NCP Cholecystitis with cholelithiasis

Cholecystitis is an acute or chronic inflammation of the gallbladder, usually associated with gallstone(s) impacted in the cystic duct, causing distension of the gallbladder. 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.


Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized patient.



Fluid and electrolyte imbalances, see Nursing Plan CD-ROM

Psychosocial aspects of care

Total nutritional support: parenteral/enteral feeding

Patient Assessment Database


May report: Fatigue

May exhibit: Restlessness


May exhibit: Tachycardia, diaphoresis, lightheadedness


May report: Change in color of urine and stools

May exhibit: Abdominal distension

Palpable mass in right upper quadrant (RUQ)

Dark, concentrated urine

Clay-colored stool, steatorrhea


May report: Anorexia, nausea/vomiting

Intolerance of fatty and “gas-forming” foods; recurrent regurgitation, heartburn, indigestion, flatulence, bloating (dyspepsia)

Belching (eructation)

May exhibit: Obesity; recent weight loss

Normal to hypoactive bowel sounds


May report: Severe epigastric and right upper abdominal pain, may radiate to mid-back, right shoulder/scapula, or to front of chest Midepigastric colicky pain associated with eating, especially after meals rich in fats

Pain severe/ongoing, starting suddenly, sometimes at night, and usually peaking in 30 min, often increases with movement

Recurring episodes of similar pain

May exhibit: Rebound tenderness, muscle guarding, or abdominal rigidity when RUQ is palpated; positive Murphy’s sign


May exhibit: Increased respiratory rate

Splinted respiration marked by short, shallow breathing


May exhibit: Low-grade fever; high-grade fever and chills (septic complications)

Jaundice, with dry, itching skin (pruritus)

Bleeding tendencies (vitamin K deficiency)


May report: Familial tendency for gallstones

Recent pregnancy/delivery; history of diabetes mellitus (DM), IBD, blood dyscrasias

Discharge plan

DRG projected mean length of inpatient stay: 4.3 days

May require support with dietary changes/weight reduction

Refer to section at end of plan for postdischarge considerations.


Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial diagnostic procedure).

Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of gallbladder, including presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting prevent oral intake, when the gallbladder cannot be visualized during OCG, or when symptoms persist following cholecystectomy. IVC may also be done perioperatively to assess structure and function of ducts, detect remaining stones after lithotripsy or cholecystectomy, and/or to detect surgical complications. Dye can also be injected via T-tube drain postoperatively.

Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum.

Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in ducts.

Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated in acute cholecystitis because patient is too ill to take the dye by mouth.

Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between obstructive/nonobstructive jaundice.

Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection.

Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases; calcification of the wall or enlargement of the gallbladder.

Chest x-ray: Rule out respiratory causes of referred pain.

CBC: Moderate leukocytosis (acute).

Serum bilirubin and amylase: Elevated.

Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction.

Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine decreases absorption of vitamin K.


1. Relieve pain and promote rest.

2. Maintain fluid and electrolyte balance.

3. Prevent complications.

4. Provide information about disease process, prognosis, and treatment needs.


1. Pain relieved.

2. Homeostasis achieved.

3. Complications prevented/minimized.

4. Disease process, prognosis, and therapeutic regimen understood.

5. Plan in place to meet needs after discharge