Cholecystitis, characterized by the inflammation of the gallbladder, is frequently triggered by gallstones obstructing the cystic duct. These stones, or calculi, are typically composed of cholesterol, calcium bilirubinate, or a combination thereof, arising from alterations in bile composition. Gallstone formation can occur throughout the biliary system, including the common bile duct, cystic duct, hepatic duct, and even smaller bile and pancreatic ducts. Furthermore, crystal formation within the gallbladder’s submucosa can initiate widespread inflammation. While acute cholecystitis associated with cholelithiasis often necessitates surgical intervention, alternative treatments focusing on stone fragmentation and dissolution are increasingly utilized.
Cholelithiasis, the presence of gallstones within the gallbladder, stems from imbalances in bile constituents. These gallstones are made up of cholesterol, calcium bilirubinate, or a mixture of both, and their development is often linked to gallbladder sluggishness associated with conditions such as pregnancy, hormonal contraceptive use, diabetes mellitus, celiac disease, liver cirrhosis, and pancreatitis.
Nursing Care Plans for Cholecystitis
Nursing care for patients diagnosed with cholecystitis is multifaceted, encompassing pain alleviation, promotion of rest, maintenance of fluid and electrolyte balance, prevention of potential complications, and comprehensive patient education regarding the disease process, prognosis, and available treatment modalities.
Risk for Deficient Fluid Volume
Patients suffering from cholecystitis and cholelithiasis face a significant risk of deficient fluid volume. This risk is primarily attributed to excessive fluid losses from vomiting or diarrhea, coupled with reduced oral intake due to nausea and anorexia. Additionally, liver dysfunction, often associated with cholecystitis, can disrupt clotting processes, further exacerbating fluid imbalance. Untreated, this fluid deficit can lead to dehydration and compromised tissue perfusion, intensifying the inflammatory response and potentially triggering systemic complications.
Nursing Diagnosis
- Risk for Deficient Fluid Volume
Risk factors may include
- Excessive fluid losses via gastric suction, vomiting, abdominal distension, and gastric hypermotility.
- Restricted fluid intake due to medical orders or patient condition.
- Altered clotting processes secondary to liver dysfunction.
Possibly evidenced by
(This section is typically for actual diagnoses, not risk diagnoses, and is therefore omitted as per the original article)
Desired Outcomes
- Patient will maintain adequate hydration as evidenced by balanced intake and output, stable vital signs, and moist mucous membranes.
- Patient will demonstrate understanding of fluid replacement needs and strategies to minimize fluid loss.
Nursing Assessment and Rationales
1. Maintain accurate record of fluid intake and output (I&O), noting output less than intake, and increased urine specific gravity. Assess skin turgor, mucous membranes, peripheral pulses, and capillary refill.
Rationale: Precise I&O monitoring, along with assessing urine specific gravity, provides essential data on the patient’s fluid balance and hydration status. Assessing skin turgor, mucous membranes, peripheral pulses, and capillary refill helps evaluate circulating volume and peripheral perfusion, crucial indicators of dehydration.
2. Monitor for signs and symptoms of increased or persistent nausea or vomiting, abdominal cramps, weakness, muscle twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, and depressed respirations.
Rationale: Prolonged vomiting, gastric aspiration, and limited oral intake can induce significant electrolyte imbalances, particularly deficits in sodium, potassium, and chloride. These electrolyte disturbances manifest through various neuromuscular and cardiovascular signs and symptoms, requiring vigilant monitoring.
3. Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis, or melena.
Rationale: Bile flow obstruction, a hallmark of cholecystitis, can impair prothrombin production and prolong coagulation time. This increases the patient’s susceptibility to bleeding and hemorrhage, necessitating careful assessment for any signs of abnormal bleeding.
Assessing hydration status of patient with cholecystitis
Nursing Interventions and Rationales
1. Eliminate noxious sights or smells from the patient’s environment.
Rationale: Offensive sights and smells can trigger the vomiting reflex, exacerbating fluid loss. Creating a calm and clean environment helps minimize nausea and vomiting.
2. Perform frequent oral hygiene with alcohol-free mouthwash; apply lip lubricants.
Rationale: Frequent vomiting and restricted oral intake can lead to dehydration and dryness of oral mucous membranes. Regular oral hygiene maintains comfort and reduces the risk of oral bleeding and cracking.
3. Use small-gauge needles for injections and apply firm pressure for a prolonged duration after venipuncture.
Rationale: Patients with cholecystitis may have impaired clotting. Utilizing small-gauge needles and applying prolonged pressure post-venipuncture minimizes tissue trauma and the risk of bleeding or hematoma formation.
4. Maintain NPO (nothing per oral) status as prescribed.
Rationale: Keeping the patient NPO reduces gastrointestinal secretions and motility, providing rest to the inflamed gallbladder and biliary system, especially during acute episodes.
