🏥 Surgical Nursing Care Plan on Cholelithiasis with Cholecystectomy

Medical-Surgical Nursing | NANDA Nursing Care Plan Format

Surgical Nursing Care Plan | Practical File Ready

⚠️ Educational Purpose Only: This surgical nursing care plan is prepared for academic practical file work. Not for actual patient care or clinical decision-making.

📄 Page 1 — Student Information

Student Name	[Your Name]
Course	BSc Nursing / GNM / ANM
Subject	Medical-Surgical Nursing
Surgical Care Plan Topic	Cholelithiasis with Cholecystectomy
Format	NANDA-I Surgical Nursing Care Plan Format
Clinical Area	Surgical Ward / Operation Theatre / Post-operative Ward
Date of Submission	[Enter Date]
Clinical Instructor	[Instructor Name]

📄 Page 2 — Patient Identification Data

Name	Mrs. Kavita Sharma
Age	42 Years
Sex	Female
Address	Jodhpur, Rajasthan
Occupation	Homemaker
Marital Status	Married
Religion	Hindu
Diagnosis	Symptomatic Cholelithiasis
Surgical Procedure	Cholecystectomy
Type of Surgery	Laparoscopic Cholecystectomy
Type of Anesthesia	General Anesthesia
Type of Family	Nuclear Family
Family Size	4 Members
Ward Name	Female Surgical Ward
Bed Number	18
Date of Admission	14/05/2026
Date of Surgery	15/05/2026
Doctor Incharge	Dr. R. K. Solanki, MS General Surgery
Hospital Name	Government Medical College Hospital, Jodhpur

📄 Page 3 — Chief Complaints & Present Illness History

Chief Complaints

Pain in right upper abdomen — since 3 days.
Pain radiating to right shoulder and back — intermittent.
Nausea and vomiting — 2 episodes.
Indigestion and bloating after fatty meals.
Loss of appetite — since 2 days.
Mild fever — since 1 day.

History of Present Illness

Mrs. Kavita Sharma, a 42-year-old female, was admitted to the female surgical ward with complaints of right upper abdominal pain, nausea, vomiting and indigestion. The pain was initially intermittent and increased after taking oily and fatty food. Gradually, the pain became more severe and radiated to the right shoulder and back.

The patient also complained of bloating, loss of appetite and mild fever. She had similar episodes of abdominal discomfort in the past after heavy meals, but the pain was relieved with medication. This time, pain was persistent and associated with vomiting, so she was brought to the hospital by her husband.

On examination, tenderness was present in the right hypochondriac region. Ultrasonography abdomen showed multiple gallstones in the gallbladder with mild gallbladder wall thickening, suggestive of symptomatic cholelithiasis. The patient was admitted, medical management was started and laparoscopic cholecystectomy was planned after pre-operative preparation.

Past Medical History

No history of diabetes mellitus.
No history of hypertension.
No history of tuberculosis, asthma or epilepsy.
History of recurrent indigestion and right upper abdominal discomfort after fatty meals.
No known drug allergy.

Past Surgical History

No previous major surgery.
No history of blood transfusion.
No history of previous hospitalization for any major illness.

📄 Page 4 — Family History & Family Composition

Family History

The patient belongs to a nuclear family.
Total family members are 4.
No family history of gallbladder stone reported.
No family history of diabetes mellitus, hypertension, tuberculosis or hereditary disease.
Husband is healthy and works as a private employee.
Two children are healthy and studying in school.
Family is cooperative and supportive during hospitalization.

