CASE STUDY BY: ADDAI FREDSUPERVISORS NAME: MR. AMANKWAHOSPITAL:
SDA HOSPITAL KWADASOWARD: SURGICAL WARDPATIENTS PARTICULARSNAME:
MRS D.OAGE: 43 YEARSSEX: FEMALEDIAGNOSIS: UTERINE FIBRIODTYPE OF
OPERATION: TOTAL ABDOMINAL HYSTERECTOMYDATE OF ADMISSION:
10/9/2013TIME OF ADMISSION: 11: 30AMDATE OF SURGERY:
11/9/2013OCCUPATION: TRADERRELIGION: CHRISTIANLOCALITY: KWADASONEXT
OF KIN: MR A.DLANGUAGE SPOKEN: TWI AND FANTEWARD IN-CHARGES NAME:
COMFORT ADU BOOBISIGNATURE..CHAPTHER ONEASSESSMENT OF PATIENT AND
FAMILYAssessment is the first step in the nursing process in which
the nurse carries out a complete and holistic nursing assessment of
every patient needs. Psychological, sociological, physiological and
spiritual statuses are all forms of information gathered about
patient. Assessment is done through observation, physical
examination, interview of patient and family, medical investigation
and laboratory investigation. The information gathered serve as a
foundation upon which appropriate nursing intervention will be
established for speedy patients recovery. and also to identify
patients problems which are expressed as actual or
potential.PATIENTS PARTICULARSComment by Amankwaa: Next of kin?,
marital statusMrs. D.O is 43 year woman born to Mr. O.O and Mrs.
R.T. sshe hails from cape coast in the central region of Ghana. She
but stays at Kwadaso. She is half Ashanti and half Fanti. Mrs. D.O
is 5.4feet tall and weighs 68kg. She is an alcohol [local gin]
seller and also a farmer. She is a Christian and worship with the
Presbyterian church of Ghana at Kwadaso. Mrs. D.O had no formal
education.FAMILYS MEDICAL AND SOCIO-ECONOMIC HISTORYThere are no
known hereditary illnesses like asthma, diabetes mellitus,
hypertension and absence of or mental illness in their family. The
family sometimes experiences headache, slight stomach aches which
are mostly managed by taking paracetamol and sometimes flaggly
flagyl tablets. There are no food and drugs allergies. She gains
her income from the products from her farm and selling of local gin
[apteshie]. She is sociable and adapt to situations that are
challenging.PATIENTS DEVELOPMENTAL HISTORYComment by Amankwaa: Was
she born at term?Comment by Amankwaa: The whole of this part is
incomplete. U need to wrk more herePatient was born by vaginal
delivery with an assistance of a traditional birth attendantce at
the house. She experienced her secondary characteristics such as
breast enlargement, menstrual flow and enlargement of hips at the
age of 14years. Mrs. D.O is currently living with her husband with
five children, two males and three females.Comment by Amankwaa:
This section should be chronological, u How can a child start
having secondary sexual characteristics soon after birth?Comment by
Amankwaa: How does this become development?She was immunized
against the six childhood killer diseases now known as childhood
preventable diseases. Client had no formal education.Comment by
Amankwaa: Never entered the classroom?PATIENTS LIFESTYLE AND
HOBBIESPatient normally goes to bed at 10:00pm and wakes up around
4:30am and prays to God for protecting her throughout the night.
She maintains her personal hygiene and goes to the farm at 6:30am.
She normally closes from the farm around 1:00pm and come to
continue her selling of local gin [apteshie] at the house. She
watches television, maintains her personal hygiene and goes to bed
at 10:00pm. Patient baths twice daily with soap, sponge and warm
water. She cleans her teeth twice daily with toothpaste and brush
and before and after going to bed. She empties her bowel once
daily. Her favorite food is banku and okro stew. She does not smoke
but drinks alcohol. Mrs. D.O favorites hobby is music and often
likes to dance to her children sight.PATIENTS PAST MEDICAL/SURGICAL
HISTORYPatient had never experienced any medical conditions like
diabetes mellitus, hypertension etc. she had no known allergies.
She hasd, had no surgical condition which might have needed her
admission to any hospital; this was her first surgery to be done.
