Risk for Deficient Fluid Volume | Nursing Care Plan for Cholecystitis

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, and absence of vomiting.

Nursing intervention with rationale:
1. Maintain accurate record of intake and output (I&O), noting output less than intake and increased urine specific gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill.
Rationale: Provides information about fluid status and circulating volume and replacement needs.

2. 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, and depressed respirations.
Rationale: Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.

3. Eliminate noxious sights and smells from environment.
Rationale: Reduces stimulation of vomiting center.

4. Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.
Rationale: Decreases dryness of oral mucous membranes and reduces risk of oral bleeding.

5. Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis, and melena.
Rationale: Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.

6. Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture.
Rationale: Reduces trauma, risk of bleeding, and hematoma formation.

7. Keep client NPO as necessary.
Rationale: Decreases gastrointestinal (GI) secretions and hypermotility.

8. Insert NG tube, connect to suction, and maintain patency, as indicated.
Rationale: Provides rest for GI tract and relief of vomiting.

9. Administer antiemetics, such as promethazine (Phenergan), prochlorperazine (Compazine), or ondansetron (Zofran).
Rationale: Helpful in reducing nausea and vomiting often associated with cholecystitis and, particularly, common bile duct obstruction.

10. Review laboratory studies such as Hgb/Hct, electrolytes, arterial blood gases (ABGs) (pH), and clotting times.
Rationale: Aids in evaluating circulating volume, identifies deficits, and influences choice of intervention for replacement or correction.