Cholelithiasis and Cholecystitis Nursing Care Plan

 

Nursing Diagnosis
  • Fluid Volume, risk for deficient
Risk factors may include
  • Excessive losses through gastric suction; vomiting, distension, and gastric hyper­motility
  • Medically restricted intake
  • Altered clotting process
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, absence of vomiting.
Nursing Interventions
  • Maintain accurate record of I&O, noting output less than intake, increased urine specific gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill.
    • Rationale: To provide information about fluid status and circulating volume needing replacement.
  • Monitor for signs and symptoms of increased or continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, depressed respirations.
    • Rationale: Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.
  • Eliminate noxious sights or smells from environment.
    • Rationale: Reduces stimulation of vomiting center.
  • Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.
    • Rationale: Decreases dryness of oral mucous membranes; reduces risk of oral bleeding.
  • Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture.
    • Rationale: Reduces trauma, risk of bleeding or hematoma formation.
  • Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis or melena.
    • Rationale: Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.
  • Keep patient NPO as necessary.
    • Rationale: Decreases GI secretions and motility.
  • Insert NG tube, connect to suction, and maintain patency as indicated.
    • Rationale: To rest the GI Tract
Nursing Diagnosis
  • Pain, acute
May be related to
  • Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis
Possibly evidenced by
  • Reports of pain, biliary colic (waves of pain)
  • Facial mask of pain; guarding behavior
  • Autonomic responses (changes in BP, pulse)
  • Self-focusing; narrowed focus
Desired Outcomes
  • Report pain is relieved/controlled.
  • Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing Interventions
  • Observe and document location, severity (0–10 scale), and character of pain (steady, intermittent, colicky).
    • Rationale: Assists in differentiating cause of pain, and provides information about disease progression and resolution, development of complications, and effectiveness of interventions.
  • Note response to medication, and report to physician if pain is not being relieved.
    • Rationale: Severe pain not relieved by routine measures may indicate developing complications or need for further intervention.
  • Promote bedrest, allowing patient to assume position of comfort.
    • Rationale: Bedrest in low-Fowler’s position reduces intra-abdominal pressure; however, patient will naturally assume least painful position.
  • Use soft or cotton linens; calamine lotion, oil bath; cool or moist compresses as indicated.
    • Rationale: Reduces irritation and dryness of the skin and itching sensation.
  • Control environmental temperature.
    • Rationale: Cool surroundings aid in minimizing dermal discomfort.
  • Encourage use of relaxation techniques. Provide diversional activities.
    • Rationale: Promotes rest, redirects attention, may enhance coping.
  • Make time to listen to and maintain frequent contact with patient.
    • Rationale: Helpful in alleviating anxiety and refocusing attention, which can relieve pain.
  • Maintain NPO status, insert and/or maintain NG suction as indicated.
    • Rationale: Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions.

Administer medications as indicated:

  • Anticholinergics: atropine, propantheline (Pro-Banthı-ne);
    • Rationale: Relieves reflex spasm and smooth muscle contraction and assists with pain management.
  • Sedatives: phenobarbital;
    • Rationale: Promotes rest and relaxes smooth muscle, relieving pain.
  • Narcotics: meperidine hydrochloride (Demerol), morphine sulfate;
    • Rationale: Given to reduce severe pain. Morphine is used with caution because it may increase spasms of the sphincter of Oddi, although nitroglycerin may be given to reduce morphine-induced spasms if they occur.
  • Monoctanoin (Moctanin);
    • Rationale: This medication may be used after a cholecystectomy for retained stones or for newly formed large stones in the bile duct. It is a lengthy treatment (1–3 wk) and is administered via a nasal-biliary tube. A cholangiogram is done periodically to monitor stone dissolution.
  • Smooth muscle relaxants: papaverine (Pavabid), nitroglycerin, amyl nitrite;
    • Rationale: Relieves ductal spasm.
  • Chenodeoxycholic acid (Chenix), ursodeoxycholic acid (Urso, Actigall);
    • Rationale: These natural bile acids decrease cholesterol synthesis, dissolving gallstones. Success of this treatment depends on the number and size of gallstones (preferably three or fewer stones smaller than 20 min in diameter) floating in a functioning gallbladder.
  • Antibiotics.
    • Rationale: To treat infectious process, reducing inflammation.
Nursing Diagnosis
  • Nutrition: Less Than Body Requirements, Risk for Imbalanced
Risk factors may include
  • Self-imposed or prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain
  • Loss of nutrients; impaired fat digestion due to obstruction of bile flow
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Report relief of nausea/vomiting.
  • Demonstrate progression toward desired weight gain or maintain weight as individually appropriate.
Nursing Interventions
  • Calculate caloric intake. Keep comments about appetite to a minimum.
    • Rationale: Identifies nutritional deficiencies and/or needs. Focusing on problem creates a negative atmosphere and may interfere with intake.
  • Weigh as indicated.
    • Rationale: Monitors effectiveness of dietary plan.
  • Consult with patient about likes and dislikes, foods that cause distress, and preferred meal schedule.
    • Rationale: Involving patient in planning enables patient to have a sense of control and encourages eating.
  • Provide a pleasant atmosphere at mealtime; remove noxious stimuli.
    • Rationale: Useful in promoting appetite/reducing nausea.
  • Provide oral hygiene before meals.
    • Rationale: A clean mouth enhances appetite.
  • Offer effervescent drinks with meals, if tolerated.
    • Rationale: May lessen nausea and relieve gas. Note:May be contraindicated if beverage causes gas formation/gastric discomfort.
  • Assess for abdominal distension, frequent belching, guarding, reluctance to move.
    • Rationale: Nonverbal signs of discomfort associated with impaired digestion, gas pain.
  • Ambulate and increase activity as tolerated.
    • Rationale: Helpful in expulsion of flatus, reduction of abdominal distension. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility (pneumonia, thrombophlebitis).
  • Consult with dietitian or nutritional support team as indicated.
    • Rationale: Useful in establishing individual nutritional needs and most appropriate route.
  • Begin low-fat liquid diet after NG tube is removed.
    • Rationale: Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence.
  • Advance diet as tolerated, usually low-fat, high-fiber. Restrict gas-producing foods (onions, cabbage, popcorn) and foods or fluids high in fats (butter, fried foods, nuts).
    • Rationale: Meets nutritional requirements while minimizing stimulation of the gallbladder.
  • Administer bile salts: Bilron, Zanchol, dehydrocholic acid (Decholin), as indicated.
    • Rationale: Promotes digestion and absorption of fats, fat-soluble vitamins, cholesterol. Useful in chronic cholecystitis.
  • Monitor laboratory studies: BUN, prealbumin, albumin, total protein, transferrin levels.
    • Rationale: Provides information about nutritional deficits or effectiveness of therapy.
  • Provide parenteral and/or enteral feedings as needed.
    • Rationale: Alternative feeding may be required depending on degree of disability and gallbladder involvement and need for prolonged gastric rest.
Nursing Diagnosis
  • Deficient Knowledge
May be related to
  • Lack of knowledge/recall
  • Information misinterpretation
  • Unfamiliarity with information resources
Possibly evidenced by
  • Questions; request for information
  • Statement of misconception
  • Inaccurate follow-through of instruction
  • Development of preventable complications
Desired Outcomes
  • Verbalize understanding of disease process, prognosis, potential complications.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions
  • Explain reasons for test procedures and preparations as needed.
    • Rationale: Information can decrease anxiety, thereby reducing sympathetic stimulation.
  • Review disease process and prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern.
    • Rationale: Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing.
  • Review drug regimen, possible side effects.
    • Rationale: Gallstones often recur, necessitating long-term therapy. Development of diarrhea or cramps during chenodiol therapy may be dose-related or correctable. Note: Women of childbearing age should be counseled regarding birth control to prevent pregnancy and risk of fetal hepatic damage.
  • Discuss weight reduction programs if indicated
    • Rationale: Obesity is a risk factor associated with cholecystitis, and weight loss is beneficial in medical management of chronic condition.
  • Instruct patient to avoid food/fluids high in fats (pork, gravies, nuts, fried foods, butter, whole milk, ice cream), gas producers (cabbage, beans, onions, carbonated beverages), or gastric irritants ( spicy foods, caffeine, citrus).
    • Rationale: Limits or prevents recurrence of gallbladder attacks.
  • Review signs and symptoms requiring medical intervention: recurrent fever; persistent nausea and vomiting, or pain; jaundice of skin or eyes, itching; dark urine; clay-colored stools; blood in urine, stools, vomitus; or bleeding from mucous membranes.
    • Rationale: Indicative of progression of disease process and development of complications requiring further intervention.
  • Recommend resting in semi-Fowler’s position after meals.
    • Rationale: Promotes flow of bile and general relaxation during initial digestive process.
  • Suggest patient limit gum chewing, sucking on straw and hard candy, or smoking.
    • Rationale: Promotes gas formation, which can increase gastric distension and discomfort.
  • Discuss avoidance of aspirin-containing products, forceful blowing of nose, straining for bowel movement, contact sports.
    • Rationale: Reduces risk of bleeding related to changes in coagulation time, mucosal irritation, and trauma.
  • Recommend use of soft toothbrush, electric razor.
    • Rationale: Reduces risk of bleeding related to changes in coagulation time, mucosal irritation, and trauma.