Nursing Care plan about Cholecystitis and Cholelithiasis

A comprehensive nursing care plan guide for Cholecystitis and Cholelithiasis

1. CHOLECYSTITIS WITH CHOLELITHIASIS
   
2. Cholecystitis is an acute or chronic inflammation of the gallbladder, usually associated with gallstone(s) impacted in the cystic duct, causing distension of the gallbladder.
   
3. 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.
   
4. 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.
   
5. CARE SETTING Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized patient.
   
6. RELATED CONCERNS Cholecystectomy Fluid and electrolyte imbalances,Psychosocial aspects of care Total nutritional support: parenteral/enteral feeding Patient Assessment Database
   
7. ACTIVITY/REST May report: Fatigue May exhibit: Restlessness
   
8. CIRCULATION May exhibit: Tachycardia, diaphoresis, lightheadedness
   
9. ELIMINATION May report: Change in color of urine and stools May exhibit: Abdominal distension Palpable mass in right upper quadrant (RUQ) Dark, concentrated urine Clay-colored stool, steatorrhea
   
10. FOOD/FLUID May report: Anorexia, nausea/vomiting Intolerance of fatty and “gas-forming” foods; recurrent regurgitation, heartburn, indigestion, flatulence, bloating (dyspepsia) Belching (eructation) May exhibit: Obesity; recent weight loss Normal to hypoactive bowel sounds
    
11. PAIN/DISCOMFORT May report: Severe epigastric and right upper abdominal pain, may radiate to mid-back, right shoulder/scapula, or to front of chest Midepigastric colicky pain associated with eating, especially after meals rich in fats Pain severe/ongoing, starting suddenly, sometimes at night, and usually peaking in 30 min, often increases with movement Recurring episodes of similar pain May exhibit: Rebound tenderness, muscle guarding, or abdominal rigidity when RUQ is palpated; positive Murphy’s sign
    
12. RESPIRATION
    
13. May exhibit: Increased respiratory rate Splinted respiration marked by short, shallow breathing
    
14. SAFETY May exhibit: Low-grade fever; high-grade fever and chills (septic complications) Jaundice, with dry, itching skin (pruritus) Bleeding tendencies (vitamin K deficiency) TEACHING/LEARNING May report: Familial tendency for gallstones Recent pregnancy/delivery; history of diabetes mellitus (DM), IBD, blood dyscrasias Discharge plan DRG projected mean length of inpatient stay: 4.3 days considerations: May require support with dietary changes/weight reduction Refer to section at end of plan for postdischarge considerations.
    
15. DIAGNOSTIC STUDIES Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial diagnostic procedure). Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of gallbladder, including presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting prevent oral intake, when the gallbladder cannot be visualized during OCG, or when symptoms persist following cholecystectomy. IVC may also be done perioperatively to assess structure and function of ducts, detect remaining stones after lithotripsy or cholecystectomy, and/or to detect surgical complications. Dye can also be injected via T-tube drain postoperatively. Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum. Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in ducts. Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated in acute cholecystitis because patient is too ill to take the dye by mouth. Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between obstructive/nonobstructive jaundice. Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection. Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases; calcification of the wall or enlargement of the gallbladder. Chest x-ray: Rule out respiratory causes of referred pain. CBC: Moderate leukocytosis (acute). Serum bilirubin and amylase: Elevated. Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction. Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine decreases absorption of vitamin K. NURSING PRIORITIES 1. Relieve pain and promote rest. 2. Maintain fluid and electrolyte balance. 3. Prevent complications. 4. Provide information about disease process, prognosis, and treatment needs. DISCHARGE GOALS 1. Pain relieved. 2. Homeostasis achieved. 3. Complications prevented/minimized. 4. Disease process, prognosis, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge NURSING DIAGNOSIS: Pain, acute May be related to Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis
16. ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Collaborative Maintain NPO status, insert/maintain NG suction as Removes gastric secretions that stimulate release of indicated. cholecystokinin and gallbladder contractions. Administer medications as indicated: Anticholinergics, e.g., atropine, propantheline (Pro- Relieves reflex spasm/smooth muscle contraction and Banthı-ne); assists with pain management. Sedatives, e.g., phenobarbital; Promotes rest and relaxes smooth muscle, relieving pain. Narcotics, e.g., meperidine hydrochloride (Demerol), Given to reduce severe pain. Morphine is used with caution morphine sulfate; 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); 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.
17. A cholangiogram is done periodically to monitor stone dissolution. Smooth muscle relaxants, e.g., papaverine (Pavabid), Relieves ductal spasm. nitroglycerin, amyl nitrite; Chenodeoxycholic acid (Chenix), ursodeoxycholic
    
18. These natural bile acids decrease cholesterol synthesis, acid (Urso, Actigall); 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. To treat infectious process, reducing inflammation.
    
19. Prepare for procedures, e.g.: Endoscopic papillotomy (removal of ductal stone); Choice of procedure is dictated by individual situation. Extracorporeal shock wave lithotripsy (ESWL); Shock wave treatment is indicated when patient has mild or moderate symptoms, cholesterol stones in gallbladder are 0.5 mm or larger, and there is no biliary tract obstruction. Depending on the machine being used, the patient may sit in a tank of water or lie prone on a water-filled cushion.
    
