DISCHARGE PLAN

PLAN

RATIONALE

Health teaching about the situation of patient.

To gain cooperation and understanding to his situation.

Teach client on how to do wound dressing.

To maintain cleanliness and to avoid farther complication.

Teach the client on what is the nutritious food that he should take to for his fast recovery.

Vitamin C rich foods promotes fast wound healing

Ask client to have good ventilation.

To have fast recovery.

Get plenty of exercise.

Exercise can help you lose weight and improve your health.

Drink plenty of water. Seek for help for signs of: Fever Chills Vomit in greenish color Incision swollen Bandage soak with blood

To promote good circulation.

Abdominal pain severe

Pharmacology(only prescribe by the doctor) It needs medicine to decrease pain. Pain medicine(ketorolac) This medicine is given to fight or prevent an infection caused by bacteria. Always take your antibiotics exactly as ordered by your primary healthcare provider. Do not stop taking your medicine unless directed by your primary healthcare provider.

Antibiotics (cefuroxime)

CHOLECYSTITIS WITH CHOLELITHIASIS 1. 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. 2. 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. 3. 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. 4. CARE SETTING Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized patient. 5. RELATED CONCERNS Cholecystectomy Fluid and electrolyte imbalances,Psychosocial aspects of care Total nutritional support: parenteral/enteral feeding Patient Assessment Database 6. ACTIVITY/REST May report: Fatigue May exhibit: Restlessness 7. CIRCULATION May exhibit: Tachycardia, diaphoresis, lightheadedness 8. ELIMINATION 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 9. FOOD/FLUID 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 10. PAIN/DISCOMFORT 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 Murphys sign 11. 12. RESPIRATION May exhibit: Increased respiratory rate Splinted

13. SAFETY May exhibit: Low-grade fever; highgrade fever and chills (septic complications) Jaundice, with dry, itching skin (pruritus) Bleeding tendencies (vitamin K deficiency) TEACHING/LEARNING 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 considerations: May require support with dietary changes/weight reduction Refer to section at end of plan for postdischarge considerations. 14. DIAGNOSTIC STUDIES 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 15. NURSING DIAGNOSIS: Nutrition: imbalanced, risk for less than body requirements Risk factors may include Self-imposed or prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain Loss of nutrients; impaired fat digestion due to obstruction of bile flow Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] 16. DESIRED OUTCOMES/EVALUATION CRITERIA PATIENT WILL: Nutritional Status (NOC) Report relief of nausea/vomiting. Demonstrate progression toward desired weight gain or maintain weight as individually appropriate. 17. ACTIONS/INTERVENTIONS RATIONALE Nutrition Management (NIC) Independent Estimate/calculate caloric intake. Keep comments about Identifies nutritional deficiencies/needs. Focusing on appetite to a minimum. problem creates a negative atmosphere and may interfere with intake. 18. ACTIONS/INTERVENTIONS RATIONALE Nutrition Management (NIC) Independent Weigh as indicated. Monitors effectiveness of dietary plan. Consult with patient about likes/dislikes, foods that cause Involving patient in planning enables patient to have a distress, and preferred meal schedule. sense of control and encourages eating. Provide a pleasant atmosphere at mealtime; remove Useful in promoting appetite/reducing

respiration marked by short, shallow breathing

nausea. noxious stimuli. Provide oral hygiene before meals. A clean mouth enhances appetite. Offer effervescent drinks with meals, if tolerated. May lessen nausea and relieve gas. Note: May be contraindicated if beverage causes gas formation/gastric discomfort. Assess for abdominal distension, frequent belching, Nonverbal signs of discomfort associated with impaired guarding, reluctance to move. digestion, gas pain. Ambulate and increase activity as tolerated. Helpful in expulsion of flatus, reduction of abdominal distension. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility 9e.g., pneumonia, thrombophlebitis). 19. Collaborative Useful in establishing individual nutritional needs and most Consult with dietitian/nutritional support team as indicated. appropriate route. Begin low-fat liquid diet after NG tube is removed. Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence. Advance diet as tolerated, usually low-fat, high-fiber. Meets nutritional requirements while minimizing Restrict gas-producing foods (e.g., onions, cabbage, stimulation of the gallbladder. popcorn) and foods/fluids high in fats (e.g., butter, fried foods, nuts). Administer bile salts, e.g., Bilron, Zanchol, dehydrocholic Promotes digestion and absorption of fats, fat-soluble acid (Decholin), as indicated. vitamins, cholesterol. Useful in chronic cholecystitis. Monitor laboratory studies, e.g., BUN, prealbumin, Provides information about nutritional albumin, total protein, transferrin levels. deficits/effectiveness of therapy. Provide parenteral/enteral feedings as needed. Alternative feeding may be required depending on degree of disability/gallbladder involvement and need for prolonged gastric rest. 20. NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, selfcare, and discharge needs May be related to Lack of knowledge/recall Unfamiliarity with Information misinterpretation information resources Possibly

Disease Process (NIC) Independent Provide explanations of/reasons for test procedures and Information can decrease anxiety, thereby reducing preparation needed. sympathetic stimulation. Review disease process/prognosis. Discuss hospitalization Provides knowledge base from which patient can make and prospective treatment as indicated. Encourage informed choices. Effective communication and support at questions, expression of concern. this time can diminish anxiety and promote healing. Review drug regimen, possible side effects. Gallstones often recur, necessitating long-term therapy. Development of diarrhea/cramps during chenodiol therapy may be doserelated/correctable. Note: Women of childbearing age should be counseled regarding birth control to prevent pregnancy and risk of fetal hepatic damage. Discuss weight reduction programs if indicated Obesity is a risk factor associated with cholecystitis, and weight loss is beneficial in medical management of chronic condition. Instruct patient to avoid food/fluids high in fats (e.g., Prevents/limits recurrence of gallbladder attacks. whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus). 21. ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Review signs/symptoms requiring medical intervention, Indicative of progression of disease process/development e.g., recurrent fever; persistent nausea/vomiting, or pain; of complications requiring further intervention. jaundice of skin or eyes, itching; dark urine; clay-colored stools; blood in urine, stools, vomitus; or bleeding from mucous membranes. Recommend resting in semi-Fowlers position after meals. Promotes flow of bile and general relaxation during initial digestive process. Suggest patient limit gum chewing, sucking on straw/hard candy, or smoking. Promotes gas formation, which can increase gastric distension/discomfort. Discuss avoidance of aspirin-containing products, forceful Reduces risk of bleeding related to changes in coagulation blowing of nose, straining for bowel movement, contact sports. Recommend use of soft toothbrush, electric razor. time, mucosal irritation, and trauma. 22. POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patients age, physical condition/presence of complications, personal resources, and life responsibilities) Pain, acuterecurrence of obstruction/ductal spasm; inflammation, tissue ischemia.

evidenced by Questions; request for information Statement of misconception Inaccurate follow-through of instruction Development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA PATIENT WILL: Knowledge: Illness Care (NOC) Verbalize understanding of disease process, prognosis, potential complications. Verbalize understanding of therapeutic needs. Initiate necessary lifestyle changes and participate in ACTIONS/INTERVENTIONS treatment RATIONALE regimen. Teaching: