Care Plan for Cholecystitis Management

Category / Primary Body System

• Digestive System

Problem

• Potential for complications related to cholecystitis.

Goal

• Patient will not experience any complications related to cholecystitis.

Plan/Approach

1. Monitoring and Assessment

   • Monitor for abdominal pain and provide pain management as ordered
   • Monitor for fevers, nausea, vomiting, changes in skin color (jaundice), and changes in stool color; notify the MD immediately
   • Monitor lab results as ordered and report abnormalities to the MD

2. Dietary Management

   • Consult with a dietitian to adjust the diet as needed

3. Follow-Up Care

   • Ensure follow-up with surgical consultations as needed

4. Patient and Family Education

   • Educate the patient and family about signs and symptoms of complications and when to seek medical attention

Rationale

1. Monitoring and Assessment

   • Regular monitoring for symptoms such as abdominal pain, fever, nausea, vomiting, jaundice, and changes in stool color helps in early detection of complications, allowing for prompt intervention.
   • Timely reporting and management of lab results ensure that any deviations are addressed quickly, preventing further complications.

2. Dietary Management

   • Consulting with a dietitian helps tailor the patient's diet to manage symptoms and promote recovery, reducing the risk of complications.

3. Follow-Up Care

   • Ensuring follow-up with surgical consultations is essential for evaluating the need for surgical intervention and managing post-operative care if surgery is performed.

4. Patient and Family Education

   • Educating the patient and family helps them understand the condition, recognize early signs of complications, and know when to seek medical help, thereby preventing serious complications.

Actions

1. Monitoring and Assessment

   • Assess the patient for abdominal pain regularly, administering pain medications as ordered and documenting the patient’s response.
   • Monitor for signs of infection such as fever, nausea, vomiting, jaundice, and changes in stool color. Notify the MD immediately if any of these symptoms occur.
   • Perform and review lab tests as ordered, such as liver function tests and complete blood count, and report any abnormalities to the MD.

2. Dietary Management

   • Consult with a dietitian to develop a diet plan that minimizes fat intake and supports gallbladder health.
   • Provide dietary education to the patient, emphasizing the importance of following the recommended diet.

3. Follow-Up Care

   • Schedule and coordinate surgical consultations as needed.
   • Ensure continuity of care by following up on any surgical interventions or recommendations.

4. Patient and Family Education

   • Educate the patient and family about the signs and symptoms of cholecystitis complications, such as severe pain, fever, and jaundice.
   • Provide written and verbal instructions on when to seek immediate medical attention.