20. Treatment takes about 1–2 hr and is 75%–95% successful.
    
21. Note: This procedure is contraindicated in patients with pacemakers or implantable defibrillators. Procedure done to widen the mouth of the common bile Endoscopic sphincterotomy; duct where it empties into the duodenum. This procedure may also include the manual retrieval of stones from the duct by means of a tiny basket or balloon on the end of the endoscope. Stones must be smaller than 15 mm.
22. Fluid/Electrolyte Management (NIC) Independent Assess for unusual bleeding, e.g., oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis/melena. Prothrombin is reduced and coagulation time prolonged Collaborative when bile flow is obstructed, increasing risk of bleeding/hemorrhage. Keep patient NPO as necessary. Insert NG tube, connect to suction, and maintain patency as Decreases GI secretions and motility. indicated. Provides rest for GI tract. Administer antiemetics, e.g., prochlorperazine (Compazine). Reduces nausea and prevents vomiting. Review laboratory studies, e.g., Hb/Hct, electrolytes, ABGs (pH), clotting times. Aids in evaluating circulating volume, identifies deficits, and influences choice of intervention for Administer IV fluids, electrolytes, and vitamin K. replacement/correction. Maintains circulating volume and corrects imbalances.
    
23. NURSING DIAGNOSIS: Nutrition: imbalanced, risk for less than body requirements 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; presence of signs and symptoms establishes an actual diagnosis.]
    
24. DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Nutritional Status (NOC) Report relief of nausea/vomiting. Demonstrate progression toward desired weight gain or maintain weight as individually appropriate.
    
25. ACTIONS/INTERVENTIONS RATIONALE Nutrition Management (NIC) Independent Estimate/calculate caloric intake. Keep comments about Identifies nutritional deficiencies/needs. Focusing on appetite to a minimum. problem creates a negative atmosphere and may interfere with intake.
26. ACTIONS/INTERVENTIONS RATIONALE Nutrition Management (NIC) Independent Weigh as indicated. Monitors effectiveness of dietary plan. Consult with patient about likes/dislikes, foods that cause Involving patient in planning enables patient to have a distress, and preferred meal schedule. sense of control and encourages eating. Provide a pleasant atmosphere at mealtime; remove Useful in promoting appetite/reducing nausea. noxious stimuli. Provide oral hygiene before meals. A clean mouth enhances appetite. Offer effervescent drinks with meals, if tolerated. May lessen nausea and relieve gas. Note: May be contraindicated if beverage causes gas formation/gastric discomfort. Assess for abdominal distension, frequent belching, Nonverbal signs of discomfort associated with impaired guarding, reluctance to move. digestion, gas pain. Ambulate and increase activity as tolerated. 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 9e.g., pneumonia, thrombophlebitis).
27. Collaborative Useful in establishing individual nutritional needs and most Consult with dietitian/nutritional support team as indicated. appropriate route. Begin low-fat liquid diet after NG tube is removed. 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. Meets nutritional requirements while minimizing Restrict gas-producing foods (e.g., onions, cabbage, stimulation of the gallbladder. popcorn) and foods/fluids high in fats (e.g., butter, fried foods, nuts). Administer bile salts, e.g., Bilron, Zanchol, dehydrocholic Promotes digestion and absorption of fats, fat-soluble acid (Decholin), as indicated. vitamins, cholesterol. Useful in chronic cholecystitis. Monitor laboratory studies, e.g., BUN, prealbumin, Provides information about nutritional albumin, total protein, transferrin levels. deficits/effectiveness of therapy. Provide parenteral/enteral feedings as needed. Alternative feeding may be required depending on degree of disability/gallbladder involvement and need for prolonged gastric rest.
    
28. NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 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/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Illness Care (NOC) Verbalize understanding of disease process, prognosis, potential complications. Verbalize understanding of therapeutic needs. Initiate necessary lifestyle changes and participate in treatment regimen. ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Provide explanations of/reasons for test procedures and Information can decrease anxiety, thereby reducing preparation needed. sympathetic stimulation. Review disease process/prognosis. Discuss hospitalization Provides knowledge base from which patient can make and prospective treatment as indicated. Encourage informed choices. Effective communication and support at questions, expression of concern. this time can diminish anxiety and promote healing. Review drug regimen, possible side effects. Gallstones often recur, necessitating long-term therapy. Development of diarrhea/cramps during chenodiol therapy may be dose-related/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 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 (e.g., Prevents/limits recurrence of gallbladder attacks. whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus).
29. ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Review signs/symptoms requiring medical intervention, Indicative of progression of disease process/development e.g., recurrent fever; persistent nausea/vomiting, or pain; of complications requiring further intervention. jaundice of skin or eyes, itching; dark urine; clay-colored stools; blood in urine, stools, vomitus; or bleeding from mucous membranes. Recommend resting in semi-Fowler’s position after meals. Promotes flow of bile and general relaxation during initial digestive process. Suggest patient limit gum chewing, sucking on straw/hard candy, or smoking. Promotes gas formation, which can increase gastric distension/discomfort. Discuss avoidance of aspirin-containing products, forceful Reduces risk of bleeding related to changes in coagulation blowing of nose, straining for bowel movement, contact sports. Recommend use of soft toothbrush, electric razor. time, mucosal irritation, and trauma.
    
30. POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities) Pain, acute—recurrence of obstruction/ductal spasm; inflammation, tissue ischemia.