I. INTRODUCTION Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal li ning.

Cholecystitis is usually caused by a gallstone in the cystic duct, the duc t that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic st ate of stones or calculi within the gallbladder lumen. A common digestive disord er worldwide, the annual overall cost of cholelithiasis is approximately $5 bill ion in the United States, where 75-80% of gallstones are of the cholesterol type , and approximately 10-25% of gallstones are bilirubinate of either black or bro wn pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East. Gallstones are crystall ine structures formed by concretion (hardening) or accretion (adherence of parti cles, accumulation) of normal or abnormal bile constituents. According to variou s theories, there are four possible explanations for stone formation. First, bil e may undergo a change in composition. Second, gallbladder stasis may lead to bi le stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation. Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup , female gender-gallbladder disease is more common in women than in men. Women w ith high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-fiber/highcho lesterol/high-starch diets all may contribute to gallstone formation. Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetabl es such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gal lstone causes a

blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone bec omes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complica tion and usually requires immediate treatment. The only treatment that cures gal lbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladde r is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patient s experience no further symptoms after cholecystectomy. However, mild residual s ymptoms can occur, which can usually be controlled with a special diet and medic ation.

II. NURSING ASSESSMENT A. Personal History Mr. Aproniano Castro is a 56 year old male, a Filipino citizen who resides at Pu long Santol, Porac Pampanga. He was born on January 22, 1950 at Pulong Santol, h is religious affiliation is Roman Catholic and he is married to Mrs. Brigida M. Castro. He is a jeepney driver bound in Porac-Angeles route. He is also the pres ident of their jeepneys association. Mr. Castro usually works for 10 to 12 hours a day usually around 7am to 7 pm. He always sleeps around 9 in the evening and w akes up at 6 in the morning. His wife was the one who prepares him the breakfast and the snack. He has day-offs but uses this day in working as the president of the jeepney association. He usually eats instant food and love eating foods whi ch has condiment like patis, vinegar and soy sauce. He also love eating vegetable salads and fatty salty food. He is not also choosy on the food he eats because h e really eat a lots. He seldom drinks alcohol and smoke. Regarding the finances about health he is using his wifes PHILHEALTH card to compensate the finances nee ded. Family Health and Illness History B. Family Health and Illness History Acco rding to Mr. Castro that the familial disease he knows that they have in their f amily was the hypertension that is on his fathers side. His father died because o f heart attack and her mother died of natural cause. He also added that cholecys titis is prone to their family, because of one of his siblings also had acquired this disease. C. History of Past and Present Illness This is the second time Mr . Castro been admitted into this hospital (Porac District Hospital). On his firs t admission into this hospital he had undergone throidectomy operation, which is almost 3 years ago. He had not experience any accident and injuries, even thoug h his job is prone to accident particularly vehicular accident. He also added th at he had an ashtma when he was 7 years old that lasts when he is 21 years old, his ashtma just stopped when he start drinking alcohol beverages as he said.

As for his present illness, he was admitted into this hospital because of cholec ystitis, he was admitted last February 13, 2006. He was been diagnosed with chol ecystitis with multiple cholelithiasis a month prior to admission due to severe epigastric pain and weight loss and was advised to remove his gallbladder. He ju st did not have his cholecystectomy done immediately due to financial problem. W hen the money needed for his operation was enough he then goes to Porac District Hospital last February 13, 2005 for his operation. He was diagnosed and surgica lly operated by Dr. Serrano.According to Mr. Castro. Upon admission he had under gone some laboratory examination such as UTZ, Chest X-ray, U/A, CBC, FBS, BUN,Cr eatinine and ECG. His initial medication were H2bloc and Cefuroxime. D. Physical Examination Physical Assessment done by the attending physician reveals that pa tient is; afebrile with pink palpebral conjunctiva (-) cyanosis (+) NABS non ten der abdomen Vital Signs upon admission (February 13, 2006) BP- 130/90 RR-19 PR-8 4 Temp-36.5 oC Physical Assessment done by the student reveals that patient is; afebrile with pink palpebral conjunctiva (+) dry lips (+) paleness (+) dryskin d ecreased skin turgor (-) bowel movement (-) weakness Vital Signs taken and recor ded as of February 15, 2006 are as follows; BP- 140/90 PR- 85 RR- 21

Temp- 36.4 oC

III. ANATOMY AND PHYSIOLOGY Gallbladder, muscular organ that serves as a reservoir for bile, present in most vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface o f the right lobe of the liver just below the lower ribs. It is generally about 7 .5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its thickest part; it h as a capacity varying from 1 to 1.5 fluid ounces. The body (corpus) and neck (co llum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the ed ge of the liver. Structurally, the gallbladder consists of an outer peritoneal c oat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunic a muscularis); and an inner mucous membrane coat (tunica mucosa). The function o f the gallbladder is to store bile, secreted by the liver and transmitted from t hat organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorptio n, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bil e is to; help the Lipases to Work, by emulsifying fat into smaller droplets to i ncrease access for the enzymes, Enable intake of fat, including fat-soluble vita mins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cho lesterol and Bilirubin.

