of
duration used in
the patient
>For general
assessment of
patient including
the effects in
accordance with
the duration of the
anesthetic agents
used
>To establish
baseline data
>To prevent
fatigue and to
conserve energy
Within 2-3
hours of nursing
intervention at
the PACU the
patient was able
to practice
simple range of
motion exercise
such as light
stretching with
assistance and
precautions.

39. 39
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED
OUTCOME
OBJECTIVE
-reduced level
of
consciousness
-depressed
cough and gag
reflex
-impaired
swallowing
Risk for aspiration
related to depressed
gag & cough reflex
secondary to
induction of general
anesthesia
After 2-3 hours of
nursing
intervention at
the PACU, the
patient will be
able to maintain
safety and
demonstrate
behaviours of
return of reflexes
>Vital signs
monitored and
recorded
>Encouraged deep
breathing and
coughing reflex
>Patent airway
maintained by
suctioning as
necessary
>Positioned the
patient on moderate
back rest
>For baseline data
>To assess reflexes
altered by
anesthesia used in
the patient,
prevent atelectasis
and improve
pulmonary
functions and
breathing pattern
>Airway
obstruction
impedes
ventilation and to
avoid aspiration.
>To prevent
aspiration and to
promote lung
expansion.
The patient did
not show any
signs of fluid
accumulation
like crackles and
was maintained
on NPO status

40. 40
>Lung fields
auscultated
>Maintained on NPO
status
>To assess if there
are accumulation
of secretions and
assess the need for
suctioning.
>To prevent
aspiration until the
gag reflex returns

41. 41
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED
OUTCOME
Objective
-Decreased level
of
consciousness
(Lethargic)
-Slightly pale in
color
Risk for injury related
to decrease level of
consciousness
secondary to
administration of pre-
operational
medications
The patient will
not experience
any physical
injury from
perioperative up
to post-operative
state.
>Raised side rails
while transferring to
operating room.
>Positioned patient
properly on the
operating room table
with proper
transferring
techniques.
>Proper restraints
attached to the
patient while on the
operating room table
>Proper grounding
pads placed
>To protect and
prevent the patient
from fall out of the
stretcher
>To assure safety
of the patient &
avoid further
injury such as c-
spine fracture.
>To prevent the
patient’s arm and
body to move and
so to prevent fall.
>To prevent burns
There are no
physical injuries
seen to patient
such as bruises
or fractures
related to fall
from
perioperative up
to post-
operative state.

42. 42
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED
OUTCOME
OBJECTIVE:
-with sterile
dressing on
post-op site.
Risk for infection
related to inadequate
primary defense
mechanism as
manifested by post
operative incision
Prevent patient
from having
infection
throughout the
operation and 2-3
hours of stay at
the PACU
>performed proper
hand washing
technique and
surgical hand scrub
by all surgical team of
the client
>Surgical team
practiced strict
sterility within the
operating room upon
assisting in surgery
>Checked for any
break in the sterility
such as tear of
packaging and
expiration date of
equipment that will
be used in the
>A first-line
defense against
nosocomial
infection/cross-
contamination, on
the operative
wound by bacteria
on the hands and
arms.
>breaking sterility
inside the
operating room
while in surgical
operation may lead
to further
complication and
high risk for
infection
>To prevent
possible
contamination of
sterile field
The patient
tolerated the
procedure and
did not show
any signs of
infection like
fever and chills

43. 43
operation
>Vital signs
monitored and
recorded
>Kept incision site dry
and intact at all times
>Medications
administered as
prescribed by the
physician
>To have baseline
data in assessing
the progress of the
patient
>soaked dressing
can harbor
bacteria causing
further infection
and complication
to the patient
>For prophylaxis
and to prevent
infection

44. 44