Comprehensive Nursing Care Plan for Cholelithiasis
Evidence-based interventions and NANDA nursing diagnoses for optimal patient care
Nursing Care Plan for Cholelithiasis
A comprehensive nursing care plan for patients with cholelithiasis (gallstones) is essential for providing quality care. This Osmosis-style guide provides 15 evidence-based NANDA nursing diagnoses with interventions, rationales, and expected outcomes to help nursing students deliver optimal care to patients with cholelithiasis.
Focus Keyword: Cholelithiasis Nursing Care Plan
This guide focuses on nursing interventions rather than the pathophysiology of the condition, providing practical, actionable care strategies for nursing professionals.
Table of Contents
1. Acute Pain
NANDA Diagnosis
Acute Pain related to inflammation, obstruction of bile ducts, and tissue distention as evidenced by verbal reports of pain, guarding behavior, and changes in vital signs.
Defining Characteristics
- Sudden onset of pain in the right upper quadrant or epigastric region
- Pain radiating to the right shoulder or back
- Guarding behavior over painful areas
- Facial grimacing
- Altered vital signs during pain episodes (increased heart rate, blood pressure)
- Diaphoresis during pain episodes
Expected Outcomes
- Patient will report pain reduced to a tolerable level (≤3/10) within 30 minutes of intervention.
- Patient will demonstrate effective use of non-pharmacological pain relief measures.
- Patient will maintain normal vital signs during pain management.
- Patient will identify factors that aggravate and relieve pain.
| Nursing Interventions | Rationales |
|---|---|
| Assess pain characteristics using a standardized pain scale (location, intensity, quality, aggravating and alleviating factors). | Establishes baseline for pain assessment and helps determine appropriate interventions. Different pain characteristics may indicate various complications of cholelithiasis. |
| Administer prescribed analgesics as ordered and evaluate effectiveness. | Medication therapy is a primary intervention for managing acute pain associated with cholelithiasis. Regular evaluation ensures optimal pain management. |
| Assist patient in assuming a position of comfort (usually sitting up with knees flexed). | This position helps relax abdominal muscles and may reduce pressure on the inflamed gallbladder. |
| Apply warm compresses to the right upper quadrant if not contraindicated. | Local heat therapy may help relax muscles and improve blood flow to the area, potentially reducing pain intensity. |
| Teach and encourage non-pharmacological pain management techniques (guided imagery, relaxation breathing, distraction). | These techniques can activate the body’s internal pain control systems and complement pharmacological interventions. |
| Monitor for changes in pain character, intensity, or location. | Changes in pain patterns may indicate complications such as ascending cholangitis, pancreatitis, or perforation requiring immediate attention. |
2. Imbalanced Nutrition: Less Than Body Requirements
NANDA Diagnosis
Imbalanced Nutrition: Less Than Body Requirements related to nausea, vomiting, and decreased appetite as evidenced by weight loss, reduced food intake, and reported food aversion.
Defining Characteristics
- Reported food intolerance, especially after consuming fatty foods
- Weight loss (>5% of body weight)
- Decreased appetite
- Abdominal discomfort after eating
- Food aversion
- Altered taste sensation
Expected Outcomes
- Patient will maintain or improve nutritional intake as evidenced by consuming at least 75% of meals.
- Patient will demonstrate understanding of appropriate food choices for cholelithiasis.
- Patient will report decreased episodes of nausea and abdominal discomfort after eating.
