Definition

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is performed most frequently through laparoscopic incisions using laser. However, traditional open cholecystectomy is the treatment of choice for many patients with multiple/large gallstones either because of acute symptomatology or to prevent recurrence of stones.

Nursing Priorities

  1. Promote respiratory function.
  2. Prevent complications.
  3. Provide information about disease, procedure(s), prognosis, and treatment needs.

Discharges Goals

  1. Ventilation/oxygenation adequate for individual needs.
  2. Complications prevented/minimized.
  3. Disease process, surgical procedure, prognosis, and therapeutic regimen understood.
  4. Plan in place to meet needs after discharge.

Nursing Care Plans

Here are 4 Nursing Care Plan (NCP) for Cholecystectomy.

Ineffective Breathing Pattern

NURSING DIAGNOSIS: Breathing Pattern, ineffective

May be related to

  • Pain
  • Muscular impairment
  • Decreased energy/fatigue

Possibly evidenced by

  • Tachypnea; respiratory depth changes, reduced vital capacity
  • Holding breath; reluctance to cough

Desired Outcomes

  • Establish effective breathing pattern.
  • Experience no signs of respiratory compromise/complications.
Nursing Interventions Rationale
Observe respiratory rate/depth. Shallow breathing, splinting with respirations, holding breath may result in hypoventilation/atelectasis.
Auscultate breath sounds. Areas of decreased/absent breath sounds suggest atelectasis, whereas adventitious sounds (wheezes, rhonchi) reflect congestion.
Assist patient to turn, cough, and deep breathe periodically. Promotes ventilation of all lung segments and mobilization and expectoration of secretions.
Show patient how to splint incision. Instruct in effective breathing techniques. Facilitates lung expansion. Splinting provides incisional support/decreases muscle tension to promote cooperation with therapeutic regimen.
Elevate head of bed, maintain low-Fowler’s position. Maximizes expansion of lungs to prevent/resolve atelectasis.
Support abdomen when coughing, ambulating. Facilitates more effective coughing, deep breathing, and activity.

Impaired Skin Integrity

NURSING DIAGNOSIS: Impaired Skin Integrity

May be related to

  • Chemical substance (bile), stasis of secretions
  • Altered nutritional state (obesity)/metabolic state
  • Invasion of body structure (T-tube)

Possibly evidenced by

  • Disruption of skin/subcutaneous tissues

Desired Outcomes

  • Achieve timely wound healing without complications.
  • Demonstrate behaviors to promote healing/prevent skin breakdown.
Nursing Interventions Rationale
Observe the color and character of the drainage. Initially, drainage may contain blood and bloodstained fluid,normally changing to greenish brown (bile color) after the first several hours
Change dressings as often as necessary. Clean the skin with soap and water. Use sterile petroleum jelly gauze, zinc oxide, or karaya powder around the incision. Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation.
Apply Montgomery straps. Facilitates frequent dressing changes and minimizes skin trauma.
Use a disposable ostomy bag over a stab wound drain. Ostomy appliance may be used to collect heavy drainage for more accurate measurement of output and protection of the skin.
Place patient in low- or semi-Fowler’s position. Facilitates drainage of bile.
Monitor puncture sites (3–5) if endoscopic procedure is done. These areas may bleed, or staples and Steri-Strips may loosen at puncture wound sites.
Check the T-tube and incisional drains; make sure they are free flowing. T-tube may remain in common bile duct for 7–10 days to remove retained stones. Incision site drains are used to remove any accumulated fluid and bile. Correct positioning prevents backup of the bile in the operative area.
Maintain T-tube in closed collection system. Prevents skin irritation and facilitates measurement of output. Reduces risk of contamination.
Anchor drainage tube, allowing sufficient tubing to permit free turning and avoid kinks and twists. Avoids dislodging tube and/or occlusion of the lumen.
Observe for hiccups, abdominal distension, or signs of peritonitis, pancreatitis. Dislodgment of the T-tube can result in diaphragmatic irritation or more serious complications if bile drains into abdomen or pancreatic duct is obstructed.
Observe skin, sclerae, urine for change in color. Developing jaundice may indicate obstruction of bile flow.
Note color and consistency of stools. Clay-colored stools result when bile is not present in the intestines.
Investigate reports of increased/unrelenting RUQ pain; development of fever, tachycardia; leakage of bile drainage around tube/from wound. Signs suggestive of abscess or fistula formation, requiring medical intervention.
Administer antibiotics as indicated. Necessary for treatment of abscess/infection.
Clamp the T-tube per schedule. Tests the patency of the common bile duct before tube is removed.

