Acute Pain | Nursing Care Plan for Cholecystitis

Nursing diagnosis: acute Pain related to Biological injuring agents: obstruction or ductal spasm, inflammatory process, tissue ischemia and necrosis.

Possibly evidenced by
Reports of pain, biliary colic
Facial mask of pain; guarding behavior
Autonomic responses including changes in blood pressure (BP), pulse
Self-focusing; narrowed focus

Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing intervention with rationale:
1. Observe and document location, severity (0 to 10 scale), and character of pain, such as steady, intermittent, or colicky.
Rationale: Assists in differentiating cause of pain and provides information about disease progression or resolution, development of complications, and effectiveness of interventions.

2. 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 and the need for further intervention.

3. Promote bedrest, allowing client to assume position of comfort.
Rationale: Bedrest in low-Fowler’s position reduces intra-abdominal pressure; however, client will naturally assume least painful position.

4. Use soft cotton linens; calamine lotion; oil bath; and cool, moist compresses, as indicated.
Rationale: Reduces irritation and dryness of the skin and itching sensation.

5. Control environmental temperature.
Rationale: Cool surroundings aid in minimizing dermal discomfort.

6. Encourage use of relaxation techniques such as guided imagery, visualization, and deep-breathing exercises. Provide diversional activities.
Rationale: Promotes rest, redirects attention, and may enhance coping.

7. Make time to listen to and maintain frequent contact with client.
Rationale: Helpful in alleviating anxiety and refocusing attention, which can relieve pain.

8. Maintain nothing by mouth (NPO) status; insert and maintain nasogastric (NG) suction, as indicated.
Rationale: Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions.

9. Prepare for procedures, such as the following: Endoscopic sphincterotomy plus extraction of stones during ERCP
Rationale: Procedure done to widen the mouth of the common bile duct where it empties into the duodenum. The procedure may be done to assist in retrieving stones from the common duct by means of a tiny basket or balloon on the end of the endoscope. Stones must be smaller than 15 mm. Larger stones may be crushed with a mechanical lithotripter inserted through the endoscope.

10. Extracorporeal shock wave lithotripsy (ESWL)
Rationale: Shock wave treatment is a little-used therapy due to high recurrence of stones. It may be indicated in a client with mild to moderate symptoms, with a single cholesterol stone (0.5 mm or larger), or in client without biliary tract obstruction. Note: This procedure is contraindicated in clients with pacemakers or implantable defibrillators.