Nursing Care Plan Case Study

Patient - Mrs. G., Age 40 years

Social history – Married, homemaker with five children, ages 14, 11, 9, 8 and 4 years. Her husband is away on business during the week and home on weekends. She has arranged for her sister to care for her children while she is a patient in hospital.

Planned surgical procedure – Elective Laparoscopic Cholecystectomy.

Medical history – 2 year history of intermittent, right upper quadrant colicky abdominal pain with radiating pain to the right shoulder and general postprandial (after meal) discomfort in the upper abdomen. Abdominal ultrasound investigations completed 2 months ago confirmed the presence of stones in the gallbladder.

Surgical history – none.

On admission her vital signs were ...

• Blood pressure 120/68

• Pulse - 84

• Respirations - 24

• Weight - 100 kg

• Height - 150 cm

Her admission orders were ...

• Serum cholesterol

• Alkaline phosphatase

• Chest x-ray

• Urinalysis

• CBC

Results of diagnostic testing preoperatively - indicated values within the normal range for all tests except for an elevated serum cholesterol level.

During the preoperative assessment visit, Mrs. G. began to cry. She stated that she is "a little afraid of the operation." She also admitted that she had never left her children before and was worried about them. She has never had surgery before.

Create a nursing care plan that identifies real and potential risks for surgery as nursing diagnoses, outcomes identification and planned nursing interventions. You are asked to then imagine Mrs. G.’s response to nursing care provided preoperatively, intraoperatively, and postoperatively, and identify possible implementation and evaluation results. Imagine that some of the patient outcomes are not met and determine what, if any revisions to the care plan are necessary. The nursing process is cyclical, and you will demonstrate this important concept as you determine additional nursing diagnoses, outcomes, and interventions required to care for Mrs. G.