NURSING DIAGNOSIS: Pain, acute
May be related to
- Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis
Possibly evidenced by
- Reports of pain, biliary colic (waves of pain)
- Facial mask of pain; guarding behavior
- Autonomic responses (changes in BP, pulse)
- Self-focusing; narrowed focus
Desired Outcomes
- Report pain is relieved/controlled.
- Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
4 Cholecystitis Nursing Care Plan (NCP)
- Risk for Deficient Fluid Volume — Cholecystitis Nursing Care Plan (NCP)
- Acute Pain — Cholecystitis Nursing Care Plan (NCP)
- Risk for Imbalanced Nutrition: Less Than Body Requirements — Cholecystitis Nursing Care Plan (NCP)
- Deficient Knowledge — Cholecystitis Nursing Care Plan (NCP)
Acute Pain — Cholecystitis Nursing Care Plans
| Nursing Interventions | Rationale |
| Observe and document location, severity (0–10 scale), and character of pain (e.g., steady, intermittent, colicky). | Assists in differentiating cause of pain, and provides information about disease progression/resolution, development of complications, and effectiveness of interventions. |
| Note response to medication, and report to physician if pain is not being relieved. | Severe pain not relieved by routine measures may indicate developing complications/need for further intervention. |
| Promote bedrest, allowing patient to assume position of comfort. | Bedrest in low-Fowler’s position reduces intra-abdominal pressure; however, patient will naturally assume least painful position. |
| Use soft/cotton linens; calamine lotion, oil bath; cool/moist compresses as indicated. | Reduces irritation/dryness of the skin and itching sensation. |
| Control environmental temperature. | Cool surroundings aid in minimizing dermal discomfort. |
| Encourage use of relaxation techniques, e.g., guided imagery, visualization, deep-breathing exercises. Provide diversional activities. | Promotes rest, redirects attention, may enhance coping. |
| Make time to listen to and maintain frequent contact with patient. | Helpful in alleviating anxiety and refocusing attention, which can relieve pain. |
| Maintain NPO status, insert/maintain NG suction as indicated. | Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions. |
| Administer medications as indicated:Anticholinergics, e.g., atropine, propantheline (Pro-Banthı-ne);Sedatives, e.g., phenobarbital;
Narcotics, e.g., meperidine hydrochloride (Demerol), morphine sulfate;
Monoctanoin (Moctanin);
Smooth muscle relaxants, e.g., papaverine (Pavabid), nitroglycerin, amyl nitrite;
Chenodeoxycholic acid (Chenix), ursodeoxycholic acid (Urso, Actigall);
Antibiotics. | Relieves reflex spasm/smooth muscle contraction and assists with pain management.Promotes rest and relaxes smooth muscle, relieving pain. Given to reduce severe pain. Morphine is used with caution because it may increase spasms of the sphincter of Oddi, although nitroglycerin may be given to reduce morphine-induced spasms if they occur.
This medication may be used after a cholecystectomy for retained stones or for newly formed large stones in the bile duct. It is a lengthy treatment (1–3 wk) and is administered via a nasal-biliary tube. A cholangiogram is done periodically to monitor stone dissolution.
Relieves ductal spasm.
These natural bile acids decrease cholesterol synthesis, dissolving gallstones. Success of this treatment depends on the number and size of gallstones (preferably three or fewer stones smaller than 20 min in diameter) floating in a functioning gallbladder.
To treat infectious process, reducing inflammation. |