Cholelithiasis Nursing Diagnosis and Care Plan

Cholelithiasis is the presence of abnormal solid concretions or gallstones in the gallbladder. Gallstones form due to the hardening of digestive fluids that deposits in the gallbladder.

The gallbladder stores and releases bile to aid in digestion. The bile consists of wastes like bile salts, lecithin, bilirubin, and cholesterol from the breakdown of red blood cells, which can also cause gallstone formation.

Gallstones can range in size from grain size to golf ball size and develop from one-to-many gallstones at the same time. It grows gradually as it collects extra materials and the bile continues to wash over it. About 10% to 20% of American adults have gallstones and 90% of these are cholesterol stones.

Signs and Symptoms of Cholelithiasis

Cholelithiasis is typically asymptomatic unless there is an obstruction of the bile ducts, cystic ducts, or both. Signs and symptoms of cholelithiasis vary depending on the size and location of the gallstone. such as:

• nausea and vomiting
• fever and chills
• tachycardia
• indigestion or dyspepsia
• clay-colored stool
• dark-colored urine
• bloating or flatulence
• excessive burping or belching
• early satiety
• biliary colic or gallbladder attacks
• Murphy’s sign or right upper quadrant pain with tenderness over the gallbladder
• postprandial or after meal abdominal pain
• severe and rapidly intensifying epigastric or right upper quadrant pain
• pain radiating to the upper back, between shoulder blades, and to the right shoulder lasting from 15 minutes to several hours

Causes of Cholelithiasis

Cholelithiasis results from a chemical imbalance of gallbladder contents in which the bile contains excessive cholesterol, bilirubin, bile salts, calcium carbonate, and lecithin.

Biliary stasis is essential to prevent gallstone formation. Conditions like infections, blood disorders, and cirrhosis can cause the liver to make an increased amount of bilirubin.

When the gallbladder cannot empty it can make the bile very concentrated causing bile stasis (cholestasis) and contributing to gallstone formation. The types of gallstones that cause cholelithiasis are:

• Cholesterol stones. The bile is needed for digestion and the dissolving of cholesterol. When the liver excretes more cholesterol than the bile can dissolve, the excess cholesterol can form crystals and trap in the gallbladder producing sludge.
• Black pigment stones. These are small and hard gallstones composed of calcium bilirubinate and inorganic calcium salts. Increased blood hemolysis also increases the circulating unconjugated bilirubin leading to stone formation. Conditions like Crohn’s disease, alcoholic cirrhosis, chronic hemolytic anemia, and advanced age are risk factors.
• Mixed/brown pigment stones. These are soft and greasy gallstones composed of bilirubinate and fatty acids. Individuals with infection or infestation usually release B-glucuronidase from the injured hepatocytes and bacteria which hydrolyzes conjugated bilirubin and lecithin in the bile. The increased unconjugated bilirubin and fatty acids cause the precipitation of calcium carbonate, calcium bilirubinate, and cholesterol in the bile leading to stone formation.

Risk Factors to Cholelithiasis

Some factors that increase the risk of developing cholelithiasis are:

• age over 40 years old
• women especially during the reproductive years due to increased estrogen and progesterone levels
• family history
• native American, European, or Mexican
• obesity
• sedentary lifestyle
• low fiber, high fat, and cholesterol diet
• use of hormone replacement therapy or birth control pills
• pregnancy or multiparity from the increased lithogenic bile secretion, smooth muscle relaxation, impaired gallbladder contraction, and bile stasis.
• dyslipidemia
• diabetic or insulin resistance
• Crohn’s disease or other intestinal disorders
• Liver cirrhosis
• Individuals with hemolytic anemia
• Taking cholesterol-lowering agents
• Fasting individuals
• Sudden weight loss

Complications of Cholelithiasis

Cholelithiasis may lead to the following complications:

• Cholecystitis. The inflammation of the gallbladder may be acute from obstruction of the cystic duct or chronic from irritation of the gallbladder wall. This can cause constant pain and lead to rupture of the gallbladder.
• Acute cholangitis. Caused by ascending bacterial infection of the biliary tract from bile stasis. It can also lead to sepsis once the bacteria spread into the bloodstream.
• Choledocholithiasis. Small gallstones that pass the cystic duct and block the common bile duct may cause itchy skin and/or yellow discoloration of the skin and eyes also known as jaundice.
• Biliary pancreatitis. The common bile duct past the pancreatic duct can become impacted by a gallstone passing through, blocking pancreatic flow causing stasis of pancreatic secretions and activation of pancreatic enzymes.
• Mirizzi syndrome. Compression of the common bile duct and impacted cystic duct or infundibulum of the gallbladder by gallstones.
• Gallbladder disease. A mucocele or gallbladder hydrops involves mucinous fluid content from chronic biliary outflow obstruction.
• Pancreatitis. Persistent blockage of the bile ducts may cause high-grade fever, chills, sweating, tachycardia, diarrhea, nausea, and vomiting.
• Liver disease. Any blockage in the biliary system can cause the bile to back up in the liver causing inflammation, long-term scarring, and infection.
• Malabsorption. If the bile can’t reach the small intestine as intended, breaking down fats and absorbing fat-soluble vitamins will not be possible resulting in malabsorption.

Diagnosis of Cholelithiasis

Cholelithiasis is most commonly an incidental finding during a routine examination in asymptomatic individuals. The diagnosis can be confirmed upon a thorough review of signs and symptoms along with the following test:

• Medical history. A complete medical history including past and present health conditions can be helpful in the diagnosis.
• Physical exam. A complete physical exam will be done focusing on the abdominal area to identify the location and possible complications.
• Blood test. These tests can be normal in uncomplicated cholelithiasis but should be done to rule out other acute biliary conditions.
  • Complete Blood Count (CBC). An elevated WBC count may suggest acute cholecystitis or acute cholangitis.
  • Liver function test (LFTs). Increased direct bilirubin, GGT, and ALP may suggest choledocholithiasis.
  • Amylase and lipase. Elevation of amylase and lipase suggests acute pancreatitis.
• Imaging test. A variety of imaging techniques is commonly used to diagnose cholelithiasis.
  • Abdominal ultrasound. This can be done initially in suspected symptomatic cholelithiasis. Sludge in the gallbladder and common bile duct measurement can be seen through ultrasound.
  • Biliary POCUS. This test has 90% sensitivity and specificity for cholelithiasis.
  • Endoscopic ultrasound. An endoscope will be inserted in the mouth toward the common bile duct and gallbladder region, to screen for gallstones.
  • Endoscopic retrograde cholangiopancreatography (ERCP). This is a diagnostic and potential treatment procedure using an imaging dye to highlight the ducts of the biliary system and remove the gallstones using the endoscope.
  • Magnetic resonance cholangiopancreatography (MRCP). This provides a detailed image of the bile ducts.
  • CT scan with IV contrast. This test detects radiopaque stones or well-defined hyperdense structures within the lumen of the gallbladder. Pure cholesterol stones are radiolucent and 15-20% are radiopaque.
  • Oral cholecystography. Taking iodine-containing tablets 1-2 nights before taking an x-ray examination of the gallbladder.
  • Hepatobiliary iminodiacetic (HIDA) scan. A radioactive tracer is injected into the vein followed by an imaging procedure showing the movement and function of the liver, bile ducts, and gallbladder.

Treatment for Cholelithiasis

Asymptomatic patients should be counseled about dietary restrictions, maintaining a healthy weight, regular exercise, and symptoms of biliary colic to seek medical attention.