- Patient will maintain stable weight or show gradual improvement in weight status.
| Nursing Interventions | Rationales |
|---|---|
| Assess nutritional status including weight, appetite, food intake, and tolerance of different foods. | Establishes baseline for nutritional assessment and helps identify specific nutritional deficiencies or problems. |
| Provide small, frequent meals (5-6 meals/day) rather than large meals. | Smaller meals require less bile for digestion, potentially reducing stimulation of the gallbladder and associated pain. |
| Recommend a low-fat diet (≤50g of fat per day), avoiding fried foods, fatty meats, and high-fat dairy products. | High-fat meals stimulate gallbladder contraction, which may trigger pain in patients with cholelithiasis. |
| Administer antiemetics as prescribed before meals if patient experiences nausea. | Controlling nausea before meals will improve food intake and nutritional status. |
| Monitor intake and output, including caloric intake and any episodes of vomiting. | Helps evaluate the effectiveness of nutritional interventions and identifies need for additional supportive measures. |
| Consult with dietitian for individualized meal planning. | Specialized nutrition expertise can help create a palatable, nutritionally adequate diet that minimizes gallbladder stimulation. |
3. Risk for Infection
NANDA Diagnosis
Risk for Infection related to inflammatory process, biliary stasis, and possible surgical intervention.
Risk Factors
- Biliary obstruction leading to bile stasis
- Surgical intervention (cholecystectomy)
- Invasive procedures such as ERCP
- Compromised immune system
- Advanced age
- Poor nutritional status
Expected Outcomes
- Patient will remain free of signs and symptoms of infection (normal vital signs, WBC count within normal range).
- Patient will demonstrate proper wound care if post-surgical.
- Patient will identify and report signs and symptoms of infection promptly.
- Patient will maintain adequate hydration and nutrition to support immune function.
| Nursing Interventions | Rationales |
|---|---|
| Monitor vital signs every 4 hours or as indicated, noting especially temperature elevations. | Fever is an early indicator of infection. Persistent or high fever may indicate complications such as cholangitis or abscess formation. |
| Monitor laboratory values including WBC count, C-reactive protein, and liver function tests. | Elevated inflammatory markers and abnormal liver function tests may indicate biliary infection or complications. |
| Administer prophylactic antibiotics as prescribed, especially perioperatively. | Antibiotic prophylaxis reduces the risk of surgical site infections and other infectious complications. |
| Use strict aseptic technique when performing wound care or handling invasive devices. | Reduces the risk of introducing pathogens into surgical wounds or through invasive access points. |
| Perform and teach proper hand hygiene to patient and visitors. | Hand hygiene is the most effective method for preventing healthcare-associated infections. |
| Assess skin around surgical site for signs of infection (redness, warmth, swelling, purulent drainage). | Early identification of surgical site infection allows prompt intervention and prevents complications. |
4. Anxiety
NANDA Diagnosis
Anxiety related to surgical procedure, uncertain prognosis, and pain as evidenced by expressed concerns, increased tension, and physiological symptoms.
Defining Characteristics
- Expressed concerns about surgical procedure and outcomes
- Restlessness and increased tension
- Difficulty concentrating or focusing
- Increased heart rate or blood pressure during discussions about condition or treatment
- Sleep disturbances
- Reduced ability to problem-solve
Expected Outcomes
- Patient will verbalize reduced anxiety levels using a scale of 1-10.
- Patient will demonstrate effective coping strategies to manage anxiety.
- Patient will maintain stable vital signs during discussions about condition and treatment.
- Patient will verbalize understanding of surgical procedure and expected recovery.
| Nursing Interventions | Rationales |
|---|---|
| Assess anxiety level using a standardized scale (e.g., 1-10 scale or State-Trait Anxiety Inventory). | Establishes baseline and helps evaluate the effectiveness of interventions for anxiety reduction. |
| Provide clear, concise information about cholelithiasis, treatment options, and expected outcomes. | Knowledge and understanding of the condition and treatment process can reduce fear of the unknown and decrease anxiety. |
| Encourage verbalization of fears and concerns, using active listening techniques. | Expression of feelings can help reduce anxiety and allows the nurse to address specific concerns. |
| Teach relaxation techniques such as deep breathing, progressive muscle relaxation, and guided imagery. | These techniques activate the parasympathetic nervous system, counteracting the sympathetic response involved in anxiety. |
| Include family members or significant others in teaching and discussions as appropriate. | Support from family can reduce anxiety and improve coping with illness and treatment. |
| Administer anxiolytic medications as prescribed and monitor effects. | Pharmacological interventions may be necessary for moderate to severe anxiety that doesn’t respond to non-pharmacological approaches. |
5. Deficient Knowledge
NANDA Diagnosis
Deficient Knowledge related to unfamiliarity with cholelithiasis management, treatment options, and self-care requirements as evidenced by questions, misconceptions, and incorrect statements.