IV. PATHOPHYSIOLOGY Risk factor Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60 Bile must become supersaturated with cholesterol and calcium The solute precipitate from solution as solid crystals Crystals must come together and fuse to form stones Gallstones Obstruction of the cystic duct and common bile duct Sharp pain in the right part of abdomen Jaundice Distention of the gall bladder Venous and lymphatic drainage is impaired Proliferation of bacteria Localized cellular irritation or infiltration or both take place Areas of ischemia may occur Inflammation of gall bladder CHOLECYSTITIS

V. DIAGNOSTIC AND LABORATORY PROCEDURE 1. Complete Blood Count (CBC) This is to det ermine blood components and the response to inflammatory process and streptococcal infection. Date Ordered: February 13, 200 6 Date Result In: February 13, 2006 Results: WBC RBC Lymphocyte Conclusion: WBC is slightly elevated based on the normal value of 4.3-10 g/l which confirms the presence of infection. 2. Fasting Blood Sugar This is to measure the blood gluco se levels. Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Res ults: 94.8 mg/dl Conclusion: The result is within normal range based on the norm al value of < 126 mg/dl. 10.9 g/l 5.5 g/l 27

3. Creatinine This is the indicator of the renal function Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: 1.0 mg/dl Conclusions: The result is within normal range based on the normal value of 0.60-1.7 mg/dl. 4. BU N This is an indicator of renal function and perfusion, dietary intake of CHON a nd the level of protein metabolism Date Ordered: February 13, 2006 Date Result I n: February 13, 2006 Results: 10.7 Mg/dl Conclusions: The result is within norma l range based on the normal value of mg/dl. 5. Urinalysis Urinalysis yields a la rge amount of information about possible disorders of the kidney and lower urina ry tract, and systematic disorders that alter urine composition. Urinalysis data include color, specific gravity, pH, and the presence of protein, RBCs, WBCs, bac teria, Leukocyte, esterase, bilirubin,glucose, ketones, casts and crystals.

Date Ordered: February 10, 2006 Date Result In: February 10, 2006 Results: Color - yellow Specific Gravity- 0.010 Sugar/ Albumin- negative Pus cells- 0.1 hpf Con clusions: The results are normal but there is a presence of pus cells in the uri ne which means that there is also the presence of infection.

VI. Patients Care a. Nursing Care Plan Preoperative NCP 1. Acute Pain Cues S O - pain scale of 7/10 - difficulty in mov ing as manifested by facial grimaces - (+) pallor - (+) muscle guarding - RR- 30 - BP- 140/90 Nursing Diagnosis Acute pain related to inflammation and distortio n of the gallbladder as evidenced by verbal reports of pain. Scientific Explanat ions Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen. Nursing Interventions After 4 hours 1. Observe and of nursing docu ment intervention the location, patient will severity (010 report relieve scale), of pain. and character of pain (e.g., steady, intermittent, colicky). 2. Promot e bedrest, allowing patient to assume position of comfort. Objectives Rationale Evaluation - Assists in Is there a change differentiating cause on the patients; of pain, a nd provides a. Pain information about scale disease b. RR progression/resolution , c. BP development of d. Reports complications, and of pain effectiveness of e. Facial interventions. expressi ons. - Bedrest in lowFowlers position reduces int raabdominal pressure; however, patient will naturally assume least painful posit ion. - Cool surroundings 3. Control

environmental temperature. 4. Encourage use of relaxation techniques, e.g., guid ed imagery, visualization, deep-breathing exercises. Provide diversional activit ies. 5. Make time to listen to and maintain frequent contact with patient. 6. Ad minister analgesics as indicated aid in minimizing dermal discomfort. - Promotes rest, redirects attention, may e nhance coping. - Helpful in alleviating anxiety and refocusing attention, which can relieve pai n. - Relief of pain facilitates cooperation with other therapeutic interventions ,

