We did this case study for us to enhance our knowledge and to understand more information about cholelithiasis , thus to give us an idea of how we could give proper nursing care for our clients with this condition, and so we could apply them on our future exposures as students and eventually as nurses. At the end of case presentation the group will:
* Indentify the causing factor that related to the disease * Determine the sign and symptoms of the disease
* Formulating a nursing care plan related to the problem
II. PATIENT’S PROFILE
Name: H.O Gender: F Civil Status: M
Birthdate: January 15, 1944
Address: Danao, Pototan, Iloilo City
Religious Affiliation: Roman Catholic
Physician: Dr.B and Dr.P
Admission date: 11-15-12
Epigastric pain : “mga isa na ka semana nga dulaan ko gana magkaon hay gasakit sulok sulokan koh” as verbalized by the patient.
III. HISTORY OF PRESENT ILLNESS
7 days PTA patient has onset of epigastric pain and admitted at LDH
6 days PTA ultrasound done and revealed cholecystolithiasis, patient was appraised for surgery.
ODA referred to IMH for further evaluation and management thus admitted.
-PAST HEALTH HISTORY
The patient is a 68 years old female housewife and appear as stated aged. She is ambulatory and conscious, cooperative and responds appropriately while on bed. Body thin is evenly distributed. Limbs and trunk are proportional to the body’s height. Motor activity is not restricted but still needs assistance. Able to respond to questions correctly. Approachable and friendly, show appropriate facial expressions, cooperative and is concerned about the situation. Childhood Illnesses
The patient stated that she experienced chickenpox and measles. Serious or chronic illnesses
The patient stated that she has a diabetes.
The patient has stroke last 2006
Last examination date
Blood chemistry (11/16/12)
Diagnostic X-ray (11/9/12)
Current medications (Prescription, OTC’s, Herbal)
The patient has a herbal supplement – Banaba for diabetes
The patient has diabetes and hypertension on both sides of her parents.
IV. PATTERNS OF FUNCTIONING
No laborious breathing pattern noted.
Usual bedtime is 7:00-9:00 pm then will wake up 5:00 am, Uses 6 medium-sized pillows, 2 on her head for slight elevation and 2 on the side and 2 on the legs. Before she sleeps she pray and recites rosary. Drinking and Eating Pattern
Patient usually drinks coffee in the morning, eats mostly of vegetable and drinks water frequently. Before she never experienced her illness she used to drink 2 liters coca cola in a day. Activities/Exercise
Patient enjoys cleaning and entertaining herself by doing the household chores and gardening, for her, gardening and household chores is her sort of exercise in her daily activities. Elimination
Has a normal bowel movement, but sometimes she stated that she has difficulty of passing her stool or constipated. Has a normal urination did not complain any pain and problem regarding her urination. Brief social,cultural and religious background
Her role being a mother for almost 68 years is being able to care for them and guide them in possible way that they do with her husband. Making their children successful in their courses made them happy and proud. She’s relying on her children for all the expenses and hospital bills and her daughter in law is the one taking of her in the hospital. Going to church every Sunday and reciting rosary and reading the bible is her intimate way to communicate with God. She has a good neighborhood, and her house has strong foundation. The patient has an access to transportation like tricycle. V. CLINICAL INSPECTION
Vital signs on admission (11-15-12)