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NURS 550 Clinical Worksheet Remember NO Patient IDENTIFIABLE INFORMATION HERE Student Name: ____Monica Sias____________________ Client Initials: PB____ Gender: F_ Age: 43__ Unit/Rm#: Med-Surg Room 362__ Date of Admission: ___04/21/2025_________ Healthcare Provider: Lauren Fleischer, MD Admitting Diagnosis: ___Cholecystitis ___ Concurrent Diagnoses: ____Hypertension (HTN) Surgery: Cholecystectomy on 04/21/ Allergies to Drugs or Foods: None Advanced Directives / Code Status: _Full code________ Nursing Kardex/Chart/Orders: Therapeutic Modalities Vital Signs and Frequency Vitals every 4 hours Vitals taken at 7am: 125/87mmHg O2 saturation 94%, temperature 36.8 C Heart-Rate 71 bpm Respiratory rate 15 breaths per minute I & O/ Fluid Restrictions None ordered Diet Cardiac diet Scheduled Diagnostics None scheduled Treatments None ordered Activity Level Pt can ambulate independently without assistive devices Dressing Changes Not ordered Resp. Therapy Not ordered Self-Care Ability Independent in all ADLs (Activities of daily living) Daily Weights Not ordered SCD, TEDS, CPM Not ordered Daily Labs. Not ordered Admitted Diagnosis: Cholecystitis
Pathophysiology Cholecystitis is the inflammation of the gallbladder. The gallbladder is a small, pear-shaped organ under your liver that stores bile, which digests fats. This can be caused by some sort of blockage in the gall bladder (Jones et al, 2025). A blocked gall bladder causes the bile to get stuck and this increases the pressure in the abdomen. This causes irritation due to the pain and swelling. This is a medical emergency and requires surgery to remove the gall bladder to prevent infection and sepsis; this surgery is called cholecystectomy (Jones et al, 2025). Jones MW, Genova R, O'Rourke MC. Acute Cholecystitis. StatPearls Publishing; 2025 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK459171/ Therapeutic Regimen The therapeutic regimen for this patient during my shift included monitoring vital signs and pain every 4 hours. As well as, managing patient’s pain by administering prescribed analgesics acetaminophen and morphine every 4 hours. The nurse also placed patient in a semi-Fowler's position for comfort and to reduce pressure on the patient’s abdomen. Independent ambulation to the bathroom to urinate and defecate within 24 hours post-op to prevent deep vein thrombosis and promote bowel motility (Jones et al, 2025). Jones MW, Genova R, O'Rourke MC. Acute Cholecystitis. StatPearls Publishing; 2025 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK459171/ Current health problems and related functional changes In addition to cholecystitis, patient has hypertension. Pain and stress from cholecystitis can raise blood pressure and worsen hypertension. The nurse must manage medications and assess for pain to avoid interactions or excessive drops or spikes in blood pressure. Laboratory Test Normal Values Result Significance of Results Complete Blood Count White blood Cell Count 3.6 – 11.2/ mcL 9.8 mcL Normal Red Blood Cell Count 4.7 – 6.1 million cells/μL 3.71 million cells/ μL Low value due to cholecystitis and loss of blood from surgery. If too low, it can cause dizziness, fatigue, and shortness of breath. Hemoglobin 12 – 15.5 g/dL 8.8 g/dL Low value due to cholecystitis. If too low, it can cause dizziness, fatigue, and shortness of breath. Hematocrit 36 – 48% 27.4% Low value due to cholecystitis. If too low, it can cause dizziness, fatigue, and shortness of breath. Platelets 150,000 – 450,000 / mm³ (or /μL)
mm³ (or /μL Normal Differential 4,000 – 11,000 / mm³ Not ordered; N/A
N/A
BNP 10-100 Not N/A
ESR < 20 mm/hr (male Not ordered; N/A
N/A
Lipid Studies: Total Cholesterol < 200 mg/dL Not ordered; N/A
N/A
Triglycerides 10- 150 mg/dL Not ordered; N/A
N/A
HDLs > 40 mg/dL Not ordered; N/A
N/A
LDLs < 100 mg/dL Not ordered; N/A
N/A
Diagnostics Tests (LAB, RADIOLOGY, CARDIAC FUNCTION i.e. EKG, stress test) Diagnostic Test Normal Finding Result for patient Definition and description of test Significance of the test for your patient Abdominal Ultrasound Thin walls, no gallstones, No signs of inflammation (no pericholecystic fluid). Not distended. No abnormal findings noted. Liver, gallbladder, pancreas, spleen, kidneys, and aorta appear within normal limits. No free fluid or masses seen. Abnormal; increased gallbladder wall thickness and inflammation of the gall bladder A test that looks at the organs and other internal structures of the body, producing 2D images, that can’t be seen otherwise. This test identifies the presence of gallstones and blockage of the gallbladder. The test showed increased gallbladder wall thickness and inflammation of the gall bladder, which was used to diagnose patient with cholecystitis. CT scan of Abdomen Normal appearance of the liver, gallbladder, pancreas, spleen, kidneys, and bowel. No mass, obstruction, inflammation, or free fluid/air. Abdominal vasculature is within normal limits. Abnormal; gallstones, thickened gallbladder wall, pericholecystic fluid collections, inflammation of the gallbladder and gallbladder distention A CT scan of the abdomen is an imaging test that uses X-rays and computer technology to create detailed images of the abdominal organs and tissues. This test identifies blockage of the gallbladder and inflammation of the gallbladder. CT showed gallstones, thickened gallbladder wall, pericholecystic fluid collections, inflammation of the gallbladder and gallbladder distention to diagnose patient with cholecystitis.
