A nurse is caring for a client with cholelithiasis. which sign indicates obstructive jaundice?

Cholecystitis is the inflammation of the gallbladder, usually associated with gallstones impacted in the cystic duct. Stones (calculi) are made up of cholesterol, calcium bilirubinate, or a mixture caused by changes in the bile composition. Gallstones can develop in the common bile duct, the cystic duct, hepatic duct, small bile duct, and pancreatic duct. Crystals can also form in the submucosa of the gallbladder causing widespread inflammation. Acute cholecystitis with cholelithiasis is usually treated by surgery, although several other treatment methods (fragmentation and dissolution of stones) are now being used.

Choleslithiasis, stones or calculi in the gallbladder, results from changes in bile components. Gallstones are made of cholesterol, calcium bilirubinate, or a mix of cholesterol and bilirubin. They arise during periods of sluggishness in the gallbladder due to pregnancy, hormonal contraceptives, diabetes mellitus, celiac disease, cirrhosis of the liver, and pancreatitis.

Nursing care planning and management for patients with cholecystitis include relieving pain and promoting rest, maintaining fluid and electrolyte balance, preventing complications, and provision of information about disease process, prognosis, and treatment.

Here are four (4) nursing care plans and nursing diagnosis for cholecystitis (cholelithiasis): 

  1. Risk for Deficient Fluid Volume
  2. Acute Pain
  3. Risk for Imbalanced Nutrition: Less Than Body Requirements
  4. Deficient Knowledge

1. Risk for Deficient Fluid Volume

Risk for Deficient Fluid Volume

Nursing Diagnosis

  • Risk for Deficient Fluid Volume

Risk factors may include

  • Excessive losses through gastric suction; vomiting, distension, and gastric hyper­motility
  • Medically restricted intake
  • Altered clotting process

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

  • Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, absence of vomiting.
Nursing InterventionsRationale
Maintain accurate record of I&O, noting output less than intake, increased urine specific gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill. To provide information about fluid status and circulating volume needing replacement.
Monitor for signs and symptoms of increased or continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, depressed respirations. Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.
Eliminate noxious sights or smells from environment. Reduces stimulation of vomiting center.
Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants. Decreases dryness of oral mucous membranes; reduces risk of oral bleeding.
Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture. Reduces trauma, risk of bleeding or hematoma formation.
Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis or melena. Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.
Keep patient NPO as necessary. Decreases GI secretions and motility.
Insert NG tube, connect to suction, and maintain patency as indicated. To rest the GI Tract

1. Risk for Deficient Fluid Volume

Recommended nursing diagnosis and nursing care plan books and resources.

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  • Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
    An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
  • Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
    A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
  • NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
    The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
  • Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
    Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
    Useful for creating nursing care plans related to mental health and psychiatric nursing.
  • Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
    Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
  • Maternal Newborn Nursing Care Plans (3rd Edition)
    If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
  • Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
    An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
  • All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
    Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

  • Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
    Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
  • Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
    Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

More nursing care plans related to gastrointestinal disorders:

  • Appendectomy | 4 Care Plans
  • Cholecystectomy | 12 Care Plans
  • Cholecystitis and Cholelithiasis | 4 Care Plans
  • Gastroenteritis | 4 Care Plans
  • Hemorrhoids | 3 Care Plans
  • Hepatitis | 7 Care Plans
  • Ileostomy & Colostomy | 10 Care Plans
  • Inflammatory Bowel Disease | 7 Care Plans
  • Intussusception | 3 Care Plans
  • Liver Cirrhosis | 8 Care Plans
  • Pancreatitis | 8+ Care Plans
  • Peritonitis | 6 Care Plans
  • Peptic Ulcer Disease | 5 Care Plans
  • Subtotal Gastrectomy | 2 Care Plans

Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram on difficult nursing topics. Finding help online is nearly impossible. His situation drove his passion for helping student nurses by creating content and lectures that are easy to digest. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. As a nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process, break down complicated topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing concepts effectively.

What are the symptoms of obstructive jaundice?

Obstructive Jaundice - What it is Yellowing of the skin and whites of the eyes, light-coloured stools and dark urine could be signs of obstructive jaundice – a condition where normal drainage of bile from the liver to the small intestines is blocked.

What is an obstructive jaundice?

Obstructive jaundice is a specific type of jaundice, where symptoms develop due to a narrowed or blocked bile duct or pancreatic duct, preventing the normal drainage of bile from the bloodstream into the intestines.

Can gallstones lead to obstructive jaundice?

You can get jaundice if a gallstone passes out of the gallbladder into the bile duct and blocks the flow of bile. Symptoms of jaundice include: yellowing of the skin and whites of the eyes. dark brown urine.

What causes jaundice in Choledocholithiasis?

Jaundice occurs when the stones obstruct the CBD, and conjugated bilirubin enters the bloodstream. A history including, clay-colored stools and urine turning tea-colored is found in such patients. Jaundice can occur in episodes.