5. Insert nasogastric (NG) tube, connect to suction, and maintain patency as indicated.
Rationale: NG tube insertion and suctioning are crucial for gastric decompression, particularly in cases of severe vomiting or abdominal distension. This intervention rests the gastrointestinal tract and prevents further fluid and electrolyte loss.
Acute Pain
Patients with cholecystitis and cholelithiasis commonly experience acute pain. This pain arises from several factors, including obstruction of the gallbladder or bile ducts by gallstones, inflammation and irritation of the gallbladder wall, and tissue ischemia due to compromised blood supply to the affected area. The pain is typically localized in the right upper quadrant of the abdomen and may be accompanied by systemic symptoms such as fever, nausea, and vomiting.
Nursing Diagnosis
- Acute Pain
May be related to
- Inflammation and distension of the gallbladder.
- Obstruction of biliary ducts.
- Tissue ischemia.
Possibly evidenced by
- Patient reports of pain, biliary colic (waves of intense pain).
- Facial grimacing or mask of pain; guarding behavior of the abdomen.
- Autonomic responses such as changes in blood pressure and pulse rate.
- Self-focusing and narrowed focus on pain.
Desired Outcomes
- Patient will report a satisfactory level of pain control, using a pain scale, within a specified timeframe.
- Patient will demonstrate effective use of relaxation techniques and diversional activities to manage pain.
Nursing Assessment and Rationales
1. Observe and meticulously document the location, severity (using a 0–10 pain scale), and character of pain (steady, intermittent, colicky).
Rationale: A thorough pain assessment aids in differentiating the underlying cause of abdominal pain and provides valuable information about the progression or resolution of the disease, development of complications, and the effectiveness of pain management interventions.
2. Note the patient’s response to prescribed pain medication, and promptly report to the physician if pain is not adequately relieved.
Rationale: Severe pain unresponsive to routine pain management measures may indicate developing complications, such as gallbladder rupture or pancreatitis, or necessitate a reassessment of the current treatment plan and potential need for more aggressive interventions.
Nursing Interventions and Rationales
1. Promote bed rest, allowing the patient to assume a position of comfort.
Rationale: Bed rest in a low-Fowler’s position can reduce intra-abdominal pressure and alleviate pain. However, allowing the patient to find their most comfortable position optimizes pain relief and promotes relaxation.
2. Utilize soft or cotton linens; apply calamine lotion, oil baths, or cool/moist compresses as indicated.
Rationale: These measures help soothe irritated skin and reduce itching, which can be exacerbated by jaundice, a common symptom of cholecystitis.
3. Control the environmental temperature to maintain a cool room.
Rationale: A cool environment can minimize dermal discomfort, particularly if the patient is experiencing fever or diaphoresis associated with cholecystitis.
4. Encourage the use of relaxation techniques and provide diversional activities.
Rationale: Relaxation techniques and diversional activities help reduce pain perception by redirecting attention and promoting mental and physical relaxation, enhancing coping mechanisms.
5. Allocate time to actively listen to the patient and maintain frequent contact.
Rationale: Providing emotional support and frequent interaction can reduce patient anxiety, which can amplify pain perception. A nurse’s presence and attentiveness can significantly contribute to pain relief.
6. Maintain NPO status and manage NG suction as prescribed.
Rationale: Maintaining NPO status and utilizing NG suction removes gastric secretions, which in turn minimizes the release of cholecystokinin. Cholecystokinin stimulates gallbladder contractions, potentially exacerbating pain in cholecystitis.
7. Administer medications as prescribed, such as:
-
Sedatives: phenobarbital
Rationale: Sedatives promote rest and relaxation of smooth muscles, which can help alleviate pain associated with gallbladder spasms. -
Antispasmodics:
Rationale: Antispasmodics directly reduce smooth muscle spasms in the biliary tract, providing targeted pain relief. -
Monoctanoin (Moctanin)
Rationale: This medication may be used post-cholecystectomy for retained stones or for dissolving newly formed large bile duct stones. It requires a prolonged treatment period (1-3 weeks) and is administered via a nasal-biliary tube, with cholangiograms performed periodically to assess stone dissolution. -
Smooth muscle relaxants: papaverine (Pavabid), nitroglycerin, amyl nitrite
Rationale: These smooth muscle relaxants relieve ductal spasms, reducing biliary colic and associated pain. -
Chenodeoxycholic acid (Chenix), ursodeoxycholic acid (Urso, Actigall)
Rationale: These bile acids reduce cholesterol synthesis, aiding in dissolving gallstones. Their effectiveness is highest for patients with a limited number of small cholesterol stones within a functioning gallbladder.