Defining Characteristics
- Verbalization of lack of information about cholelithiasis
- Misconceptions about dietary restrictions
- Questions about treatment options and recovery process
- Uncertainty about medication regimen
- Lack of knowledge about signs of complications
- Difficulty understanding medical terminology related to condition
Expected Outcomes
- Patient will verbalize understanding of cholelithiasis, its treatment, and management.
- Patient will correctly describe dietary modifications needed for gallstone management.
- Patient will identify signs and symptoms requiring medical attention.
- Patient will demonstrate understanding of medication purpose, dosage, and side effects.
| Nursing Interventions | Rationales |
|---|---|
| Assess patient’s current level of understanding about cholelithiasis and treatment options. | Identifies knowledge gaps and misconceptions to tailor teaching appropriately to patient needs. |
| Provide education about cholelithiasis pathophysiology using simple language and visual aids. | Multi-modal teaching approaches enhance understanding and retention of information. |
| Teach about dietary modifications necessary for gallstone management (low-fat diet, small frequent meals). | Dietary management is crucial for preventing symptomatic episodes and supporting recovery. |
| Explain medication regimen including purpose, dosage, administration, and potential side effects. | Understanding medications improves adherence and promotes early recognition of adverse effects. |
| Instruct on signs and symptoms requiring immediate medical attention (severe pain, fever, jaundice, persistent vomiting). | Early recognition of complications allows for prompt intervention and prevention of serious consequences. |
| Provide written materials and reliable resources for future reference. | Written information reinforces verbal teaching and serves as a reference after discharge. |
6. Impaired Physical Mobility
NANDA Diagnosis
Impaired Physical Mobility related to pain, discomfort, and surgical intervention as evidenced by reluctance to attempt movement, limited range of motion, and guarding behaviors.
Defining Characteristics
- Reluctance to move or change positions due to pain
- Guarding behavior when moving
- Limited range of motion
- Decreased activity level
- Difficulty with activities of daily living
- Self-imposed movement restrictions
Expected Outcomes
- Patient will demonstrate progressive increase in activity level as evidenced by ambulation with minimal assistance.
- Patient will perform activities of daily living with minimal discomfort.
- Patient will engage in prescribed exercise regimen.
- Patient will utilize appropriate pain management strategies to facilitate mobility.
| Nursing Interventions | Rationales |
|---|---|
| Assess level of mobility, pain during movement, and ability to perform self-care activities. | Establishes baseline for mobility status and helps identify specific interventions needed. |
| Administer analgesics 30 minutes prior to planned activity or physical therapy. | Pre-emptive pain management facilitates movement with reduced discomfort. |
| Assist with early and progressive ambulation, starting with sitting at bedside and gradually increasing distance walked. | Early mobilization after surgery helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis. |
| Teach proper body mechanics and techniques for getting in and out of bed, especially after abdominal surgery. | Proper body mechanics help prevent strain on the surgical site and reduce pain during movement. |
| Encourage deep breathing and splinting of incision site during movement if post-surgical. | Splinting provides support to the incision area and reduces pain during movement. |
| Collaborate with physical therapy for exercise regimen appropriate for patient’s condition. | Specialized expertise ensures exercises are safe and effective for the patient’s specific circumstances. |
7. Risk for Ineffective Breathing Pattern
NANDA Diagnosis
Risk for Ineffective Breathing Pattern related to pain, abdominal distention, and surgical intervention.