2. Fluid Volume deficient Cues S O (+) pallor (+) body weakness (+) vomiting wit h poor skin turgor (+) dry skin (+) dry mouth Nursing Diagnosis Fluid Volume Def icient related to vomiting Scientific Explanations Because of vomiting excessive losses through normal routes occur thus causes Fluid Volume Deficient Objective s After series of NI the pt. will maintain adequate fluid volume as evidenced by moist mucous membranes and good skin turgor, Nursing Interventions 1. Maintain accurate record of I&O, noting output less than Intake, increased urine specific gravity. Assess skin/mucous membranes, peripheral pulses, and capillary refill. 2. Perform frequent oral hygiene Rationale - Provides information about fluid s tatus/circulating volume and replacement needs. Evaluation Is there still the pr esence of; a. vomiting b. dry skin c. dry mouth d. poor skin turgor e. body weak ness - Decreases dryness of oral mucous membranes; reduces risk of oral bleeding. - S kin and mucous membranes are dry, with decreased 3. Provide skin and mouth care

4. Increase fluid intake 5. Ascertain patients beverage preferences, and set up a 24hr schedule for fluid intake. Encourage foods with high fluid content. 6. Adm inister antiemetics, e.g., prochlorperazine (Compazine) as ordered by the physic ian. elasticity, because of vasoconstriction and reduced intracellular water. - promo tes hydration. - Relieves thirst and discomfort of dry mucous membranes and augm ents parenteral replacement. - Reduces nausea and prevents vomiting.

Post-operative NCP 3. Knowledge Deficit Cues S pwede bang maulit ang sakit ko as v erbalized by the patient O Frequently asking question about his condition, treat ment and diet With worried gaze Nursing Diagnosis Deficient knowledge related to condition, prognosis, treatment, self-care, and discharge needs Scientific Expl anations There is this presence of knowledge deficit due to some unfamiliar info rmation that causes some confusion to the client that needs to be discussed. Nur sing Interventions After an hour 1. Provide of nurse-patient explanations intera ction the of/reasons for test patient will procedures and Verbalize preparation understanding needed. of disease process, 2. Review prognosis, and disease poten tial process/prognosis. complications. Discuss hospitalization and prospective t reatment as indicated. Encourage questions, expression of concern. 3. Review dru g regimen, possible side effects. Objectives Rationale - Information can decreas e anxiety, thereby reducing sympathetic stimulation. - Provides knowledge base f rom which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing. Evaluation Does the pati ent understands and could recall all the teachings given? Is there a significant changes that occur on the patients knowledge regarding; disease condition diet treatment medication self-care needs a. b. c. d. e. - Gallstones often recur, necessitating long-term therapy. - Prevents/limits

4. Instruct patient to avoid food/fluids high in fats (e.g., whole milk, ice cre am, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, bea ns, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caff eine, citrus). recurrence of gallbladder attacks. - Promotes gas 5. Suggest patient formation, which can limit gum increase gastri c chewing, sucking distension/discomfort. on straw/hard candy, or smoking.

b. Drug Study Name of Drug GN: H2Bloc (Pepcidine) BN: Famotidine Date Ordered 02 -13-06 Route/ Action Dosage and Frequency PO - Anti-ulcer 20 mg tab at - competi tively bedtime inhibits action of histamine on the H2 at receptor sites of parie tal cells, decreasing gastric acid secretion Indication -for short term treatmen t of duodenal ulcer Adverse Reaction - headache, dizziness, malaise, dry mouth N ursing Consideration 1. Check for doctors order 2. not to be given in patients hy persensitive to drugs 3. Inform the patient about the possible side effect of th e drug 4. Instruct patient to take drug with food 5. Advised patient to take dru g once daily usually at bed time 6. Advise patient to report abdominal pain or b lood in stools or is vomiting. 1. Check for doctors order 2. Perform ANST prior t o admission 3. Should not be given if positive skin test 4. Slow IV push 5. Info rm the patient about the possible side effect of the drug 6. Advise patient to r eport any discomfort on the IV insertion site GN: Cefuroxime BN: Zinacef 02-13-06 IV 750 mg every 8o prior to OR (30 to 60 minutes before) - anti-infective - a 2nd generation cephalosporin that inhibits cell-wall synthe sis, promoting osmotic instability - perioperative prophylaxis - Nausea and Vomiting

