What is Cholecystectomy?

Cholecystectomy is a term used to describe the surgical procedure of removing the gallbladder. In most cases, it is performed via laparoscopic incision utilizing the laser. Traditional open Cholecystectomy is, however, an optional treatment for patients with cholelithiasis either to prevent stones recurrence or due to acute symptomatology.

Cholecystectomy involves removing the gallbladder from the backside of the liver and tying off the vein, cystic, bile duct, and artery. Usually, the physician accesses the gallbladder via the upper midline incision or right upper paramedian. The typical vent, if necessary, is examined via the same incision. The physician may enlarge the bile duct further if it is already enlarged because of pathological processes to remove the stones effectively. A thin instrument is passed via the common duct to gather the whole or crushed stones before removing them.

T-tube is usually inserted in the common duct after exploring it to enhance bile drainage during the healing period. Besides, T-tube is vital in stone dissolution or postoperative cholangiography when appropriate. Conventional open Cholecystectomy is necessary when the patient’s physique blocks access to the gallbladder or laparoscopic Cholecystectomy hinders the removal of stones in the duct. It is impossible to retrieve gallbladders through laparoscopic instruments in obese patients. The surgeons also find it challenging to access the gallbladder in people with small frames, making it essential to conduct gallbladder removal surgery.

Nursing Care Plans

Cholecystectomy patients undergo the following nursing care plans; preventing complications, promoting normal respiratory function, managing pain, and providing information about the illness, treatment needs, and procedures.

Below are NCP and nursing diagnoses for Cholecystectomy

Ineffective Breathing pattern
Impaired Skin Integrity
Risk for Deficient Fluid Volume
Deficient Knowledge

1. Ineffective Breathing Pattern

This is a state in which the patient’s depth, rate, breathing pattern, rhythm, or timing is altered. It is usually a common nursing diagnosis the nurses should focus on when the patient’s abdominal wall excursion does not uphold optimum ventilation during expiration, inspiration, or both. The body cells generally receive insufficient oxygen when the patient’s breathing pattern is ineffective. Respiratory rate and thoracic and abdominal patterns are associated with respiratory failure.

Ineffective breathing patterns may also be caused by airway obstruction, heart failure, diaphragmatic paralysis, infection, and liver cirrhosis. Patient with oxygenation difficulties is given appropriate care management to improve or sustain pulmonary ventilation and oxygenation, improve functioning, and promote ease and comfortable breathing. In addition, it minimizes risks associated with oxygenation difficulties like skin breakdown, syncope, and imbalances of acid-based.

Nursing Diagnosis

Ineffective breathing patterns

It might be associated to

Reduced energy/fatigue
Pain
Muscle dysfunction

May be evidenced by

Tachypnea; Minimized vital capacity, altered respiratory depth
Holding breath and reluctance to cough

Possible outcome

The patient will not experience impaired respiration or complications.
The patient will experience an effective breathing pattern.

