Acute Calculous Cholecystitis Case Study (PDF)

ACUTE CALCULOUS CHOLECYSTITIS WITH CONTROLLED HYPERTENSION: POST-LAPAROSCOPIC CHOLECYSTECTOMY CARE AND MANAGEMENT A Case Study Presented to the Faculty of the Nursing Program of Lourdes College Cagayan de...

ACUTE CALCULOUS CHOLECYSTITIS WITH CONTROLLED HYPERTENSION: POST-LAPAROSCOPIC CHOLECYSTECTOMY CARE AND MANAGEMENT A Case Study Presented to the Faculty of the Nursing Program of Lourdes College Cagayan de Oro In Partial Fulfillment Of the Requirements for the NCM 112: Care of Clients with Problems in Oxygenation, Fluids and Electrolytes Submitted by: Libres, Jessie Allen P. Perez, Kyle Angel Marie O. Pimentel, Angel Jade A. Salo, Redeemer M. Sarip, Hanifa H. Soberano, Krushnaia A. Yee, Kent Justin P. November 18, 2024  ACKNOWLEDGMENT This case study could not have been done without the support and assistance of numerous individuals whose names cannot be enumerated individually. However, we extend our warm appreciation and acknowledges their contribution to the success of this endeavor. Most of all, we would like to thank the Almighty Father for giving us the strength of body, solemnity of spirit, purity of soul, and for the provision of knowledge and wisdom for us to finish this study. We thanked Him with all our hearts, minds, and souls. We would also like to extend our deepest thanks and gratitude to Dr. Madeleine C. Zamayla, RN, MAN, Dean of the Allied Health Program, for the endless support and guidance for us to finish this case study. Warmest thanks are also extended to Ms. Sheryl Caseres, RN and Mr. Roy A. Neri, Jr., RN, MN, Medical-Surgical Nursing Clinical Instructors, for the ever-supportive spirits, patience, understanding, and genuine advice in imparting the necessary knowledge for this paper. We would also like to thank Mr. Roy Gumayao, RN, Mr. Ednichson Alpas, RN, and Mr. Arsenio Poral, Jr., RN, MAN, for the benevolent advices for the betterment of this paper. Additionally, the researcher would also like to thank his family for their holistic support, especially in financial and moral matters. Without their benevolent help, the researcher could not have made this paper possible.  TABLE OF CONTENTS Page I. INTRODUCTION 1 A. Overview of the Study 3 B. Objectives of the Study 4 C. Scope and Limitation of the Study 6 II. HEALTH PROFILE A. Patient’s Profile 7 B. Chief Complaint C. History of Present Illness D. Medical History 8 E. Family History F. Surgical History III. COMPREHENSIVE NURSING ASSESSMENT A. First Assessment 10 B. Second Assessment 13 IV. ANATOMY AND PHYSIOLOGY A. Gastrointestinal System 16 B. Pathophysiology 19 V. MEDICAL AND NURSING MANAGEMENT A. Ideal Nursing Management 21 B. Actual Nursing Management 22 C. Drug Study 24 VI. NURSING CARE PLAN 28 VII. DISCHARGE CARE PLAN A. Daily Routine 34 B. Treatment 35 C. Health Teaching 36 D. Diet 38 VIII. CONCLUSION, EVALUATION, AND PROGNOSIS A. Conclusion 40 B. Evaluation 41 C. Prognosis 42 IX. RECOMMENDATION 43 X. APPENDICES 44 XI. REFERENCES 55  Chapter 1 INTRODUCTION Acute calculous cholecystitis is a prevalent inflammatory condition of the gallbladder that occurs when the cystic duct becomes obstructed by gallstones, leading to irritation, inflammation, and potential necrosis of the gallbladder wall. According to Jones, et al. (2023), the risk for gallbladder disease most specifically cholecystitis is more prevalent to women aging 40 years old and above. Also, according to Genova, et al. (2023), cholecystitis can run in families. This means this could be pass from one generation to another in the bloodline. The international study of Patel, et al. (2024) in BMJ Publishing Group about a 45-year-old woman with a 2-year history of gallstone who presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner, states that cholecystitis develops in up to 10 percent of patients with symptomatic gallstones. In most cases (90 percent), it is caused by complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall. This is supported by the national study of O’Rourke, et al. (2023), stating that about 95 percent of people with acute cholecystitis have gallstones. However, that does not mean incidental findings of gallstone should be treated, as it is estimated that only 20 percent of patients with asymptomatic stones will develop symptoms within 20 years, and because approximately 1 percent of patients with asymptomatic stones develop complications of their stones before the onset of symptoms, prophylactic cholecystectomy is not warranted in asymptomatic patients. Furthermore, for symptomatic patients, the most appropriate management of cholecystitis is laparoscopic cholecystectomy. The local study of Reyes, et al. (2021), states that this condition accounts for a significant portion of gallbladder disease presentations, manifesting predominantly in adults and especially in those with pre-existing risk factors such as obesity, advanced age, and metabolic syndromes. The management strategies for this condition must be comprehensive, particularly for patients with underlying comorbidities such as hypertension, which can complicate both surgical interventions and recovery. This case study focuses on a patient diagnosed with acute calculous cholecystitis alongside controlled hypertension who underwent laparoscopic cholecystectomy—a procedure recognized for its minimally invasive nature and favorable postoperative outcomes. The decision to perform laparoscopic cholecystectomy is often guided by clinical presentations that include classic symptoms such as severe right upper quadrant pain, fever, and leukocytosis, all of which characterize acute cholecystitis. However, the interplay of chronic conditions like hypertension adds layers of complexity to the patient's perioperative care, emphasizing the importance of a meticulous and individualized management plan. This case study not only delves into the pathophysiology and clinical presentation of acute calculous cholecystitis but also emphasizes the intricate relationship between surgical intervention and chronic disease management, particularly in patients with hypertension. By exploring the specific needs of this patient population, this analysis aims to contribute to a broader understanding of effective nursing strategies and interdisciplinary approaches in managing complex cases, ultimately enhancing patient outcomes and quality of care in surgical settings. The findings and insights gleaned from this case study will serve as a valuable resource for healthcare professionals in optimizing care for patients with acute cholecystitis, particularly those with concurrent chronic conditions. Overview of the Study Patient T was admitted to the hospital on October 7, 2024, with a chief complaint of severe abdominal pain rated 10/10 on the pain scale, particularly in the right upper quadrant. The patient's family reported that the abdominal pain had been worsening over the previous two months, accompanied by intermittent vomiting. The patient, a 56-year-old widowed woman currently living with a partner in Lower Palalan, Lumbia, Cagayan de Oro City, has a notable medical history, including hypertension, angina, and a previous ischemic stroke, which are critical factors in her overall health status. Upon admission, the nurse performed a comprehensive assessment, revealing that Patient T exhibited significant distress due to abdominal pain and had an associated productive cough that began shortly after her admission. Her vital signs indicated controlled hypertension, with a blood pressure of 140/70 mmHg, yet she experienced bradycardia with a pulse rate of 57 bpm. The patient's respiratory support was set at 1 liter per minute via nasal cannula due to the cough, which she attributed to exposure to vehicular fumes from living near a highway. Diagnostic imaging, specifically an abdominal ultrasound conducted on September 24, 2024, revealed the presence of gallstones in the gallbladder, prompting the surgical team to schedule a laparoscopic cholecystectomy to address the acute calculous cholecystitis. This condition is characterized by inflammation of the gallbladder often resulting from the obstruction caused by gallstones, leading to potential complications if not treated promptly. The nursing care plan for Patient T focuses on managing her acute symptoms while considering her chronic health issues. Interventions include pain management through medication administration, monitoring of vital signs, and assessing the patient’s neurological status due to her history of stroke. The nursing team also emphasizes patient education regarding the importance of medication adherence and lifestyle modifications to manage her hypertension and prevent future complications. Objectives of the Study General Objective The objective of this case study is to underscore the significance of prompt identification, diagnosis, and management of acute calculous cholecystitis in patients with underlying comorbidities, such as hypertension and a history of stroke. This case study aims to highlight the critical role of nursing care in delivering comprehensive preoperative and postoperative support, ensuring effective monitoring, and addressing potential complications. A multidisciplinary approach, involving collaboration among healthcare professionals—including physicians, nurses, and dietitians—is essential for optimizing patient outcomes. The primary focus of care is to alleviate pain, maintain stable vital signs, ensure proper nutritional intake, and prevent postoperative complications while managing the patient’s chronic health conditions effectively. Specific Objective At the conclusion of the patient interaction, the student nurse will be able to achieve the following goals through the specific actions aligned with nursing core values: a) Knowledge: The student nurse will develop an understanding of acute calculous cholecystitis, including its pathophysiology, clinical manifestations, treatment options, and potential complications associated with the condition, particularly in patients with comorbidities like hypertension and a history of stroke. b) Skills: The student nurse will apply essential nursing skills in assessing the patient’s condition, administering prescribed medications, managing postoperative pain, and ensuring appropriate nutritional intake while utilizing clinical judgment to prioritize care based on the patient’s needs and acuity level. c) Attitude: The student nurse will foster a therapeutic nurse-patient  relationship, enhancing communication and rapport with the patient and their family. This includes demonstrating empathy, patience, and respect throughout the care process, ensuring that the patient feels supported and valued during their recovery. Scope and Limitation of the Study The scope of this case study focuses on the post-laparoscopic cholecystectomy care and management of a patient diagnosed with acute calculous cholecystitis and controlled hypertension. A comprehensive overview of the patient’s medical history, presenting symptoms, diagnostic assessments, and the rationale behind the chosen treatment options is also included. On the other hand, the limitations imposed in this case study includes the limited timeframe which only encompasses the assessments conducted on October 14 and 15, 2024. This timeframe facilitates an analysis of acute management strategies and does not fully capture the long-term recovery process or the eventual rehabilitation needs that might arise following her discharge.  Chapter 2 HEALTH PROFILE 2.1 Patient’s Profile Patient T is a 56-year-old female residing in Lower Palalan, Lumbia, Cagayan de Oro City, Misamis Oriental. She was born on January 8, 1968, in the same locality and is currently widowed but has a live-in partner. Patient T has four children in her previous partner and finishes secondary education but due financial constraints, she was not able to proceed to college. She is a member of the Tribu Alimaong tribe under the leadership of Datu Dimantag as the chieftain. Patient T practices Roman Catholic faith while incorporating tribal customs into her life, such as participating in family blessing rituals known as “Panumpay”. 2.2 Chief Complaint Patient T was admitted to the hospital with a primary complaint of intense abdominal pain, which she rated as 10 out of 10 in the right upper quadrant (RUQ). Along with the pain, she experienced frequent nausea and episodes of vomiting, which had worsened significantly in the days leading up to her admission. 2.3 History of Present Illness Two months prior to admission, noted onset of intermittent sharp right upper quadrant (RUQ) pain associated with vomiting. Consulted at the emergency room and abdominal ultrasound performed on September 24, 2024. The patient was then scheduled for a laparoscopic cholecystectomy surgery. Six hours prior to admission, noted increased intensity of pain in the right upper quadrant rated as 10/10 in the pain scale with vomiting. Hence, patient was admitted. 2.4 Medical History In 1997, she underwent a cesarean section for the delivery of a male neonate in breach position. In 2013, was admitted to the hospital due to an ischemic stroke where she can only move her head and the rest of her body remains immovable. Additionally, she has a history of heart failure, diagnosed in 1974. Patient T has no known allergies food, only medication specifically noting a past allergic reaction to Cotrimoxazole in 2005, which presented with swelling, redness, and itching. 2.5 Family History Patient T’s family history reveals a concerning pattern of cardiovascular health issues. As verbalized by the patient, both maternal and paternal relatives have a documented history of hypertension, indicating a hereditary predisposition to elevated blood pressure. Furthermore, both of her parents and her sister in sixth birth order died because of heart attack. Refer to genogram at chapter ten for further elaborations. 2.6 Surgical History Patient T’s surgical history includes a significant procedure in 1997 when she underwent a cesarean section for the delivery of her male neonate in breach position. More recently, on October 10, 2024, she had a laparoscopic cholecystectomy performed due to acute calculous cholecystitis, which was necessitated by the presence of gallstones discovered during an abdominal ultrasound.  Chapter 3 COMPREHENSIVE NURSING ASSESSMENT 3.1 First Assessment (October 14, 2024) Respiration Patient T’s respiratory rate was recorded at 19 cycles per minute (cpm), which falls within the normal range. However, she exhibited a productive cough characterized by yellow sputum with a nicotine odor as verbalized by the patient, which began post-operatively on October 12, 2024. Upon auscultation, adventitious breath sounds, specifically crackles, suggesting the presence of secretions and airway obstruction. Her oxygen saturation levels were measured at 96% and she has an oxygen support at 2 liters per minute (lpm), indicating adequate oxygenation. Patient T reported discomfort from her cough, which highlighted the need for interventions aimed at airway clearance and respiratory support. Thus, Salbutamol neb was administered on the patient as advised by the physician. Additionally, Patient T revealed that she smokes 1 pack of cigarette per day before her admission in the hospital which means she smoked 7,300 cigarettes in 34 pack years since 1990 according to Roswell Park Comprehensive Cancer Center’s formula. Circulation Patient T’s blood pressure was recorded at 140/70 mmHg, while her heart rate was significantly low at 57 beats per minute (bpm), indicating bradycardia. The heart rhythm was regular. Peripheral circulation appeared adequate, with a capillary refill time (CRT) of less than 2 seconds, suggesting good perfusion. However, she reported numbness in her lower extremities, raising concerns about potential circulatory deficits. A comprehensive vascular assessment revealed a carotid pulse of 68 bpm (normal) and a radial pulse of 57 bpm. Cognitive and Perception / Sensory Reflexes The patient verbalized experiencing minimal body weakness, however, displayed normal motor function and sensation, with effective coordination. The patient’s Glasgow Coma Scale (GCS) score was 15 scoring 4 in eye opening, 5 for verbal response, and 6 for motor response, indicating full alertness and orientation. On her eye and visual assessment relating to optic nerve functioning as a part of her sensory reflex, the patient’s cardinal fields of gaze are normal, his pupils are equally round, reactive to light and accommodation measuring 3 mm upon examining using a penlight. However, the patient mentioned having orthostatic hypotension when rapidly getting up in bed. Nutrition / Metabolic Pattern Patient T reported consuming a typical diet that included oily foods such as fried chicken and pork chop, alongside stir-fried vegetables, pre-operatively. She was able to maintain eating three times a day with snacks. There were no reported issues with swallowing, indicating the absence of dysphagia. However, due to her recent surgery and postoperative state, careful monitoring of her caloric intake and nutritional status is essential to prevent malnutrition. Activity / Safety / Mobility Status Pre-operatively, Patient T’s live-in partner managed all the household chores, highlighting that her activities of daily living (ADLs) were light. Post- operatively, she has experienced restrictions on excessive movements due to pain at the surgical site, impacting her ability to ambulate independently. Elimination / Gastrointestinal Tract Patient T’s abdomen was observed to be distended, though bowel sounds were normal, indicating that gastrointestinal activity was functioning adequately. She reported her last bowel movement occurred on the same day at 11:30 a.m., suggesting that her bowel function remained regular. To manage her elimination needs post-operatively, she was wearing a diaper due to urinary incontinence, reflecting her reliance on assistance and her limited mobility during the surgical recovery process. 