Name of Drug GN: Clomipramine HCl BN: Placil Date Ordered 02-13-06 Route/ Action Dosage and Frequency PO - Anti10 mg tab, depressants at 6 am Indication - for depression and chronic pain Adverse Reaction - headache, dizziness, malaise, dry mouth Nursing Consideration 1. Check for doctors order 2. not to be given in patients h ypersensitive to drugs 3. Inform the patient about the possible side effect of t he drug GN: Gentamicin Dulfate BN: Genticin 02-14-06 IV 80 mg amp, every 80 - Anti-infective - inhibits protein synthesis - endocarditis prophylaxis for GI or GU procedure or surgery - Nausea and Vomiting, headache, dizziness 1. Check for doctors order 2. Perform ANST prior to admission 3. Should not be gi ven if positive skin test 4. Slow IV push 5. Inform the patient about the possib le side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site 7. Monitor urine output, specific gravity, U/A, BUN and creatinin e levels

Name of Drug Date Ordered GN: Ampicillin 02-14-06 BN: Omnipen Route/ Action Dosage and Frequency IV - Anti-infective 1 g amp, - inhibits every 80 protein synthesis Indication - endocarditis prophylaxis for GI or GU procedure or surgery Adverse Reaction - Nausea and Vomiting, headache, dizziness Nursing Consideration 1. Check for doctors order 2. Perform ANST prior to admissi on 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the pa tient about the possible side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site GN: MgSO4 02-14-06 IV 0.03% 7ml every 120 -anti-convulsant -replaces magnesium and maintains magnesium level - magnesium supplementation - drowsiness, hypotension 1. Use parenteral magnesium with extreme caution in patients with impaired renal function 2. Test knee jerk and patellar reflexes before each additional dose 3. check magnesium level after repeated doses 4. Monitor fluid intake and output 5 . Monitor renal function

Name of Drug GN: Ketorolac Tromethamine BN: Toradol Date Ordered 02-14-06 Route/ Action Dosage and Frequency IV - Anti30 mg amp, inflammatory every 60 - i nhibits prostaglandin synthesis Indication - short term management of moderately severe, acute pain Adverse Reaction - dizziness, sedation, headache, flatulence, nausea and vomitin g Nursing Consideration 1. Check for doctors order 2. Perform ANST prior to admissi on 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the pa tient about the possible side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site Anesthetic drug Name of Drug GN: Lidocaine HCl Date Ordered 02-14-06 Route IV Ac tion Anesthetic drugs Adverse Reaction -lethargy, hypotension Nursing Considerat ion 1. Monitor BP, PR, and RR before and after giving the medication 2. Monitor patient for toxicity

c. Medical/ Surgical Management 1. Chest X-ray- this is used to rule out respira tory causes of referred pain. 2. Intake and Output- I&O measurement provide an o ther means of assessing fluid balance. This data provide insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. These measure ment are not that accurate as body weight, however, because of relative risk of errors in recording. 3. Electrocardiogram- The ECG is an essential tool in evalu ating cardiac rhythm. Electrocardiography detects and amplifies the very small e lectrical potential changes between different points on the surface of the body as a myocardial cell depolarize and repolarize, causing the heart to contract. 4 . O2 Inhalation- Oxygen therapies are used to provide more oxygen to the body in to order to promote healing and health. 5. Intravenous Rehydration- when the flu id loss is severe or life threatening, intravenous (IV) fluids are used for repl acement. 6. ultrasound (Also called sonography.) - a diagnostic imaging techniqu e which uses high-frequency sound waves to create an image of the internal organ s. Ultrasounds are used to view internal organs of the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels. 7. hepato biliary scintigraphy - an imaging technique of the liver, bile ducts, gallbladde r, and upper part of the small intestine. 8. cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast). 9. percutaneous tra nshepatic cholangiography (PTC) - a needle is introduced through the skin and in to the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray.

10. endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that all ows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope. A long, flexible, lighted tube. The scope is guided through the patient s mouth and throat, then through the esophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal o rgans to appear on an x-ray. 11. computed tomography scan (CT or CAT scan) - a d iagnostic imaging procedure using a combination of x-rays and computer technolog y to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the bod y, including the bones, muscles, fat, and organs. CT scans are more detailed tha n general x-rays. 12. Cholecystectomy- removal of the gallbladder. This procedur e may be performed to treat chronic or acute cholecystitis, with or without chol elithiasis, to remove a malignancy or to remove polyps. 13. Cholecystotomy- the establishment of an opening into the gallbladder to allow drainage of the organ and removal of stones. A tube is then placed in the gallbladder to established e xternal drainage. This is performed when the patient cannot tolerate cholecystec tomy. 14. Choledochoscopy- the insertion of a choledoscope into the common bile duct in order to directly visualize stones and facilitate their extraction.