Treatment choice for cholelithiasis usually depends on the patient’s overall health, age, medical history, the severity of symptoms; as well as the number, size, and location of the gallstones. This includes the following methods:

• Initial supportive therapy. For symptomatic patients, bowel rest or NPO (nothing by mouth) status should be instructed until the pain subsides. IV fluid therapy, antiemetics, or NG tube insertion for patients with vomiting.
• Medications. This is used to relieve signs and symptoms.
  • Analgesics. NSAIDs are the first-line analgesic of choice and opioids for severe pain that does not improve with NSAIDs.
  • Spasmolytics. Use as adjuvant therapy with analgesic for patients with biliary colic or severe pain.
  • Oral bile acid dissolution therapy. Useful in pure cholesterol stones of less than 0.5cm taken within 6-24 months. Gallstones may not completely dissolve and with high recurrence rates. It can also be used to prevent stone formation in morbidly obese patients who had bariatric surgery and who are rapidly losing weight or are on a low-calorie diet.
• Non-invasive procedure. Used.
  • Endoscopic retrograde cholangiopancreatography (ERCP). This is an effective procedure used to remove gallstones found in the bile ducts. A dye is injected in the vein to facilitate viewing of the ducts and an endoscope is used to remove the gallstones.
  • Extracorporeal shock wave lithotripsy (ESWL). Use of acoustic pulse or shock waves for solitary stones localized on imaging for stone fragmentation.
• Surgery.
  • Cholecystectomy. Elective surgical removal of the gallbladder for symptomatic or complicated gallstone disease. Prophylactic cholecystectomy can be warranted in asymptomatic patients if they have large gallstones or calcified gallbladder which both increase the risk for gallbladder carcinoma.
  • Laparoscopic cholecystectomy. A minimally invasive procedure uses to remove the gallbladder through several small incisions.
  • Percutaneous drainage. A drainage tube is inserted into the gallbladder through the abdomen facilitating drainage of infection until cholecystectomy can be performed.

Prevention of Cholelithiasis

Lowering the risk of having gallstones starts with lifestyle changes such as:

• Eating a healthy diet such as high fiber and good fats. Avoid unhealthy fats, sugar, and refined carbohydrates. Replace red meat with fish which promotes HDL cholesterol. Eat more fruits, vegetables, and whole grains to flush out excess cholesterol. Avoid skipping meals or fasting and stick with the usual daily mealtime pattern.
• Have a regular exercise of at least 30 minutes per day.
• Women with a family history of gallstones should consult about the use of hormonal birth control medications.
• Maintain a healthy weight by reducing caloric intake and increasing physical activity. Avoid diets and activities that can cause sudden weight loss.

Cholelithiasis Nursing Diagnosis

Cholelithiasis Nursing Care Plan 1

Acute Pain

Nursing Diagnosis: Acute Pain related to inflammation of the gallbladder secondary to cholelithiasis as evidenced by reports of biliary colic and tenderness over the right upper quadrant of the abdomen.

Desired Outcomes:

• The patient will verbalize relief of pain at a 5/10 pain scale after 4 hours of nursing intervention.
• The patient will display reduced tenderness over the right upper abdomen.

Intervention	Rationale
Assess the patient’s pain and document the location, frequency, intensity, and characteristics of pain. Note exacerbating and relieving factors associated.	It can help determine the underlying cause and the effectiveness of nursing interventions. Biliary colic presents with rapidly intense right upper quadrant postprandial (after meal) pain with tenderness radiating to the upper back, between shoulder blades, and to the right shoulder lasting from 15 minutes to several hours.
Advised the patient on NPO status.	To facilitate bowel rest until the pain subsides.
Provide a comfortable and restful environment.	A restful sleep and a comfortable environment can alleviate anxiety reducing pain.
Keep the patient on bed rest and assist in a position of comfort such as low-Fowler’s, knee-to-chest, or side-lying position.	Bed rest reduces metabolic rate and digestive secretions promoting bowel rest. These positions minimize intra-abdominal pressure and tension.
Provide diversional activities and relaxation techniques like deep breathing and guided imagery.	This diverts the patient’s focus on pain and promotes muscle relaxation throughout the body reducing the pain.
Provide medication as ordered such as analgesics or spasmolytics.	Give immediate relief for severe pain, discomfort, nausea, and vomiting.
Provide IV fluid therapy as ordered.	Since the patient is on NPO status, fluids and medications can be given through an IV line. This will maintain fluid balance and prevent dehydration in vomiting patients.
Insert a nasogastric (NG) tube as ordered.	This helps decompress the stomach promoting bowel rest.
Document the patient’s response to medication and interventions.	Pain that is unrelieved with the above intervention and medications may suggest a developing complication that needs further medical intervention.

