Nursing Care Plan Cholecystitis with cholelithiasis

CARE SETTING

Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized patient.

RELATED CONCERNS

1. Cholecystectomy
2. Fluid and electrolyte imbalances, see Nursing Plan CD-ROM
3. Psychosocial aspects of care
4. Total nutritional support: parenteral/enteral feeding
5. Patient Assessment Database

ACTIVITY/REST

May report: 
Fatigue

May exhibit: 
Restlessness

CIRCULATION

May exhibit: 
Tachycardia, diaphoresis, lightheadedness

ELIMINATION

May report: 
Change in color of urine and stools

May exhibit: 

1. Abdominal distension
2. Palpable mass in right upper quadrant (RUQ)
3. Dark, concentrated urine
4. Clay-colored stool, steatorrhea

FOOD/FLUID

May report: 

1. Anorexia, nausea/vomiting
2. Intolerance of fatty and “gas-forming” foods; recurrent regurgitation, heartburn, indigestion, flatulence, bloating (dyspepsia)
3. Belching (eructation)

May exhibit: 

1. Obesity; recent weight loss
2. Normal to hypoactive bowel sounds

PAIN/DISCOMFORT

May report: 

1. 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
2. Pain severe/ongoing, starting suddenly, sometimes at night, and usually peaking in 30 min, often increases with movement
3. Recurring episodes of similar pain

May exhibit: 
Rebound tenderness, muscle guarding, or abdominal rigidity when RUQ is palpated; positive Murphy’s sign

RESPIRATION

May exhibit: 

1. Increased respiratory rate
2. Splinted respiration marked by short, shallow breathing

SAFETY

May exhibit: 

1. Low-grade fever; high-grade fever and chills (septic complications)
2. Jaundice, with dry, itching skin (pruritus)
3. Bleeding tendencies (vitamin K deficiency)

TEACHING/LEARNING

May report: 

1. Familial tendency for gallstones
2. Recent pregnancy/delivery; history of diabetes mellitus (DM), IBD, blood dyscrasias
3. Discharge plan
4. DRG projected mean length of inpatient stay: 4.3 days
5. May require support with dietary changes/weight reduction
6. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial diagnostic procedure).
2. 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.
3. Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum.
4. 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.
5. 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.
6. Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between obstructive/nonobstructive jaundice.
7. 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.
8. Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases; calcification of the wall or enlargement of the gallbladder.
9. Chest x-ray: Rule out respiratory causes of referred pain.
10. CBC: Moderate leukocytosis (acute).
11. Serum bilirubin and amylase: Elevated.
12. Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction.
13. 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