12 Cholecystectomy Nursing Care Plans

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy

is performed most frequently through laparoscopic incisions using laser.
However, traditional open cholecystectomy is the treatment of choice for many
patients with multiple/large gallstones (cholelithiasis) either because of acute
symptomatology or to prevent recurrence of stones.

A cholecystectomy consists of excising the gallbladder from the posterior

liver wall and ligating the cystic duct, vein, and artery. The surgeon usually
approaches the gallbladder through a right upper paramedian or upper midline
incision if necessary, the common duct may be explored through this incision.
When stones are suspected in the common duct, operative cholangiography
may be performed (if it has not been ordered preoperatively). The surgeon
may dilate the common duct if it is already dilated as a result of a pathologic
process. Dilation facilitates stone removal. The surgeon passes a thin
instrument into the duct to collect the stones, either whole or after crushing
them.

After exploring the common duct, the surgeon usually inserts a T-tube to
ensure adequate bile drainage during duct healing (choledochostomy). The T-
tube also provides a route for postoperative cholangiography or stone
dissolution, when appropriate.

A conventional open cholecystectomy is indicated when a laparoscopic

cholecystectomy does not allow for retrieval of a stone in the common bile
duct and when the client’s physique does not allow access to the gallbladder.
Occasionally, when a client is very obese, the gallbladder is not retrievable via
laparoscopic instruments. Further, a surgeon may have difficulty accessing
the gallbladder in an adult with a small frame and may need to perform the
conventional open cholecystectomy.

Nursing Care Plans

Nursing care plans for patients who underwent cholecystectomy includes

promoting optimal respiratory function, preventing complications,
management of pain, and provision of information about disease, procedures
and treatment needs.

Here are 12 cholecystectomy nursing care plans (NCP):

1. Ineffective Breathing Pattern

Ineffective Breathing Pattern: Inspiration and/or expiration that does not

provide adequate ventilation

May be related to

• Pain
• Muscular impairment
• Decreased energy/fatigue

Possibly evidenced by

• Tachypnea; respiratory depth changes, reduced vital capacity

• Holding breath; reluctance to cough

Desired Outcomes

• Establish effective breathing pattern.

• Experience no signs of respiratory compromise/complications.

Nursing Interventions Rationale

Shallow breathing, splinting with respirations,

Observe respiratory rate, depth. holding breath may result in hypoventilation or
atelectasis.

Areas of decreased or absent breath sounds

Auscultate breath sounds. suggest atelectasis, whereas adventitious sounds
(wheezes, rhonchi) reflect congestion.

Assist patient to turn, cough, and deep breathe Promotes ventilation of all lung segments and
periodically. mobilization and expectoration of secretions.

Facilitates lung expansion. Splinting provides

Show patient how to splint incision. Instruct in
incisional support and decreases muscle tension to
effective breathing techniques.
promote cooperation with therapeutic regimen.

Elevate head of bed, maintain low-Fowler’s Maximizes expansion of lungs to prevent or resolve
position. atelectasis.

Facilitates more effective coughing, deep

Support abdomen when coughing, ambulating.
breathing, and activity.
2. Impaired Skin Integrity

Impaired Skin Integrity: Altered epidermis and/or dermis [The integumentary

system is the largest multifunctional organ of the body.]

May be related to

• Chemical substance (bile), stasis of secretions

• Altered nutritional state (obesity)/metabolic state
• Invasion of body structure (T-tube)

Possibly evidenced by

• Disruption of skin/subcutaneous tissues

Desired Outcomes

• Achieve timely wound healing without complications.

• Demonstrate behaviors to promote healing/prevent skin breakdown.

Nursing Interventions Rationale

Initially, drainage may contain blood and

Observe the color and character of the drainage. bloodstained fluid,normally changing to greenish
brown (bile color) after the first several hours

Change dressings as often as necessary. Clean the

skin with soap and water. Use sterile petroleum Keeps the skin around the incision clean and
jelly gauze, zinc oxide, or karaya powder around provides a barrier to protect skin from excoriation.
the incision.

Facilitates frequent dressing changes and

Apply Montgomery straps.
minimizes skin trauma.

Ostomy appliance may be used to collect heavy

Use a disposable ostomy bag over a stab wound
drainage for more accurate measurement of
drain.
output and protection of the skin.

Place patient in low- or semi-Fowler’s position. Facilitates drainage of bile.

Monitor puncture sites (3–5) if endoscopic These areas may bleed, or staples and Steri-Strips
procedure is done. may loosen at puncture wound sites.
 Nursing Interventions Rationale

T-tube may remain in common bile duct for 7–10

days to remove retained stones. Incision site drains
Check the T-tube and incisional drains; make sure
are used to remove any accumulated fluid and bile.
they are free flowing.
Correct positioning prevents backup of the bile in
the operative area.

Prevents skin irritation and facilitates measurement

Maintain T-tube in closed collection system.
of output. Reduces risk of contamination.

Anchor drainage tube, allowing sufficient tubing to Avoids dislodging tube and/or occlusion of the
permit free turning and avoid kinks and twists. lumen.

Dislodgment of the T-tube can result in

Observe for hiccups, abdominal distension, or signs diaphragmatic irritation or more serious
of peritonitis, pancreatitis. complications if bile drains into abdomen or
pancreatic duct is obstructed.

Developing jaundice may indicate obstruction of

Observe skin, sclerae, urine for change in color.
bile flow.

Clay-colored stools result when bile is not present

Note color and consistency of stools.
in the intestines.

Investigate reports of increased or unrelenting RUQ

Signs suggestive of abscess or fistula formation,
pain; development of fever, tachycardia; leakage of
requiring medical intervention.
bile drainage around tube or from wound.

Necessary for treatment of abscess and/or

Administer antibiotics as indicated.
infection.

Tests the patency of the common bile duct before

Clamp the T-tube per schedule.
tube is removed.

3. Risk for Deficient Fluid Volume

Risk for Deficient Fluid Volume: At risk for experiencing vascular, cellular,
or intracellular dehydration.

Risk factors may include

• Losses from NG aspiration, vomiting

• Medically restricted intake
• Altered coagulation, e.g., reduced prothrombin, prolonged coagulation
time
Possibly evidenced by

• Not applicable. A risk diagnosis is not evidenced by signs and

symptoms, as the problem has not occurred and nursing interventions
are directed at prevention.

Desired Outcomes

• Display adequate fluid balance as evidenced by stable vital signs, moist

mucous membranes, good skin turgor/capillary refill, and individually
appropriate urinary output.

Nursing Interventions Rationale

Provides information about replacement needs and

organ function. Initially, 200–500 mL of bile
drainage may be expected via the T-tube,
Monitor I&O, including drainage from NG tube, T-
decreasing as more bile enters the intestine.
tube, and wound. Weigh patient periodically.
Continuing large amounts of bile drainage may be
an indication of unresolved obstruction or,
occasionally, a biliary fistula.

Monitor vital signs. Assess mucous membranes, Indicators of adequacy of circulating volume,
skin turgor, peripheral pulses, and capillary refill. perfusion.

Prothrombin is reduced and coagulation time

Observe for signs of bleeding: hematemesis,
prolonged when bile flow is obstructed, increasing
melena, petechiae, ecchymosis.
risk of bleeding or hemorrhage.

Use small-gauge needles for injections, and apply

firm pressure for longer than usual after Reduces trauma, risk of bleeding or hematoma.
venipuncture.

Have patient use cotton or sponge swabs and

Avoids trauma and bleeding of the gums.
mouthwash instead of a toothbrush.

Provides information about circulating volume,

Monitor laboratory studies: Hb/Hct, electrolytes,
electrolyte balance, and adequacy of clotting
prothrombin level or clotting time.
factors.

Maintains adequate circulating volume and aids in

Administer IV fluids, blood products, as indicated
replacement of clotting factors.

Corrects imbalances resulting from excessive

Electrolytes
gastric or losses.
 Nursing Interventions Rationale

Provides replacement of factors necessary for

Vitamin K
clotting process.

4. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related

to specific topic.

May be related to

• Lack of exposure; information misinterpretation

• Unfamiliarity with information resources
• Lack of recall

Possibly evidenced by

• Questions; statement of misconception

• Request for information
• Inaccurate follow-through of instructions

Desired Outcomes

• Verbalize understanding of disease process, surgical

procedure/prognosis, and potential complications.
• Verbalize understanding of therapeutic needs.
• Correctly perform necessary procedures and explain reasons for the
actions.
• Initiate necessary lifestyle changes and participate in therapeutic
regimen.

Nursing Interventions Rationale

Review disease process, surgical procedure and Provides knowledge base on which patient can make
prognosis. informed choices.

Demonstrate care of incisions, dressings, and Promotes independence in care and reduces risk of
drains. Promote good hand hygiene. complications.

Recommend periodic drainage of T-tube Reduces risk of reflux, strain on tube or appliance seal.
collection bag and recording of output. Provides information about resolution of ductal edema
 Nursing Interventions Rationale

and return of ductal function for appropriate timing of

T-tube removal.

Emphasize importance of maintaining low-fat

During initial 6 mo after surgery, low-fat diet limits
diet, eating frequent small meals, gradual
need for bile and reduces discomfort associated with
reintroduction of foods or fluids containing fats
inadequate digestion of fats.
over a 4- to 6-mo period.

Discuss use of medication such as florantyrone Oral replacement of bile salts may be required to
(Sancho) or dehydrocholic acid (Decholin). facilitate fat absorption.

Discuss avoiding or limiting use of alcoholic

Minimizes risk of pancreatic involvement.
beverages.

Inform patient that loose stools may occur for Intestines require time to adjust to stimulus of
several months. continuous output of bile.

Although radical dietary changes are not usually

necessary, certain restrictions may be helpful; e.g., fats
Advise patient to note and avoid foods that
in small amounts are usually tolerated. After a period of
seem to aggravate the diarrhea.
adjustment, patient usually will not have problems with
most foods.

Identify signs and symptoms requiring

notification of healthcare provider: dark urine; Indicators of obstruction of bile flow or altered
jaundiced color of eyes, skin; clay-colored digestion, requiring further evaluation and
stools, excessive stools; or recurrent intervention.
heartburn, bloating.

Review activity limitations depending on Resumption of usual activities is normally accomplished

individual situation. within 4–6 wk.

5. Preoperative Problem: Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from

actual or potential tissue damage or described in terms of such damage;
sudden or slow onset of any intensity from mild to severe with anticipated or
predictable end and a duration of <6 months.

The flow of bile in the gallbladder is obstructed due to the presence of stones.
When the bladder releases bile, it contracts and there is spasm, thus it cannot
adequately release bile due to the stone, it stimulates the release of cytokines
resulting to pain
Cholecystectomy Nursing Care Plan: Preoperative Problem: Acute Pain

Assessment

S: patient mayverbalize:

-> unrelieved pain

O: patient maymanifest:

->(+) facialgrimaces

-> appears irritable,restlessness

-> guarded orprotectivebehavior

-> diaphoresis

-> inability to sleep

-> pain on theabdominal area

Nursing Diagnosis

-> Acute pain

ScientificExplanation

-> The flow of bile inthe gall bladder is obstructed due tothe presence of
stones. When thebladder releases bile, it contracts and there is spasm, thus it
cannot adequately release bile dueto the stone, it stimulates the release of
cytokines resulting to pain.

Planning(Objective/Goal)

->Short-term: After 1-2 hours of nursing interventions,the patient

will demonstrate behaviorsto relieve pain

->Long-term: After 4 hours of nursing interventions,the patient will report pain

is controlled

Interventions
-> Establish rapport

-> Monitor and record vital signs

-> assess the severity,frequency, and characteristic of pain

-> administer medication as ordered

-> provide non-pharmacologic al intervention such as touch and

frequent changing of position

Rationale

-> To gain patient’s trust and cooperation

-> for baseline data

-> pain is a subjective data, therefore it should be reported and to

determine patient’s level of pain

-> to minimize/relieve pain

-> to provide comfort

Evaluation

->Short-term: After 1-2 hours of nursing interventions, the patient shall

have demonstrated behaviors to relieve pain

->Long-term: After 4 hours of nursing interventions, the patient shall

have reported pain is controlled.

6. Preoperative Problem: Fear

Fear: Response to perceived threat that is consciously recognized as a

danger.

Undergoing open cholecystectomy, the patient may perceive threat like the
outcome of the surgery that is consciously recognized by the client as danger

Cholecystectomy Nursing Care Plan: Fear RT Outcome of Surgery

Assessment

S: The patient may verbalize:

-> statements about the object of fear

-> decreased self assurance

-> increased tension; jitteriness

O: The patientmay manifest:

-> increase alertness

-> impulsive

-> diaphoresis

-> pallor

-> muscle tightness

Nursing Diagnosis

-> Fear r/t out come of surgery

Scientific Explanation

-> Undergoing open cholecystectomy,the patient may perceive threat like the
out come of the surgery that is consciously recognized by the client as danger

Planning(Objective/Goal)

-> Short-term: After 1 hour of nursing interventions, the patient will

verbalize accurate knowledge or sense of safety related to current situation

-> Long-term: After 4 hours of nursing intervention the patient

will demonstrate under standing through use of effective coping behaviors
and resources

