Post-Operative Nursing Diagnoses for Cholelithiasis (Post-Cholecystectomy)

1. Acute Pain

• Assess pain using a numeric scale (0-10) every 2-4 hours
• Administer analgesics as prescribed (NSAIDs, opioids) and evaluate effectiveness
• Encourage splinting of the incision site with a pillow when coughing or moving
• Position patient in semi-Fowler's to reduce abdominal tension
• Apply ice packs to incision sites to reduce swelling and pain
• Monitor for adverse effects of opioids (respiratory depression, sedation)

2. Ineffective Breathing Pattern

• Assess respiratory rate, depth, and oxygen saturation continuously
• Auscultate breath sounds for atelectasis or congestion (absent/diminished sounds)
• Encourage incentive spirometry use every 1-2 hours while awake
• Assist patient with turning, coughing, and deep breathing exercises
• Elevate head of bed 30-45 degrees to facilitate diaphragm descent

3. Risk for Infection

• Perform strict aseptic wound care with each dressing change
• Monitor incision site for signs of infection: redness, warmth, swelling, purulent drainage, dehiscence
• Monitor vital signs for fever (>38.5°C), elevated WBC, tachycardia
• Maintain patency and sterility of T-tube and drainage system (if present)
• Monitor bile drainage: amount, color, consistency (should be golden yellow/green)
• Administer prescribed prophylactic antibiotics

4. Risk for Deficient Fluid Volume

• Monitor intake and output strictly (urine output >0.5 mL/kg/hr is the target)
• Assess for signs of dehydration: tachycardia, hypotension, poor skin turgor
• Administer IV fluids as prescribed to maintain hemodynamic stability
• Monitor electrolytes and hemoglobin/hematocrit
• Advance oral fluids and diet as tolerated once bowel function returns

5. Imbalanced Nutrition: Less Than Body Requirements

• Introduce clear liquids first, then progress to low-fat soft diet as tolerated
• Encourage small, frequent meals rather than large ones
• Educate patient to avoid high-fat foods for 4-6 months post-surgery (bile is now continuously secreted vs. stored)
• Monitor for bloating, loose stools (common for several months as intestines adjust)
• Consult dietitian for meal planning guidance
• Administer antiemetics (ondansetron) as prescribed for nausea

6. Impaired Physical Mobility / Activity Intolerance

• Encourage early ambulation (within 6-8 hours post-op for laparoscopic; day 1-2 for open)
• Assist with positioning and transfers to prevent falls
• Educate on activity restrictions: no heavy lifting (>5 kg) for 4-6 weeks (open), 1-2 weeks (laparoscopic)
• Encourage progressive activity increase each day

7. Deficient Knowledge

• Teach wound care: how to clean incision, signs of infection to report
• Instruct on low-fat diet and gradual reintroduction of fats over 4-6 months
• Advise to report danger signs: jaundice, dark urine, clay-colored stools, fever, chills, severe abdominal pain (may indicate bile duct obstruction or retained stones)
• Educate on medication use (bile salt replacements if prescribed, laxatives for opioid-induced constipation)
• Advise that loose stools may persist for several months post-operatively

8. Risk for Constipation

• Monitor bowel sounds and bowel movements
• Encourage early ambulation to promote peristalsis
• Ensure adequate fluid intake
• Administer prescribed stool softeners or laxatives if on opioid therapy
• Advance diet progressively to include fiber-rich foods

9. Anxiety / Fear

• Provide clear, consistent information about recovery expectations
• Allow patient to verbalize concerns; validate feelings
• Include family/support persons in discharge teaching
• Explain all procedures before performing them

Special Considerations: T-Tube Care (Open Cholecystectomy)

• Keep tube patent and monitor drainage (300-500 mL/day is normal initially)
• Gradually clamp as ordered before removal
• Position drainage bag below incision level
• Teach patient T-tube care at home if discharged with it

Priority Nursing Diagnoses (Post-Op Day 1)