Cholecystectomy Nursing Care Plans

12 Cholecystectomy Nursing Care Plans 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. A cholecystectomy consists of excising the gallbladder from the posterior liver wall and ligating the cystic duct, vein, and artery. The surgeon usually approaches the gallbladder through a right upper paramedian or upper midline incision if necessary, the common duct may be explored through this incision. When stones are suspected in the common duct, operative cholangiography may be performed (if it has not been ordered preoperatively). The surgeon may dilate the common duct if it is already dilated as a result of a pathologic process. Dilation facilitates stone removal. The surgeon passes a thin instrument into the duct to collect the stones, either whole or after crushing them. After exploring the common duct, the surgeon usually inserts a T-tube to ensure adequate bile drainage during duct healing (choledochostomy). The T-tube also provides a route for postoperative cholangiography or stone dissolution, when appropriate. A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does not allow for retrieval of a stone in the common bile duct and when the client’s physique does not allow access to the gallbladder. Occasionally, when a client is very obese, the gallbladder is not retrievable via laparoscopic instruments. Further, a surgeon may have difficulty accessing the gallbladder in an adult with a small frame and may need to perform the conventional open cholecystectomy. Nursing Care Plans Nursing care plans for patients who underwent cholecystectomy includes promoting optimal respiratory function, preventing complications, management of pain, and provision of information about disease, procedures and treatment needs. Here are 12 nursing care plan (NCP) and nursing diagnosis for cholecystectomy: Ineffective Breathing Pattern Impaired Skin Integrity Risk for Deficient Fluid Volume Deficient Knowledge Preoperative Problem: Acute Pain Preoperative Problem: Fear Ineffective Breathing Pattern Risk for Aspiration Postoperative Acute Pain Activity Intolerance Impaired Physical Mobility Risk for Infection Ineffective Breathing Pattern Nursing Diagnosis Ineffective Breathing Pattern 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 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 the patient how to splint incision. Instruct effective breathing techniques. Facilitates lung expansion. Splinting provides incisional support and decreases muscle tension to promote cooperation with the therapeutic regimen. Elevate the head of bed; maintain lowFowler’s position. Maximizes expansion of lungs to prevent or 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. Use a disposable ostomy bag over a stab wound drain. Facilitates frequent dressing changes and minimizes skin trauma. Ostomy appliance may be used to collect heavy drainage for more accurate measurement of output and protection of the skin. Nursing Interventions Place the patient in low- or semi-Fowler’s position. Rationale Facilitates drainage of bile. Monitor puncture sites (3–5) if the 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 the backup of the bile in the operative area. Maintain T-tube in a closed collection system. Prevents skin irritation and facilitates measurement of output. Reduces the 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 the abdomen or pancreatic duct is obstructed. Observe skin, Developing jaundice may indicate Nursing Interventions sclerae, urine for change in color. Rationale 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 the tube or from a 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 the 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. 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 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 the 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 the 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 the risk of bleeding or hemorrhage. Nursing Interventions Rationale 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 the replacement of clotting factors. Electrolytes Vitamin K Corrects imbalances resulting from excessive gastric or losses. Provides replacement of factors necessary for the 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 the reasons for the actions. Initiate necessary lifestyle changes and participate in the therapeutic regimen. Nursing Interventions Rationale 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 the risk of complications. Recommend periodic drainage of T-tube collection bag and recording of output. Reduces the risk of reflux, strain on tube or appliance seal. Provides information about the resolution of ductal edema and return of ductal function for appropriate timing of T-tube Nursing Interventions Rationale removal. Emphasize the importance of maintaining a 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 the need for bile and reduce discomfort associated with inadequate digestion of fats. Discuss the 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 the 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 the stimulus of the continuous output of bile. Advise patient to note and avoid foods that seem to aggravate 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; Indicators of obstruction of bile flow or altered digestion, requiring further evaluation and Nursing Interventions Rationale jaundiced color of eyes, skin; clay-colored stools, excessive stools; or recurrent heartburn, bloating. intervention. Review activity limitations depending on the individual situation. Resumption of usual activities is normally accomplished within 4–6 wks. Preoperative Problem: Acute Pain Nursing Diagnosis Acute Pain The flow of bile in the gallbladder is obstructed due to the presence of stones. When the bladder releases bile, it contracts and there is spasm, thus it cannot adequately release bile due to the stone, it stimulates the release of cytokines resulting to pain. Preoperative Problem: Fear Nursing Diagnosis Fear Undergoing open cholecystectomy, the patient may perceive threat like the outcome of the surgery that is consciously recognized by the client as danger. Ineffective Breathing Pattern Nursing Diagnosis Ineffective Breathing Pattern Respirations may be increased as a result of pain or as an initial compensatory mechanism. However, increased work of breathing may indicate increasing oxygen consumption and energy expenditures and/or reduced respiratory reserve. Risk for Aspiration Nursing Diagnosis Risk for Aspiration Prior to any surgical invasion, general anesthesia is induced. It relaxes the muscles of the body and depresses the sensation of pain, thus the gag and swallowing reflex is temporarily suppressed that may lead to aspiration. Postoperative Acute Pain Nursing Diagnosis Acute Pain In performing cholecystectomy, surgical incision is done. By which, the incision causes direct irritation to the nerve endings by chemical mediators released at the site such as bradykinin. This irritation will send signal to the cortex and thalamus of the brain thus producing pain perception. Activity Intolerance Nursing Diagnosis Activity Intolerance Post-op pt. usually is under bed rest for few days that may hinder them to their usual activity. Presence of surgical incision procedures causes the pt. to be reluctant in doing personal activities, because those may result in the stimulation of the nerve endings, during movement, thus, increase pain sensation. Impaired Physical Mobility Nursing Diagnosis Impaired Physical Mobility Presence of surgical incision procedures causes the pt. to be reluctant in doing movements such as ROM, because those may result in the stimulation of the nerve endings, during movement, thus, increase pain sensation. Risk for Infection Nursing Diagnosis Risk for Infection The patient is at risk of acquiring infection due to the break in the continuity of the first line defense which is the skin. The patient shall have undergone cholecystectomy, thus there is an incision and suture made in the abdomen. If there is a breakage in the skin, the pathogens will easily invade the body’s system thus increasing risk for infection.