Family Composition

Name	Age/Sex	Education	Occupation	Relationship	Health Status
Mr. Suresh Sharma	45/M	Graduate	Private Employee	Husband	Healthy
Mrs. Kavita Sharma	42/F	12th Pass	Homemaker	Self / Patient	Cholelithiasis with Cholecystectomy
Master Rahul Sharma	16/M	Class 10	Student	Son	Healthy
Miss Riya Sharma	12/F	Class 7	Student	Daughter	Healthy

Family Tree

👨

Mr. Suresh Sharma

Husband

Healthy

♡

👩

Mrs. Kavita Sharma

Patient

Cholelithiasis with Cholecystectomy

👦

Master Rahul Sharma

Son

Healthy

👧

Miss Riya Sharma

Daughter

Healthy

Male Female Patient Highlighted

📄 Page 5 — Dietary, Personal, Socio-economic & Environmental History

Dietary History

The patient takes a vegetarian diet.
Usually takes 3 meals per day with tea and snacks.
Frequently consumes oily and fried foods such as puri, kachori, pakora and namkeen.
Complains of bloating and abdominal discomfort after fatty meals.
Low intake of fruits, salads and fiber-rich foods.
Fluid intake is approximately 1.5–2 liters per day.
Loss of appetite present since 2 days.
Patient was kept NPO before surgery.

Personal History

Sleep: 6–7 hours per night before illness; disturbed due to abdominal pain.
Appetite: Reduced since 2 days.
Bowel: Occasional constipation; no diarrhea.
Bladder: Normal micturition, no burning or frequency.
Habits: No smoking, no alcohol, no tobacco chewing.
Activity: Performs household work; activity reduced due to abdominal pain.
Allergy: No known drug or food allergy.

Socio-economic History

The patient belongs to a middle-class family.
Husband is the main earning member of the family.
Family income is adequate for basic needs and treatment.
Patient has good family support during hospitalization.
Family is cooperative and willing to follow medical and surgical advice.

Environmental History

The family lives in a pucca house with proper ventilation and lighting.
Safe drinking water is available at home.
Sanitation facility is available.
Kitchen hygiene is maintained.
No exposure to harmful chemicals or occupational hazards.
Home environment is suitable for post-operative recovery.

📄 Page 6 — Physical Examination

General Condition

Patient is conscious, oriented to time, place and person. She appears uncomfortable due to right upper abdominal pain and nausea. Patient is cooperative and answers questions appropriately.

Vital Signs on Admission

Temperature: 99.8°F
Pulse: 96 beats/min
Respiration: 20 breaths/min
Blood Pressure: 124/78 mmHg
SpO₂: 98% on room air
Pain Score: 7/10

General Appearance

Built: Moderate
Nutrition: Moderate
Posture: Lying with mild guarding of abdomen
Facial expression: Anxious and painful
Skin: Warm, no cyanosis, no edema
Hydration: Mild dehydration due to vomiting and reduced oral intake
Icterus: Not present

Systemic Examination

Abdomen	Tenderness present in right hypochondriac region, mild guarding present, no abdominal distension, bowel sounds present.
Cardiovascular System	S1 and S2 heard normally, no murmur, pulse 96/min, regular rhythm.
Respiratory System	Chest clear bilaterally, normal vesicular breath sounds, no wheeze or crackles.
Central Nervous System	Conscious, oriented, GCS 15/15, no neurological deficit.
Skin	Skin warm and intact pre-operatively; post-operatively laparoscopic port site dressings present on abdomen.

📄 Page 7 — Vital Signs Monitoring Record

Date / Time	Temperature	Pulse	Respiration	BP	SpO₂	Pain Score
14/05/2026 — Admission	99.8°F	96/min	20/min	124/78	98%	7/10
15/05/2026 — Post-op	99.2°F	90/min	18/min	120/76	99%	5/10
16/05/2026 — POD 1	98.8°F	84/min	18/min	118/76	99%	3/10
17/05/2026 — POD 2	98.6°F	80/min	16/min	118/78	99%	2/10
18/05/2026 — Discharge	98.4°F	78/min	16/min	116/76	99%	1/10

Nursing Trend: Patient’s pain, pulse rate and mild fever gradually reduced after laparoscopic cholecystectomy. Vital signs remained stable during post-operative period.