3.2 Second Assessment (October 15, 2024) Respiration During the second assessment, Patient T’s respiratory rate was recorded at 18 cycles per minute (cpm), still demonstrating normal cycles. She continued to have a productive cough, with yellow sputum still present; however, the amount of sputum appeared reduced. Oxygen saturation levels stabilized at 97%, indicating satisfactory oxygenation. Patient T reported decreased discomfort from her cough, reflecting the effectiveness of the nebulization therapy implemented previously. Circulation Patient T’s blood pressure was recorded at 130/80 mmHg, and her heart rate improved to 68 bpm, indicating normal pulse rate. Peripheral circulation appeared sufficient, with a capillary refill time (CRT) of less than 2 seconds, indicating effective perfusion. However, Patient T still reported numbness in her lower extremities. Cognitive and Perception / Sensory Reflexes Patient T exhibited full alertness and orientation, maintaining a GCS of 15. Patient reports the absence of weakness that she felt on the first assessment. The assessment of her eye and visual functions revealed normal cardinal fields of gaze and pupils that were equally round and reactive to light measuring 3 mm. Patient T continued to experience orthostatic hypotension when changing positions, though she reported improved awareness of her need to change positions slowly, enhancing her safety. Nutrition / Metabolic Pattern During the second assessment, Patient T’s dietary intake remained consistent, with a balanced consumption of three meals a day. She mentioned having soups on her meal and lessened the intake of oily foods. She demonstrated a good appetite, and there was no swallowing issues reported, indicating continued absence of dysphagia. Nutritional monitoring was ongoing, focusing on ensuring adequate caloric intake and hydration. Activity / Safety / Mobility Status Patient T remained dependent on her live-in partner for activities of daily living (ADLs), as she continued to follow post-operative movement restrictions. However, she demonstrated improved compliance with safety measures and was able to participate more actively in her own care by expressing needs and preferences regarding her mobility. Support systems in place were effective in ensuring her safety and facilitating her recovery. Elimination / Gastrointestinal Tract During the assessment, Patient T’s abdomen remained distended, but bowel sounds were normal, indicating adequate gastrointestinal activity. She reported her last bowel movement occurring on October 15 at 10:00 a.m., suggesting continued regular bowel function. To manage her elimination needs post-operatively, she was still wearing a diaper reflecting her ongoing reliance on assistance during recovery.  Chapter 4 ANATOMY AND PHYSIOLOGY 4.1 Anatomy and Physiology of the Gastrointestinal System The digestive system is a complex network of organs working in harmony to break down food, absorb nutrients, and eliminate waste, ensuring that the body receives essential energy and nourishment. This system begins with the mouth, where food is chewed and mixed with saliva to initiate carbohydrate digestion. From there, food passes through the esophagus to the stomach, where powerful gastric acids and enzymes further break down food particles, especially proteins. The partially digested food, now called chyme, moves into the small intestine, a lengthy, highly convoluted organ where most nutrient absorption occurs. Here, enzymes from the pancreas and bile from the gallbladder and liver mix with the chyme to aid in the breakdown of fats, carbohydrates, and proteins. The gallbladder, a small, pear-shaped organ located beneath the liver, plays a crucial role in the body’s ability to digest fats efficiently. It serves as a storage reservoir for bile, a digestive fluid produced by the liver. Bile is composed primarily of bile salts, bilirubin, cholesterol, and electrolytes, each of which contributes to its role in breaking down and absorbing dietary fats. When we eat, especially meals rich in fats, a hormone called cholecystokinin (CCK) is released, signaling the gallbladder to contract. This contraction propels stored bile through the cystic duct, which merges with the common bile duct, eventually delivering bile into the small intestine. There, bile salts work to emulsify fats, essentially breaking them into smaller droplets that can be more easily acted upon by digestive enzymes like lipase. This emulsification process is vital for the absorption of fat-soluble vitamins—A, D, E, and K—allowing them to enter the bloodstream and support various bodily functions. The gallbladder’s role in fat digestion, while essential, also makes it susceptible to certain complications. One of the most common issues is the formation of gallstones—solid particles that develop from the crystallization of cholesterol or bilirubin within bile. Gallstones can range from tiny grains to large stones that block the bile ducts, causing pain and potentially leading to severe complications like inflammation (cholecystitis) or infection. Blockages can also impair the flow of bile, causing jaundice, where bilirubin accumulates in the blood, leading to yellowing of the skin and eyes. In some cases, untreated blockages may result in pancreatitis, as bile may back up into the pancreas, triggering inflammation. These conditions can produce intense abdominal pain, fever, nausea, and vomiting, often requiring medical intervention, such as surgery to remove the gallbladder (cholecystectomy). Though not vital to life, the gallbladder’s presence optimizes fat digestion and absorption, making it a significant part of the digestive system’s functionality. 