Cholelithiasis Nursing Care Plan 2

Risk for Fluid Volume Deficit

Nursing Diagnosis: Risk for Fluid Volume Deficit related to excessive fluid loss through vomiting secondary to cholelithiasis.

Desired Outcomes:

• The patient will be able to display an absence of vomiting.
• The patient will be able to demonstrate adequate body fluid balance as evidenced by stable vital signs, good skin turgor, moist mucous membrane, adequate capillary refill, and urine output.

Intervention	Rationale
Assess the patient’s extent of vomiting including the characteristic, frequency, and amount of vomitus. Keep an accurate intake and output record.	Prolonged vomiting may lead to fluid and electrolyte imbalance. Monitoring the intake and output will determine fluid status and circulating blood volume needing replacement.
Assess the patient for signs of dehydration by checking the patient’s vital signs, mucous membrane, skin turgor, and capillary refill.	This provides information about the patient’s fluid status and the need for fluid replacement therapy.
Advised the patient on NPO status.	This facilitates bowel rest until the vomiting subsides.
Provide frequent oral hygiene with alcohol free-mouthwash. Keep the emesis basin within reach.	Frequent oral care removes the bad taste and smell of the vomitus avoiding further stimulation.
Assist the patient in a semi-Fowler’s position.	This prevents aspiration of vomitus.
Provide diversional activities and relaxation techniques like deep breathing and guided imagery	This might help direct the patient’s focus away from vomiting and relax the abdominal muscle.
Provide medication as ordered such as antiemetics.	This helps to control and prevent further vomiting.
Provide IV fluid therapy as ordered.	Since the patient is on NPO status, fluids and medications can be given through an IV line maintaining fluid and electrolyte balance.
Insert a nasogastric (NG) tube and connect to suction as ordered.	This promotes bowel rest.
Refer to a dietitian upon consent.	This provides appropriate guidelines for diet modifications due to cholelithiasis and resuming food intake after NPO.

Cholelithiasis Nursing Care Plan 3

Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Risk for Imbalanced Nutrition less than the body requirements related to dietary restrictions secondary to cholelithiasis.

Desired Outcomes:

• The patient will be able to maintain desired weight as individually appropriate.
  • The patient will be able to identify appropriate nutritional requirements as prescribed.
  • The patient will recognize appropriate nutrition management at home.

Intervention	Rationale
Assess the patient’s present nutritional status. Calculate caloric intake, food preferences, preferred meal schedule, and restrictions.	This will allow the nurse to understand the patient’s needs and wants. Involve the patient in planning by asking about food preferences and preferred meal schedules.
Assess the patient’s weight daily as indicated. Monitor laboratory values regularly.	This aids in identifying the effectiveness of the dietary plan and response to the patient’s cholelithiasis.
Provide a pleasant environment during mealtime.	This helps to increase the patient’s appetite. Unpleasant smells or stimuli can reduce appetite during mealtime.
Assist the patient with proper oral hygiene before meals.	Good oral hygiene can stimulate appetite and saliva production which can also aid in the digestion of food.
Encourage the patient to keep upright after a meal.	This will help in the digestion of food and minimize nausea, abdominal distention, and regurgitation of food.
Provide enteral or parenteral feedings as needed.	A patient who cannot tolerate oral intake may need alternative feeding depending on the degree of gallbladder involvement and the need for bowel rest.
Provide nutritional supplements as appropriate.	This will support and give additional nutrition to the patient upon the recommendation of a doctor or dietitian.
Provide antiemetics or bile salts as needed before meals.	This may be helpful in patients with nausea and cholelithiasis, promoting the digestion of fat-soluble vitamins and cholesterol.
Refer the patient to a nutritionist or dietitian upon consent.	These professionals can adequately assess the patient’s nutritional needs and plan appropriate interventions.
Educate the patient about nutritional needs and resources.	This will ensure continuity of care with the patient’s adequate knowledge and resources needed for his/her condition and dietary restrictions.

