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Concept Map Cholesectomy

The patient, a 52-year-old female, presented with abdominal pain and vomiting after eating. She had a history of gallstones and underwent a cholecystectomy. Post-operatively, she experienced abdominal pain, difficulty maintaining oxygen levels, and lacked knowledge about her condition. Nurses addressed her acute pain, risk of infection, and need for education by closely monitoring her, administering medications, keeping the incision clean, and providing information about her prognosis, care, and diet.

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Doreen Claire
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103 views

Concept Map Cholesectomy

The patient, a 52-year-old female, presented with abdominal pain and vomiting after eating. She had a history of gallstones and underwent a cholecystectomy. Post-operatively, she experienced abdominal pain, difficulty maintaining oxygen levels, and lacked knowledge about her condition. Nurses addressed her acute pain, risk of infection, and need for education by closely monitoring her, administering medications, keeping the incision clean, and providing information about her prognosis, care, and diet.

Uploaded by

Doreen Claire
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Risk factors

-Cholelithiasis also known as gallstones, are formed through the accumulation of Signs and symptoms
-Obesity and sedentary lifestyle cholesterol and bilirubin in the gall bladder.
-abdominal pain at the right upper quadrant
-Female (Gender) -Abnormalities in the composition of bile, stasis of bile and gallbladder inflammation radiating to her upper back
contribute to the formation of stones.
-Age -vomiting episodes after eating a heavy meal
Cholecystitis is the inflammation of the gall bladder secondary to the outlet obstruction.
-Estrogen -abdominal cramping and bloating
-90% of cases are associated with gallstones.
-Genetics

A cholecystectomy is a surgical procedure to remove your gallbladder — a pear-shaped


organ that sits just below your liver on the upper right side of your abdomen. Your
gallbladder collects and stores bile — a digestive fluid produced in your liver.

Medications

-promethazine
Past Medical and Surgical History 52 years old
-meperidine
-three years prior to admission, patient was -pt. under went cholecystectomy under general anesthesia
suffering from right upper quadrant pain. Sought -ciprofloxacin
consultation and was given pain reliever. Patient -Assessment findings: abdominal pain at the right upper quadrant radiating to her upper
has a history of 3x caesarean sections. No back with vomiting episodes, pain scale of 8 on a 1-10 scale -loperamide
known allergies.
Difficulty keeping 02 above 90% immediately post-op -IVF of 0.45% Normal Saline Solution 1
-Risk for infection related to impaired primary defense.

-Acute pain related to surgical incision secondary to cholecystectomy

-Deficient knowledge related to condition prognosis, treatment, self-care and discharge needs.

Acute pain related to surgical incision secondary to Deficient knowledge related to condition prognosis,
Risk for infection related to impaired primary defense. cholecystectomy treatment, self-care and discharge needs.

Interventions Interventions Interventions

-Assessed the level of the patient’s capabilities and the


-Monitored vital signs and assessed patient’s condition. -Assessed pain including location, duration, frequency possibilities of the situation. 
-Monitored medication regimen. and severity. -Provided information relevant only to the situation to
-Kept the dressings clean and dry. -Monitored skin color and temperature and vital signs, prevent overload.
-Increased oral fluid intake if not contraindicated which are usually altered in acute pain. -Provided explanations of reasons for test procedures.
-Administered antibiotic therapy as prophylaxis. -Noted attitude toward pain and use of pain medications, -Provided positive reinforcement. Avoid the use of
-Strict compliance to hospital control, sterilization, and including any history of substance abuse. negative reinforcers (e.g. criticism, threats). 
aseptic policies -Performed pain assessment each time pain occurs. -Discussed one topic at a time; avoid giving too much
Documented and investigated changes from previous information in one session.
-Instructed patient before and after emptying the drain reports and evaluated results of pain interventions. -Discussed the patient’s perception of need. Relate the
reservoir to wash the hands well with soap and running -Observed nonverbal cues and pain behaviors. information to the patient's personal desires, needs,
water. Pay special attention to rubbing the fingers, -Provided a quiet environment. values, and beliefs. 
fingernails and the backs of the hands. Hand washing is -Administered analgesics, as indicated, to maximum -Reviewed disease process/ prognosis. Discussed
an important step to help prevent infection. dosage, as needed, to maintain acceptable level of pain. hospitalization and prospective treatment as indicated. 
-Evaluated and documented response to analgesia and -Reviewed drug regimen, and possible side effects.
assisted in transitioning or altering drug regimen, based
on individual needs and protocols.
-Encouraged adequate rest periods to prevent fatigue
that can impair ability to manage or cope with pain
-Educated about non pharmacological ways to lessen
pain, including techniques such as Therapeutic Touch, -Instructed to avoid food/fluids high in fats (e.g. whole
heat or cold therapy, biofeedback, and relaxation skills. milk, ice cream, butter, fried foods, nuts), gas producers
-Educated  the patient and significant others that (e.g. cabbage, beans, onions, carbonated beverages), or
decrease tolerance to pain and methods for decreasing gastric irritants (e.g. spicy foods, caffeine, citrus). 
these factors:   (lack of knowledge regarding disease -Encouraged questions and expression of concern.
process, lack of support from significant others, fear of
addiction or loss of control,  fatigue, boredom,  improper
positioning)

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