Nursing Assessment and Rationales

Nursing Assessment	Rationale
Observe respiratory depth and rate	Shallow breathing, holding breath, and splinting with respirations may cause atelectasis or hypoventilation.
Listen to breath sounds	episodes of absent or reduced respiration sounds indicate atelectasis, while unplanned sounds (rhonchi, wheezes) suggest congestion. Abnormal breath sounds include: Bronchospasm Regular breath sounds of wheezing and rhonchi. They are usually treated using a bronchodilator. RALES Cracking, clicking, or rattling sounds are heard during respiration. Rhonchi The coarse crackle sounds wet than rales. Suctioning is typically recommended. Wheeze Air moving via narrow respiratory tubes in the lungs produces a whistling, high-pitched sound. Often heard in CHF and asthmatics patients. Stridor whistling, the high-pitched sound caused by an obstruction in the larynx. Expiratory grunt Occurs in combination with subcostal or intercostal retractions and nasal flaring. It is related to increased breathing work.
Monitor breathing patterns	Anormal breathing patterns may suggest a dysfunctional or underlying disease process. Cheyne-Stoke respiration indicates diencephalon associated with metabolic abnormalities, brain injury, or bilateral dysfunction in the deep cerebral. Ataxic and Apneusis breathing are related to respiratory center failure in the medulla and pons. Depth and rate of breathing pattern include: Apnea Brief cessation of breathing during sleep Bradypnea Respiration drops below 12 breaths per minute. Biot’s respiration Shallow and fast inspirations and abnormal or regulation apnea episodes (10 to 60 seconds). Eupnea Good, regular, unlabored ventilation, quiet rest or breathing, respiratory rate. Ataxic patterns Abnormal breathing pattern with irregular pauses and growing apnea periods. Apneusis The patient takes a difficult and deep breath, maintaining it momentarily at its most entire point before exhaling incompletely and quickly. Cheyne-Stokes respiration Continuous deeper and faster breathing succeeded by gradual decrease leading to Apnea. Hyperventilation Maximized depth and rate of breathing. Tachypnea Shallow, rapid breathing of about 24 breaths per minute. Kussmaul’s respiration Deep breathing at a regular, low, or fast rate is related to chronic metabolic acidosis, especially kidney failure and diabetic ketoacidosis.
Examine and note respiratory depth and rate after every 4 hours	In adults, the respiratory rate is about 10 to 20 breaths in a minute. It is crucial to take necessary actions to identify early signs of an impaired respiratory system in case of breathing alteration.
Note any dyspnea and ask the patient if they experience shortness of breath	Dyspnea can sometimes be caused by anxiety. Therefore, observe the patient for air hunger because the shortness of breath is physical.
Examine the use of accessory muscle	As lung compliance decreases, the work of breathing increases significantly.
Monitor for nostrils flaring or retractions	The signs of retractions and flaring indicate an increase in breathing effort.
Monitor the position a patient prefers for breathing	Orthopnea is related to difficulties in breathing
Observe for paradoxical motion (diaphragmatic muscle weakness or fatigue)	Paradoxical motion (outward and inward movement during respiration) indicates respiratory muscle weakness and fatigue.
Check pulse rate and oxygen saturation using pulse oximetry	This is an effective tool in detecting oxygenation alterations initially; however, for carbon dioxide, arterial blood gases and end-tidal CO2 monitoring would require obtaining.
Assess for alleviating and precipitating factors	Information about these factors is essential in planning interventions to manage or prevent future respiratory problems.
Examine the ability to mobilize secretions	Difficulties in mobilizing secretions may lead to alterations in breathing patterns.
Monitor for levels of consciousness	Confusion, restlessness, or irritability could be valuable indicators of inadequate oxygen in the brain.
Examine for upper abdominal or thoracic pain	Shallow breathing can result in pain.
Examine skin color, capillary refill, and temperature; monitor peripheral versus central cyanosis.	Inadequate oxygens result in blue coloring on the tongue, fingers, and lips. Cyanosis inside the mouth is a medical emergency.
Avoid high oxygen concentration in CPD patient	Hypoxia increases the need to breathe in chronic CO2 patients. Close monitoring is essential when administering oxygen to minimize the dangerous rising of PaO2 in patients resulting in Apnea.

