Cholecystitis and Cholelithiasis

Nursing Care Plans

PRESENTATION BY: LOUELLA G. RAMOS, R.N.

Cholecystitis is the inflammation of the gallbladder, usually associated
with gallstones impacted in the cystic duct. Stones (calculi) are made
up of cholesterol, calcium bilirubinate, or a mixture caused by changes
in the bile composition. Gallstones can develop in the common bile
duct, the cystic duct, hepatic duct, small bile duct, and pancreatic duct.
Crystals can also form in the submucosa of the gallbladder causing
widespread inflammation. Acute cholecystitis with cholelithiasis is
usually treated by surgery, although several other treatment methods
(fragmentation and dissolution of stones) are now being used.
Choleslithiasis, stones or calculi in the gallbladder, results from changes
in bile components. Gallstones are made of cholesterol, calcium
bilirubinate, or a mix of cholesterol and bilirubin. They arise during
periods of sluggishness in the gallbladder due to pregnancy, hormonal
contraceptives, diabetes mellitus, celiac disease, cirrhosis of the liver,
and pancreatitis.
PSYCHOLOGIC
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “Ano na Deficient Knowledge After 8 hours of • Explain reasons • Information can After 8 hours of
mangyayari sa nursing for test decrease anxiety, nursing
akin?” as Related to : interventions the procedures and thereby reducing interventions the
verbalized by • Lack of pt will able to: preparations as sympathetic pt was able to:
the pt. knowledge/recall • Verbalize needed. stimulation. • Verbalize
understanding of understanding of
O: Restless • Information disease process, • Review disease • Provides disease process,
misinterpretation prognosis, process and knowledge base prognosis,
potential prognosis. from which potential
As evidenced by: complications. Discuss patient can make complications.
• Questions; request hospitalization informed
for information • Verbalize and prospective choices. Effective • Verbalize
understanding of treatment as communication understanding of
• Statement of therapeutic indicated. and support at therapeutic
misconception needs. Encourage this time can needs.
questions, diminish anxiety
• Initiate expression of and promote • Initiate
necessary concern. healing. necessary
lifestyle changes lifestyle changes
& participate in & participate in
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
treatment • Review drug • Gallstones often treatment
regimen. regimen, recur, regimen.
possible side necessitating
effects. long-term
therapy.

Note: Women of
childbearing age
should be
counseled
regarding birth
control to prevent
pregnancy and
risk of fetal
hepatic damage.

• Discuss weight • Obesity is a risk

reduction factor associated
programs if with
indicated cholecystitis,
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
& weight loss is
beneficial in
medical
management of
chronic condition.

• Instruct patient to • Limits or

avoid food/fluids prevents
high in fats (pork, recurrence of
gravies, nuts, fried gallbladder
foods, butter, whole attacks.
milk, ice cream), gas
producers (cabbage,
beans, onions,
carbonated
beverages), or
gastric irritants (
spicy foods, caffeine,
citrus).
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Review signs • Indicative of
and symptoms progression of
requiring disease process
medical and
intervention: development of
recurrent fever; complications
persistent requiring
nausea and further
vomiting, or intervention.
pain; jaundice
of skin or eyes,
itching; dark
urine; clay-
colored stools;
blood in urine,
stools, vomitus;
or bleeding
from mucous
membranes.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Recommend • Promotes flow of
resting in semi- bile and general
Fowler’s position relaxation during
after meals. initial digestive
process.

• Suggest patient • Promotes gas

limit gum formation, which
chewing, sucking can increase
on straw and gastric
hard candy, or distension and
smoking. discomfort.

• Discuss • Reduces risk of

avoidance of bleeding related
aspirin- to changes in
containing coagulation
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
products, forceful time, mucosal
blowing of nose, irritation, and
straining for trauma.
bowel movement,
contact sports.

• Recommend use • Reduces risk of

of soft bleeding related
toothbrush, to changes in
electric razor. coagulation
time, mucosal
irritation, and
trauma
ELIMINATION
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “Nasusuka ako” Risk for Deficient After 8 hours of • Maintain • To provide After 8 hours of
as verbalized by Fluid Volume nursing accurate record information nursing
the pt. interventions the of I&O, noting about fluid interventions the
patient will be output less than status and patient was able
able to intake, increased circulating to Demonstrate
O: (+) Vomiting Demonstrate urine specific volume needing adequate fluid
adequate fluid gravity. Assess replacement. balance
(+) gastric hyper- balance skin and mucous evidenced by
motility evidenced by membranes, stable vital signs,
stable vital signs, peripheral moist mucous
(+) Poor skin moist mucous pulses, and membranes, good
turgor membranes, good capillary refill. skin turgor,
skin turgor, capillary refill,
(+) Body capillary refill, • Monitor for signs • Prolonged individually
weakness individually and symptoms vomiting, gastric appropriate
appropriate of increased or aspiration, and urinary output,
urinary output, continued restricted oral absence of
absence of nausea or intake can lead vomiting.
vomiting. vomiting, to deficits in
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
abdominal sodium,
cramps, potassium, and
weakness, chloride.
twitching,
seizures, irregular
heart rate,
paresthesia,
hypoactive or
absent bowel
sounds,
depressed
respirations.

