Nursing Diagnosis for postop gallbladder

  1. I have a 63yr male who is going into gallbladder surgery today. My instructor wants a care plan done for tomorrow on postop. I am not sure how to proceed because he hasn't had the surgery yet. These are the diagnosis I have come up with:

    Impaired skin integrity
    Acute pain
    Risk for infection

    Do I write these as risk for since the surgery has not been done yet. Are there better diagnosis that I should be thinking of? The other problem I have is not knowing which of the 2 gallbladder surgeries he will have. It was not specified before I left.

    Any help would be appreciated!!!!!!!
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    About Kaiulani

    Joined: Aug '06; Posts: 20


  3. by   P_RN
    How sick is your guy? Is he already in the hospital?

    I believe you can put Potential/Actual _____ related to _______ As evidenced by______

    The laparoscopic surgery has minimal pain-most of which comes from the gas that is used to inflate the abdominal cavity. The open kind has MUCH more.

    Your plan looks good. Maybe add nausea?
  4. by   Kaiulani
    He had been in the hospital since Monday. He doesn't appear to be to sick. I talked and joked with him today. I did a physical assessment today and he did not complain. The only way I know he is sick is because his abd is tender and he has pain that comes and goes.
  5. by   Daytonite
    I am in a bit of a rush to get out of the house right now, but there are a number of things that need to be addressed with any general pre-op and post op patient beside the issues you have already listed. You need to look at the effects of anesthesia. Patients are subject to breathing problems due to intubation and the build up of secretions in the lung due to immobility during surgery. This is a big problem. So, you will either have nursing diagnoses that pertain to risk of airway obstruction or gas exchange problems. With the gut, no matter what the approach is, scope or incision, there is going to be some interruption of peristalsis, so issues of nausea and vomiting or possible ileus are always going to need to be addressed. Other post op issues are urinary retention, hemorrhage, hypovolemeia and thrombophlebitis. Don't forget that before discharge the patient will also need teaching regarding diet, activity and wound care.

    Sorry I can't get more specific with you, but I have to fly. I will check back later this evening when I get home. Good luck!
  6. by   classicdame
    don't forget education (knowledge deficit)
    and anything having to do with the psycho/social aspect