Cholecystitis & Cholelithiasis Nursing Care Plan
Gallbladder inflammation/stones; pain control, low-fat diet and surgical preparation.
Quick answer
A Cholecystitis & Cholelithiasis nursing care plan centers on relieve biliary colic pain; rest the gastrointestinal tract and maintain hydration; monitor for complications: perforation, sepsis, pancreatitis, obstruction. Priority nursing diagnoses are Acute pain, Imbalanced nutrition, Risk for deficient fluid volume. The plan below gives assessment cues, measurable goals, 3 intervention sets with rationales, and patient teaching.
Overview
Cholecystitis is inflammation of the gallbladder, most often caused by a stone obstructing the cystic duct (cholelithiasis). Bile stasis irritates the wall, bacteria proliferate, and the gallbladder becomes distended, edematous and potentially gangrenous.
The classic presentation is severe right upper quadrant pain radiating to the right shoulder or scapula, often after a fatty meal, with nausea, vomiting, fever and a positive Murphy's sign. Stones lodged in the common bile duct add jaundice, dark urine and clay-colored stools, and can trigger pancreatitis.
Nursing care controls pain, keeps the gut at rest during the acute phase, monitors for perforation and biliary obstruction, and prepares most patients for laparoscopic cholecystectomy.
Key numbers to know
Murphy's sign
Inspiratory arrest during deep palpation of the right upper quadrant.
Risk profile
Traditionally described as female, forty, fertile, fat and fair, though anyone can be affected.
Obstruction picture
Jaundice, pruritus, dark urine and clay stools with elevated bilirubin and alkaline phosphatase.
Diet
Low-fat meals reduce gallbladder contraction and pain between attacks.
Nursing priorities
- Relieve biliary colic pain.
- Rest the gastrointestinal tract and maintain hydration.
- Monitor for complications: perforation, sepsis, pancreatitis, obstruction.
- Prepare for surgical or endoscopic intervention.
- Teach dietary management and postoperative expectations.
Nursing assessment
Subjective data
- Reports of severe right upper quadrant pain radiating to the shoulder
- Complaints of nausea, vomiting and fatty-food intolerance
- Reports of itching, dark urine or pale stools
- Reports of fever or chills
Objective data
- Right upper quadrant tenderness, guarding and positive Murphy's sign
- Fever, tachycardia, leukocytosis
- Jaundice, scleral icterus, elevated bilirubin, ALP, ALT and amylase/lipase
- Ultrasound showing stones, wall thickening or pericholecystic fluid
- Vomiting, decreased bowel sounds, abdominal distention
Related factors
- Gallstone obstruction of the cystic or common bile duct
- Bile stasis, obesity, rapid weight loss, pregnancy
- High-fat diet and sedentary lifestyle
- Bacterial infection of stagnant bile
- Prolonged fasting or total parenteral nutrition
Key nursing diagnoses
Goals and expected outcomes
- The client will report pain reduced to an acceptable level.
- The client will maintain hydration and electrolyte balance.
- The client will remain free from perforation, sepsis and pancreatitis.
- The client will describe a low-fat diet and postoperative care plan.
Nursing interventions and rationales
Pain and comfort
- Administer prescribed analgesia promptly and reassess; give antispasmodics as ordered.
- Position in semi-Fowler or side-lying with knees flexed.
- Provide antiemetics and oral care during vomiting.
- Avoid fatty foods entirely during an acute attack.
Rest the gut and hydrate
- Maintain NPO status with IV fluids during severe attacks; insert NG tube if vomiting persists.
- Monitor intake, output and electrolytes.
- Administer antibiotics as ordered and monitor temperature trends.
- Advance to clear liquids then a low-fat diet as symptoms settle.
Monitor and prepare
- Assess for rigid abdomen, rebound tenderness or sudden pain relief followed by shock — signs of perforation.
- Track bilirubin, liver enzymes and lipase for duct obstruction and pancreatitis.
- Prepare the patient for ERCP or cholecystectomy including preoperative teaching.
- Observe stool and urine color for changes indicating obstruction.
Patient and family teaching
- Explain which foods commonly trigger attacks and how to build low-fat meals.
- Advise gradual weight loss rather than crash dieting.
- Report fever, jaundice, severe unrelenting pain or persistent vomiting.
- Review what to expect from laparoscopic surgery and recovery timelines.
How to build this plan
- 1Assess the patient. Collect subjective and objective data through interview, physical assessment, labs and chart review. Complete, accurate data is the foundation of every later step.
- 2Analyze and cluster the data. Group related cues, compare them with normal findings, and identify patterns that point to actual or potential problems.
- 3Formulate nursing diagnoses. Write the problem statement using a recognized diagnostic label plus related factors and evidence (problem related to cause as evidenced by signs).
- 4Set priorities. Rank diagnoses as high, medium or low using ABCs, Maslow's hierarchy and the patient's own stated priorities. Life-threatening problems come first.
- 5Establish goals and outcomes. Write SMART, patient-centered outcomes: specific, measurable, attainable, realistic and time-bound (short-term and long-term).
- 6Select nursing interventions. Choose independent, dependent and collaborative actions that are safe, evidence-based and matched to the outcome.
- 7Provide rationales. State the scientific reason each intervention works. Rationales are what turn a task list into clinical reasoning.
- 8Evaluate the plan. Compare the patient's actual response with the expected outcome: met, partially met or not met — then continue, revise or discontinue.
- 9Document and communicate. Record the plan and the patient's response in the health record so the whole team works from the same information.
Summarized for study use. Always follow your school's or facility's approved care plan format and current clinical policy.
Practice Cholecystitis & Cholelithiasis questions
These concepts are tested on the ATI proctored exams below — every set has answers and rationales.
More Gastrointestinal care plans
Plans that share these nursing diagnoses
Care plan writing guides
Common questions
What are the nursing diagnoses for Cholecystitis & Cholelithiasis?
Priority nursing diagnoses for Cholecystitis & Cholelithiasis: Acute pain; Imbalanced nutrition; Risk for deficient fluid volume.
What are the nursing interventions for Cholecystitis & Cholelithiasis?
Administer prescribed analgesia promptly and reassess; give antispasmodics as ordered. Position in semi-Fowler or side-lying with knees flexed. Provide antiemetics and oral care during vomiting. Avoid fatty foods entirely during an acute attack. Maintain NPO status with IV fluids during severe attacks; insert NG tube if vomiting persists. Monitor intake, output and electrolytes.
What are the nursing care goals for Cholecystitis & Cholelithiasis?
The client will report pain reduced to an acceptable level. The client will maintain hydration and electrolyte balance. The client will remain free from perforation, sepsis and pancreatitis. The client will describe a low-fat diet and postoperative care plan.
What should you assess in a patient with Cholecystitis & Cholelithiasis?
Reports of severe right upper quadrant pain radiating to the shoulder; Complaints of nausea, vomiting and fatty-food intolerance; Reports of itching, dark urine or pale stools; Reports of fever or chills; Right upper quadrant tenderness, guarding and positive Murphy's sign; Fever, tachycardia, leukocytosis; Jaundice, scleral icterus, elevated bilirubin, ALP, ALT and amylase/lipase; Ultrasound showing stones, wall thickening or pericholecystic fluid; Vomiting, decreased bowel sounds, abdominal distention