Risk for Imbalanced Nutrition: Less Than Body Requirements
Patients with cholecystitis and cholelithiasis are at risk for imbalanced nutrition, specifically less than body requirements. This risk is multifactorial, stemming from dietary restrictions aimed at preventing symptom exacerbation, nutrient losses due to impaired digestion and absorption (particularly fat malabsorption), and pain and dyspepsia leading to decreased oral intake. These factors can collectively contribute to malnutrition and nutrient deficiencies, potentially hindering healing and worsening the inflammatory response.
Nursing Diagnosis
- Risk for Imbalanced Nutrition: Less Than Body Requirements
Risk factors may include
- Self-imposed or medically prescribed dietary restrictions, nausea, vomiting, dyspepsia, pain.
- Nutrient loss and impaired fat digestion due to bile flow obstruction.
Possibly evidenced by
(This section is typically for actual diagnoses, not risk diagnoses, and is therefore omitted as per the original article)
Desired Outcomes
- Patient will report a reduction in nausea and vomiting.
- Patient will demonstrate progress towards desired weight gain or maintain weight as appropriate for their individual condition.
- Patient will tolerate a diet that meets nutritional needs without exacerbation of symptoms.
Nursing Assessment and Rationales
1. Calculate and document caloric intake. Minimize negative comments about appetite.
Rationale: Monitoring caloric intake identifies potential nutritional deficits and needs. Negative comments about appetite can create a negative atmosphere and further discourage eating.
2. Weigh the patient regularly as indicated.
Rationale: Regular weight monitoring provides objective data on the effectiveness of the nutritional plan and helps track progress towards nutritional goals.
3. Assess for abdominal distension, frequent belching, guarding behavior, and reluctance to move.
Rationale: These are nonverbal indicators of discomfort associated with impaired digestion and gas pain, common in cholecystitis. These signs can impact nutritional intake.
4. Monitor relevant laboratory studies: BUN, prealbumin, albumin, total protein, and transferrin levels.
Rationale: These laboratory values provide objective information about the patient’s nutritional status and the presence and severity of protein-calorie malnutrition. They also help evaluate the effectiveness of nutritional support interventions.
Nursing Interventions and Rationales
1. Consult with the patient about food preferences, dislikes, foods that trigger distress, and preferred meal schedules.
Rationale: Involving the patient in dietary planning promotes a sense of control and increases the likelihood of adherence to the prescribed diet. Understanding food preferences helps in tailoring meals to the patient’s liking within dietary restrictions.
2. Create a pleasant and calm atmosphere during meal times; remove any noxious stimuli from the environment.
Rationale: A relaxed and pleasant environment can enhance appetite and reduce nausea. Removing unpleasant sights or odors minimizes factors that could suppress appetite.
3. Provide thorough oral hygiene before meals.
Rationale: A clean and fresh mouth enhances appetite and makes eating more enjoyable, especially if the patient has experienced nausea or vomiting.
4. Offer effervescent drinks with meals if tolerated.
Rationale: Effervescent drinks may help reduce nausea and relieve gas. However, it’s crucial to monitor for any adverse effects, as these beverages can sometimes exacerbate gas formation or gastric discomfort in some individuals.
5. Encourage ambulation and increased activity as tolerated.
Rationale: Increased activity promotes bowel motility and helps in the expulsion of flatus, reducing abdominal distension and discomfort. Ambulation also contributes to overall well-being and recovery, preventing complications associated with immobility.
6. Consult with a registered dietitian or nutritional support team as indicated.
Rationale: Dietitians are experts in nutritional management and can provide individualized dietary plans tailored to the patient’s specific needs and preferences. A nutritional support team can be valuable in complex cases requiring specialized nutritional interventions.
7. Initiate a low-fat liquid diet after NG tube removal, as prescribed.
Rationale: Limiting fat intake reduces gallbladder stimulation and pain associated with incomplete fat digestion. A low-fat liquid diet is often the initial step in reintroducing oral intake post-NPO.
8. Progress the diet as tolerated, typically to a low-fat, high-fiber diet. Restrict gas-producing foods (onions, cabbage, popcorn) and high-fat foods (butter, fried foods, nuts).
Rationale: A low-fat, high-fiber diet meets nutritional needs while minimizing gallbladder stimulation and preventing recurrence of symptoms. Avoiding gas-producing foods reduces abdominal discomfort, and limiting high-fat foods eases the digestive burden on the biliary system.
9. Administer bile salts: Bilron, Zanchol, and dehydrocholic acid (Decholin), as prescribed.
Rationale: Bile salts promote the digestion and absorption of fats, fat-soluble vitamins, and cholesterol, which may be impaired in cholecystitis. Bile salt supplementation is particularly useful in chronic cholecystitis to improve fat digestion.
