Miami Dade College – School of Nursing
Plan of Care
Student Name: Dienifer Gonzalez Santana Clinical Date: 05/21/2026
CLIENT’S INITIALS: H.R AGE: 67 SEX: Male LANGUAGE: English ADMISSION DATE: 05/21/26
ALLERGIES & REACTIONS: Penicillin
ADMITTING DIAGNOSIS: Cholelithiasis
and Cholecystitis
PATHOPHYSIOLOGY: Cholelithiasis is
the formation of gallstones in the
gallbladder. These stones may obstruct
the cystic duct, causing inflammation
known as cholecystitis. Obstruction
leads to bile buildup, gallbladder
distention, inflammation, pain in the
right upper quadrant, nausea, vomiting,
and fever.
PAST MEDICAL/ SURGICAL HISTORY:
Type II diabetes, coronary artery bypass
graft x4 two years ago, hypertension,
and chronic insomnia.
HISTORY OF PRESENT ILLNESS/ CHIEF COMPLAINT
Patient reports intermittent abdominal pain and
nausea for several weeks, with worsening symptoms
over the past 2 days. Complaints of right upper
quadrant abdominal pain radiating to the right
shoulder, abdominal fullness, nausea, vomiting, and
fever. Pain rated 6/10. Ultrasound revealed
gallstones with partial obstruction of the cystic duct
RECENT (SINCE ADMISSION) PROCEDURES/
SURGERY:
Abdominal ultrasound showing gallstones and cystic
duct obstruction
Scheduled open cholecystectomy for tomorrow
morning
DIAGNOSTIC TESTS & LABS ORDERED:
CBC
Electrolytes
Revised by N. Jules_08/06/25
, BUN/Creatinine
Glucose
Bilirubin
Liver function tests
INR
HgA1c
Urinalysis
Portable chest x-ray
12-lead ECG
WHAT MEDICATIONS WAS CLIENT TAKING (PRIOR TO ADMISSION)?
Insulin glargine 16 units SUBCUT at bedtime for diabetes mellitus type 2
SCHEDULED MEDICATIONS ORDERED:
Medication Drug Side Effects Contraindication Nursing
(Dose/Route/ Classification s Interventions
Time/ Frequency) & Action
Normal Saline IV 75 Isotonic fluid Fluid overload Heart Failure, renal Monitor I&O and
mL/hr replacement failure lung sounds
Dicyclomine 20 mg IM Antispasmodic Dry mouth, GI obstruction Assess abdominal
q6h dizziness pain
Enoxaparin 40 mg Anticoagulant Bleeding Active bleeding Monitor bleeding
SUBCUT daily and platelets
Insulin glargine 16 units Long-acting insulin Hypoglycemia Hypoglycemia Monitor blood
HS glucose
Ticarcillin IVPB q6h Penicillin antibiotic Rash, diarrhea Penicillin allergy HOLD and notify
provider due to
allergy
Nitroglycerin patch Vasodilator Hypotension, Severe hypotension Monitor BP
headache
PRN MEDICATIONS ORDERED: TIME GIVEN (IF
APPLICABLE)
Revised by N. Jules_08/06/25
Plan of Care
Student Name: Dienifer Gonzalez Santana Clinical Date: 05/21/2026
CLIENT’S INITIALS: H.R AGE: 67 SEX: Male LANGUAGE: English ADMISSION DATE: 05/21/26
ALLERGIES & REACTIONS: Penicillin
ADMITTING DIAGNOSIS: Cholelithiasis
and Cholecystitis
PATHOPHYSIOLOGY: Cholelithiasis is
the formation of gallstones in the
gallbladder. These stones may obstruct
the cystic duct, causing inflammation
known as cholecystitis. Obstruction
leads to bile buildup, gallbladder
distention, inflammation, pain in the
right upper quadrant, nausea, vomiting,
and fever.
PAST MEDICAL/ SURGICAL HISTORY:
Type II diabetes, coronary artery bypass
graft x4 two years ago, hypertension,
and chronic insomnia.
HISTORY OF PRESENT ILLNESS/ CHIEF COMPLAINT
Patient reports intermittent abdominal pain and
nausea for several weeks, with worsening symptoms
over the past 2 days. Complaints of right upper
quadrant abdominal pain radiating to the right
shoulder, abdominal fullness, nausea, vomiting, and
fever. Pain rated 6/10. Ultrasound revealed
gallstones with partial obstruction of the cystic duct
RECENT (SINCE ADMISSION) PROCEDURES/
SURGERY:
Abdominal ultrasound showing gallstones and cystic
duct obstruction
Scheduled open cholecystectomy for tomorrow
morning
DIAGNOSTIC TESTS & LABS ORDERED:
CBC
Electrolytes
Revised by N. Jules_08/06/25
, BUN/Creatinine
Glucose
Bilirubin
Liver function tests
INR
HgA1c
Urinalysis
Portable chest x-ray
12-lead ECG
WHAT MEDICATIONS WAS CLIENT TAKING (PRIOR TO ADMISSION)?
Insulin glargine 16 units SUBCUT at bedtime for diabetes mellitus type 2
SCHEDULED MEDICATIONS ORDERED:
Medication Drug Side Effects Contraindication Nursing
(Dose/Route/ Classification s Interventions
Time/ Frequency) & Action
Normal Saline IV 75 Isotonic fluid Fluid overload Heart Failure, renal Monitor I&O and
mL/hr replacement failure lung sounds
Dicyclomine 20 mg IM Antispasmodic Dry mouth, GI obstruction Assess abdominal
q6h dizziness pain
Enoxaparin 40 mg Anticoagulant Bleeding Active bleeding Monitor bleeding
SUBCUT daily and platelets
Insulin glargine 16 units Long-acting insulin Hypoglycemia Hypoglycemia Monitor blood
HS glucose
Ticarcillin IVPB q6h Penicillin antibiotic Rash, diarrhea Penicillin allergy HOLD and notify
provider due to
allergy
Nitroglycerin patch Vasodilator Hypotension, Severe hypotension Monitor BP
headache
PRN MEDICATIONS ORDERED: TIME GIVEN (IF
APPLICABLE)
Revised by N. Jules_08/06/25