Route: Oral Dose: 4 mg every 4 hours as needed analgesic to reduce abdominal pain receptors to reduce pain perception constipation, nausea Respiratory depression, hypotension severe asthma and paralytic ileus respiratory depression and signs of opioid overdose Caution in elderly and those with liver/kidney impairment Max Dose: 60 mg/day
Physical Assessment Cognitive / Neurosensory: Cardiovascular: Respiratory Pt alert, awake and oriented x 4 to person, place, and time, and situation. Pt follows commands and answers questions appropriately. Pt makes appropriate eye-contact No abnormal heart sounds were heard upon auscultation. Pt had a heart rate of 71 bpm. S1 and S auscultated and there were no abnormal heart rhythms, heart sounds, and no murmurs or rubs. Pt had a blood pressure of 125/87. Capillary refills on all fingernails and toenails present and normal. Peripheral pulses present. Pt denies cardiovascular or chest pain No abnormal lung sounds heard upon auscultation. Breathing pattern regular and unlabored. No use of accessory muscles or nasal flaring or grunting observed. Full expansion of lungs with air movement present No oxygen use, pt breathing room air. Denies pain during respiration. No dyspnea present Gastrointestinal: Genitourinary: Patient reports having a bowel movement at 8:00 AM today. Bowel sounds present in all four quadrants upon auscultation. Abdomen was soft, tender, and distended and pt reports pain in Abdomen 4/10. Patient is continent of bowels. Patient is continent of bladder and uses the toilet independently. Pt not using a urine collection device. Pt denies pain when urinating Pt denies urgency, hesitancy during urination Pt reports that she has been urinating once every 2 hours Pt reports urine is pale yellow, unknown amount, and is clear without sediment Integument: Nutrition: Pain Assessment:
Depth Unknown; unable to assess N/A N/A Drainage None observed N/A N/A Odor None observed N/A N/A Undermining / Tunneling None indicated N/A N/A Wound bed tissue type Unknown; unable to assess N/A N/A Tubes/Lines/Drains Assessment: Location Assessment Drainage IV, 22G in left hand IV site was clean, no visible blood, taped in place, and without bruising or redness. No drainage observed
Assessment Priority Nursing Diagnosis Goal/ Outcome (Short and Long Term) Nursing Interventions Rationale Evaluation of Goal Achieveme nt Subjective Data: Pt reports pain and tenderness in abdomen with rating pain 4/ Objective Data: Facial grimacing and guarding of abdomen. Acute pain related to inflammation and tissue damage as evidenced by verbal report of pain rated 4/10, facial grimacing, and guarding behavior over the abdomen. Short-term goal: The patient will verbalize pain scale is a 2/10 or less by 11am. Long-term goal: The patient will be able to ambulate independentl y a distance of 100 feet, with pain rating at 2/ or less by discharge. Short-term:
- The nurse will administer pain medication as ordered; every 4 hours as needed.
- The nurse will encourage patient to practice deep breathing exercises to relieve pain every 2 hours.
- The nurse will assist pt to sit on chair twice during shift. Long-term:
- The nurse will position patient into semi-Fowler’s position once during shift.
- The Nurse will administer pain medications 30 minutes before patient ambulates.
- The nurse will teach Short-term:
- Providing pharmacologic relief will decrease pain intensity and enhance comfort.
- Reduces pressure on the abdomen and promotes relaxation which may relieve tension on inflamed tissues.
Long-term: - Positioning the patient in semi- Fowler’s position will reduce abdominal pressure and pain by reducing muscle tension and guarding, allowing for better pain Short Term Goal: Goal met Long Term Goal: Goal met