4.2 Pathophysiology of Acute Calculous Cholecystitis  Calculous cholecystitis begins with the formation of gallstones, typically due to an imbalance in bile components, such as excess cholesterol or bilirubin and low bile salts, leading to crystal and stone development. When a gallstone lodges in the cystic duct, it obstructs bile flow, causing bile to build up in the gallbladder. This blockage results in increased intraluminal pressure and distension, reducing blood flow to the gallbladder wall and leading to cellular injury and hypoxia. In response, the body triggers an inflammatory reaction, releasing mediators that cause swelling, pain, and further inflammation. The trapped bile can also encourage bacterial growth, leading to secondary infection, which worsens the inflammation. Together, these factors contribute to acute calculous cholecystitis, manifesting in symptoms such as severe pain in the right upper quadrant, fever, chills, nausea, vomiting, and abdominal tenderness. If untreated, complications like gangrene, abscess formation, or perforation of the gallbladder can occur.  Chapter 5 MEDICAL MANAGEMENT 5.1 Ideal Management The ideal management for a patient with acute calculous cholecystitis and a history of hypertension begins with a thorough and systematic assessment to establish a comprehensive baseline and identify any immediate needs. This includes closely monitoring vital signs, especially blood pressure, heart rate, and temperature, as fever may indicate infection. Pain assessment is crucial, as the patient likely experiences significant right upper quadrant pain. Ensuring adequate pain relief while assessing the effectiveness of interventions is important for patient comfort and cooperation. The diagnoses may encompass acute pain related to inflammation and obstruction, risk for infection due to potential bacterial colonization of bile, impaired physical mobility related to discomfort and surgery, and deficient knowledge regarding dietary and lifestyle modifications. The individualized care plan focuses on managing these diagnoses with realistic and measurable goals, such as reducing pain levels, preventing infection, and promoting understanding of dietary modifications. Interventions for pain management include administering prescribed analgesics and positioning the patient for comfort, often with the head of the bed elevated to reduce pressure on the inflamed gallbladder. Infection prevention involves monitoring for signs of infection (such as fever and changes in white blood cell count) and ensuring proper hand hygiene and aseptic technique in care. Educating the patient about diet modifications, particularly reducing fatty and oily foods, is essential to prevent further gallstone formation and decrease the risk of future attacks. Collaborating with a dietitian can provide the patient with a well-balanced diet plan, low in fat and high in fiber, to support digestive health. Encouraging mobility as tolerated, with assistance if needed, can prevent complications related to immobility, such as venous thromboembolism and decreased lung expansion. Monitoring for post-operative complications, such as bleeding or bile leakage, if surgery is indicated, is also essential. Lastly, providing emotional support and reinforcing education regarding the importance of lifestyle changes for long-term health are important, as this diagnosis may require significant dietary and behavioral adjustments. This holistic approach ensures comprehensive care, optimizes recovery, and helps reduce the risk of recurrence or complications. 5.2 Actual Management The actual management for Patient T with acute calculous cholecystitis and controlled hypertension and was admitted in a certain healthcare facility in Northern Mindanao has focused on prioritizing pain management, infection prevention, and patient education on dietary modifications. Initial assessments revealed severe right upper quadrant pain with occasional radiation to the shoulder, which has been a significant source of distress for the patient. Frequent monitoring of vital signs has shown stable blood pressure, though intermittent fever spikes have indicated potential inflammatory responses, warranting close observation. The diagnoses identified include acute pain related to inflammation and obstruction, and risk for infection due to bile stasis, guiding targeted interventions.  Analgesic administration such as Tramadol has provided some relief, but the patient reports persistent discomfort, especially after meals, indicating that further adjustments to pain management strategies may be necessary. Infection prevention measures, including aseptic technique for care and hand hygiene education for the patient and family, have been implemented to minimize risks. Despite receiving dietary counseling on low-fat meal options, the patient and family have expressed challenges in modifying long-standing eating habits, and adherence to the recommended diet has been inconsistent. To address this, additional educational sessions have been done to reinforce understanding of the importance of dietary changes, particularly in reducing fat intake to prevent further gallstone formation. Ambulation support has also been provided to prevent immobility-related complications, with gradual improvements observed, though fatigue and pain have limited the patient’s endurance. Evaluation of patient outcomes indicates moderate progress in pain control and infection prevention, but persistent challenges in dietary compliance. These observations highlight the need for ongoing reassessment of pain management, enhanced educational support for diet adherence, and possibly coordinating community resources for dietary counseling and meal planning assistance to support the patient’s long-term recovery and reduce recurrence risks. 