Total abdominal hysterectomy was done for uterine fibroid.PATIENTS
PRESENT MEDICAL HISTORYPatient was apparently well until 6th day of
September 2013 when she started experiencing profuse bleeding and,
abdominal pains that was associated with her when she got into
menstruation. Prior to that, she was admitted at the SDA Hospital
Kwadaso to be taking care of. It was later confirmed that patient
was having uterine fibroid of which she was to undergone total
abdominal hysterectomy.Comment by Amankwaa: Why was she admitted? I
think this should be part of the past medical historyADMISSION OF
PATIENTMrs. D.O was admitted to the surgical ward at the S.D.A
hospital Kwadaso on the 10th September, 2013 at 11:30am with the
diagnosis of uterine fibroid. She was in the company of two
relatives, the husband and the child. The patients folder was
collected from the admission nurse and patients name and other
particulars were verified mentioned to confirm whether she was the
right patient. Patient and her family were warmly received and
given seats to make them comfortable and were reassured that all
the necessary measures would be put in place to ensure her comfort
throughout her hospitalization. Patient was put on a comfortable
bed and quick assessment from head to toe was done to ascertain her
general condition.Comment by Amankwaa: This shd be done before
verifying pts identityHer vital signs were checked and recorded as
follows;Temperature = 38.4 degree CelsiusPulse = 80 beats per
minuteRespiration = 20 cycles per minuteBlood pressure= 130/80
mmHgTepid sponging was done to reduce patients body temperature to
37.5 degree Celsius.Family members were educated on visiting hours
and the meal time and all ward policies were explained to them.
They were also shown to the bathroom and toilet. They were also
introduced to doctors, nurses and other staff on the ward as well
as other patients.Comment by Amankwaa: Is this admission of patient
or summary of actual care rendered to patient?Anxiety level of
patients rose up due to the impending surgery, so she was reassured
that she will have a successful surgery. This helped to allay
anxiety and wins her cooperation. She was introduced to other
patients who have undergone similar surgery successfully; this and
it helped to release relieve her psychologically. She was also
allowed tos expressing her fears through questioning. and Hher
questions were answered in simple terms to clear any
misconception.Patient had inadequate knowledge on the condition
(uterine fibroid) and so the definition, causes, signs and symptoms
and treatment of the condition were explained to patient. Clients
and familys questions were answered in simple and appropriate terms
to aid in the full understanding of the condition.Bed rest was
ensured and in a quit environment provided. Assisted bed bath and
oral care were given. Clients vital signs were was checked and
recorded and all measures were put in place to relieve pain. Nil
per oS was instituted due to the impending surgery. Patient went to
bed around 7:20pm to prepare for the operation on the following
day, (11th September 2013). Procedures done were recorded and
documented in the nurses notes. Vital signs checked and recorded
for the ranges within;Temperature= 37.5-38.4 degrees CelsiusPulse =
78-80 beats per minuteRespiration = 18-20 cycles per minuteBlood
pressure= 120/70-130/80millimetre per mercury PATIENTS CONCEPT OF
ILLNESSPatient does not know what actually contributed to her
illness. She believes that with God on her side and with care
rendered she would be able to pass through the surgery
successfully.
LITERATURE REVIEW ON UTERINE FIBROIDComment by Amankwaa: This
shd start on a fresh pageDEFINITIONUterine fibroid is a
noncancerous growth of the uterus that often appears during
childbearing years. It is not associated with an increased risk of
uterine cancer and also never develops into cancer.CAUSES/RISK
FACTORS-Hereditary or family history.-Race and ethnicity-Age-Other
factorsHereditary or family history: uterine fibroids are the most
common tumor found in female reproductive organs. If your mother or
sister had fibroid, you are at increased risk of developing
them.Race and ethnicity: black women are more likely to have
fibroids than women of other racial groups. Also black women have
fibroids at younger ages and they are likely to have more or larger
fibroids.Age: fibroids are more common in women who are their 30s
through early 50s. [After menopause, fibroids tend to shrink].