VII. Clients Daily Progress DAYS ADMISSION 2/13/06 * * BP- 130/90 PR- 84 RR- 19 Temp36.5 oC * * * * * * * * * * * * * DAY 2 2/14/16 * * * BP- 140/90 PR- 82 RR- 21 Temp- 36.2 oC BP- 140/90 PR- 85 RR- 21 Temp- 36.4 oC * BP- 130/90 PR- 83 RR- 20 Temp- 36.1 oC DAY 3 2/15/16 DISCHARGE 2/16/06 Nursing Problem Acute pain Fluid Volume Deficient Knowledge Deficit Vital Signs Dx & Lab Procedures CBC U/A FBS BUN Creatinine Medical & Surgical Management Che st X-ray 12-L ECG O2 inhalation D5LRS, 1Lx 30-31 gtts/min D5NM, 1Lx 30-31 gtts/m in Drugs H2 Bloc

Cefuroxime Ketorolac Ampicillin Gentamicin MgSO4 Lidocaine Placil Diet NPO Clear liquid Soft Diet DAT Activity & Exercise FOB Sit on Bed Ambulation as Tolerated * * * * * * * * * * * * * * * * * * * * * * * * * First started and indicates the duration it was done and taken.

VIII. M DISCHARGE PLANNING Instructed the patient to continue medication as ordered 1. C ephalexin 500 mg cap 3 x day (8am-1pm-8pm) for 1 week 2. Mefenamic Acid 500 mg c ap 3 x day (am-1pm-8pm) for 1 week E T H foods Instructed the patient to e patient to continue the ake 2. Encouraged patient ge patient to avoid salty st O D and Instructed to come back for follow-up check-up on February 23, 2006, Thursday. A dvised the patient to a diet as tolerated but preferably avoiding salty fatty fo ods. do exercise as tolerated such as walking Instructed th medication 1. Encouraged patient to increase fluid int to eat foods rich in Vitamin and Nutritious 3. Encoura and fatty foods 4. Encourage patient to have enough re

IX. Conclusion Our patient, Mr. Aproniano Castro has a chief complaint of epigas tric pain. He was admitted in Porac District Hospital and he was diagnosed of ha ving a cholecystitis with multiple cholelithiasis based on the diagnostic proced ure conducted in him like the CBC, U/A, 12-L ECG, FBS, BUN, Crea, X-ray and UTZ. Due to the result the surgeon decided for a surgery to remove the gallbladder w hich is known as the cholecystectomy. We are happy to say that most of our group mates witness the operation. The following day we were given the chance to visi t and assess our patients condition. Fortunately, the patient had recovered at on ce he is no longer complaining of epigastric pain. What he was complaining is if he could already eat his food for he is on a liquid diet! And of course the pai n of his operative site which is just normal for several days after undergoing t he operation. Since cholecystitis is the inflammation of the gall bladder which is usually accompanied by gallstones or cholelithiasis these gallstones may bloc k the way of toxic substances that really needs to go out, but due to this block age this toxic substances are not then being expelled and are just being stored in the bladder for a period of time. This then causes inflammation of the gallbl adder. The treatment usually done is the cholecystectomy. In order to lower the risk of having this kind of condition each and every one of us must be conscious in our diet. We should try to avoid foods which are rich in salt and fats, espe cially those foods which contains many seasonings. Though there is a saying that Mas masarap pag bawal which always pertains to the food were eating we should sti ll be conscious on our health especially if we want to live longer and also to a void those life-threatening diseases which not only shorten our life but causes us some financial problem. Remember also the saying Mahal ang magkasakit. Just lik e on what our patient had experience he still has to collect money for the opera tion he had underwent causing them to have debt with different persons. Let us n ot enjoy ourselves with the delicious food were eating that is rich in salts and fats but we should enjoy living because we have a healthy condition.

X. BIBLIOGRAPHY Books Joyce M. Black,PhD, RN, CPSN, CWCN & Jane Hokanson Hawks, DNSc, RN, BC, Medical- Surgical Nursing 7th edition, pg.1302-1314. Nursing 2004 Dr ug Handbook, 24th edition Doenges, Moorhouse, & Murr, Nurses pocket guide 9th editi on. Online Resources www.facs.org http://tjsamson.client.web-health.com/webhealt h/topics/GeneralHealth/generalhealthsub/generalhealth/liver&gallbladder/what_gal l bladder.html http://www.emedicine.com/emerg/topic97.htm http://www.emedicine.c om/radio/topic163.htm http://www.healthsystem.virginia.edu/uvahealth/adult_liver /chole.cfm http://www.emedicine.com/EMERG/topic98.htm Microsoft Encarta 2004 Nur sing Care Plan Content CD-ROM