5.3 Drug Study  Chapter 6 NURSING CARE PLAN 6.1 Nursing Care Plan on Airway 6.2 Nursing Care Plan on Pain 6.3 Nursing Care Plan on Comfort  Chapter 7 DISCHARGE CARE PLAN 7.1 Daily Routine Upon discharge, the patient and her caregiver are advised to establish a structured daily routine that supports her recovery and optimizes her health status following surgery for acute calculous cholecystitis. This routine should include: Morning Activities: Supervised personal care is essential, incorporating gentle bathing and dressing, while paying special attention to wound care to prevent infection. It is crucial that the caregiver assists with these tasks to ensure safety and comfort. Medication Management: Medications should be scheduled around meal times for consistency and improved tolerance, helping the patient to integrate them seamlessly into her daily life. The caregiver should maintain a medication schedule, potentially using a pill organizer for clarity and to prevent missed doses. Physical Activity: Light physical activities, such as short walks or prescribed exercises, should be performed within her capacity to avoid fatigue. The patient should aim for at least 5-10 minutes of walking several times a day, gradually increasing as tolerated. Careful monitoring for any signs of dizziness or increased pain during these activities is essential.  Rest Periods: Adequate rest periods throughout the day are crucial. The patient should be encouraged to listen to her body and rest when needed. A cozy, quiet space should be designated for relaxation. Hydration and Output Monitoring: The patient is encouraged to track her intake and output daily, recording any deviations to monitor hydration and kidney function. She should aim to drink at least 8-10 glasses of water a day, unless otherwise advised by her healthcare provider. Stress Management: Creating a calm and stress-free environment is advised to aid in recovery, reducing the risk of elevated blood pressure or other complications. Incorporating relaxation techniques, such as deep breathing exercises or guided imagery, can be beneficial. 7.2 Treatment The patient and her caregiver have received thorough education on the importance of adhering to her prescribed medications, which include: Cefuroxime 500 mg: 1 tablet three times a day for 7 days to prevent infection. Celecoxib 200 mg: 1 capsule twice a day for 5 days to manage pain and inflammation. Ursodeoxycholic Acid: 1 tablet three times a day for 7 days to assist in bile flow and gallstone management.  Instructions on wound care after each bath were provided, emphasizing cleanliness and sterility to prevent infection. The caregiver should be informed to change dressings as recommended by the healthcare provider and observe for any signs of infection, such as increased redness, swelling, or drainage at the site. The caregiver is encouraged to monitor for potential side effects, such as gastrointestinal discomfort, and to ensure that the patient completes the full course of medications. A follow-up appointment at the outpatient department is scheduled for 7 days post-discharge to assess healing and recovery progress. Furthermore, the patient was educated on recognizing signs of complications, such as fever, increased pain, or redness around the wound, and was provided guidance on seeking immediate medical assistance if these occur. The importance of regular follow-ups with her primary healthcare provider and any specialists for ongoing management of her chronic conditions has also been emphasized. 7.3 Health Teaching Extensive health education was provided to the patient and her family, focusing on understanding post-operative recovery and preventing complications. Key points covered include: Medication Adherence: The significance of taking medications as prescribed to prevent infections and manage pain effectively.  Wound Care Techniques: Proper techniques for cleaning and dressing the surgical site to minimize infection risk. Caregivers should be instructed on how to assess the wound for signs of healing and infection. Pain Management: Understanding the importance of managing pain effectively to enhance recovery, including when to use prescribed medications and alternative methods such as ice packs or relaxation techniques. Monitoring Intake and Output: Education on the significance of monitoring daily fluid intake and urine output to detect any potential hydration issues early. Recognizing Signs of Infection: Training on identifying critical symptoms that indicate possible complications, such as fever, increased pain, or excessive swelling at the surgical site, and the actions to take should these symptoms arise. Stress Management Techniques: Instruction on techniques to manage stress, such as deep breathing exercises, mindfulness, or engaging in light, enjoyable activities to promote emotional well-being. Follow-Up Check-up: The patient has a follow-up visit scheduled at the outpatient department (OPD) for 7 days post-discharge, where her surgical site will be assessed, and overall recovery will be evaluated 7.4 Diet The patient was instructed to follow a low-fat, low-oil diet that promotes healing and supports optimal digestion after gallbladder surgery. Key dietary guidelines include: Lean Proteins: Incorporating lean protein sources such as skinless poultry, fish, and legumes. These foods provide essential nutrients for recovery without adding excessive fat. Fruits and Vegetables: A variety of fresh fruits and vegetables should be included, focusing on high-fiber options such as apples, berries, carrots, and leafy greens. These foods are rich in vitamins and minerals, essential for healing and maintaining digestive health. Whole Grains: Recommended whole grains like brown rice and oats, which provide fiber and help regulate digestion while being low in fat. Healthy Cooking Methods: Emphasized cooking methods that minimize added fat, such as steaming, baking, or boiling, instead of frying. When fats are necessary, suggest using minimal amounts of heart-healthy oils, such as olive oil or avocado oil, sparingly. Hydration: Encouraged the patient to drink plenty of water throughout the day to stay hydrated. She was also educated to avoid sugary beverages and caffeine, which can lead to discomfort and dehydration.  