Florence College of nursing

Irba, Ranchi
Medical Surgical Nursing
A Surgical Care Plan
On
CHOLELITHIASIS

Submitted To: Submitted By:

Anand Kujur Sunil Kumar
Head of the Department M. Sc(Nsg) 1st Year
Medical Surgical Nursing Florence College
Florence College Of Nursing
Of Nursing
 INTRODUCTIO
N
As a part of my clinical posting I was posted in
3rd flood general ward in ORCHID MEDICAL
CENTRE. I selected a Mrs. Shusmita Devi of 62
years old with the complaints of abdomen
pain, fever vomiting and weakness since one
month. The doctor diagnosed the condition as
cholelithiasis patient has undergone surgery
chalecystectomy.
 PATIENT INFORMATION
Name of the patient: Miss. Shushmita Devi
Age: 62years
Sex: Female
Marital status: Married
Ward : Surgical ward
Address: Bodra , Pathrgama, Godda
Religion: Hindu
Education: Inter
Admission date: 3/9/15
Date of surgery: 7/9/15
Occupation: House wife
Monthly family income : 30,000/-
Weight: 48Kg
Height: 5feet
Chief complains: Abdomen pain vomiting, fever
Diagnosis: Cholecystectomy
Pre operative diagnosis: Cholelithiasis
Post operative diagnosis: Chalecystectomy
CHIEF COMPLAIN WITH DURATION
Mrs. Shusmita Devi admitted to the hospital on 3/9/15 with the chief
complaint of abdominal pain, fever vomiting and weakness.
On admission the vital sign of the patient-
Temperature- 100 degree F
Pulse -86 beats/min
Respiration-14 breaths/min
Blood pressure- 140/70 mm of Hg

Past Medical History

Miss. Shushmita Devi of 62 year old was not having past medical history.

Present medical History

Miss Shusmita Devi come to the hospital with complain of abdominal pain, fever,
vomiting and weakness.

Past surgical history

Miss Shusmita Devi has not having any past surgical.

Present Surgical History

Miss Shusmita Devi of 62 years come to the hospital on 03/09/15 at 2:05 pm in
OPD with the complain of chaleslithiasis abdominal pain, vomiting fever had gone
under surgery name chalecystectomy under general anosthesia on 7/9/15

Family History
Miss Shusmita Devi belong to a nuclear family ,lives in Bodra, Pathrgama, Godda
Jharkhand stays with her husband ,father in low, mother, in low and their children.
 Family chart
S.NO Name of Age/sex occupation education Relation Health
the status
family
members
1. Nilesh 70/M Business Inter Husband Healthy
Prasad
2. Shusmita 62/F House Secondary Self Unhealthy
Devi wife
3. Nirmal 35/M Business B.A Son Healthy
Devi
4. Nikita 34/F Housewife Inter Daughter Healthy
Devi in low
5. Ritika 10/F Student Primary Grand Healthy
Kumari daughter
6. Reena 8/F Student Primary Grand Healthy
kumari daughter
 FAMILY TREE

Sushmita Devi
Nilesh Prasad 62 Years
70 Years

Nikita Devi
Nirmal Prasad 34 Years
35 Years

Ritika Kumari Reena Kumari

10 Years 8 Years

Keywords:-
Male
Female

Female Patient
Type of family- Nuclear

No. Of Member- six

Head of the Family- father

Any illness- No any illness

Health Facility Near Home

Mrs sushmita Devi has health facility near home.
Hospital is available about 1 km distance from her home
All transport facility available to travel to hospital
Housing
Type- Pakka
No. Of Rooms- 9 Rooms
Toilet – Western
Electricity- available
Drinking water- well