About 20-40percent of women age 35 and over have fibroids.Other
factors: onset of menstruation at an early age, having a diet
higher in red meat and lower in green vegetables and fruits, and
drinking alcohol such as beer appears to increase risk of
developing fibroid.LOCATION OF FIBROIDS-Sub mucosal fibroids:
fibroids that grow into the inner cavity of the uterus are more
likely to cause prolonged, heavy menstrual bleeding and sometimes
problem for women attempting pregnancy.-Subserosal fibroids:
fibroids that projects to the outside of the uterus can press on
the bladder causing one to have urinary symptoms.-Intramural
fibroids: some fibroids grow within the muscular uterine wall. If
large enough, they can distort the shape of the uterus and cause
prolonged, heavy periods as well as pain.PATHOPHISIOLOGYUterine
fibroids develop from the smooth muscular tissue of the uterus
[myometrium]. A single cell divides repeatedly, eventually creating
a firm, robbery mass distinct nearby tissues. The growth patterns
of uterine fibroids vary, grow slowly or rapidly, remain the same
size, some fibroids go through growth sports and some may shrink on
their own. Many fibroids that present during pregnancy shrink or
disappear after pregnancy as the uterus goes back to a normal size.
They can be single or multiple expanding the uterus so much it that
it reaches the rib cage.CLINICAL FEATURES-Heavy menstrual
bleeding-Prolonged menstrual periods-Pelvic pressure or pain
-Frequent urination-Difficulty emptying the
bladder-Constipation-Lows
backacheCOMPLICATIONS-Infertility-Pregnancy loss-Anemia-Urinary
tract infection-Uterine cancersDIAGNOSTIC INVESTIGATION-Ultrasound:
the ultrasound device [transducer] is moved over the abdomen [Trans
abdominal] or places it inside the vaginal [transvaginal] to get
images of the uterus.-Laboratory tests: These might include a
complete blood count to determine if there is anemia due to chronic
blood loss and other blood test to rule out bleeding disorders.
Other imaging test-Magnetic resonance imaging [MRI]: this shows the
size and location of the fibroid, identify different types of
tumors and help determine appropriate treatment
options.-Hysterosonography: Also called a saline infusion sonogram,
uses sterile saline to expand the uterine cavity making it easier
to get images of the cavity and endometrium. It is useful when one
has heavy bleeding.-Hysterosalpingography: Uses a dye to highlight
the uterus and fallopian tube on x-ray images to determine if the
fallopian tubes are opened.-Hysteroscopy: A small lighted telescope
called a hysteroscope is inserted through the cervix and into the
uterus. Other diagnosis-Physical examination.-History from the
patient.-Signs and symptoms.SPECIFIC MEDICATIONSMedications for
uterine fibroid target hormones that regulates menstrual bleeding
and pelvic pressure. They do not eliminate fibroid but may shrink
them. Medications include;-Gonadotropin releasing hormone [Gn-RH]
agonist. Example; Lupron, synarel and others are used to treat
fibroid by blocking the production of estrogens and progesterone
putting a person into a temporally postmenopausal state.-Progestin
releasing intrauterine device [IUD] to help relieve heavy bleeding
caused by fibroid. It provides symptom relieve only and does not
shrink fibroid or make them disappear.-Non steroidal
anti-inflammatory drugs [NSAIDS] may be effective in relieving pain
but not to reduce bleeding caused fibroid.-Oral contraceptives or
progestin can help control menstrual bleeding but do not reduce
fibroid size.-Intravenous fluids such as dextrose saline, normal
saline may be given to correct fluid and electrolyte loss.