Risk Factors
- Abdominal pain causing shallow breathing
- Reluctance to breathe deeply due to incisional pain
- Effects of anesthesia on respiratory function
- Abdominal distention affecting diaphragmatic excursion
- Limited mobility and prolonged bed rest
- Respiratory depressant effects of opioid pain medications
Expected Outcomes
- Patient will maintain effective breathing pattern with normal respiratory rate, depth, and rhythm.
- Patient will demonstrate effective deep breathing and coughing techniques.
- Patient will maintain oxygen saturation levels >95% on room air.
- Patient will remain free of signs and symptoms of respiratory complications.
| Nursing Interventions | Rationales |
|---|---|
| Monitor respiratory rate, depth, and pattern every 4 hours or as indicated. | Early detection of respiratory changes allows for prompt intervention to prevent complications. |
| Assess oxygen saturation levels via pulse oximetry regularly. | Provides objective measurement of oxygenation status and effectiveness of respiratory function. |
| Position patient in semi-Fowler’s or high Fowler’s position. | Upright positioning promotes lung expansion and decreases pressure on the diaphragm from abdominal contents. |
| Teach and encourage deep breathing exercises, incentive spirometry, and effective coughing techniques every 2 hours while awake. | These techniques promote alveolar expansion, mobilize secretions, and prevent atelectasis and pneumonia. |
| Provide adequate pain management, especially before breathing exercises. | Effective pain control allows patient to participate in deep breathing without limitation from pain. |
| Teach splinting technique for the incision site during coughing. | Supporting the incision during coughing reduces pain and encourages more effective clearance of secretions. |
8. Disturbed Sleep Pattern
NANDA Diagnosis
Disturbed Sleep Pattern related to physical discomfort, pain, anxiety, and unfamiliar environment as evidenced by reports of difficulty falling asleep, frequent awakening, and fatigue.
Defining Characteristics
- Difficulty falling asleep
- Frequent awakening during night
- Reports of not feeling rested after sleep
- Increased fatigue and irritability
- Dark circles under eyes
- Excessive yawning
- Difficulty concentrating
Expected Outcomes
- Patient will report improved sleep quality and feeling rested upon awakening.
- Patient will identify and implement effective sleep-promoting strategies.
- Patient will achieve 6-8 hours of uninterrupted sleep per night.
- Patient will report decreased daytime fatigue.
| Nursing Interventions | Rationales |
|---|---|
| Assess sleep patterns, habits, and factors affecting sleep. | Establishes baseline for sleep assessment and identifies specific factors disrupting sleep. |
| Cluster care activities to minimize nighttime disruptions. | Reduces unnecessary awakenings and allows for longer periods of uninterrupted sleep. |
| Administer pain medication approximately 30 minutes before bedtime if pain is affecting sleep. | Controlling pain before bedtime facilitates falling asleep and reduces night awakenings due to discomfort. |
| Promote comfort measures such as proper positioning, clean linen, appropriate room temperature, and reduced noise and light. | Environmental comfort is essential for quality sleep, especially in a hospital setting. |
| Teach relaxation techniques such as progressive muscle relaxation, guided imagery, or deep breathing to use before bedtime. | These techniques help reduce anxiety and promote physical relaxation conducive to sleep. |
| Encourage avoiding caffeine, heavy meals, and excessive fluids close to bedtime. | These substances and practices can interfere with the ability to fall and stay asleep. |
9. Nausea
NANDA Diagnosis
Nausea related to inflammation of gallbladder, biliary obstruction, and gastrointestinal irritation as evidenced by reports of nausea, decreased appetite, and food aversion.
Defining Characteristics
- Report of nausea or “sick to stomach” feeling
- Increased salivation
- Aversion to food
- Gagging sensation
- Sour taste in mouth
- Increased swallowing
- Pallor
Expected Outcomes
- Patient will report decreased frequency and intensity of nausea.
