4 Cholecystitis and Cholelithiasis Nursing Care Plans

Risk for Deficient Fluid Volume

Patients with cholecystitis and cholelithiasis are at risk for deficient fluid volume due to excessive losses resulting from vomiting or diarrhea, limited intake due to nausea and anorexia, and altered clotting processes due to liver dysfunction. This can lead to dehydration and impaired perfusion, which can worsen the inflammatory response associated with these conditions and potentially lead to systemic complications.

Nursing Diagnosis

• Risk for Deficient Fluid Volume

Risk factors may include

• Excessive losses through gastric suction; vomiting, distension, and gastric hyper­motility
• Medically restricted intake
• Altered clotting process

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.

Desired Outcomes

• The client will demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, and absence of vomiting.

Nursing Assessment and Rationales

1. Maintain accurate record of I&O, noting output less than intake, and increased urine specific gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill.
To provide information about the fluid status and circulating volume needing replacement.

2. Monitor for signs and symptoms of increased or continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, and depressed respirations.
Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.

3. Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis, or melena.
Prothrombin is reduced and coagulation time is prolonged when bile flow is obstructed, increasing the risk of bleeding or hemorrhage.

Nursing Interventions and Rationales

1. Eliminate noxious sights or smells from the environment.
Reduces stimulation of vomiting center.

2. Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.
Decreases dryness of oral mucous membranes; reduces the risk of oral bleeding.

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

4. Keep patient NPO as necessary.
Decreases GI secretions and motility.

5. Insert NG tube, connect to suction, and maintain patency as indicated.
To rest the GI Tract