SPECIFIC SURGICAL TREATMENTSurgery is usually the curative
treatment of uterine fibroid and the type of surgery is total
abdominal hysterectomy or subtotal abdominal
hysterectomy.HYSTERECTOMYA hysterectomy is the surgical procedure
whereby the uterus [womb] is removed. Or it can be define as the
surgical removal of the uterus to treat cancer, dysfunctional
uterine bleeding, endometriosis, non-malignant growths, persistent
pain, pelvic relaxation and prolapsed and previous injury to the
uterus.TYPES OF HYSTERECTOMIES-Total abdominal hysterectomy-vaginal
hysterectomy-Assisted vaginal hysterectomy-Supracervical
hysterectomy-Laparoscopic supra cervical hysterectomy-Radical
hysterectomy-Oophorectomy and salpingo-oophorectomyTOTAL ABDOMINAL
HYSTERECTOMYThis is the most common type of hysterectomy. During a
total abdominal hysterectomy, there is the removal of the uterus,
including the cervix. The scar may be horizontal or vertical,
depending on the reason the procedure is performed, and the size of
the area being treated. Cancer of the ovary[s] and uterus,
endometriosis, and large uterine fibroids are treated with total
abdominal hysterectomy. Total abdominal hysterectomy may also be
done in some unusual cases of very severe pelvic pain, after a very
thorough evaluation to identify the cause of the pain, and only
after several attempts at non-surgical treatments. Clearly a woman
cannot bear children herself after this procedure, so it is not
performed on women of childbearing age unless there is a serious
condition, such as cancer. Total abdominal hysterectomy allows the
whole abdomen and pelvis to be examined, which is an advantage in
women with cancer or investigating growths of unclear
cause.COMPLICATION OF SURGICAL TREATMENT-Infection-Pain-Bleeding at
the surgical area
SPECIFIC NURSING MANAGEMENTPRE-OPERATIVE NURSING
MANAGEMENTPSYCHOLOGICAL CAREa. Reassure the patient and the
relative by explaining the type of surgery to be performed for her
and explain the disease condition to patient. This will help to
relieve her of anxiety and fears.b. Introduce people who have
undergone such operation to her to allay anxiety.c. Allow her to
ask questions about her condition and this will help her gain
knowledge and understand her condition. REST AND SLEEPa. Her bed
should be free from creases and crump to prevent her being
uncomfortable.b. Reduce noise at the ward: make sure all procedures
are performed in bulk to prevent procedures destructing her
sleep.OBSERVATIONa. Vital signs such as temperature, pulse,
respiration and blood pressure are observed to serve as a baseline
to evaluate the patients condition.b. Patient must be observed for
pain, and to be encouraged to assume the position she find
comfortable which is not contradicted to her condition.CONSENT OF
PATIENTAfter all the explanations necessary for the patient to gain
knowledge, understand the surgery, a consent form is signed by the
patient and this give the legal right for the operation to be
performed on her.INVESTIGATIONAll investigations must be done on
the patient to correct any abnormalities related to blood,
hemoglobin estimation, white blood cell count, and
etc.NUTRITIONServe fluid diet the night before the surgery.
Intravenous fluids such as dextrose saline, normal saline, ringers
lactate may be given to correct fluid and electrolytes loss.
Nothing is given by mouth on the morning of the operation.SKIN
PREPARATIONThe area to be shaved must be washed and dried, and
clean the shaved area with antiseptic lotion. Sterile procedure of
shaving should be done.
POST OPERATIVE NURSING MANAGEMENTOBSERVATIONa. Observe and
monitor vital signs every 15minutes, 30minutes and hourly till
patients condition stabilizes.b. Monitor the intravenous fluid for
blood clot in the needle, presence of air bubbles, all these are
done to prevent any complications.c. Observe for signs of
complication such as bleeding, cyanosis, infection and pain.
PREVENTION FROM INJURYSince patient is unconscious, she needs to
be protected from injury by ensuring that all procedures are done
using the right technique.WOUND CAREa. Dressing is normally changed
on the third day of post operative; wound dressing must be done
under aseptic technique.b. Alternate stitches must be removed
before the remaining stitches also removed and it depends on the
condition of the wound and the hospital policy.c. Wound should be
observed for signs of bleeding, infection and pain.PERSONAL
HYGIENEPersonal hygiene such as oral care, bed bath should be done
regularly to prevent harboring of microbes, thereby preventing
secondary infection.EDUCATIONa. Assess patient understanding with
regard to her condition.b. Educate her based on the causes of
uterine fibroid, signs and symptoms of the condition, the need for
surgical intervention, preventive measures, the need for periodic
medical examination and the need to take drugs.c. Educate on the
review date and the day for removal of stitches.DRUGSPrescribed
drugs may be given to patient to relieve pain. Antibiotics may also
be given to prevent secondary infections. Desired and side effect
of drugs must be observed.
VALIDATION OF DATAComment by Amankwaa: The whole of this portion
is not clear to me. Can u write it again?With reference to the data
collected clinical features of uterine fibroid were confirmed by
the literature review of the condition. Data collected from the
patient and relatives were cross checked with patients folder,
laboratory investigations and assessment. All these proved that
patient was suffering from uterine Comment by Amankwaa: ??
CHAPTER TWOANALYSIS OF DATAComment by Amankwaa: It appears you
have left out lots of information in the introductory section of
the care study. See that of ur friends.Analysis of data is the
interpretation of data collected to identify patients specific
needs and strengths, which help in the information of an
appropriate nursing diagnosis. It includes actual and potential
identified needs. It also covers diagnostic investigations, causes,
clinical features, treatment, complications and pharmacology of
drugs.