Nursing Interventions and Rationales

Nursing Interventions	Rationale
Help the patient cough, turn, and breathe deeply periodically.	This helps in improving lung segment ventilation and expectoration and mobilization of secretions.
Help the patient to understand techniques to splint the incision. Provide applicable breathing methods.	Enhance lung expansion. Splinting minimizes muscle tension and provides incisional support, thus promoting therapeutic regimen cooperation.
Raise the head of the bed, uphold a low Fowler’s position.	Increase lung expansion to resolve or prevent atelectasis.
When ambulating and coughing, support the abdomen	Promotes effective coughing, activity, and deep breathing.
For a patient with chronic illness, encourage diaphragmatic breathing.	The technique relaxes muscles and minimizes the levels of oxygen.
Assess respiratory muscle training appropriateness.	The training is essential in enhancing both respiratory and inspiratory muscle strength.
Give respiratory drugs and oxygen as prescribed.	Beta-adrenergic agonist drugs help relax the airway, leading to air passage opening by bronchodilation.
Ensure a clear airway	Promote mobilization of secretion through effective coughing to enhance sufficient clearance of secretions.
Appropriately suction the secretions.	Facilitates clearing of airway blockages.
During acute respiratory distress, stay with the patient.	This helps to lower patient anxiety and minimize oxygen requirement.
Ambulate the patient three times a day as ordered by a doctor	Facilitates break up and removes secretion that may block airways.
Promote regular rest and teach the patient to pace activity	Shortness of breath can be worsened by extra activity. During strenuous activities, ensure the patient gets enough rest.
Promote small regular meals	Facilitates less crowding of the diaphragm
Provide a fan in the room	Moving air reduces the feeling of air hunger
Facilitate interactions between patients with ineffective breathing patterns.	Interactions with the patient with the same conditions help to ease anxiety and maximize coping skills.
Inform the patient about proper coughing, breathing, and splinting techniques.	Facilitates adequate mobilization of secretions.
Instruct the patient on medication: dosage, indication, side effects, and frequency. Review nebulizer treatment and metered-dose inhaler as needed.	This helps to promote the effective and safe administration of medication.
Inform the patient about abdominal breathing, pursed-lip breathing, performing relaxation methods, promoting rest periods, and scheduling activities to reduce fatigue and	This intervention helps the patient to participate in ensuring health status and enhancing ventilation.
Consult a nutritionist for diet modifications	Malnutrition may be caused by COPD, resulting in altered breathing patterns. Proper nutrition enhances the functionality of respiratory muscles.
Patients with ADLs should be helped as necessary	This helps to conserve energy and prevent fatigue and overexertion

2. Impaired Skin Integrity

The skin is the largest body organ that provides a protective barrier to the human body. The skin protects the body from light, heat, injury and infections. In this case, skin integrity is associated with maintaining skin health. Impaired skin integrity indicates damage to the skin, exposure to injury, or inability to repair and recover as needed. In this case, maintaining skin integrity is a key marker of quality nursing care. The nurse must be aware of how to identify factors that put patients at risk of impaired skin integrity, as well as at-risk individuals.

Patients who are bedridden, overweight and those with edema have a higher risk of skin integrity impairment. Having the skills and knowledge to deal with patients at risk of altered skin integrity is crucial since skin assessment is a continuous process rather than a one-time event. Assessment demands the nurse to repeat regularly to establish any changes or alterations in skin condition. In addition, having knowledge of wound management can go a long way to help nurses create a care plan.

Nursing Diagnosis

Impaired skin integrity

May be Related to:

Altered metabolic state or nutritional state (obesity).
Statis of secretions, chemical substance (bile).
Body structure invasion (T-tube).

Possibly Evidenced by:

Disruption of the skin

Nursing Care Goals

The patient’s wound will heal with no complications.
The patient’s behaviors will support healing.
The nurse and patient will prevent skin breakdown.

Nursing Assessment and Rationales

The nursing assessments done for the diagnosis of impaired skin integrity in cholecystectomy patients includes the following:

Nursing Assessment	Rationale
Assess the overall skin condition.	This will provide crucial baseline data for possible nursing interventions for the nursing diagnosis.
Assess the patient’s ability to move (turn over, in bed, shift weight.)	Immobility is a great risk factor for skin breakdown.
Observe the drainage color and character.	Drainage may have blood or bloodstains with changing color to greenish brown.
Assess the patient for edema.	Tightening or completely stretching the skin over the edematous area could increase the risk of edema.
Assess the patient for abdominal distention, hiccups or pancreatitis or peritonitis signs.	The draining of bile into the abdomen or the obstruction of the pancreatic duct can lead to dislodgement of the T-tube, resulting in diaphragmatic irritation and other complications.
Assess the skin, eye white, and urine for color changes.	The development of jaundice could indicate bile flow obstruction.
Observe the stool color and consistency.	Lack of bile in the intestines could result in clay-colored stools.
Note reports of increasing pain; bile drainage leakage around the tube or from the wound; and development of tachycardia and fever.	These signs suggest fistula formation or abscess creating the need for medical intervention.
Monitor the puncture sites, especially following endoscopic procedures.	If an endoscopic procedure is done, punctured wound areas could bleed or have loose staples

Nursing Interventions and Rationales

The following are the therapeutic nursing interventions for nursing care plans in cholecystectomy patients with a risk for impaired skin integrity.

Nursing Intervention	Rationale
Change the wound dressing as needed. Use clean water and soap to clean the wound area and apply petroleum jelly.	This will help keep the area around the incision site clean while protecting the skin from excoriation.
Encourage the patient to keep changing position.	This is crucial to help prevent skin breakdown and ischemia.

Apply Montgomery straps on the patient.	This helps facilitate dressing as often as necessary while reducing skin trauma.
Use an ostomy bag to collect drainage.	Using an ostomy bag can help collect heavy drainage for skin protection and accurate output measurement.
Ensure the patient maintain a semi-Fowler’s position.	This will facilitate effective drainage of the bile.
Administer antibiotics to the patient.	This is crucial for the treatment of infections or abscesses.
Check to ensure the incisional and T-tube drains are free-flowing.	The T-tube could stay in the bile duct to help remove retained stones. In addition, the incision site helps drain any accumulated fluid or bile. Positioning the drains correctly is key to preventing bile back up in the operative area.
Keep the T-tube in a closed collection system.	This is crucial to help measure output and also prevent skin irritation. A closed collection system also minimizes the risk of contamination.
Anchor the drainage tube properly to avoid kinks and twists.	Anchoring drainage tubes helps avoid tube dislodging and lumen occlusion.
Clamp the T-tube as instructed per schedule.	This will help test the common bile duct’s patency before removing the tube.
Educate the patient and the caregiver about appropriate skin care.	This is a crucial step towards maintaining skin integrity since education enhances self-efficacy, preventing skin breakdown.

3. Risk for Deficient Fluid Volume

Fluid volume deficiency is when a patient’s fluid output exceeds input. It mainly occurs when the body loses water and electrolytes and could be due to increased bleeding, nausea, vomiting, diarrhea, and bile drainage in a cholecystectomy patient. Appropriate patient management is crucial to restoring fluid volume and electrolyte balance and avoiding hypovolemic shock.

Nursing Diagnosis

Risk for Deficient Fluid Volume

It may be Related to

Abnormal fluid loss through the skin or kidneys
Bleeding
Reduced intake of fluid.
Losses from NG vomiting and
Medical intake restriction.
Abnormal drainage.
Increased metabolism due to fever and infection.
Altered coagulation, such as prolonged coagulation time.

May be evidenced by

Signs and symptoms of Deficient Fluid Volume could include the following:

Complaints of thirst and weakness by the patient.
Altered mental state.
Reduced urine output with concentrated urine.
Decreased skin turgor.
Tachycardia and weak pulse.
Postural hypotension.
Dry mucous membranes.
Sunken eyeballs.

Nursing Goals/ Desired Outcomes

The patient will have adequate fluid balance, evidenced by the following:
- Maintained vital signs stability
- Moist mucous membranes.
- Appropriate skin turgor.
- Appropriate urinary output.

Nursing Assessment and Rationale

The nursing assessment for a cholecystectomy patient with fluid volume deficiency includes the following:

Nursing Assessment	Rationale
Monitor input and output, including NG tube, wound and T-tube drainage.	This provides crucial information about organ function and replacement needs. During the initial stages, bile drainage of between 200 to 500mL via the T-tube is expected but will reduce as the bile enters the intestine. Continuous drainage of a large amount of bile could indicate biliary fistula or unresolved obstruction
Monitor the vital signs, including the HR and BP.	The reduced blood volume in circulation could lead to tachycardia and hypotension. An altered heart rate is a compensatory mechanism aiming to maintain cardiac output.
Assess the patient’s skin turgor, capillary refill and mucous membranes	These are crucial signs/indicators of dehydration.
Monitor the patient’s blood pressure for postural or orthostatic hypotension.	Postural hypotension indicates a fluid loss. It manifests through a systolic BP loss of 20mmHg and a diastolic BP loss of 10mmHg.
Monitor and observe the patient for bleeding signs, including petechiae, hematemesis and melena.	Obstruction of bile flow could lead to reduced prothrombin, prolonging coagulation time which increases bleeding/hemorrhage risk.
Assess the patient for altered mentation, including agitation, confusion and slow responses.	This can be a sign of dehydration.
Assess and monitor urine color, amount, serum electrolytes, and osmolality and report abnormal values.	Dark yellow and urine output less than 30ml/hour could indicate fluid deficit. In addition, increased blood urea nitrogen and urine-specific gravity indicate a fluid deficit
Monitor fever, nausea and vomiting.	These factors cause fluid deficiency and influence fluid intake and replacement routes.
Monitor the patient for active fluid loss from the tubes, wound drainage and other means, such as diarrhea.	Fluid loss through these means could lead to reduced fluid volume causing dehydration.
Weigh the patient daily.	This provides crucial assessment data that could indicate a possible imbalance in fluid volume.

Nursing Intervention and Rationale

The nursing intervention for a cholecystectomy patient with a deficit in fluid volume includes:

Nursing Intervention	Rationale
Give oral fluids the patient prefers if they can tolerate oral fluids.	Oral fluids are recommended for mild fluid deficits since they are cost-effective replacement interventions.
Encourage/urge the patient to drink the prescribed fluid amount.	The patient, especially older patients, may have a reduced sense of thirst requiring reminders to drink fluid.
Emphasize the need to maintain oral hygiene.	Dehydration/fluid deficit could lead to a sticky or dry mouth. Paying attention to appropriate mouth care could create interest in fluid intake while reducing discomfort associated with dry mucous membranes.
Have the patient use sponge swabs, cotton, and mouthwash instead of a toothbrush.	This can help avoid trauma and gum bleedings.
Inject the patient with small-gauge needles and apply pressure for longer following venipuncture.	This is crucial to help reduce trauma and the risk of bleeding/hematoma.
Administer IV fluids as indicated.	Fluids are important in achieving and maintaining hydration status since they maintain adequate circulating volume.
Administer blood products as indicated.	A patient experiencing gastrointestinal bleeding may require blood transfusions to replace lost fluids.
Administer electrolytes as indicated.	This is crucial to correct the imbalances associated with excessive gastric losses.
Administer Vitamin K as indicated	It helps replace required factors for faster clotting.
Emphasize the importance of maintaining proper hydration.	The patient needs to understand the importance of drinking more fluid to prevent the problem in the future.

4. Deficient Knowledge

Knowledge deficit is associated with low psychomotor ability or cognitive information needed for health preservation, promotion, or restoration. Knowledge plays a significant or influential part in patient recovery and life. Knowledge may include the following domains: psychomotor (physical procedures or skills), cognitive domain (problem-solving, intellectual activities), and effective domain (belief, attitudes, feelings). The patient and the nurse are responsible for assessing what, when, and how to teach particular health concerns.

Physicians play a significant role in patient learning, although they do not educate them alone. The nurses participate in patient education to provide nursing care to attain the desired outcome. Patients with access to information whenever needed are believed to be the most effective.

The self-Care Theory of Dorothea Orem provides that the nursing objective was to enable the patient to gain self-care requirements, which involves educating the patient. However, various factors may impact patient teachings, such as physical limitation, age, cognitive level, sociocultural factors, development stage, and the primary disease comorbidities and process. When developing a teaching plan, it is vital to consider certain religious and ethnic healthcare practices and unique beliefs.

Nursing Diagnosis

Deficient Knowledge

It may be associated to

Misinterpretation of information and lack of exposure.
Lack of memory
Ignorance of information resources.

May be evidenced by

Inquiries; expression of misunderstanding.
Incorrect execution of instructions.
Solicitation for information.

Possible outcomes

The patient is expected to understand the illness, surgical outlook/intervention, and potential issues expressed in words.
The patient is anticipated to communicate their understanding of treatment requirements effectively.
The patient is anticipated to execute necessary procedures effectively and explain the reason behind their actions.
It is anticipated that the patient will lead in making necessary lifestyle adjustments and participate in the therapeutic routine.

