Cholelithiasis, commonly known as gallstones, is a condition characterized by the formation of solid deposits in the gallbladder. This nursing diagnosis focuses on identifying symptoms, managing pain, preventing complications, and promoting optimal patient outcomes through comprehensive care planning.
Causes (Related to)
Cholelithiasis can develop due to various risk factors and underlying conditions:
- Altered bile composition
- Gallbladder stasis
- Hormonal influences
- Metabolic disorders
Patient-specific factors include:
- Female gender
- Age over 40
- Obesity
- Rapid weight loss
- Pregnancy
- Family history
Contributing conditions include:
- Diabetes mellitus
- Hyperlipidemia
- Cirrhosis
- Crohn’s disease
- Hemolytic disorders
Signs and Symptoms (As evidenced by)
Cholelithiasis presents with characteristic signs and symptoms that nurses must recognize for accurate diagnosis and treatment.
Subjective: (Patient reports)
- Right upper quadrant pain
- Nausea and vomiting
- Food intolerance
- Pain radiating to the right shoulder
- Indigestion
- Early satiety
- Fatty food intolerance
Objective: (Nurse assesses)
- Positive Murphy’s sign
- Elevated liver function tests
- Fever
- Jaundice
- Tachycardia during pain episodes
- Abdominal tenderness
- Diaphoresis during attacks
- Changes in vital signs during pain
Expected Outcomes
The following outcomes indicate successful management of cholelithiasis:
- The patient will report pain level <3 on a 0-10 scale
- The patient will demonstrate an understanding of dietary modifications
- The patient will identify triggers and warning signs
- The patient will maintain adequate nutrition
- The patient will avoid complications
- The patient will verbalize understanding of surgical options if indicated
- The patient will demonstrate compliance with a prescribed treatment plan
Nursing Assessment
Pain Assessment
- Evaluate pain characteristics
- Document pain patterns
- Assess pain triggers
- Monitor response to interventions
- Track pain frequency
Nutritional Status
- Monitor dietary intake
- Assess weight changes
- Document food intolerances
- Evaluate hydration status
- Track bowel patterns
Physical Assessment
- Perform abdominal examination
- Check vital signs
- Monitor for jaundice
- Assess skin color
- Document Murphy’s sign
Complication Monitoring
- Watch for cholecystitis
- Monitor for pancreatitis
- Assess for common bile duct obstruction
- Check for infection signs
- Document systemic symptoms
Laboratory Values
- Monitor liver function tests
- Track bilirubin levels
- Assess lipase/amylase
- Check complete blood count
- Monitor electrolytes
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to inflammation and obstruction of the biliary tract as evidenced by right upper quadrant pain, guarding behavior, and verbal pain rating of 7/10.
Related Factors:
- Gallstone obstruction
- Inflammation of gallbladder
- Increased biliary pressure
- Visceral tissue distension
Nursing Interventions and Rationales:
- Assess pain characteristics regularly
Rationale: Establishes baseline and monitors progression - Administer prescribed pain medications
Rationale: Provides comfort and prevents complications - Position patient for comfort
Rationale: Reduces pressure on the affected area - Monitor vital signs
Rationale: Evaluates physiological response to pain
Desired Outcomes:
- The patient will report pain level <3/10
- The patient will demonstrate improved comfort
- The patient will identify pain triggers
- The patient will use effective pain management strategies
Nursing Care Plan 2: Imbalanced Nutrition
Nursing Diagnosis Statement:
Imbalanced Nutrition: Less than body requirements related to reduced oral intake as evidenced by food avoidance and weight loss.
Related Factors:
- Fear of pain with eating
- Nausea and vomiting
- Reduced appetite
- Dietary restrictions
Nursing Interventions and Rationales:
- Monitor nutritional intake
Rationale: Ensures adequate nutrition - Teach low-fat diet principles
Rationale: Prevents gallbladder stimulation - Document weight changes
Rationale: Tracks nutritional status
Desired Outcomes:
- The patient will maintain adequate nutritional intake
- The patient will demonstrate weight stability
- The patient will identify appropriate food choices
Nursing Care Plan 3: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to biliary stasis and potential bacterial overgrowth as evidenced by elevated white blood cell count.
Related Factors:
- Biliary obstruction
- Compromised immune system
- Inflammatory process
- Altered bile flow
Nursing Interventions and Rationales:
- Monitor temperature
Rationale: Early detection of infection - Assess laboratory values
Rationale: Identifies inflammatory response - Maintain sterile technique
Rationale: Prevents secondary infection
Desired Outcomes:
- The patient will remain free from infection
- The patient will demonstrate a normal temperature
- The patient will show normal laboratory values
Nursing Care Plan 4: Knowledge Deficit
Nursing Diagnosis Statement:
Knowledge Deficit related to unfamiliarity with condition and management strategies as evidenced by questions about diet and lifestyle modifications.
Related Factors:
- Lack of exposure to information
- Misinterpretation of information
- Limited previous experience
- Complex medical terminology
Nursing Interventions and Rationales:
- Provide disease education
Rationale: Increases understanding and compliance - Teach dietary modifications
Rationale: Prevents symptom exacerbation - Explain warning signs
Rationale: Promotes early intervention
Desired Outcomes:
- The patient will verbalize understanding of the condition
- The patient will demonstrate proper dietary choices
- The patient will identify warning signs
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to uncertain prognosis and potential surgical intervention as evidenced by expressed concerns and increased tension.
Related Factors:
- Threat to health status
- Surgical concerns
- Pain experience
- Lifestyle changes
Nursing Interventions and Rationales:
- Assess anxiety level
Rationale: Establishes baseline for intervention - Provide emotional support
Rationale: Reduces stress and promotes coping - Explain procedures
Rationale: Increases understanding and reduces fear
Desired Outcomes:
- The patient will report decreased anxiety
- The patient will use effective coping strategies
- Patient will verbalize understanding of treatment plan
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches. World J Gastroenterol. 2021 Jul 28;27(28):4536-4554. doi: 10.3748/wjg.v27.i28.4536. PMID: 34366622; PMCID: PMC8326257.
- Di Ciaula A, Garruti G, Frühbeck G, De Angelis M, de Bari O, Wang DQ, Lammert F, Portincasa P. The Role of Diet in the Pathogenesis of Cholesterol Gallstones. Curr Med Chem. 2019;26(19):3620-3638. doi: 10.2174/0929867324666170530080636. PMID: 28554328; PMCID: PMC8118138.
- Fujita N, Yasuda I, Endo I, Isayama H, Iwashita T, Ueki T, Uemura K, Umezawa A, Katanuma A, Katayose Y, Suzuki Y, Shoda J, Tsuyuguchi T, Wakai T, Inui K, Unno M, Takeyama Y, Itoi T, Koike K, Mochida S. Evidence-based clinical practice guidelines for cholelithiasis 2021. J Gastroenterol. 2023 Sep;58(9):801-833. doi: 10.1007/s00535-023-02014-6. Epub 2023 Jul 15. PMID: 37452855; PMCID: PMC10423145.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