Foods to Avoid: The patient should avoid high-fat foods, including fried items, fatty cuts of meat, full-fat dairy products, and overly processed snacks. These foods can lead to digestive upset and hinder recovery.  Chapter 8 CONCLUSION, EVALUATION, AND PROGNOSIS 8.1 Conclusion In conclusion, this case highlights the critical need for a comprehensive, patient-centered approach for managing Patient T following surgery for acute calculous cholecystitis, especially given her complex medical history that includes hypertension, a previous ischemic stroke, and current post-operative challenges. The discharge plan focused on multiple essential components: establishing a structured daily routine that promotes gradual recovery, educating the patient and her caregiver about medication adherence, and implementing specific dietary modifications to support her recovery. The education provided emphasized the importance of recognizing signs of potential complications, such as fever, increased pain, or any abnormal changes in her condition. Given Patient T's complex medical history, including cardiovascular issues and diabetes, it is crucial to monitor her closely for any changes in her health status. By fostering a collaborative environment involving the patient, her family, and the healthcare team, this plan aims to empower Patient T to take an active role in her recovery and management of her health conditions. 8.2 Evaluation This case study illustrates the significant role of nursing care in addressing the diverse and complex needs of Patient T, who presents multiple health challenges. The nursing interventions were designed to ensure effective management of her post-operative condition, as well as her existing chronic issues, which include hypertension and a history of stroke. Education on medication adherence was a central focus, highlighting the importance of taking Cefuroxime for infection prevention, Celecoxib for pain management, and Ursodeoxycholic Acid to assist in bile flow. The patient and her caregiver received tailored guidance on daily activities to facilitate mobility and reduce the risk of complications such as bradycardia and orthostatic hypotension. The emphasis on dietary modifications, specifically a low-fat and low-oil diet, is crucial to prevent exacerbation of her gallbladder issues and support digestive health. Collaborative efforts with the healthcare team, including physical therapists and dietitians, ensured a comprehensive care approach, allowing for timely interventions and adjustments to the care plan as necessary. This experience reinforces the vital role of proactive monitoring and continuous education in nursing practice, illustrating how these strategies are essential in preventing complications and promoting positive health outcomes. 8.3 Prognosis The prognosis for Patient T is good, contingent upon her adherence to the prescribed treatment plan and recommended lifestyle modifications. Effective management of her hypertension and monitoring of her overall health, including regular assessment of vital signs and recognition of warning signs, will be essential to minimize future health risks. The patient is expected to benefit from the structured daily routine, which incorporates gradual increases in physical activity and dietary modifications that align with her health needs. Regular follow-up appointments will be necessary to assess her recovery progress, particularly concerning her mobility and respiratory function, given her history of cough and wheezing post-operatively. With consistent adherence to health education regarding medication, dietary choices, and recognition of signs of complications, Patient T is expected to achieve gradual improvements in her overall health. If she successfully implements the strategies discussed and maintains ongoing communication with her healthcare team, a stable health outcome is anticipated over time.  Chapter 9 RECOMMENDATION For Patient T, following her surgery for acute calculous cholecystitis and considering her complex medical history, a structured and multidisciplinary approach is crucial to support her recovery and prevent complications. It is highly recommended that: She maintains regular follow-up appointments with her healthcare team, including her primary care physician, to monitor her progress and adjust her treatment plan as needed. Strict adherence to her prescribed medications—Cefuroxime 500 mg three times daily, Celecoxib 200 mg twice daily, and Ursodeoxycholic Acid three times daily—is essential for managing her pain, preventing infection, and supporting overall recovery; education on the importance of completing the full course of antibiotics and recognizing potential side effects is necessary for her and her caregiver. Patient T should follow a low-fat and low-oil diet to promote digestive health and minimize strain on her gallbladder, emphasizing easy-to-digest foods such as lean proteins, fruits, and vegetables while avoiding greasy and fried items, along with adequate hydration. Incorporating gentle physical activities, like supervised short walks and prescribed exercises, into her daily routine is vital for improving mobility, with  supportive measures provided to prevent falls. Home monitoring of blood pressure is advised, with any significant changes promptly reported to her healthcare provider; both the patient and her caregiver should be educated on recognizing early warning signs of complications and the importance of seeking immediate medical care if symptoms worsen. Stress management techniques, such as relaxation exercises and mindfulness, should be encouraged to maintain a calm and supportive home environment, which is essential during her recovery. Follow-up appointment at the outpatient department is recommended within one-week post-discharge to assess her healing process and recovery; continued patient and family engagement in her care plan will enhance her recovery and empower them to manage her health conditions effectively, leading to improved health outcomes and a stable recovery phase, thereby significantly reducing the risk of potential complications.  