📄 Page 8 — Diagnostic Investigations

Sr. No.	Investigation	Normal Value	Patient Value	Interpretation
1	Hemoglobin	12–15 g/dL	12.6 g/dL	Normal
2	Total WBC Count	4,000–11,000/mm³	12,600/mm³	Mild leukocytosis
3	Platelet Count	1.5–4 lakh/mm³	2.8 lakh/mm³	Normal
4	Random Blood Sugar	80–140 mg/dL	118 mg/dL	Normal
5	Blood Urea	15–40 mg/dL	26 mg/dL	Normal
6	Serum Creatinine	0.6–1.2 mg/dL	0.8 mg/dL	Normal
7	Serum Bilirubin	0.3–1.2 mg/dL	1.0 mg/dL	Normal
8	SGOT/AST	Up to 40 IU/L	38 IU/L	Normal
9	SGPT/ALT	Up to 40 IU/L	42 IU/L	Mildly raised
10	Alkaline Phosphatase	44–147 IU/L	138 IU/L	Normal-high
11	Urine Routine	No sugar/protein	Normal	No abnormality
12	USG Abdomen	Normal gallbladder without stones	Multiple gallstones in gallbladder, mild wall thickening, CBD not dilated	Suggestive of cholelithiasis
13	Blood Group	-	O Positive	Recorded for surgical safety

📄 Page 9 — Medical & Surgical Management / Drug Chart

Medical Management

Patient was kept NPO before surgery to prevent aspiration during anesthesia.
IV line was secured and intravenous fluids were started to maintain hydration.
Analgesics were administered to relieve right upper abdominal pain.
Antiemetic medication was given to control nausea and vomiting.
Broad-spectrum antibiotics were administered as prescribed.
Proton pump inhibitor was given to reduce gastric irritation.
Vital signs, pain score, vomiting and hydration status were monitored regularly.
Liver function tests and ultrasonography findings were reviewed before surgery.

Surgical Management

Name of Surgery: Laparoscopic Cholecystectomy
Indication: Symptomatic Cholelithiasis
Date of Surgery: 15/05/2026
Type of Anesthesia: General Anesthesia
Port Sites: Umbilical port, epigastric port and right subcostal ports
Operative Finding: Gallbladder containing multiple stones with mild inflammation
Procedure Done: Gallbladder dissected laparoscopically, cystic duct and cystic artery clipped and divided, gallbladder removed, port sites closed and sterile dressing applied.
Drain: Not placed
Post-operative Status: Patient shifted to post-operative ward in stable condition.

Pre-operative Nursing Care

Verified patient identity, diagnosis and planned surgical procedure.
Checked informed written consent for surgery and anesthesia.
Maintained NPO status as ordered.
Recorded baseline vital signs and pain score.
Secured IV cannula and administered IV fluids as prescribed.
Administered prescribed pre-operative antibiotics.
Removed ornaments, dentures, nail polish and valuables if present.
Prepared abdominal operative area as per hospital protocol.
Encouraged patient to pass urine before shifting to operation theatre.
Explained deep breathing, coughing and early ambulation after surgery.
Provided psychological support and reduced anxiety.
Completed pre-operative checklist and shifted patient safely to OT.

Post-operative Nursing Care

Maintained airway, breathing and circulation after anesthesia.
Monitored vital signs frequently during immediate post-operative period.
Observed laparoscopic port site dressings for bleeding, soakage and discharge.
Assessed pain score and administered analgesics as prescribed.
Observed for nausea, vomiting, abdominal distension and shoulder tip pain.
Maintained IV fluids until oral intake was allowed.
Encouraged deep breathing and coughing exercises.
Encouraged early ambulation to prevent gas discomfort and thrombosis.
Maintained aseptic technique during wound care.
Educated patient regarding low-fat diet, wound care, activity and follow-up.

Drug Chart

Drug Name	Dose	Route	Frequency	Purpose	Nursing Responsibility
Inj. Ceftriaxone	1 g	IV	BD	Broad-spectrum antibiotic	Check allergy, administer slowly, monitor rash, diarrhea and IV site.
Inj. Metronidazole	500 mg	IV	TDS	Anaerobic infection control	Give slowly, monitor nausea, metallic taste and IV site irritation.
Inj. Pantoprazole	40 mg	IV	OD	Gastric protection	Administer before meals/early morning, monitor abdominal discomfort.
Inj. Ondansetron	4 mg	IV	SOS/BD	Controls nausea and vomiting	Assess nausea, monitor headache and constipation.
Inj. Paracetamol	1 g	IV	TDS/SOS	Pain and fever relief	Monitor temperature, pain score and total daily dose.
Inj. Tramadol	50 mg	IV/IM	SOS	Moderate to severe post-operative pain	Monitor sedation, dizziness, nausea and respiratory depression.
IV Ringer Lactate	500 ml	IV	As ordered	Maintains hydration and electrolyte balance	Monitor flow rate, IV site, intake-output and signs of overload.
IV Normal Saline	500 ml	IV	As ordered	Fluid replacement	Check patency, monitor input-output and edema.

