Care Plan for Cholelithiasis
Category: Gastrointestinal
Assessment
Patient presents with intermittent right upper quadrant pain, nausea, and vomiting.
Diagnosis
Risk for biliary colic related to gallstone obstruction.
Goals
Patient will report a reduction in pain as evidenced by fewer episodes of biliary colic. Patient will verbalize understanding of dietary modifications and potential treatment options.
Interventions
Administer prescribed analgesics and antiemetics to manage pain and nausea. Educate patient on dietary modifications to reduce fat intake and prevent gallstone formation. Prepare patient for potential surgical intervention such as cholecystectomy. Encourage regular follow-up appointments to monitor the patient's condition.
Rationale
These interventions aim to manage symptoms, prevent complications, and ensure the patient is well-informed about their condition.
Evaluation
Patient's pain levels and symptomatology will be monitored to evaluate the effectiveness of interventions.
⚠️ Educational Care Plan Notice
This care plan is for educational purposes only and represents general nursing concepts.
All care plans must be individualized based on:
- Individual patient assessment and current condition
- Healthcare provider orders and facility protocols
- Current evidence-based practice guidelines
- Nursing scope of practice in your jurisdiction
Do not use as direct patient care instructions. Always follow your facility's policies, physician orders, and professional nursing judgment.