Nursing diagnosis for choledocolithiasis pre operative

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nursing diagnosis choledocholithiasis preoperative NANDA

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Nursing Diagnoses for Choledocholithiasis - Pre-Operative

Choledocholithiasis is the presence of stones in the common bile duct (CBD), causing obstruction of bile flow. Pre-operatively, patients typically await laparoscopic cholecystectomy +/- CBD exploration, or have undergone ERCP with sphincterotomy. The nursing diagnoses below are organized by priority using NANDA-I framework.

1. Acute Pain

Related to: Biological injury - obstruction and spasm of the common bile duct, inflammatory process, tissue ischemia/necrosis from impaired bile flow

As evidenced by: Patient reports of right upper quadrant (RUQ) or epigastric pain, pain radiating to right shoulder or scapula, guarding/splinting, grimacing, diaphoresis, tachycardia, restlessness

Goals: Patient will report pain reduced to ≤3/10 on NRS within 1 hour of intervention

Interventions:

Assess pain using a validated scale (NRS 0-10), noting character, location, radiation, and duration
Administer prescribed analgesics (opioids, NSAIDs, antispasmodics) and antiemetics; monitor response
Position patient for comfort (semi-Fowler's or side-lying with knees flexed)
Apply ice/heat per order to the RUQ to reduce muscle spasm
Maintain NPO status to reduce biliary and GI stimulation
Teach non-pharmacological techniques: deep breathing, relaxation

2. Risk for Deficient Fluid Volume

Related to: Nausea and vomiting from biliary obstruction, NPO status, fever (if cholangitis is present), NG tube drainage

As evidenced by (risk factors): Active vomiting, fever >38°C, decreased PO intake, elevated WBC, NPO order

Goals: Patient will maintain adequate hydration with stable vital signs and urine output ≥30 mL/hr

Interventions:

Monitor vital signs (BP, HR, temp) every 4 hours or more frequently if unstable
Monitor urine output hourly if acutely ill; report output <30 mL/hr
Administer IV fluids (NS or LR) as prescribed
Insert and maintain NG tube if prescribed for GI decompression; record output
Monitor electrolytes (Na+, K+, Cl-), BUN, creatinine, and hematocrit
Assess skin turgor, mucous membranes, and mental status for hydration status

3. Imbalanced Nutrition: Less Than Body Requirements

Related to: Impaired fat digestion and absorption from obstructed bile flow, anorexia, nausea/vomiting, NPO restrictions, pain limiting intake

As evidenced by: Reported inadequate food intake, weight loss, jaundice, steatorrhea, low albumin/pre-albumin, fatigue

Goals: Patient will maintain stable weight and receive adequate nutritional support pre-operatively

Interventions:

Weigh daily; document trends
Assess for jaundice, pruritus, dark urine, pale stools - all signs of biliary obstruction affecting fat metabolism
Provide parenteral or enteral nutrition as ordered if NPO is prolonged
When allowed, offer a low-fat, high-protein diet in small frequent meals
Monitor serum albumin, prealbumin, glucose, and lipid-soluble vitamins (A, D, E, K)
Administer fat-soluble vitamin supplements and vitamin K if prescribed (prolonged PT/INR from decreased bile can impair clotting - important pre-operatively)

4. Hyperthermia / Risk for Infection

Related to: Ascending cholangitis secondary to CBD obstruction; bacterial seeding from biliary stasis

As evidenced by: Fever, chills, Charcot's triad (fever + jaundice + RUQ pain), elevated WBC, elevated bilirubin and alkaline phosphatase

Goals: Patient will be afebrile (<37.5°C) with no signs of systemic sepsis prior to surgery

Interventions:

Monitor temperature every 4 hours; report T >38.5°C
Administer prescribed IV antibiotics (commonly piperacillin-tazobactam, metronidazole, or fluoroquinolones for biliary coverage) on time
Monitor blood cultures if ordered; note Charcot's triad or Reynolds' pentad (adds altered consciousness + hypotension = septic cholangitis - emergency)
Apply cooling measures (tepid sponging, cooling blankets) if fever is high
Monitor liver function tests (AST, ALT, ALP, bilirubin), CBC with differential

5. Anxiety / Fear

Related to: Diagnosis, impending surgery, fear of the unknown, pain, potential complications (pancreatitis, sepsis)

As evidenced by: Verbalized worry, restlessness, increased heart rate and respiratory rate, difficulty concentrating, asking repetitive questions

Goals: Patient will verbalize reduced anxiety and demonstrate understanding of the surgical procedure

Interventions:

Establish a therapeutic nurse-patient relationship; provide a calm, reassuring environment
Explain all procedures, tests, and the plan of care in clear, simple language
Allow patient to verbalize fears; listen actively without judgment
Provide written educational materials about the surgery (cholecystectomy +/- ERCP) and recovery
Involve family or support persons in education with patient's consent
Refer to hospital chaplain, social worker, or psychological support if needed
Administer anxiolytics if prescribed and monitor response

6. Deficient Knowledge

Related to: Unfamiliarity with the diagnosis of choledocholithiasis, treatment plan, and surgical procedure

As evidenced by: Patient/family asking many questions, expressing misconceptions, inability to state the purpose of NPO or medications

Goals: Patient will accurately describe their condition, the planned procedure, and pre-operative requirements

Interventions:

Assess baseline knowledge of the diagnosis and procedure
Teach about the biliary system, what stones in the CBD mean, and why surgery is necessary
Explain pre-operative preparations: NPO, bowel prep if applicable, IV access, informed consent
Reinforce surgeon's and anesthesiologist's explanations
Provide post-operative expectation teaching: pain management, diet, activity restrictions, wound care
Document teaching and patient's demonstrated understanding

7. Risk for Bleeding / Impaired Coagulation (Pre-Op Safety Priority)

Related to: Obstructive jaundice impairing bile-mediated absorption of vitamin K, leading to decreased synthesis of clotting factors II, VII, IX, X

As evidenced by (risk factors): Prolonged PT/INR, jaundice, elevated direct bilirubin, history of prolonged obstruction

Goals: Coagulation parameters will be within acceptable surgical range prior to operation

Interventions:

Monitor PT, INR, PTT, and platelet count pre-operatively; report abnormal values
Administer IV/IM vitamin K (phytonadione) as prescribed
Prepare for possible FFP administration if surgery is urgent with coagulopathy
Educate patient to report unusual bruising or bleeding
Ensure IV access and type-and-screen are completed per pre-op protocol
Coordinate with the surgical and anesthesia team regarding coagulation status

Summary Table

Priority	NANDA Diagnosis	Focus
1	Acute Pain	RUQ pain from CBD obstruction
2	Risk for Deficient Fluid Volume	Vomiting, fever, NPO
3	Imbalanced Nutrition: Less Than Body Requirements	Fat malabsorption, anorexia
4	Hyperthermia / Risk for Infection	Cholangitis, biliary sepsis
5	Anxiety / Fear	Impending surgery
6	Deficient Knowledge	Surgery, disease, pre-op prep
7	Risk for Bleeding	Vitamin K deficiency from obstruction

Clinical note: If the patient also presents with acute pancreatitis secondary to CBD stone (gallstone pancreatitis), add diagnoses for impaired gas exchange (if severe/pleural effusion), acute pain (pancreatic), and risk for impaired skin integrity (jaundice + pruritus). Always confirm surgery clearance with INR, LFTs, CBC, and metabolic panel results before proceeding.

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