📄 Page 10 — NANDA Nursing Diagnoses

Sr. No.	NANDA Nursing Diagnosis	Related To	Evidenced By / Risk Factors
1	Acute Pain	Gallbladder inflammation, biliary colic and surgical port site trauma	Pain score 7/10, right upper abdominal pain, guarding, post-operative port site pain
2	Risk for Infection	Surgical incision/port sites and invasive procedure	Laparoscopic port wounds, mild leukocytosis, post-operative state
3	Impaired Skin Integrity	Laparoscopic port incisions and tissue trauma	Multiple abdominal port site dressings present
4	Imbalanced Nutrition: Less Than Body Requirements	Nausea, vomiting, anorexia and fat intolerance	Reduced appetite, nausea, vomiting, bloating after fatty meals
5	Deficient Knowledge	Lack of information regarding post-operative care, low-fat diet, wound care and activity	Patient asks about diet, wound care and daily household work after surgery

Note: Main detailed nursing care plans are prepared for the first three priority diagnoses: Acute Pain, Risk for Infection and Impaired Skin Integrity.

📄 Page 11 — Nursing Care Plan 1: Acute Pain

Assessment	Nursing Diagnosis	Goal / Expected Outcome	Planning	Implementation	Evaluation
Subjective Data: Patient complains, “Mere pet ke right upper side me dard ho raha hai.” Pain increases after fatty food and movement. Post-operatively, patient complains of mild port site pain and shoulder discomfort. Objective Data: Pain score 7/10 before surgery and 5/10 after surgery. Facial grimacing, guarding of abdomen and laparoscopic port site dressings present.	Acute Pain related to gallbladder inflammation, biliary colic and surgical port site trauma as evidenced by verbal complaint of pain, guarding, facial grimacing and pain score 7/10.	Short-Term Goal: Patient will report reduction in pain from 7/10 to 3/10 within 24–48 hours. Long-Term Goal: Patient will remain comfortable and perform deep breathing, coughing and ambulation with minimal pain before discharge.	Assess pain location, intensity, duration and aggravating factors. Monitor vital signs regularly. Provide comfortable position. Administer analgesics as prescribed. Encourage early ambulation to reduce gas discomfort. Teach relaxation and splinting technique.	Assessed pain score using 0–10 pain scale every 4 hours. Observed facial expression, guarding and restlessness. Positioned patient in semi-Fowler’s position for comfort. Administered Inj. Paracetamol and Inj. Tramadol as prescribed. Supported abdomen during coughing, turning and ambulation. Encouraged deep breathing and relaxation exercises. Encouraged early ambulation after surgery to reduce shoulder tip pain due to laparoscopic gas. Reassessed pain after analgesic administration.	Patient reported pain reduction from 7/10 to 2/10 within 48 hours. Patient was able to deep breathe, cough and ambulate with minimal discomfort before discharge.

Outcome: Goal achieved. Patient’s pain reduced and comfort improved.