10. Provide parenteral and/or enteral feedings as needed.
Rationale: In cases of severe and prolonged inability to tolerate oral intake, parenteral (intravenous) or enteral (tube feeding) nutrition may be necessary to meet nutritional requirements and prevent malnutrition. The choice depends on the severity of the patient’s condition and the anticipated duration of nutritional support.
Deficient Knowledge
Patients with cholecystitis and cholelithiasis may experience deficient knowledge regarding their condition. This knowledge deficit can arise from a lack of information, misinformation about the disease, misinterpretation of available resources, and unfamiliarity with medical terminology and concepts. This lack of understanding can lead to confusion, anxiety, and uncertainty about managing their condition and preventing future complications.
Nursing Diagnosis
- Deficient Knowledge
May be related to
- Lack of exposure to information or recall deficit.
- Misinterpretation of information.
- Unfamiliarity with information resources.
Possibly evidenced by
- Patient questions and requests for information.
- Statements of misconception about cholecystitis.
- Inaccurate follow-through of prescribed instructions.
- Development of preventable complications due to misunderstanding of self-care.
Desired Outcomes
- Patient will verbalize an understanding of the cholecystitis disease process, prognosis, and potential complications.
- Patient will verbalize understanding of their therapeutic needs, including medications, diet, and activity restrictions.
- Patient will actively participate in their treatment regimen and initiate necessary lifestyle modifications.
Nursing Assessment and Rationales
1. Review the cholecystitis disease process and prognosis with the patient. Discuss hospitalization and prospective treatments as indicated. Encourage questions and expressions of concerns.
Rationale: Providing a solid knowledge base empowers patients to make informed decisions about their health. Open communication and emotional support during this time can reduce anxiety and promote patient cooperation with the treatment plan.
2. Review the prescribed medication regimen, including dosages, routes, frequency, and potential side effects.
Rationale: Gallstone recurrence is common, and long-term medication therapy may be necessary. Patients need to understand their medications to ensure adherence and manage potential side effects appropriately. For example, diarrhea or cramps during chenodiol therapy may be dose-related and correctable.
3. Review signs and symptoms that require prompt medical intervention: recurrent fever, persistent nausea and vomiting, unrelieved pain, jaundice of skin or eyes, itching, dark urine, clay-colored stools, blood in urine, stools, or vomitus, or bleeding from mucous membranes.
Rationale: These signs and symptoms can indicate disease progression or the development of serious complications, such as infection, bile duct obstruction, or liver damage, necessitating timely medical attention. Patient education on these warning signs promotes early detection and intervention.
Nursing Interventions and Rationales
1. Explain the reasons for diagnostic test procedures and necessary preparations.
Rationale: Providing clear explanations about tests and procedures reduces patient anxiety, which can, in turn, decrease sympathetic nervous system stimulation and improve patient comfort and cooperation.
2. Discuss weight reduction programs if indicated.
Rationale: Obesity is a significant risk factor for cholecystitis. Weight loss, if appropriate, is a beneficial component of long-term medical management and can reduce the risk of recurrent gallbladder issues.
3. Instruct the patient to avoid foods and fluids high in fats (pork, gravies, nuts, fried foods, butter, whole milk, ice cream), gas producers (cabbage, beans, onions, carbonated beverages), and gastric irritants (spicy foods, caffeine, citrus).
Rationale: Dietary modifications are crucial for preventing recurrence of gallbladder attacks. Limiting these food types minimizes gallbladder stimulation and reduces the likelihood of symptom exacerbation.
4. Recommend resting in a semi-Fowler’s position after meals.
Rationale: This position promotes bile flow and general relaxation during the initial digestive process, potentially reducing discomfort and aiding digestion.
5. Suggest the patient limit gum chewing, sucking on straws and hard candy, or smoking.
Rationale: These habits promote air swallowing, which can increase gas formation, gastric distension, and abdominal discomfort. Reducing these habits can help manage gas-related symptoms.
6. Discuss avoidance of aspirin-containing products, forceful nose blowing, straining during bowel movements, and contact sports.
Rationale: Patients with cholecystitis may have impaired coagulation and are at increased risk of bleeding. Avoiding these activities minimizes the risk of bleeding related to changes in coagulation, mucosal irritation, and potential trauma.
7. Recommend the use of a soft toothbrush or electric razor.
Rationale: Using a soft toothbrush and electric razor reduces the risk of bleeding from gums and skin due to potential coagulation issues or mucosal irritation.
Recommended Resources
This section is kept as in the original article, as it provides valuable resources for nurses.
Recommended nursing diagnosis and nursing care plan books and resources.
Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
See also
This section is kept as in the original article, as it provides valuable related resources.
Other recommended site resources for this nursing care plan:
More nursing care plans related to gastrointestinal disorders:
