Risk for Deficient Fluid Volume | Nursing Care Plan for Cholecystectomy

Risk factors may include
Losses from nasogastric (NG) aspiration, vomiting
Medically restricted intake
Altered coagulation, such as reduced prothrombin, prolonged coagulation time

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

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

Nursing intervention with rationale:
1. Monitor intake and output (I&O), including drainage from NG tube, T-tube, and wound. Weigh client periodically.
Rationale: Provides information about replacement needs and organ function. Initially, 200 to 1,000 mL of bile drainage per 24 hours may be expected via the T-tube, decreasing as more bile enters the intestine. Continuing large amounts of bile drainage may be an indication of unresolved obstruction or, occasionally, a biliary fistula. Note: Sudden cessation of drainage may indicate blockage of tube.

2. Monitor vital signs. Assess mucous membranes, skin turgor, peripheral pulses, and capillary refill.
Rationale: Indicators of adequacy of circulating volume and perfusion.

3. Observe for signs of bleeding, such as hematemesis, melena, petechiae, ecchymosis, epistaxis, and oozing from incision and injection sites.
Rationale: Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.

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

5. Have client use soft toothbrush or cotton or sponge swabs and alcohol-free mouthwash instead of a toothbrush, if bleeding is a problem.
Rationale: Avoids trauma and bleeding of the gums. Alcohol can be drying and cause irritation to mucosa.

6. Monitor laboratory studies, such as complete blood count (CBC), electrolytes, prothrombin and clotting time, and amylase.
Rationale: Provides information about circulating volume, electrolyte balance, and adequacy of clotting factors. The hematocrit (Hct) rises when plasma volume is reduced, as in dehydration from vomiting. Falling hemoglobin (Hgb) and Hct may reflect bleeding as a complication of obstructed bile flow, surgical procedure, or preexisting bleeding disorder. Elevated white blood cells (WBCs) can indicate inflammation from surgery, peritonitis, or pancreatitis or other infection. Damage to the pancreas is indicated by elevated levels of amylase.

7. Administer the following, as indicated: Intravenous (IV) fluids, blood products, and vitamin K
Rationale: Maintains adequate circulating volume and aids in replacement of clotting factors.

8. Electrolytes (such as potassium, sodium, and chloride)
Rationale: Imbalances resulting from excessive gastric or surgical fluid losses may require replacement via oral and parenteral routes.