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

Nursing Diagnoses for Diarrhea

NANDA-I Update Note: NANDA International has recently renamed "Diarrhea" to "Impaired Fecal Continence" in its latest classification. However, "Diarrhea" remains in widespread clinical and academic use and is retained here.

Primary Nursing Diagnosis

1. Diarrhea

• Malabsorption (e.g., lactose intolerance, celiac disease, short bowel syndrome)
• Infection (bacterial, viral, parasitic - e.g., C. difficile, Salmonella, rotavirus)
• Inflammatory bowel disease (Crohn's disease, ulcerative colitis)
• Irritable bowel syndrome (IBS)
• Side effects of medications (antibiotics, laxatives, chemotherapy, antacids with Mg)
• Enteral tube feedings
• High-osmolarity feedings or foods
• Radiation therapy to the abdomen/pelvis
• Anxiety and psychological stress
• Dietary factors (high-fat, high-fiber, caffeine, alcohol)

• Three or more loose or liquid stools per day
• Hyperactive bowel sounds on auscultation
• Urgency to defecate
• Abdominal cramping and pain
• Loose, watery stools

• Patient re-establishes and maintains a normal pattern of bowel functioning within 24 hours of interventions
• Patient consumes at least 1,500-2,000 mL of fluids per day to maintain adequate hydration
• Patient verbalizes understanding of diarrhea's causes and rationale for treatment within 8 hours

1. Assess onset, frequency, character, and amount of stool (color, consistency, presence of blood/mucus)
2. Auscultate bowel sounds - hyperactive sounds are expected with diarrhea
3. Assess for signs of dehydration: dry mucous membranes, poor skin turgor, sunken eyes, decreased urine output
4. Review current medications for diarrhea-causing agents (antibiotics, laxatives, Mg-containing antacids)
5. Assess dietary history - method of food preparation, recent food intake, allergies
6. Monitor electrolytes (Na+, K+, Cl-) and fluid status via lab work
7. Examine GI history for IBD, C. difficile, autoimmune disease, or recent GI surgery

1. Record stool frequency, volume, and characteristics each shift
2. Administer antidiarrheal medications as ordered (loperamide, bismuth subsalicylate, diphenoxylate)
3. Encourage clear liquid diet initially; advance as tolerated using the BRAT diet (Bananas, Rice, Applesauce, Toast)
4. Increase fluid intake to 1.5-2.5 L/day in adults plus 200 mL for each loose stool
5. Restrict caffeine, milk, dairy, spicy foods, and high-fat foods that worsen diarrhea
6. Maintain or initiate IV fluid replacement if oral intake is inadequate
7. Promote good perianal hygiene after each stool to prevent skin breakdown
8. Obtain stool cultures per order to identify infectious agents

Associated / Secondary Nursing Diagnoses

2. Risk for Deficient Fluid Volume

• Decreased urine output
• Dry mucous membranes
• Orthostatic hypotension
• Increased heart rate
• Poor skin turgor

• Stable vital signs and adequate urine output (>0.5 mL/kg/hr)
• Moist mucous membranes and good skin turgor

• Monitor I&O strictly; weigh daily at same time
• Administer IV fluids (NS, LR) as ordered
• Monitor electrolytes and replace as needed (oral rehydration salts, IV electrolytes)
• Administer antiemetics if vomiting accompanies diarrhea

3. Imbalanced Nutrition: Less Than Body Requirements

• Unintentional weight loss
• Muscle wasting
• Weakness and fatigue
• Abnormal laboratory values (low albumin, protein)

• Patient maintains or progresses toward target body weight
• Patient tolerates advancing diet without worsening diarrhea

• Calculate caloric intake; consult dietitian if prolonged diarrhea
• Provide small, frequent meals of easily digestible foods
• Advance diet from clear liquids → full liquids → soft diet as tolerated
• Monitor weight daily and track trends
• Supplement with potassium-rich foods (bananas, broth) to replace losses

4. Acute Pain

• Patient reports of sharp or cramping abdominal pain
• Guarding behavior
• Facial grimacing
• Autonomic changes (increased HR, BP)

• Patient reports pain reduced to acceptable level (≤3/10 on pain scale)
• Patient demonstrates use of non-pharmacologic comfort measures

• Assess pain using 0-10 scale; document character and location
• Administer analgesics and antispasmodics as ordered
• Apply warm compresses or heating pad to the abdomen (low setting)
• Encourage position of comfort; knee-to-chest may reduce cramping
• Identify and eliminate triggering foods

5. Impaired Skin Integrity

• Redness, excoriation, and irritation of the perianal area
• Patient complaints of burning or itching at the perianal region

• Skin remains intact and free of excoriation
• Patient demonstrates proper perianal care technique

• Cleanse perianal area gently with soft cloth and mild soap after each stool; pat dry
• Apply barrier cream (zinc oxide, petroleum jelly) after each cleaning
• Avoid harsh, scented wipes that further irritate skin
• Use a sitz bath for comfort if irritation is significant
• Assess perianal skin at each shift

6. Deficient Knowledge

• Questions about the condition
• Non-compliance with fluid or dietary recommendations
• Repeated episodes due to avoidable triggers

• Patient verbalizes understanding of causes and treatment within 8 hours
• Patient identifies dietary modifications and hydration goals

• Teach the patient to avoid known triggers: dairy (if lactose intolerant), caffeine, alcohol, high-fat and spicy foods
• Educate on oral rehydration: importance of water, electrolyte drinks (ORS, Pedialyte)
• Instruct on proper handwashing and food safety (avoid undercooked meats, contaminated water)
• Teach signs of worsening requiring medical attention:
  • Blood or pus in stool
  • Fever >38.5°C (101.3°F)
  • Signs of severe dehydration (very dry mouth, no urination for 8+ hours, confusion)
  • Diarrhea lasting >3 days without improvement

7. Risk for Impaired Skin Integrity (Perianal)

• Frequency of liquid stools
• Fecal incontinence
• Altered skin moisture
• Elderly or immunocompromised patients

Summary Table

Sample Diagnostic Statements (PES Format)