Interventions

-> Establish rapport

-> Monitor/ recordvital signs

-> Assess patient’s condition

-> Determine client’s ability to learn

-> Provide information relevant to the situation

-> Compare verbal and non verbal responses

-> Note degree of concentration or focus

-> Stay with the client

-> Provide

-> Information in verbal and written form

-> Provide opportuniy for questions and answer honestly

-> Explain procedure within client’s abilitie

Rationale

-> To gain trust of the patient

-> for baseline datato note any abnormalities within the patient

-> to assess the capability of the client

-> to present reality to the patientto note congruencies or misperceptio ns of

situation

-> identifies the starting point of what to do

-> sense of abandonement can exacerbate fearfacilitates understanding

and retention of information

-> enhance sense of trust and nure-patient relationship to prevent confusion

Evaluation
-> Short-term: After 1 hour of nursing interventions, the patient shall
have verbalized accurate knowledge or sense of safety related to
current situation

-> Long-term: After 4 hours of nursing interventions, the patient shall

have demonstrated understanding through use of effective coping behaviors
and resources

7. Ineffective Breathing Pattern

Ineffective Breathing Pattern: Inspiration and/or expiration that does not

provide adequate ventilation

Respirations may be increased as a result of pain or as an initial

compensatory mechanism. However, increased work of breathing may
indicate increasing oxygen consumption and energy expenditures and/or
reduced respiratory reserve.

Cholecystectomy Nursing Care Plan: Ineffective Breathing Pattern

Assessment

S: –
O: The patient may manifest:

-> Tachypnea

-> Reluctance tocough

-> Holding breath

-> DOB

NursingDiagnosis

-> In effective breathing patternr/t to pain

Scientific Explanation
-> Short-term:After 1 hour of nursing interventions, the patient
will demonstrate improved breathing pattern.

-> Long-term:After 4 hours of nursing intervention the patient will establish

effective breathing pattern

Interventions

-> Administer supplemental oxygen via nasal cannula asordered

-> Wdminister pain medications as ordered

-> monitor vital signs especially respiratory rate

-> encourage/assist with deep-breathing exercises and pursed-lip breathing

as appropriate

-> check for restlessness and changes in mental status

Rationale

-> Maximize sava ilable oxygen,especially while ventilation

is reduced because pain

-> To treat underlying cause of respiratory problem

-> For baseline data

-> Promotes maximal ventilati on and oxygenation

-> may indi catehypoxi

Evaluation

-> Short-term: After 1 hour of nursing interventions, the patient shall

have demonstrated improved breathing pattern.

-> Long-term: After 4 hours of nursing interventions, the patient shall

have established an effective breathing pattern
8. Risk for Aspiration

Risk for Aspiration: At risk for entry of gastrointestinal secretions,

oropharyngeal secretion, solids, or fluids into tracheobronchial passages.

Prior to any surgical invasion, general anesthesia is induced. It relaxes the

muscles of the body and depresses the sensation of pain, thus the gag and
swallowing reflex is temporarily suppressed that may lead to aspiration.

Cholecystectomy Nursing Care Plan: Intraoperative Problem: Risk for

Aspiration

Assessment

Risk Factors:

-> Reduced level of consciousness

-> Depressed cough and gagre flex

-> Impaired swallowing

NursingDiagnosis

-> Risk for Aspirationr/t induction of general anesthesia

Scientific Explanation

-> Prior to any surgical invasion, general anesthesia is induced. It relaxes the
muscles of the body and depresses the sensation of pain,thus the gag
and swallowing reflex is temporarily suppressed that may lead to aspiration.

Planning(Objective/Goal)

-> Short-term: After 1 hour of nursing interventions, the patient will

maintain safety and maintain homeostasis

-> Long-term: After 3 hours of nursing intervention the patient

will demonstrate behaviors of return of reflexes

Interventions

-> Monitor and record vital signs

-> Assess patient’s condition

-> Note the duration of anesthetic medications

-> Maintain patent airway by suctioning, use of airway adjuncts.

Rationale

-> For baseline data

-> To note any abnormalities with in the patient

-> To assess presence of the gag reflex

-> Airway obstruction impedes ventilation

Evaluation

-> Short-term: After 1 hour of nursing interventions, the patient shall

have maintained safety and homeostasis

-> Long-term: After 3 hours of nursing interventions, the patient shall

have demonstrated behaviors of return of reflexes

9. Postoperative Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from

actual or potential tissue damage or described in terms of such damage;
sudden or slow onset of any intensity from mild to severe with anticipated or
predictable end and a duration of <6 months.