- Patient will identify and avoid triggers that exacerbate nausea.
- Patient will maintain adequate nutritional intake despite nausea.
- Patient will demonstrate effective use of non-pharmacological techniques to manage nausea.
| Nursing Interventions | Rationales |
|---|---|
| Assess pattern, frequency, duration, and severity of nausea, and identify triggering factors. | Establishes baseline for nausea assessment and helps identify specific triggers to avoid. |
| Administer antiemetics as prescribed, ideally 30-60 minutes before meals or known triggering activities. | Antiemetics are more effective when given before nausea becomes severe, and pre-emptive administration before meals can improve food tolerance. |
| Provide small, frequent meals with mild, non-fatty foods at room temperature. | Large meals can exacerbate nausea; fatty foods stimulate gallbladder contraction; cold or hot foods may intensify nausea. |
| Ensure adequate hydration with small, frequent sips of clear fluids. | Dehydration can worsen nausea; small amounts are better tolerated than large volumes. |
| Teach acupressure techniques, particularly stimulation of the P6 point (inside of wrist). | Research suggests acupressure at specific points may help reduce nausea through neurological pathways. |
| Promote rest in a quiet environment with fresh air, avoiding strong odors. | Environmental factors like odors and excessive stimulation can trigger or worsen nausea. |
10. Risk for Deficient Fluid Volume
NANDA Diagnosis
Risk for Deficient Fluid Volume related to decreased oral intake, vomiting, NPO status, and increased metabolic demands.
Risk Factors
- Persistent nausea and vomiting
- Decreased oral intake due to pain or discomfort
- NPO status for diagnostic tests or surgical preparation
- Fever causing increased insensible fluid loss
- Possible drainage from surgical site or drains
- Advanced age with decreased thirst response
Expected Outcomes
- Patient will maintain adequate hydration status as evidenced by normal skin turgor, moist mucous membranes, and balanced intake and output.
- Patient will maintain urine output >0.5 mL/kg/hr with normal specific gravity.
- Patient will maintain stable vital signs without orthostatic changes.
- Patient will have normal laboratory values including BUN, creatinine, and electrolytes.
| Nursing Interventions | Rationales |
|---|---|
| Monitor vital signs, specifically assessing for tachycardia and orthostatic hypotension. | Increased heart rate and orthostatic hypotension are early signs of fluid volume deficit. |
| Maintain accurate intake and output records, including all sources of fluid loss (urine, emesis, drains). | Allows for early identification of fluid imbalances and guides replacement needs. |
| Assess skin turgor, mucous membranes, and capillary refill time. | These physical findings help evaluate hydration status; dry mucous membranes and poor skin turgor suggest dehydration. |
| Administer IV fluids as prescribed, monitoring infusion rate and patient response. | IV fluids provide necessary hydration when oral intake is insufficient or contraindicated. |
| Encourage oral fluid intake when appropriate, offering small amounts frequently. | Small, frequent amounts are better tolerated and less likely to trigger nausea than large volumes. |
| Monitor laboratory values including electrolytes, BUN, creatinine, and hematocrit. | Elevated BUN, creatinine, and hematocrit may indicate dehydration; electrolyte imbalances often accompany fluid deficits. |
11. Risk for Impaired Skin Integrity
NANDA Diagnosis
Risk for Impaired Skin Integrity related to surgical incision, immobility, and possible nutritional deficits.
Risk Factors
- Surgical incision site
- Immobility or limited mobility post-surgery
- Decreased nutritional intake
- Possible edema at surgical site
- Potential for wound drainage
- Advanced age with decreased skin elasticity
- Obesity affecting wound healing
Expected Outcomes
- Patient’s surgical site will remain clean, dry, and intact without signs of infection or dehiscence.
- Patient will demonstrate proper wound care techniques.
- Patient will maintain intact skin in all areas with no pressure injuries.
