Jennifer Kiaha-Raquino

Concept Map Care Plan

March 2016

2. Infection (Cholangitis, bacterial inf of

biliary tract)

1. Pain (Biliary Colic)

Gallstones-> Blockage-> Inflammation->
Distension -> Pain

Fever

Sharp, constant RUQ pain with guarding rated

5/10

Pain/ Inflammation

+ murphy's sign

Ceftriaxone 1g q 24h IV

Ibuprofen 400mg q6h PO PRN

Indomethacin supp 100mg x1 pre op

Increased neutrophils

Morphine Sulfate 4 mg q4h IV PRN

Indomethacin supp 100mg x1 pre op

3. Impaired Digestion/Nutrition

Chief Medical Diagnosis:

Blockage of common bile duct

Gallstone
Choledocholithiasis (common bile duct)

Nausea/Vomiting
Ondansetron 4mg q4h PRN IV

Cholangitis

Pantoprazole Inj 40mg daily IV

Elevated Transaminase Level

NPO

Priority Assessments:
Pain, Vital Signs, RUQ distention,
Labs, I&O, signs of rupture or shock

D5 1/2 NS 100ml/h cont IV

Elevated Transaminase Levels
AST=140
ALT=391
AlkPhos=117
BilirubinTotal=2.3

4. Immobility

5. Risk for Anxiety

GI consult for ERCP

Pain

Surgical Consult Lap Chole

(gallbladder removal)

Nausea/Vomiting
Enoxaparin 40 mg daily SQ

BilirubinDirect=1.3
US &CT-> increased hepatic texture -> fatty liver
Pure Hypercholesterol
Impaired fasting glucose (gallstone
pancreatitis?)

Jennifer Kiaha-Raquino

Concept Map Care Plan

Desired Outcomes
1. Pain (Biliary Colic)
-The patient will have pain controlled at an
acceptable level.

March 2016

Interventions
1. Pain (Biliary Colic)
-Educate patient of signs of increasing pain
and need to medicate prior to intolerable pain
level
-Educate patient on pain medication available
and times they can or will be given
-Administer medications promptly
-Educate patient on medication side effects
-Teach patient alternative pain management
techniques
-Keep environment calm with lights dimmed
-Position for comfort
2.Infection (Cholangitis)
2.Infection (Cholangitis)
-Infection will improve and sepsis will be
-Monitor vital signs closely, report changes
avoided.
promptly
-Administer antibiotic as prescribed
-Assess the need for and remove unnecessary
IV sites or other lines, tubes, or drains
-Use proper hand hygiene
-Teach patient proper hand hygiene
-Monitor WBC count
3. Impaired Digestion /Nutrition
3. Impaired Digestion /Nutrition
-Digestion and nutritional status will improve -Assess need for continued NPO status
with treatment
-Assess need for IVF therapy
-Monitor labs and weight
-Monitor vital signs
-Assess for nausea and vomiting
-Administer ondansetron as needed and
pantoprazole daily
4. Immobility
4. Immobility
-Mobility will increase with pain management -Prophylaxis enoxaparin will be given daily
and DVT will be prevented
-ICD will be used while in bed
-Encourage movement/mobility as tolerated
shortly after pain medication given
-Turn position q2h or sooner
5. Risk for Anxiety
5. Risk for Anxiety
-Anxiety levels will be controlled throughout -Educate patient on condition and relating
treatment
factors -Explain all procedures and treatments
to patient
-Seek additional support as needed

Jennifer Kiaha-Raquino

Concept Map Care Plan

March 2016

Evaluation
-Pain will be measured q shift and as needed with a pain rating scale and a consistent decrease is
desired. Infection status/improvement will be measured by having vital signs WNL and lab
results WNL as well a decrease in pain and inflammation. Digestion and nutritional
status/improvement will be measured by lab results WNL as well as no nausea and vomiting.
Increasing mobility will be measured by observing patient up out of bed without pain. Anxiety
management will be measured by patient stating tolerable anxiety as well as understanding of
condition and treatments.

Discharge Plan/ Patient Teaching

-Patient will be discharged to home with help of family and or friends. Minimal assistance will
be needed by family or friends until pain fully subsides. Pain medication and antibiotics will be
needed. Teaching will be needed on medical condition, medications, diet, prevention, follow up
appointments, surgical incision care if indicated. Lifestyle changes will need to be made
regarding diet and preceding factors to condition. Discharge instructions to be given verbally as
well as in writing.

Jennifer Kiaha-Raquino

Concept Map Care Plan

March 2016

References
Gulanick, M. & Myers, J. (2011). Nursing care plans diagnoses, interventions, and outcomes. St.
Louis, MO: Elsevier.
Ignatavicius, D.D. & Workman, M.L. (2013). Care of patients with problems of the biliary
system and pancreas. In Medical-surgical nursing patient-centered collaborative care.
St. Louis, MO: Elsevier.
Wilson, B., Shannon, M., Shields, K. (2013). Pearson nursess drug guide. Upper Saddle River,
NJ: Pearson.