Nursing Diagnoses for Cholelithiasis (Gallstones)

1. Acute Pain

• Patient reports of pain (biliary colic - waves of severe, cramping pain in right upper quadrant/epigastrium)
• Facial grimacing, guarding behavior
• Autonomic responses: changes in BP and pulse, diaphoresis
• Self-focusing and narrowed attention

• Patient reports pain relief or adequate control (target score on 0-10 scale)
• Patient uses relaxation techniques and diversional activities effectively

• Assess and document location, severity (0-10 scale), and character of pain (steady vs. colicky)
• Administer prescribed analgesics (NSAIDs, opioids, antispasmodics) and evaluate effectiveness
• Encourage semi-Fowler's or side-lying position to reduce pressure
• Apply heat to right upper quadrant cautiously per orders
• Maintain NPO status as needed - reduces GI secretions and gallbladder stimulation
• Provide non-pharmacologic comfort measures: distraction, relaxation, deep breathing

2. Risk for Deficient Fluid Volume

• Vomiting associated with biliary colic
• Anorexia and reduced oral intake
• Surgical intervention (pre/post-op)
• Fever increasing insensible losses

• Stable vital signs
• Moist mucous membranes and good skin turgor
• Adequate urinary output (>0.5 mL/kg/hr)
• Absence of vomiting

• Monitor vital signs, urine output, skin turgor, and mucous membranes
• Administer IV fluids and electrolytes as ordered
• Record accurate intake and output
• Administer antiemetics as prescribed
• Advance diet gradually as tolerated when vomiting resolves
• Keep NPO and insert NG tube to suction if ordered (to rest the GI tract)

3. Risk for Imbalanced Nutrition: Less Than Body Requirements

• Patient reports relief from nausea and vomiting
• Patient maintains weight or demonstrates progression toward desired weight

• Calculate caloric intake; minimize negative comments about appetite
• Weigh patient regularly to monitor dietary effectiveness
• Provide a low-fat, high-fiber diet when oral intake resumes
• Encourage small, frequent meals to facilitate gallbladder emptying
• Administer fat-soluble vitamin supplements (A, D, E, K) if prolonged obstruction
• Monitor for signs of malnutrition (weight loss, weakness, poor wound healing)

4. Deficient Knowledge

• Questions or statements of misconception about the condition
• Non-compliance with dietary recommendations
• Failure to recognize signs/symptoms requiring medical attention

• Patient verbalizes understanding of cholelithiasis, its causes, and treatment
• Patient identifies dietary modifications to prevent symptom exacerbation
• Patient lists warning signs requiring medical attention

• Explain the disease process, treatment options (laparoscopic cholecystectomy, ERCP, lithotripsy), and expected outcomes
• Teach a low-fat diet: avoid fried foods, butter, lard, full-fat dairy, and spicy foods
• Encourage increased fiber and calcium intake
• Discuss weight reduction if obesity is a contributing factor (but caution against rapid weight loss, which promotes stone formation)
• Review warning signs requiring urgent medical attention:
  • Recurring fever, persistent pain, worsening jaundice
  • Dark (cola-colored) urine and clay-colored stools
  • Bleeding from mucous membranes or in stools/vomitus
  • Signs of ascending cholangitis (Charcot's triad: RUQ pain + fever + jaundice)

5. Anxiety

• Verbalization of fear or worry
• Restlessness, insomnia
• Increased heart rate or blood pressure

• Patient reports decreased anxiety
• Patient demonstrates understanding of planned procedures

• Explain all diagnostic tests and procedures before they happen
• Use active listening and therapeutic communication
• Encourage patient to verbalize fears and concerns
• Provide accurate, reassuring information about laparoscopic cholecystectomy outcomes

6. Risk for Infection (Post-operative / Acute Cholecystitis)

• Empyema or gangrene of the gallbladder
• Common causative organisms: E. coli, streptococci, Salmonella spp.
• Surgical wound

• No signs of wound infection or systemic sepsis
• WBC count within normal limits

• Monitor WBC, temperature trends, and signs of sepsis (WBC >20,000 may suggest gangrene/perforation)
• Administer antibiotics as prescribed
• Maintain aseptic technique with wound and T-tube care
• Monitor T-tube drainage (color, volume, and character)

7. Ineffective Breathing Pattern (Post-operative)

• Shallow respirations
• Splinting with breathing
• Reduced oxygen saturation

• Adequate respiratory rate and depth
• No atelectasis or pneumonia

• Encourage deep breathing and use of incentive spirometry every 1-2 hours
• Teach splinting techniques to support incision during coughing
• Administer adequate pain control to facilitate deeper breathing
• Ambulate early as tolerated

Summary Table