In performing cholecystectomy, surgical incision is done. By which, the

incision causes direct irritation to the nerve endings by chemical mediators
released at the site such as bradykinin. This irritation will send signal to the
cortex and thalamus of the brain thus producing pain perception.

Cholecystectomy Nursing Care Plan: Post-Operative Acute Pain

Assessment

S: Patient mayverbalize:
-> unrelieved pain

O: Patient maymanifest:

-> (+) Facialgrimaces

-> Appearsirritable,restlessness

-> Guarded orprotectivebehavior

-> Diaphoresis

-> Inability to sleep

NursingDiagnosis

-> Acute pain

Scientific Explanation

-> In performing cholecystectomy,surgical incision is done. By which,the

incision causes direct irritation to the nerve endingsby chemical mediators
released at the site such as bradykinin. This irritation will send signal to the
cortex and thalamus of the brain thus producing pain perception

Planning(Objective/Goal)

-> Short-term: After 2 hours of nursing interventions,the patient will

report relief from pain.

-> Long-term: After 4 hours of nursing interventions,the patient report pain is

controlled

Interventions

-> Administer medication as ordered

-> Monitor and record vital signs

-> Assess the severity,frequency, and characteristic of pain

-> provide divertional activities suchas reading news papers

-> provide non-pharmacologial intervention such as touch and
frequent changing of position

Rationale

-> to minimizethe pain

-> for baselinedata

-> pain is asubjectivedata,therefore itshould bereported andto

determine patient’s level of pain

-> to divert thepain thepatient isexperiencing

-> to provide comfor

Evaluation

-> Short-term: After 2 hours of nursing interventions. the patient shall

have reported relief from pain.

-> Long-term: After 4 hours of nursing interventions, the patient shall

have reported pain is controlled

10. Activity Intolerance

Activity Intolerance: Insufficient physiologic or physiological energy to

endure or complete required or desired activity.

Post-op pt. usually is under bed rest for few days that may hinder them to their
usual activity. Presence of surgical incision procedures causes the pt. to be
reluctant in doing personal activities, because those may result in the
stimulation of the nerve endings, during movement, thus, increase pain
sensation.

Cholecystectomy Nursing Care Plan: Activity Intolerance

Assessment

S:Ø
O: The pt.manifested

-> difficulty turning from one side to another

-> generalized weakness

-> limited ROM

-> needs assistance when moving Pt. may manifest

-> bed sores

-> muscle weakness

NursingDiagnosis

-> Activity intolerance r/t generalized weakness 2°Cholecystectomy

Scientific Explanation

-> Post-op pt. usually is under bed restfor few days that may hinder them to
their usualactivity. Presence of surgical incision procedures cause sthe pt. to
bereluctant in doing personal activities,because thosemay result in
the stimulation of thenerve endings,during movement,thus, increase
pain sensation

Planning(Objective/Goal)

-> Short term: After 1° of NI, the ptwill verbalize understanding

on improvement of activity tolerance within his/ herlimitation.

-> Long term: After 4° of NI, the pt.will participate in conditioning program to
enhance ability to perform activities

Interventions

-> Establish rapport

-> Monitor VS.

-> Assess pt.Condition.

-> Monitor vitalsigns.

-> Provide adequaterest.

-> Adjust activities to enhance ability.

-> Encourage pt. to maintain a positive out come>assist pt. to lean and
demonstrate safety measures.

-> Teach ways on how to conserve energy such assitting when doing activities

-> Administer medprior to activity as need

Rationale

-> To establish nurse-pt.relationship.

-> To establish baseline data.

-> To gather baseline data and compare it with normal findings.

-> To gather baseline data.

-> To prevent fatigue and conserve energy.

-> To partici patein activities.

-> To enhan cesense of well being.

-> To prevent injuries.

-> To limitfatigue& maximize use of energy.

-> For pain relief,to permit maximal effortand involvementin activity

Evaluation

-> Short term: Pt. shall have verbalizedunderstandingon improvementof

activitytolerance withinhis/her limitation

-> Long term:Pt. shall have participated inconditioningprogram toenhance

abilityto performactivities.
11. Impaired Physical Mobility

Impaired Physical Mobility: Limitation in independent, purposeful physical

movement of the body or of one or more extremities.

Presence of surgical incision procedures causes the pt. to be reluctant in

doing movements such as ROM, because those may result in the stimulation
of the nerve endings, during movement, thus, increase pain sensation.