Nursing Assessment and Rationale

Nursing Assessment	Rationale
Determine the patient’s ability to learn or participate in desired healthcare-associated care.	The patient’s cognitive impairment should be recognized to provide an appropriate teaching plan.
Identify the learner: the family, patient, caregiver, or significant other.	Some patients, such as older adults and very sick people, see themselves as dependent on caregivers and do not like participating in the learning process.
Examine the willingness and motivation of the patient to learn.	Energy is required in learning. The patient must see the purpose or need for learning. Besides, the patient has the right to decline educational services.
Give patients time to share their past teaching experiences.	Older patients share their life experiences during each learning season. Their learning is based on previous experience and knowledge.
Assess learning priority within the overall care plan.	This helps in knowing what needs to be taught, especially when a patient has a situational background. Knowledge of what to prioritize helps in saving time.
Acknowledge ethnic or racial differences at the begging of care.	This will establish rapport, enhance communication, and promote treatment outcomes.
Assess the patient’s self-efficacy in learning and apply new knowledge.	Self-efficacy is individual confidence in their ability to perform a specific behavior. The initial step in teaching may be fostering maximized self-efficacy in the patient’s ability to learn desired skills and information.
Recognize cultural impact on health education.	Interventions should be specific and considerable to individual backgrounds and differences.
Watch and note existing myths regarding materials to be taught.	The assessment is an essential starting point in learning. Knowledge helps in correcting wrong ideals.
Identify symptoms that require the healthcare professional to know; yellowing of the skin and eyes, dark urine, frequent movement of the bowel, pale stool, recurrent bloating, or heartburn.	Indicates bile flow obstruction or altered digestion; further interventions and evaluations are necessary.

Nursing Interventions and Rationale.

Nursing Interventions	Rationale
Consider what is essential to the patient	The most effective way to teach a patient is by allowing them to choose the content to be presented first.
Encourage self-designed and self-directed learning	The patients should be supported in approaching learning activities of their choice.
Review surgical procedures, disease process, and prognosis	Provides the patient with the informational foundation to enhance them make knowledgeable decisions.
Assess feelings and reactions about change.	Assessment helps the nurses understand the learners’ response to information and the success levels with expected learner changes.
Demonstrate incision care, drains, and dressing. Encourage hand hygiene.	Encourage care independence and minimize the risk of complications.
Recommend regular T-tube collection bag drainage and note its output	Minimize the influx risk while reducing pressure on the tube or seal of the appliance. Besides, it provides insights into mitigating swelling in the duct and recovery.
Keep sessions short and pace the instructions.	Energy is required in learning. Therefore, shorten the sessions and pace them well to minimize fatigue and allow the learner to absorb more.
Support patients to integrate information into their daily life.	The strategy helps the patient make adjustments in their daily life, resulting in desired behavior changes.
Engage the patient in writing particular outcomes for the learning session, like identifying the essential content to learn from their lifestyle and viewpoint.	Involving patients enhances compliance with health programs. Besides, it makes learning and teaching a partnership.
Stress the significance of upholding a low-fat diet, eating small meals regularly, and introducing fluids or foods with fats gradually throughout 4 to 6 months.	In the initial 6 months after surgery, a low-fat food minimizes the need for bile and minimizes discomfort related to insufficient fat digestion.
Talk about the use of particular medication like Dehydrocholic acid or Florantyrone	To facilitate fat absorption, oral replacement of bile salt is necessary.
Talk about limiting or avoiding alcoholic beverages.	Reduces the risk of pancreatic involvement.
Inform the patient about loose stools that may occur for some time.	Time is required for the intestines to adjust to the continuous stimulus of bile output.
Advise the patient to avoid and note foods that aggravate diarrhea.	Specific food restrictions may be necessary, although radical changes are not significant. Small amounts of fat are tolerated. After a period of diet adjustment, the patient will not experience complications with most foods.
Depending on the patient’s situation, assess activity limitations.	The patient’s expected functioning resumption is usually accomplished within 4 to 6 weeks.