Nursing Care for Cholelithiasis: Assessment, Interventions, and Education

Cholelithiasis (gallstones) affects up to 20% of adults in developed countries. Gallstones may remain asymptomatic or trigger biliary colic, acute cholecystitis, and complications such as cholangitis and pancreatitis. Comprehensive nursing care—encompassing assessment, pre- and postoperative interventions, patient education, and follow-up—supports optimal recovery and reduces morbidity.

1. Introduction and Pathophysiology

• Gallstones form when bile becomes supersaturated with cholesterol or bilirubin, leading to crystal precipitation and stone formation.
• Common risk factors: the “Four Fs” (female, forty, fertile, fat), rapid weight loss, prolonged fasting, hemolytic disorders, and chronic inflammation.
• Clinical manifestations range from silent stones to severe right upper quadrant pain, fever, and jaundice.

2. Nursing Assessment

2.1 Subjective Data

• Pain: onset, location (RUQ/epigastric), radiation, intensity, duration, relieving/exacerbating factors.
• Gastrointestinal symptoms: nausea, vomiting, bloating, dyspepsia.
• Past medical history: prior episodes, comorbidities (liver disease, hemolysis).
• Dietary and lifestyle patterns: high-fat intake, rapid weight changes.

2.2 Objective Data

• Vital signs: fever, tachycardia, hypotension (signs of infection or obstruction).
• Physical exam: Murphy’s sign, abdominal tenderness, guarding.
• Laboratory results: elevated WBC count, bilirubin, liver enzymes, amylase/lipase (if pancreatitis).
• Imaging: ultrasound findings (stones, gallbladder wall thickening, duct dilation).

3. Preoperative Nursing Interventions

• Provide emotional support: explain diagnosis, treatment plan (laparoscopic vs. open cholecystectomy), and expected outcomes.
• Fasting and fluid management: enforce NPO status per protocol; administer IV fluids and electrolytes to maintain hydration.
• Nutritional optimization: encourage small, low-fat meals before surgery; assess nutritional status.
• Medication review: withhold anticoagulants as ordered; administer vitamin K if coagulopathy present.
• Baseline documentation: record intake/output, urine output, pain score, and vital signs.

4. Postoperative Nursing Interventions

4.1 Pain Management

• Assess pain using a standardized scale; administer analgesics (opioid or NSAID) and instruct on PCA use if applicable.
• Encourage nonpharmacologic methods: positioning, relaxation techniques, cold packs.

4.2 Respiratory Care

• Encourage deep breathing, incentive spirometry, and early ambulation to prevent atelectasis and pneumonia.

4.3 Gastrointestinal and Nutritional Support

• Advance diet as tolerated: clear liquids → full liquids → low-fat soft diet → regular diet.
• Monitor bowel sounds, abdominal distension, and signs of ileus.
• Maintain T-tube or surgical drain patency: measure and record drainage characteristics; protect skin at insertion site.

4.4 Mobility and Activity

• Assist early ambulation within 4–8 hours post-surgery to reduce risk of DVT and promote GI motility.
• Provide compression stockings or sequential compression devices as ordered.

4.5 Monitoring and Complication Prevention

• Vital signs: q4h for the first 24 hours, then per protocol.
• Observe for surgical site infection: redness, swelling, drainage.
• Monitor for signs of bile leak or pancreatitis: increasing abdominal pain, elevated amylase.
• Assess fluid balance: hourly urine output initially, then q shift.

5. Patient Education and Discharge Planning

• Dietary Modifications: adopt a low-fat diet post-discharge; eat small, frequent meals; avoid high-cholesterol foods.
• Wound Care: keep incision site clean and dry; recognize signs of infection.
• Activity Guidelines: avoid heavy lifting (>10 pounds) for 4–6 weeks; gradually resume normal activities.
• Medication Adherence: complete prescribed antibiotics, analgesics, and bile acid supplements (if indicated).
• Complication Signs: teach to report fever, increasing pain, persistent nausea/vomiting, jaundice, or changes in stool/urine color.
• Follow-Up: schedule outpatient surgical and primary care appointments; remove T-tube per surgical plan.

6. Special Considerations

• High-Risk Patients: adjust care for elderly, immunosuppressed, or comorbid patients (e.g., diabetes, cardiovascular disease).
• Patient-Centered Communication: involve family in education, use teach-back method to confirm understanding.

References

1. Working Party of the British Society of Gastroenterology. Guidelines on the management of cholelithiasis. Gut. 2018.
2. Strasberg SM. Clinical practice of laparoscopic cholecystectomy. Ann Surg. 2020.
3. SAGES Guidelines for laparoscopic gallbladder removal. Surg Endosc. 2019.