Cholecystitis
NURSING CARE PLAN FOR ACUTE CHOLECYSTITIS
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Assessment
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Assessing (Pre-operative): Head-to-toe subjective and objective assessments including smoking history, OTC drugs, anti-coagulant drugs, herbal remedies, past respiratory problems, and nutritional status. Focused assessment of the heart, lungs and abdomen. Completion of an ECG because of the patient’s previous myocardial infarction history, and chest X-ray to exclude right lower lobe pneumonia. Full pain assessment (COLDSPAA), and assessment for nausea. Assess for skin integrity: wound, infection, rashes, excoriations or bruises. Potential for acute pain and discomfort related to the inflammation and obstruction of the gall bladder and its associated ducts. Potential for nutritional deficiency related to nausea and vomiting and anorexia. Potential for anxiety and frustration related to pain, frequent hospital changes and upcoming cholecystectomy procedure.
Diagnosis
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Pain management – Goal: Pain free or at least tolerable pain. Maintain fluid and electrolyte balance – Goal: Homeostasis. Educate patient regarding dietary restrictions. – Goal: Decrease acute pain attack related to fatty foods. Maintain Respiratory Status. – Goal: Optimum pulmonary function and prevention of post-op complications. Encourage walking, when pain is under control. – Goal: Prevention of DVT, Prevention of pressure sores/ulcers. Encourage deep breathing exercises and relaxing techniques. – Goal: Decrease anxiety. Regain strength. Explore and encourage patient’s prior means of coping with pain. – Goal: Facilitates self-care management Explain and make care plan with the patient. – Goal: Build trust, decrease anxiety and fear, Increase confidence and comfort. Respect and consider cultural sensitivity. – Goal: Establish trust and comfort. Notify primary nurse/physician immediately if complications arise. – Goal: Best patient outcome. Pain management: PRN morphine administration for
•
Assessment
• • • • • •
Assessing (Pre-operative): Head-to-toe subjective and objective assessments including smoking history, OTC drugs, anti-coagulant drugs, herbal remedies, past respiratory problems, and nutritional status. Focused assessment of the heart, lungs and abdomen. Completion of an ECG because of the patient’s previous myocardial infarction history, and chest X-ray to exclude right lower lobe pneumonia. Full pain assessment (COLDSPAA), and assessment for nausea. Assess for skin integrity: wound, infection, rashes, excoriations or bruises. Potential for acute pain and discomfort related to the inflammation and obstruction of the gall bladder and its associated ducts. Potential for nutritional deficiency related to nausea and vomiting and anorexia. Potential for anxiety and frustration related to pain, frequent hospital changes and upcoming cholecystectomy procedure.
Diagnosis
• • • • • • • • • • • • • • •
Pain management – Goal: Pain free or at least tolerable pain. Maintain fluid and electrolyte balance – Goal: Homeostasis. Educate patient regarding dietary restrictions. – Goal: Decrease acute pain attack related to fatty foods. Maintain Respiratory Status. – Goal: Optimum pulmonary function and prevention of post-op complications. Encourage walking, when pain is under control. – Goal: Prevention of DVT, Prevention of pressure sores/ulcers. Encourage deep breathing exercises and relaxing techniques. – Goal: Decrease anxiety. Regain strength. Explore and encourage patient’s prior means of coping with pain. – Goal: Facilitates self-care management Explain and make care plan with the patient. – Goal: Build trust, decrease anxiety and fear, Increase confidence and comfort. Respect and consider cultural sensitivity. – Goal: Establish trust and comfort. Notify primary nurse/physician immediately if complications arise. – Goal: Best patient outcome. Pain management: PRN morphine administration for