Cholelithiasis Nursing Care Plan 4

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with the new diagnosis secondary to cholelithiasis as evidenced by reports of poor understanding and confusion on the information given.

Desired Outcomes:

• The patient will be able to report familiarity with the diagnosis and its treatment.
• The patient will be able to actively participate in the treatment plan.

Intervention	Rationale
Assess the patient’s level of understanding, readiness to learn, health literacy, limitations, and ability to comprehend.	These factors should be taken into consideration to fully understand the patient and adjust the teaching and treatment plan within the patient’s ability to comprehend.
Establish rapport and provide a quiet learning environment.	A trusting environment is essential for the patient to feel secure. A quiet environment promotes comprehension.
Educate the patient about the disease process, prognosis, treatment options, and alternative management while encouraging questions and expression of concerns.	Provides adequate information while ensuring that the patient understands every piece of information given. Giving support and effective communication promotes healing and reduces anxiety.
Provide information using multiple learning modalities such as verbal instructions, visual aids, pictures, instructional videos, and written materials. Repeat the information as needed.	Patients may not easily recall initial instructions and may need other sources of information to comprehend. Repetition and reinforcement may help in memory recall.
Provide a schedule of activities and establish priorities along with simple discussion.	The patient may be overwhelmed with too much information at a time. Present information individually at a time to increase comprehension.
Provide positive reinforcement.	This increases the patient’s self-esteem and compliance with the treatment plan.
Involve family or significant others as requested.	Additional support can be helpful especially if the patient relies on family for support.

Cholelithiasis Nursing Care Plan 5

Risk for Infection

Nursing Diagnosis: Risk for Infection related to cholecystectomy secondary to cholelithiasis.

Desired Outcomes:

• The patient will be able to remain free from infection and achieve fast recovery.
• The patient will be able to demonstrate techniques to prevent infection, such as handwashing and wound care.

Intervention	Rationale
Assess the surgical site for signs of infection such as redness, swelling, pain, and discharge.	Surgical wounds are prone to infection and should be monitored frequently. Drainage may contain blood changing to greenish brown.
Assess and document vital signs and laboratory findings using the Sepsis and SIRS criteria (tools for early recognition of systemic infection).	This helps to determine improvements or early signs of infection.
Educate the patient about the importance of frequent handwashing and the use of the aseptic technique for wound care, intravenous therapy, and catheter handling.	This aids in significantly reducing the transmission and spread of pathogens preventing infection.
Educate the patient and significant others about appropriate cleaning, disinfecting, and sterilizing of any articles before use.	This eliminates pathogens and the likelihood of transmission.
Provide frequent wound dressing changes and apply Montgomery straps. Provide a disposable ostomy bag over the wound drain.	Keeping the barrier clean to prevent excoriation and skin trauma. Ostomy bags collect heavy drainage with more accurate measurements.
Assist the patient in a low or semi-Fowler’s position. Check the incisional drain and T-tube for kinks or blockages.	These positions facilitate the drainage of bile preventing backup in the operative area.
Limit visitors and use personal protective equipment.	Protective isolation and additional protection reduce the chance of pathogen transmission.
Encourage protein and vitamin-rich intake along with the prescribed dietary restriction.	This facilitates wound healing by increasing the immune system response while adhering to the prescribed diet.
Administer antibiotics as prescribed.	Antibiotics are the treatment of choice for abscesses and/or infections.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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