Please help, care map needed for tomorrow!

Nursing Students Student Assist

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Hey everyone. Got my assignment today and I need 6-10 nsg diagnosis for a 25 year old female with cholelithiasis that just had a cholecystectomy today. She has a history of cholelithiasis (had a bout of stones last year, no surgery needed), she is morbidly obese, African American, and that is all. I have some but I am hitting a dead end. Also, can I use Imbalanced Nutrition: less than if she is obese, my rationale is that she isn't digesting fats because of the gallbladder dysfunction.

I have:

Acute Pain r/t to inflammation of tissues (or surgical procedure)

Risk for deficient fluid volume r/t vomiting (or medically restricted intake)

Deficient Knowledge r/t dietary modification

Imabalanced nutrition; less than body requirements r/t inadequate bile secretion

Risk for infection r/t invasive procedure

Any help would be soooo much appreciated.

THANK YOU!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

there is information on writing care plans and care maps on these sticky threads:

since care planning is problem solving it is most logical to follow the nursing process when writing a care plan. a care map is just one formatted way of presenting your care planning process on paper.

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

assessment and the information you collect during that step of the nursing process is the most critical. your entire care plan (care map) is dependent on the information you have gathered. you cannot even begin to determine what this patient's nursing diagnoses are until you do some investigation about this lady's medical disease and condition. i am assuming that this is a patient you are going to be taking care of in clinicals tomorrow. all you know about her is

  • had a cholecystectomy today
  • morbidly obese

the very first thing you need to do is look up information about cholecystectomies (http://www.surgeryencyclopedia.com/ce-fi/cholecystectomy.html). i'm assuming this was an open procedure and not a laparoscopic one, so there is an incision. do you think that having an incision, sutures/or staples and a dressing with perhaps a drain coming from the surgical wound is a nursing problem that some attention should be given to (impaired tissue integrity)? how do you suppose having her abdomen cut into is going to affect this person's ability to accomplish her adls (activities of daily living) when you take care of her today? think about whether or not she is going to need assistance with bathing, hygiene, dressing, grooming, toileting, eating or moving around. this person will just have undergone general anesthesia. there are side effects to having had general anesthesia that you should be monitoring for:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

some of these side effects are more likely to occur in someone who is obese. i'm betting they put a foley catheter in this patient because of her obesity that will probably be removed today--i've seen this done a lot on obese patients. with obesity and having been intubated for general anesthesia i would be watching this patient like a hawk for a respiratory problem. the incision is very close to the chest cavity and will affect the patient's ability to deep breathe and cough. in addition, the pathophysiology of trauma tells us that tissue that has been traumatized (surgically cut into) sets off an inflammatory response in that local area (redness, heat, swelling, pain). swelling of those tissues involved in the operative area cause some of the complications that might occur. the amount of swelling depends on how aggressively the surgeon got when he was in the surgical wound. while diet needs to be addressed for someone who is obese, this is an acute surgical patient who just had their abdominal cavity opened. eating is most likely going to be the last thing on this patient's mind. she's likely to be npo. do you know why? the minute the surgeon placed a gloved finger on any part of this patient's digestive track when she was opened up on the or table, peristalsis shut down. it takes a few days for peristalsis to start up again. if the patient were allowed to begin eating right after surgery, food would sit in her stomach and go nowhere. eventually she would throw it up. this is also the reason why she might have an ng tube in place--to remove gastric secretions that would build up and just sit in the stomach and irritate it. her post op diet will be gradually advanced from npo to clear liquids then full liquids and finally a regular diet. she won't be discharged until the doctor is satisfied that there is evidence that peristalsis has restarted. you want to address nutrition, but for fluid imbalances and/or maintenance. we can survive for some time without food (and she's got plenty of fat to help her out), but not without fluid.

obesity is the least of this patient's problems at this time. you need to get her through this acute surgical and anesthesia experience.

the complications of a cholecystectomy, in particular are:

  • peritonitis
  • bile duct injury
  • small bowel injury
  • wound infection
  • ileus
  • retained gallstones

your patient's knowledge deficit is more likely to be in regard to her discharge care of her surgical wound, physical activity and post op diet now that her gall bladder has been removed.

you should be able to find a sample care plan for a cholecystectomy on this web site:

  • http://www.pana.org/ - generic care plans for all kinds of surgeries - to access the care plan bank, click on the "student activities" link at the left side of the home page. when the pana student resources page comes up, scroll down and click on the "care plan bank" link. these are intraoperative care plans.

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wow, thank you! i just got home from clinical and my teacher said us to consider this patient practice so i didn't even have to hand in the paperwork for this client but this is a great help.

surprisingly, this client had a lap chole! her pain level was at a 10 all day even with 5mg of inj morphine q6h with percocet prn q4h. she was very difficult to ambulate, and when i did get her moving, she scared me to death. got about 10 feet and was in severe distress, she became very vocal, began to cry and became diaphoretic saying she was experiencing muscle spasms in her anterior thigh. she was 336 pounds so the assist of two wouldn't have been sufficient. rushed to get a cardiac chair and got her safely back to bed. said this is a common thing at home, and her mom gives her a "shot of vinegar" to relieve the cramping. learned a lot that's for sure! anyway...thank you tremendously for the post. i know it took some time and it's full of great info. i will use it often. hope you have a great holiday and weekend!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Wow! They were able to do her through a scope? It still is a major surgery.

Just guessing, but it sounds like this patient probably has a pinched nerve in the back which might explain the hip spasms. Stretching the muscle that is spasming also works--a physical therapist or a personal trainer will verify that.

Keep in mind that the focus of medical care today is to do as much on an outpatient basis as possible because of high cost of medical care. So, anyone who is confined to the hospital is there because they are getting treatments (medications, tests, surgery) that cannot be done at home and they need monitoring and specialized nursing care that also cannot be done at home. Keep that in mind when you are working on your care plans. Obesity is something that people don't get hospitalized for unless they are having gastric bypass surgery or some complication of the obesity. As you found, she had mobility and, actually, an Activity Intolerance problem.

I'm pulling out my tapes of V, the miniseries and the follow up TV series, that I recorded from 1988 and plan on doing my own marathon of them here at home over the holiday.

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Yes. they did her through a scope! Again, you have been a great help. I truly appreaciate it. I haven't utilized this site as much as I should have in the past, I know I will be coming here a lot more often as it's a wonderful resource. I hope you enjoy your marathon!

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