• Eliminate • Reduces
noxious sights or stimulation of
smells from vomiting center.
environment.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Perform • Decreases
frequent oral dryness of oral
hygiene with mucous
alcohol-free membranes;
mouthwash; reduces risk of
apply lubricants. oral bleeding.

• Use small-gauge • Reduces trauma,

needles for risk of bleeding
injections and or hematoma
apply firm formation.
pressure for
longer than
usual after
venipuncture.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Assess for unusual • Prothrombin is
bleeding: oozing reduced and
from injection sites, coagulation time
epistaxis, bleeding prolonged when
gums, ecchymosis, bile flow is
petechiae, obstructed,
hematemesis or increasing risk of
melena. bleeding or
hemorrhage.

• Keep patient NPO as • Decreases GI

necessary. secretions and
motility.

• Insert NG tube, • To rest the GI

connect to suction, Tract
and maintain patency
as indicated.
REST & COMFORT
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “Hindi ako Acute Pain After 8 hours of • Note response • Severe pain not After 8 hours of
makatulog sa sakit related to nursing to medication, relieved by nursing
ng tiyan ko” as obstruction/ interventions the and report to routine interventions the
verbalized by the pt ductal spasm patient will be physician if measures may patient was able
able to: pain is not indicate to:
• Pain Scale: 8/10 being relieved. developing
• Report pain is complications or • Report pain is
O: (+) Facial grimace relieved/ need for further relieved/
controlled. intervention. controlled.
(+) guarding
behavior • Demonstrate • Promote • Bedrest in low- • Demonstrate
use of bedrest, Fowler’s use of
• BP=140/90mmHg relaxation skills allowing position reduces relaxation skills
and diversional patient to intra-abdominal and diversional
• PR= 100bpm activities as assume pressure; activities as
indicated for position of however, indicated for
individual comfort. patient will individual
situation. naturally situation.
assume least
painful position.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Use soft or cotton • Reduces irritation
linens; calamine and dryness of the
lotion, oil bath; skin and itching
cool or moist sensation.
compresses as
indicated.

• Encourage use of • Promotes rest,

relaxation redirects attention,
techniques. may enhance coping.
Provide diversional
activities.

• Make time to listen • Helpful in alleviating

to and maintain anxiety and
frequent contact refocusing attention,
with patient. which can relieve
pain.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Sedatives: • Promotes rest and
phenobarbital relaxes smooth
muscle, relieving
pain.

• Narcotics: • Given to reduce

meperidine severe pain.
hydrochloride Morphine is used
(Demerol), with caution
morphine because it may
sulfate increase spasms of
the sphincter of
Oddi, although
nitroglycerin may
be given to reduce
morphine-induced
spasms if they
occur.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Smooth muscle • Relieves ductal
relaxants: spasm.
papaverine
(Pavabid),
nitroglycerin,
amyl nitrite

• Chenodeoxycholi • These natural

c acid (Chenix), bile acids
ursodeoxycholic decrease
acid (Urso, cholesterol
Actigall) synthesis,
dissolving
gallstones.
Success of this
treatment
depends on the
number and size
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
of gallstones
(preferably three
or fewer stones
smaller than 20
min in diameter)
floating in a
functioning
gallbladder.

• Antibiotics. • To treat
infectious
process,
reducing
inflammation.
SAFETY
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “ Nilalamig ako” Risk for infection, After 8 hrs. of • Instruct the pt • Hand washing After 8 hrs. of
as verbalized by related to nursing and caregiver to remains the most nursing
the pt. potential bacterial interventions wash hands effective method interventions
contamination of the pt will before contact of infection the pt was able
abdominal cavity remain free of with the control. to remain free
O: Temp=38.5 C infection as postoperative of infection as
evidenced by pt. evidenced by
(+) chills healing wound healing wound
or incision that • Teach use • Aseptic technique or incision that
(+) Redness and is free of aseptic prevents is free of
swelling at the redness, technique transmission of redness,
incision site swelling, during dressing bacterial swelling,
purulent change, or infections to the purulent
(+) Purulent discharge, and handling or area. discharge, and
discharge pain, and by manipulating of pain, and by
normal body tubes and normal body
temperature drains. temperature
within 48 hrs. within 48 hrs.
postoperatively postoperatively
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Ensure the • Opening sterile
surgical tubes systems allows
and drains are access by
not pathogens and
inadvertently puts the pt at risk
interrupted for infection to
(opened). the area.
Securely tape Drains may be left in
connectors and place until the first
pin extension or return visit to the
drainage tubing surgeon (about 7
to the pt.'s days), if not
clothing. removed at the time
of discharge.