📄 Page 12 — Nursing Care Plan 2: Risk for Infection

Assessment	Nursing Diagnosis	Goal / Expected Outcome	Planning	Implementation	Evaluation
Subjective Data: Patient asks, “Operation ke baad wound infection to nahi hoga?” Objective Data: Laparoscopic cholecystectomy done. Multiple abdominal port site dressings present. WBC count 12,600/mm³ before surgery. Mild fever present on admission.	Risk for Infection related to laparoscopic port site wounds, invasive procedure and post-operative state.	Short-Term Goal: Patient will remain free from signs of wound infection during hospitalization. Long-Term Goal: Port site wounds will heal without redness, swelling, pus discharge or fever before follow-up.	Monitor temperature and signs of infection. Observe port site dressings for soakage and discharge. Maintain aseptic technique during wound care. Administer antibiotics as prescribed. Promote hand hygiene. Educate patient about wound infection warning signs.	Monitored temperature, pulse and wound condition regularly. Observed port site dressings for bleeding, pus, foul smell and excessive soakage. Performed hand hygiene before and after patient care. Maintained aseptic technique during dressing and wound inspection. Administered Inj. Ceftriaxone and Inj. Metronidazole as prescribed. Encouraged adequate fluid intake after oral intake was allowed. Encouraged protein-rich and low-fat diet to support wound healing. Educated patient to report fever, increased pain, redness, swelling or discharge from wound.	Patient remained afebrile after post-operative day 2. Port site dressings were dry and clean. No redness, swelling, pus discharge or foul smell was observed. Patient understood infection prevention measures.

Outcome: Goal achieved. No signs of port site wound infection were observed.

📄 Page 13 — Nursing Care Plan 3: Impaired Skin Integrity / Port Site Wound

Assessment	Nursing Diagnosis	Goal / Expected Outcome	Planning	Implementation	Evaluation
Subjective Data: Patient asks, “Mere operation ke chhote wounds kab theek honge?” Patient reports mild discomfort at port sites. Objective Data: Laparoscopic cholecystectomy performed. Multiple abdominal port site dressings present. Dressings are dry and intact.	Impaired Skin Integrity related to laparoscopic port incisions and tissue trauma as evidenced by multiple abdominal port site wounds with sterile dressings.	Short-Term Goal: Patient’s port site wounds will remain clean, dry and intact during hospitalization. Long-Term Goal: Patient will demonstrate proper wound care and port sites will heal without complications.	Assess port site wounds regularly. Maintain sterile dressing as ordered. Prevent pressure and strain on abdominal wounds. Promote adequate nutrition for wound healing. Teach wound care and hygiene. Observe for redness, swelling, discharge and wound opening.	Inspected port site dressings for dryness, soakage and discharge. Maintained aseptic technique during dressing care. Kept wound area clean and dry. Supported abdomen during coughing, turning and ambulation. Encouraged protein-rich low-fat diet for wound healing. Advised patient not to touch wounds with unclean hands. Educated patient to avoid heavy household work until advised. Taught warning signs such as redness, swelling, pus discharge, fever and wound opening.	Port site dressings remained clean and dry. No wound discharge, redness or wound opening was observed. Patient verbalized proper wound care instructions before discharge.

Outcome: Goal achieved. Port site wounds remained clean, dry and healing was satisfactory.

📄 Page 14 — Discharge Summary

Patient Name: Mrs. Kavita Sharma
Age/Sex: 42 Years / Female
Hospital Name: Government Medical College Hospital, Jodhpur
Ward: Female Surgical Ward
Date of Admission: 14/05/2026
Date of Surgery: 15/05/2026
Date of Discharge: 18/05/2026
Final Diagnosis: Symptomatic Cholelithiasis
Surgery Performed: Laparoscopic Cholecystectomy under General Anesthesia

Summary of Hospital Stay

Mrs. Kavita Sharma, a 42-year-old female, was admitted with complaints of right upper abdominal pain, nausea, vomiting, bloating and indigestion after fatty meals. On examination, tenderness was present in the right hypochondriac region.

Ultrasonography abdomen showed multiple gallstones in the gallbladder with mild wall thickening. Blood investigations showed mild leukocytosis. The patient was kept NPO, IV fluids, antibiotics, analgesics and antiemetics were started, and laparoscopic cholecystectomy was planned after pre-operative preparation.

Laparoscopic cholecystectomy was performed on 15/05/2026 under general anesthesia. Post-operatively, the patient was monitored for pain, bleeding, infection, nausea, vomiting, abdominal distension and vital signs. Patient’s condition improved gradually. Pain reduced, oral diet was tolerated and port site wounds remained clean and dry.