- Patient will maintain adequate nutrition and hydration to support wound healing.
| Nursing Interventions | Rationales |
|---|---|
| Assess surgical incision and surrounding skin at least once per shift, noting color, approximation of edges, drainage, and signs of infection. | Early identification of wound complications allows for prompt intervention and prevents progression to more serious issues. |
| Use aseptic technique when performing dressing changes and wound care. | Prevents introduction of pathogens to the wound site and reduces infection risk. |
| Change dressings as ordered or when soiled, wet, or loosened. | Maintains a clean wound environment; wet or soiled dressings can harbor bacteria and compromise skin integrity. |
| Conduct pressure injury risk assessment using a validated tool (e.g., Braden Scale) and implement prevention measures as needed. | Identifies patients at risk for pressure injuries and guides implementation of specific preventative measures. |
| Assist with position changes at least every 2 hours for bedbound patients. | Regular repositioning reduces pressure on bony prominences and prevents tissue ischemia. |
| Teach patient proper incision care techniques for home management. | Promotes continued proper wound care after discharge to prevent complications. |
12. Constipation
NANDA Diagnosis
Constipation related to decreased activity, dietary changes, pain medications, and surgical manipulation as evidenced by decreased bowel movement frequency, hard/dry stool, and straining with defecation.
Defining Characteristics
- Decreased frequency of bowel movements
- Hard, dry stools
- Straining with defecation
- Feeling of incomplete evacuation
- Abdominal distention or bloating
- Decreased appetite
- Possible abdominal pain
Expected Outcomes
- Patient will establish or return to normal bowel elimination pattern.
- Patient will pass soft, formed stools without straining.
- Patient will identify dietary and lifestyle factors that promote regular bowel elimination.
- Patient will increase fluid intake to at least 2000 mL/day unless contraindicated.
| Nursing Interventions | Rationales |
|---|---|
| Assess bowel function including frequency, consistency, and associated symptoms. | Establishes baseline for bowel function and helps identify specific issues. |
| Document bowel movements and characteristics. | Tracking bowel movements helps evaluate the effectiveness of interventions and detect changes in pattern. |
| Encourage fluid intake of at least 2000 mL/day unless contraindicated. | Adequate hydration softens stool and facilitates elimination. |
| Promote gradual increase in dietary fiber as tolerated. | Fiber adds bulk to stool and stimulates peristalsis; gradual increase helps prevent gas and bloating. |
| Encourage physical activity and ambulation as condition permits. | Physical activity stimulates peristalsis and promotes normal bowel function. |
| Administer prescribed stool softeners, laxatives, or enemas as needed and monitor response. | Pharmacological interventions may be necessary to prevent or treat constipation, especially when opioid pain medications are used. |
13. Ineffective Coping
NANDA Diagnosis
Ineffective Coping related to situational crisis, inadequate coping resources, and uncertainty about treatment outcomes as evidenced by expressed inability to cope, anxiety, and difficulty with problem-solving.
Defining Characteristics
- Verbalization of inability to cope or ask for help
- Excessive worry or anxiety about condition
- Inadequate problem-solving
- Inability to meet basic needs
- Use of inappropriate defense mechanisms
- Sleep disturbance
- Decreased use of social support
Expected Outcomes
- Patient will identify effective coping strategies to manage stress related to cholelithiasis and treatment.
- Patient will verbalize reduced anxiety and increased confidence in managing condition.
- Patient will utilize available support systems appropriately.
- Patient will demonstrate effective problem-solving related to health management.
| Nursing Interventions | Rationales |
|---|---|
| Assess patient’s current coping mechanisms, support systems, and stressors. | Identifies strengths and weaknesses in coping abilities and available resources for support. |
| Establish therapeutic relationship through active listening and non-judgmental attitude. | Creates trust and encourages patient to express feelings and concerns openly. |
| Provide accurate information about cholelithiasis, treatment options, and expected recovery process. | Knowledge reduces uncertainty and fear of the unknown, which can improve coping abilities. |
| Teach stress management techniques such as deep breathing, progressive muscle relaxation, and guided imagery. | These techniques provide practical tools for reducing anxiety and managing stress independently. |
| Encourage identification and utilization of support systems (family, friends, support groups). | Social support is associated with improved coping and better health outcomes. |
| Assist patient in breaking down problems into manageable components and identifying potential solutions. | Enhances problem-solving skills and reduces feeling of being overwhelmed by health challenges. |
14. Risk for Impaired Liver Function
NANDA Diagnosis
Risk for Impaired Liver Function related to biliary obstruction, inflammation, and possible complications of cholelithiasis.
Risk Factors
- Common bile duct obstruction by gallstones
- Inflammatory process affecting the biliary tract
- Potential for ascending cholangitis
- Altered bile flow and metabolism
- Possible hepatotoxic medications
- Pre-existing liver conditions
Expected Outcomes
- Patient will maintain normal liver function as evidenced by normal liver enzyme levels and bilirubin.
- Patient will remain free of signs and symptoms of hepatic dysfunction (jaundice, pruritus, clay-colored stools).
- Patient will identify signs and symptoms requiring prompt medical attention.
- Patient will demonstrate understanding of medication and dietary adjustments to support liver function.
| Nursing Interventions | Rationales |
|---|---|
| Monitor liver function tests including AST, ALT, ALP, GGT, and bilirubin levels. | Elevated liver enzymes and bilirubin may indicate biliary obstruction or liver cell damage requiring intervention. |
| Assess for signs of jaundice in sclera, skin, and mucous membranes. | Jaundice indicates hyperbilirubinemia from impaired bile excretion or liver dysfunction. |
| Monitor for signs of hepatic encephalopathy (altered mental status, asterixis, confusion). | Hepatic encephalopathy can develop with severe liver dysfunction and requires immediate medical attention. |
| Assess stool and urine color (clay-colored stools and dark urine suggest bile duct obstruction). | Biliary obstruction prevents bile from entering the intestine (causing clay-colored stools) and increases urinary excretion of bilirubin (causing dark urine). |
| Review medication profile for potential hepatotoxic drugs and monitor for adverse effects. | Patients with compromised liver function may have altered metabolism of medications, increasing risk of toxicity. |
| Provide education about signs of complications requiring medical attention (increasing jaundice, severe pruritus, mental status changes). | Early recognition and reporting of complications allows for prompt intervention and prevention of serious sequelae. |
15. Self-Care Deficit
NANDA Diagnosis
Self-Care Deficit related to pain, fatigue, and surgical recovery as evidenced by difficulty performing activities of daily living independently.
Defining Characteristics
- Inability to perform hygiene care independently
- Difficulty with dressing/undressing
- Impaired ability to perform toileting activities
- Difficulty with meal preparation or feeding self
- Fatigue during self-care activities
- Discomfort with reaching or bending
Expected Outcomes
- Patient will demonstrate progressive independence in self-care activities.
- Patient will utilize adaptive equipment or techniques to enhance independence in ADLs.
- Patient will identify resources for assistance with complex self-care activities as needed.
- Patient will maintain personal hygiene and grooming at a satisfactory level.
| Nursing Interventions | Rationales |
|---|---|
| Assess level of independence in activities of daily living using a standardized tool. | Establishes baseline for functional abilities and helps identify specific areas requiring assistance or intervention. |
| Provide assistance with self-care activities as needed while encouraging maximum participation. | Balancing assistance with encouragement for independence promotes gradual return to self-care abilities. |
| Schedule self-care activities for times when pain medication is most effective. | Pain control facilitates participation in self-care activities with less discomfort. |
| Teach energy conservation techniques such as pacing activities and alternating rest periods with activity. | Conserving energy allows patient to complete necessary self-care without excessive fatigue. |
| Recommend and demonstrate use of adaptive equipment as appropriate (long-handled reacher, shower chair, raised toilet seat). | Adaptive equipment can compensate for temporary limitations and increase independence in self-care. |
| Collaborate with occupational therapy for specialized assessment and interventions. | Occupational therapists provide expertise in adapting activities and environments to maximize independence. |
Home Care Advice for Cholelithiasis
Dietary Recommendations
- Low-fat diet: Limit fat intake to 40-50 grams per day. Choose lean meats, low-fat dairy, and cooking methods that require little oil.