Chapter 10 APPENDICES 10.1 Laboratory Results HEMATOLOGY (10/08/2024) 02:11 PM Blood Typing: O Rh+ Test Result Normal Values Significance 1) Complete Blood Count a) WBC Count 13,940 mm^3 5,000 – 10,000 High b) RBC Count 4.86 mil/mm^3 3.69 – 5.13 Normal c) Hemoglobin 13.11 g/dL 11.7 – 14.5 Normal d) Hematocrit 38.30 % 34.1 – 44.3 Normal e) Platelet Count 273,800 mm^3 174,000 – 390,000 Normal 2) Red Cell Indices a) MCV 79.0 U^3 81.5 – 96.7 Normal b) MCH 27.0 pg 26.5 – 33.5 Normal c) MCHC 34.0 g/dL 31.9 – 35.3 Normal d) RDW-CV 16.4 % 11.5 – 14.5 High 3) Differential Count a) Neutrophils 70.7 % 43.4 – 76.2 Normal b) Lymphocytes 17.7 % 17.4 – 46.2 Normal c) Monocytes 9.6 % 4.5 – 10.5 Normal d) Eosinophils 1.3 % 2.0 – 3.0 Low e) Basophils 0.5 % 0 – 0.5 Normal HEMATOLOGY (10/07/2024) 03:24 AM Test Result Normal Values Significance 1) Complete Blood Count a) WBC Count 14,230 mm^3 5,000 – 10,000 High b) RBC Count 4.66 mil/mm^3 3.69 – 5.13 Normal c) Hemoglobin 12.52 g/dL 11.7 – 14.5 Normal d) Hematocrit 36.50 % 34.1 – 44.3 Normal e) Platelet Count 83,800 mm^3 174,000 – 390,000 Low  2) Red Cell Indices a) MCV 78.0 U^3 81.5 – 96.7 Normal b) MCH 27.0 pg 26.5 – 33.5 Normal c) MCHC 34.0 g/dL 31.9 – 35.3 Normal d) RDW-CV 16.4 % 11.5 – 14.5 High 3) Differential Count a) Neutrophils 84.0 % 43.4 – 76.2 High b) Lymphocytes 13.2 % 17.4 – 46.2 Low c) Monocytes 1.8 % 4.5 – 10.5 Low d) Eosinophils 1.90% 2.0 – 3.0 Low e) Basophils 0.2 % 0 – 0.5 Normal *Remarks: Hematology sample tested twice. CLINICAL CHEMISTRY (10/10/2024) 10:30 AM Test Result Normal Values Significance Fasting Blood Sugar 84.0 mg/dL 70 - 110 Normal LIPID PROFILE (10/10/2024) 10:30 AM Test Result Normal Values Significance Total Cholesterol 237.0 mg/dL 140 - 200 High Triglycerides 131.0 mg/dL 0 - 200 Normal HDL Cholesterol 43.0 mg/dL 40 - 80 Normal LDL Cholesterol 167.80 mg/dL 80 - 100 High VLDL 26.20 mg/dL 26 - 30 Normal Chol / HDL Ratio 5.51 mg/dL 1-6 Normal LIVER PROFILE (10/07/2024) 07:20 AM Test Result Normal Values Significance Total Bilirubin 0.76 mg/dL 0.1 - 1.2 Normal Date: September 24, 2024 File No.: 24-2049-42 Procedure: Ultrasound Name: Patient T Age: 56 years old of Whole Abdomen Findings: Liver is of normal size and parenchymal echogenicity. No cysts or solid mass seen. The intrahepatic ducts are not dilated. Gallbladder measures 9.5 x 3.2 cm. Multiple hyperechoic foci with posterior acoustic shadowing are seen in the gallbladder lumen, the largest measuring 1.0 cm. Wall is thickened, measuring 4 mm, and there is pericholecystic fluid present. Positive sonographic Murphy’s sign. Common bile duct is not dilated. Pancreas is normal in size, shape, and echogenicity. No focal mass lesion. Abdominal aorta and inferior vena cava are normal. Spleen and both kidneys are normal in size and echogenicity. No lithiasis or masses. Visualized bowel loops appear normal. Urinary bladder is well distended with smooth and thin walls. No intraluminal echoes. Wall is not thickened. Uterus is unremarkable. Impression: Acute cholecystitis: Gallbladder inflammation with gallstones, wall thickening, pericholecystic fluid, and a positive sonographic Murphy’s sign. No focal liver lesions. No significant abnormalities in other visualized structures. Radiologist: Syrenia Agustin Siban, MD 10.2 Documentation Figures: The student nurses as they conduct their assessment on Patient T. 10.3 Genogram The genogram depicts a multi-generational family health issue of heart disease and hypertension, which are prevalent across generations. The parents comprises the deceased mother, who was a housewife and manicurist, and the deceased father, who worked as a warehouse in-charge; both suffered from heart disease and hypertension, with the cause of death for each being a heart attack. They had seven children including Patient T. The first child, an 87-year-old former jeepney driver, and the second child, an 84-year-old carpenter, show no documented health issues. The third child, a 79-year- old househusband, has heart disease and hypertension, as does the fourth child, a 73-year-old store owner. The fifth child, a 67-year-old teacher, also has heart disease and hypertension. The sixth child is marked as deceased, having been a housewife, and like her parents, she suffered from heart disease and hypertension, with her cause of death noted as a heart attack. She died on the day of Patient T’s surgical operation which added more into the patient’s sadness. As verbalized by Patient T, the sixth child experienced angina and afterwards, she was brought to a certain private healthcare institution in Northern Mindanao due to blood coming out from her mouth, nose, eyes, and ears. The youngest member is Patient T, a 56-year-old housewife who also has a history of heart disease and present hypertension, along with cholecystitis and a past ischemic stroke. The genogram underscores a strong familial trend of heart disease and hypertension, suggesting potential genetic or lifestyle factors contributing to these conditions within the family. 10.4 Doctor’s Order  References Araujo, L. J., & Bittencourt, P. F. (2023). 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