Cholecystectomy Nursing Care Plan: Impaired Physical Mobility

Assessment

S: Ø

O:

The pt.manifested:

-> surgical incision on RUQ of the abdomen

-> guarding behavior

The pt. maymanifest:

-> cold clammy skin

-> perspiration

-> anxiety

-> restlessness

-> redness onthe incision site

NursingDiagnosis

-> Impaired Physicalmobility r/t pain2°Cholecystectom

Scientific Explanation
-> Presence of surgical incision procedure scauses the pt. tobe reluctant
in doing movements such as ROM,because thosemay result in the stimulation
of the nerve endings, during movement, thus,increase pain sensation.

Planning(Objective/Goal)

-> Short term: After 1° of NI, pt.will be able to identify appropriate interventions
or measures in order to move safely and freely

-> Long term: After 3° of NI, pt.will demonstrate behaviors that enable
resumptionof activities

Interventions

-> establish rapport.

-> monitor V/S.

-> assess the degree of pain.

-> note emotional responses to problems of immobility.

-> instruct SO tostay at bedside.

-> support bodyparts/joints using pillows.

-> Administer medications prior to activity as needed for pain relief Schedule
activities with adequate

-> restperiods during the day

-> encourage performing diversional activities such as puzzles etc.

-> encourage tomin crease oral fluidin take.

-> place essential equipments near the client.

-> encourage ROM exercises.

-> place client in acom for table position

Rationale
-> to establish nurse-pt. relationship.

-> to establish baseline data.

-> to determine appropriate interventions.

-> feeling of frustration or powerlessness may impede attainment of goals.

-> for position changes/transfers.

-> to maintain position of functionand reduce risk of pressure ulcers.

-> to permit maximal effort / involvementin activity.

-> to reduce fatigue

-> enhances self-concept and senseof independence

-> promotes well being and maximizes energy production.

-> to promote independence and enhance ROM exercises.

-> to maintain muscle strength.

-> to lessen pain and discomfort

Evaluation

-> Short term: Pt. shall have identified appropriate interventions or measures
in order to move safely and freely.

-> Long term: Pt. shall have demonstrated behaviors that enable resumption
of activities.

12. Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic

organisms.

The patient is at risk of acquiring infection due to the break in the continuity of
the first line defense which is the skin. The patient shall have undergone
cholecystectomy, thus there is an incision and suture made in the abdomen. If
there is a breakage in the skin, the pathogens will easily invade the body’s
system thus increasing risk for infection.

Cholecystectomy Nursing Care Plan: Risk for Infection

Assessment

S: Ø
O: pt. maymanifest:

-> inadequate secondary defenses

-> insufficient knowledge to avoid exposure to pathogen

NursingDiagnosis

-> Risk for infectionr/t impairedprimary defense.

Scientific Explanation

-> The patient is atrisk of acquiring infection due to the break in the continuity
of the first line defense which is the skin.The patient shall have
undergone cholecystectomy,thus there is anincision and suture made in
the abdomen. If thereis a breakage in theskin, the pathogens will easily
invade the body’s system thus increasing riskfor infection

Planning(Objective/Goal)

-> Short-term: After 1 hour of nursing interventions, the patient

will demonstrate techniques in reducing risk of having infection.

-> Long-term: After 1 day of nursing interventions, the patient will

achieve timely wound healing,be free of purulent drainage, be afebrile

Interventions

-> monitor v/s and assess patient’s condition

-> stress proper hand washing techniques

-> strict compliance to hospital control,sterilization,and aseptic policies

-> increase oral fluid in take if not contraindicated

-> tell patient to comply to antibiotic therapy as prophylaxis

-> monitor medication regime

Rationale

-> for baseline data

-> first line defense against nosocomia linfection or cross contamination

-> to establish mechanism to prevent occurrence of infection

-> to hasten wound healing

-> to prevent the occurrence of infection

-> to determine effectiveness of therapy

Evaluation

-> Short-term: After 1 hour of nursing interventions, the patient shall

have demonstrated techniques in reducing risk of having infection.

-> Long-term:After 1 day of nursing interventions, the patient shall

have achieved timely wound healing,be free of purulent drainage, be afebrile

13. Other Possible Nursing Care Plans

Here are other nursing diagnoses you can develop into a care plan for
cholecystectomy:

-> Diarrhea—continuous excretion of bile into bowel, changes in digestive

process.

-> Infection, risk for—invasive procedure (discharge with T-tube in place).

References and Sources : nurseslabs.com

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