• Instruct the Antibiotics are

patient and necessary for the
caregiver in treatment of abscess
administration & infection.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
of antibiotics and Antipyretics will
antipyretics as reduce fever and
prescribed. promote comfort.
OXYGENATION
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “Masakit kapag Ineffective After 8 hours of Assess rate and Respirations are After 8 hours of
nag uubo, hirap Breathing pattern nursing depth of typically shallow, nursing
huminga” as related to: interventions respirations. because the least interventions
verbalized by the the pt will be amount of excursion the pt was able
pt • Abdominal able to maintain is less painful when to maintain an
incision pain an effective an abdominal effective
O: Poor coughing breathing incision is present. breathing
effort • Abdominal pattern as Also higher the pattern as
distention evidenced by a incision, the more evidenced by a
• Shallow compromising respiratory rate, the breathing is respiratory
breathing lung expansion non labored affected. rate, non
deep labored deep
• Splinting • Sedation respirations, Auscultate lung The bases of the respirations,
respirations ability to use sounds at least lungs are least likely ability to use
• Lack of incentive every 4 hours to be ventilated; incentive
• RR = 24 cpm knowledge spirometer postoperatively. therefore lung spirometer
correctly, & sounds may be correctly, &
clear lung diminished over the clear lung
sounds. bases. sounds.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Observe for Splinting refers to
splinting. the conscious
minimization of an
inspiration to reduce
the amount of
discomfort caused
by full expansion.

Elevate head of bed This position puts

at least 30 degrees. the least strain on
abdominal muscles
and enhances
diaphragmatic
excursion.

Encourage the pt to Keeps the alveoli

do deep breathing from collapsing.
exercises.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Help the pt splint Splinting the incision
the abdominal eases discomfort of
incision by using coughing and taking
hands or pillow. deep breaths.

Administer oxygen Promoting lung

as prescribed expansion and
oxygenation of the
tissues is a goal of
the pt with
atelectasis.
NUTRITION
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “Wala siyang Imbalanced After 8 hours of • Calculate caloric •Identifies After 8 hours of
ganang kumain” nutrition: Less nursing intake. Keep nutritional nursing
as verbalized by than body interventions the comments about deficiencies interventions the
the watcher requirements, patient will be able appetite to a and/or needs. patient was able
related to to: minimum. Focusing on to:
anorexia and problem creates
recent weight • Report relief of a negative •Report relief of
O : (+) Vomiting loss nausea/vomiting. atmosphere and nausea/vomiting.
may interfere
• Demonstrate with intake. •Demonstrate
progression progression
toward desired • Weigh as •Monitors toward desired
weight gain or indicated. effectiveness of weight gain or
maintain weight as dietary plan. maintain weight
individually as individually
appropriate. • Consult with •Involving patient appropriate.
patient about in planning
likes and dislikes, enables patient
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
foods that cause to have a sense of
distress, and control and
preferred meal encourages
schedule. eating.

• Provide a pleasant • Useful in

atmosphere at promoting
mealtime; remove appetite/reducin
noxious stimuli. g nausea.

• Provide oral hygiene • A clean mouth

before meals. enhances
appetite.

• Offer effervescent • May lessen

drinks with meals, if nausea and
tolerated. relieve gas.
Note: May be
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
contraindicated if
beverage causes
gas
formation/gastric
discomfort.

• Assess for • Nonverbal signs

abdominal of discomfort
distension, associated with
frequent impaired
belching, digestion, gas
guarding, pain.
reluctance to
move.

• Ambulate and • Helpful in

increase activity expulsion of
as tolerated. flatus, reduction
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
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 •Useful in

dietitian or establishing
nutritional individual
support team as nutritional needs
indicated. and most
appropriate route.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Begin low-fat • Limiting fat
liquid diet after content reduces
NG tube is stimulation of
removed. gallbladder and
pain associated
with incomplete
fat digestion and
is helpful in
preventing
recurrence.

• Advance diet as • Meets

tolerated, nutritional
usually low-fat, requirements
high-fiber. while minimizing
Restrict gas- stimulation of
the gallbladder.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
producing foods
(onions, cabbage,
popcorn) and
foods or fluids
high in fats
(butter, fried
foods, nuts).

• Administer bile • Promotes

salts: Bilron, digestion and
Zanchol, absorption of
dehydrocholic fats, fat-
acid soluble
(Decholin), as vitamins,
indicated. cholesterol.
Useful in
chronic
cholecystitis.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Monitor • Provides
laboratory information
studies: BUN, about nutritional
pre albumin, deficits or
albumin, total effectiveness of
protein, therapy.
transferrin
levels.

• Provide • Alternative
parenteral feeding may be
and/or enteral required
feedings as depending on
needed. degree of
disability and
gallbladder
involvement and
need for
prolonged
gastric rest.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
• Maintain NPO • Removes gastric
status, insert secretions that
and/or maintain stimulate release
NG suction as of
indicated. cholecystokinin
and gallbladder
contractions.
Administer
medications as
indicated:

• Anticholinergics: • Relieves reflex

atropine, spasm and
propantheline smooth muscle
(Pro-Banthı-ne) contraction and
assists with pain
management.
THANK YOU FOR LISTENING