- Small, frequent meals: Eat 5-6 smaller meals instead of 3 large ones to reduce gallbladder stimulation.
- Gradual fat introduction: After cholecystectomy, gradually reintroduce fats to determine tolerance.
- Foods to avoid: Fried foods, fatty meats, high-fat dairy, pastries, chocolate, and other high-fat foods.
- Fiber-rich foods: Include whole grains, fruits, and vegetables to maintain bowel regularity.
- Hydration: Drink at least 8-10 glasses of water daily unless contraindicated.
Pain Management
- Take medications as prescribed: Follow the exact dosage and schedule for pain medications.
- Non-pharmacological techniques: Use relaxation breathing, warm compresses (not hot), and position changes.
- Activity pacing: Balance activity with rest to avoid triggering pain.
- Pain diary: Track pain triggers, intensity, and effective relief methods to recognize patterns.
- Contact healthcare provider if pain is severe, uncontrolled, or changing in character.
Wound Care (Post-Cholecystectomy)
- Keep incision clean and dry: Shower as directed by your surgeon, patting incision dry gently.
- Dressing changes: Follow specific instructions for changing dressings if applicable.
- Avoid soaking: No baths, swimming, or hot tubs until incision is fully healed.
- Watch for infection signs: Increasing redness, warmth, swelling, purulent drainage, fever, or increased pain.
- Avoid tight clothing over incision site to prevent irritation.
Activity Guidelines
- Gradual activity increase: Start with short walks and gradually increase activity as tolerated.
- Lifting restrictions: Avoid lifting more than 10 pounds (4.5 kg) for 4-6 weeks after surgery.
- Driving: Avoid driving until off narcotic pain medications and able to make emergency maneuvers without discomfort.
- Return to work: Follow surgeon’s recommendations based on job requirements and recovery progress.
- Sexual activity: Resume when comfortable, typically 1-2 weeks after laparoscopic surgery.
When to Seek Medical Attention
- Severe, persistent, or worsening pain not relieved by prescribed medications
- Fever above 101°F (38.3°C)
- Jaundice: Yellowing of skin or eyes
- Persistent nausea or vomiting lasting more than 24 hours
- Signs of wound infection: Increasing redness, warmth, swelling, or purulent drainage
- Clay-colored stools or dark urine
- Persistent bloating or distention of the abdomen
- Difficulty breathing or chest pain
Follow-up Care
- Keep all follow-up appointments with healthcare providers.
- Take all medications as prescribed, including completing full course of antibiotics if prescribed.
- Report any new or worsening symptoms promptly to healthcare provider.
- Maintain a health journal tracking symptoms, diet tolerance, and recovery milestones.
- Consider joining a support group if adjusting to lifestyle changes is challenging.
Conclusion
This comprehensive cholelithiasis nursing care plan provides a structured approach for addressing the complex needs of patients with gallstones. By implementing these 15 nursing diagnoses with their corresponding interventions, nurses can provide holistic care addressing physical, psychological, and educational needs.
Remember that each patient with cholelithiasis will present with unique circumstances and may not have all these nursing diagnoses. Clinical judgment is essential in selecting appropriate diagnoses and interventions based on individual assessment findings.
For nursing students applying this care plan, focus on understanding the rationale behind each intervention and how it relates to the specific pathophysiology of cholelithiasis. This understanding will help develop critical thinking skills necessary for adapting care to diverse patient situations.