Condition at Discharge

Patient is conscious, oriented and hemodynamically stable.
No fever at the time of discharge.
Pulse: 78/min, BP: 116/76 mmHg, Respiratory rate: 16/min.
SpO₂: 99% on room air.
Pain score: 1/10.
Port site dressings are clean and dry.
No redness, swelling, pus discharge or wound gaping present.
Patient is able to walk independently.
Patient tolerates soft low-fat oral diet.
Patient and family understand discharge instructions.

Discharge Medications

Medication	Dose	Frequency	Purpose
Tab. Cefixime	200 mg	Twice daily for 5 days	Antibiotic
Tab. Metronidazole	400 mg	Three times daily for 5 days	Anaerobic infection control
Tab. Paracetamol	500 mg	SOS after food	Pain and fever relief
Tab. Pantoprazole	40 mg	Once daily before breakfast for 5 days	Gastric protection
Multivitamin	1 tablet	Once daily	Recovery support

Follow-Up Advice

Follow-up in surgical OPD after 7 days for wound inspection.
Continue prescribed medicines as directed.
Keep port site wounds clean and dry.
Avoid heavy lifting and strenuous household work until doctor permits.
Take soft, low-fat and easily digestible diet.
Report immediately if fever, severe abdominal pain, vomiting, jaundice, wound discharge or wound opening occurs.

📄 Page 15 — Health Education

1. Wound Care

Keep port site wounds clean and dry.
Do not touch wounds with unwashed hands.
Do not remove dressing unless advised.
Observe wounds for redness, swelling, discharge, foul smell or wound opening.
Visit hospital for dressing and follow-up as advised.

2. Medication Advice

Take antibiotics for the full prescribed course.
Do not skip or stop medicines without doctor’s advice.
Take pain medicine only as prescribed.
Take gastric protection medicine before breakfast if prescribed.
Report allergy symptoms such as rash, itching, swelling or breathing difficulty immediately.

3. Diet Advice After Cholecystectomy

Take soft and easily digestible food during early recovery.
Take small frequent meals instead of heavy meals.
Avoid oily, fried, spicy and high-fat foods for some weeks.
Include low-fat foods such as dal, curd, fruits, vegetables and soft chapati.
Drink adequate water unless restricted.
Gradually resume normal diet as tolerated and as advised by doctor.

4. Activity and Rest

Take adequate rest during recovery period.
Walk slowly at home to improve circulation and reduce gas discomfort.
Avoid heavy lifting, bending and strenuous household work until advised.
Support abdomen while coughing, sneezing or getting up from bed.
Resume normal activities only after medical advice.

5. Prevention of Complications

Maintain hand hygiene before touching dressing area.
Do deep breathing exercises as advised.
Avoid constipation by taking fluids and fiber-rich foods.
Do not ignore persistent abdominal pain, vomiting or fever.
Attend follow-up visits regularly.

6. Warning Signs Requiring Immediate Medical Help

Fever above 100.4°F.
Severe abdominal pain or increasing pain.
Persistent vomiting.
Yellow discoloration of eyes or skin.
Redness, swelling, pus discharge or foul smell from port site wounds.
Bleeding from wound site.
Wound opening.
Abdominal distension or inability to pass stool/gas.

Patient Teaching Outcome: Patient and family verbalized understanding of wound care, medication, low-fat diet, activity restriction, follow-up and warning signs.

📄 Page 16 — Bibliography

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Latest Edition, Wolters Kluwer.
NANDA International Nursing Diagnoses: Definitions and Classification 2024–2026.
Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Latest Edition.
Bailey & Love’s Short Practice of Surgery, Latest Edition.
Indian Nursing Council recommended Medical-Surgical Nursing syllabus and clinical practical guidelines.
Hospital surgical nursing care protocols for pre-operative and post-operative care.

⚕️ Medical Disclaimer: This surgical nursing care plan is prepared for educational and academic purposes only for ANM, GNM and BSc Nursing students. It is not intended for actual patient care or clinical decision-making. Always follow hospital protocol, physician orders and standard nursing textbooks.