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 (cholelithiasis) either because of acute symptomatology or to prevent recurrence of stones.
Nursing Care Plans
Here are 4 cholecystectomy nursing care plans (NCP).
- Promote respiratory function.
- Prevent complications.
- Provide information about disease, procedure(s), prognosis, and treatment needs.
- Ventilation/oxygenation adequate for individual needs.
- Complications prevented/minimized.
- Disease process, surgical procedure, prognosis, and therapeutic regimen understood.
- Plan in place to meet needs after discharge.
1. Ineffective Breathing Pattern
- Breathing Pattern, ineffective
May be related to
- Muscular impairment
- Decreased energy/fatigue
Possibly evidenced by
- Tachypnea; respiratory depth changes, reduced vital capacity
- Holding breath; reluctance to cough
- Establish effective breathing pattern.
- Experience no signs of respiratory compromise/complications.
|Observe respiratory rate, depth.||Shallow breathing, splinting with respirations, holding breath may result in hypoventilation or atelectasis.|
|Auscultate breath sounds.||Areas of decreased or 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 and decreases muscle tension to promote cooperation with therapeutic regimen.|
|Elevate head of bed, maintain low-Fowler’s position.||Maximizes expansion of lungs to prevent or resolve atelectasis.|
|Support abdomen when coughing, ambulating.||Facilitates more effective coughing, deep breathing, and activity.|
2. Impaired Skin Integrity
- 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
- Achieve timely wound healing without complications.
- Demonstrate behaviors to promote healing/prevent skin breakdown.
|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 or unrelenting RUQ pain; development of fever, tachycardia; leakage of bile drainage around tube or from wound.||Signs suggestive of abscess or fistula formation, requiring medical intervention.|
|Administer antibiotics as indicated.||Necessary for treatment of abscess and/or infection.|
|Clamp the T-tube per schedule.||Tests the patency of the common bile duct before tube is removed.|
3. Risk for Deficient Fluid Volume
- 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. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
- Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor/capillary refill, and individually appropriate urinary output.
|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: hematemesis, melena, petechiae, ecchymosis.||Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.|
|Use small-gauge needles for injections, and apply firm pressure for longer than usual after venipuncture.||Reduces trauma, risk of bleeding or hematoma.|
|Have patient use cotton or sponge swabs and mouthwash instead of a toothbrush.||Avoids trauma and bleeding of the gums.|
|Monitor laboratory studies: Hb/Hct, electrolytes, prothrombin level or 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 or losses.|
|Vitamin K||Provides replacement of factors necessary for clotting process.|
4. Deficient Knowledge
- 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
- 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.
|Review disease process, surgical procedure and prognosis.||Provides knowledge base on which patient can make informed choices.|
|Demonstrate care of incisions, dressings, and drains. Promote good hand hygiene.||Promotes independence in care and reduces risk of complications.|
|Recommend periodic drainage of T-tube collection bag and recording of output.||Reduces risk of reflux, strain on tube or appliance seal. Provides information about resolution of ductal edema and 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 or 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 or 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 and symptoms requiring notification of healthcare provider: dark urine; jaundiced color of eyes, skin; clay-colored stools, excessive stools; or recurrent heartburn, bloating.||Indicators of obstruction of bile flow or 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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