Risk for Deficient Fluid Volume

NURSING DIAGNOSIS: Risk for Deficient Fluid Volume

Risk factors may include

  • Losses from NG aspiration, vomiting
  • Medically restricted intake
  • Altered coagulation, e.g., reduced prothrombin, prolonged coagulation time

Possibly evidenced by

  • [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

  • Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor/capillary refill, and individually appropriate urinary output.
Nursing Interventions Rationale
Monitor I&O, including drainage from NG tube, T-tube, and wound. Weigh patient periodically. Provides information about replacement needs and organ function. Initially, 200–500 mL of bile drainage 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.
Monitor vital signs. Assess mucous membranes, skin turgor, peripheral pulses, and capillary refill. Indicators of adequacy of circulating volume/perfusion.
Observe for signs of bleeding, e.g., hematemesis, melena, petechiae, ecchymosis. Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding/hemorrhage.
Use small-gauge needles for injections, and apply firm pressure for longer than usual after venipuncture. Reduces trauma, risk of bleeding/hematoma.
Have patient use cotton/sponge swabs and mouthwash instead of a toothbrush. Avoids trauma and bleeding of the gums.
Monitor laboratory studies, e.g., Hb/Hct, electrolytes, prothrombin level/clotting time. Provides information about circulating volume, electrolyte balance, and adequacy of clotting factors.
Administer IV fluids, blood products, as indicated; Maintains adequate circulating volume and aids in replacement of clotting factors.
Electrolytes; Corrects imbalances resulting from excessive gastric/wound losses.
Vitamin K. Provides replacement of factors necessary for clotting process.

Deficient Knowledge

NURSING DIAGNOSIS: Deficient Knowledge

May be related to

  • Lack of exposure; information misinterpretation
  • Unfamiliarity with information resources
  • Lack of recall

Possibly evidenced by

  • Questions; statement of misconception
  • Request for information
  • Inaccurate follow-through of instructions

Desired Outcomes

  • Verbalize understanding of disease process, surgical procedure/prognosis, and potential complications.
  • Verbalize understanding of therapeutic needs.
  • Correctly perform necessary procedures and explain reasons for the actions.
  • Initiate necessary lifestyle changes and participate in therapeutic regimen.
Nursing Interventions Rationale
Review disease process, surgical procedure/prognosis. Provides knowledge base on which patient can make informed choices.
Demonstrate care of incisions/dressings and drains. Promotes independence in care and reduces risk of complications (e.g., infection, biliary obstruction).
Recommend periodic drainage of T-tube collection bag and recording of output. Reduces risk of reflux, strain on tube/appliance seal. Provides information about resolution of ductal edema/return of ductal function for appropriate timing of T-tube removal.
Emphasize importance of maintaining low-fat diet, eating frequent small meals, gradual reintroduction of foods/fluids containing fats over a 4- to 6-mo period. During initial 6 mo after surgery, low-fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats.
Discuss use of medication such as florantyrone (Sancho) or dehydrocholic acid (Decholin). Oral replacement of bile salts may be required to facilitate fat absorption.
Discuss avoiding/limiting use of alcoholic beverages. Minimizes risk of pancreatic involvement.
Inform patient that loose stools may occur for several months. Intestines require time to adjust to stimulus of continuous output of bile.
Advise patient to note and avoid foods that seem to aggravate the diarrhea. Although radical dietary changes are not usually necessary, certain restrictions may be helpful; e.g., fats in small amounts are usually tolerated. After a period of adjustment, patient usually will not have problems with most foods.
Identify signs/symptoms requiring notification of healthcare provider, e.g., dark urine; jaundiced color of eyes/skin; clay-colored stools, excessive stools; or recurrent heartburn, bloating. Indicators of obstruction of bile flow/altered digestion, requiring further evaluation and intervention.
Review activity limitations depending on individual situation. Resumption of usual activities is normally accomplished within 4–6 wk.

Other Possible Nursing Diagnoses

  • Diarrhea—continuous excretion of bile into bowel, changes in digestive process.
  • Infection, risk for—invasive procedure (discharge with T-tube in place).

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