TABLE ONE: DIAGNOSTIC INVESTIGATION ON MRS. D.ODATE SPECIFIC/
BODY PART INVOLVEDINVESTIGATIONRESULTSNORMAL
VALUEINTERPRETATIONREMARKS
07/08/13BloodHemoglobin level estimation10.1gldlMale: 14-18gldl
Female: 12-16gldlComment by Amankwaa: You may reduce the font size
of all information in table to abt 10 or 11 so that it can fit well
into the tableBelow normalVitamin B12 was prescribed for
patient.Patient advised on nutritious diet
07/08/13BloodRed blood cell
count4.21[106/ul]4.50-5.50[106/ul]Below normalTablet zincovit was
prescribed for patient.
07/08/13BloodWhite blood cell
count3.65[10/ul]2.60-8.50[10/ul]NormalNo treatment was given.
07/08/13Blood Serum calcium
level2.45mmol/l2.15-2.55mmol/lNormalNo treatment was given.
07/08/13BloodSerum potassium level3.8mmol/l3.5-5.5mmol/lNormalNo
treatment was given.
07/08/13BloodSerum chloride level98mmol/l90-100mmol/lNormalNo
treatment was given.
TABLE TWO: COMPARISON OF CLINICAL MANIFESTATION FROM CLINICAL
MANIFESTATION EXHBITED BY PATIENTCLINICAL MANIFESTATION OUTLINED IN
LITERATURE REVIEWCLINICAL MANIFESTATION EXHBITED BY PATIENT
.Heavy menstrual bleedingPatient experienced heavy menstrual
bleeding
.Prolonged menstrual bleedingPatient had prolonged menstrual
bleeding
.Pelvic pressure or painThere was a complained of pelvic
pressure
.Frequent urinationShe had frequent urination
.ConstipationPatient had constipation
.Low backacheShe experienced low backache
.DehydrationPatient was dehydrated
SPECIFIC TREATMENT GIVEN TO PATIENTAccording to the literature
review on the treatment for uterine fibroid, the following
treatment was given to patient;Comment by Amankwaa: This part is
not clear. Must literature review be done before u get to know the
treatment given to your patient?SURGICAL TREATMENT1. Total
abdominal hysterectomy was done for patient.PRE OPERATIVE
TREATMENT1. Intravenous normal saline 1litre2. Intravenous ringers
lactate 1litre3. Intravenous ciprofloxacin 400mg ads x2INTRA
OPERATIVE TREATMENT1. Intravenous Atropine 0.5mg2. Intravenous
Suxamethionum POST OPERATIVE TREATMENT1. Intramuscular pethidine
50mg bdx24hours2. Suppository Diclofenac 100mg bdx5/73. Intravenous
metronidazole 500mg 8hourly x244. Intravenous Dextrose saline 3L5.
Intravenous Normal saline 3L6. Intravenous Ringers lactate 3L7.
Tablet flagyl 400mg tdsx58. Tablet Zincovit 1 tablet daily x159.
Intravenous Ciprofloxacin 400mg bd x 5
TABLE THREE: PHARMACOLOGY OF DRUGS PRESCRIBED TO MRS.
D.ODATEComment by Amankwaa: Table incomplete, where is the remark
section?DRUGDOSAGE AND ROUTE OF ADMINISTRATIONCLASSIFICATIONDESIRED
EFFECTS
11/09/13 PethidineAdult dose:25-100mg every 3 to 4 hours
Child dose:0.5mg per kg
Route: Intramuscular
Patient:50mg st, intramuscularly
Narcotic analgesicsRelieves of pain
11/09/13DiclofenacAdult dose: 75-150mg bdComment by Amankwaa: I
know adults can be given as low as 50mg
Child dose:30-60mg bd
Route :RectalComment by Amankwaa: The route here should refer to
all the possible routes that this drug can be given
Patient: 100mg bd x5, rectallyAntipyretic, sedatives
,NSAIDSComment by Amankwaa: Can u show me the book you are using?
How can u refer to diclofenac as a sedative?Relieves inflammation,
pain
11/09/13MetronidazoleAdult dose:400-500mg tds x7days
Child dose:200mg tds x 7daysComment by Amankwaa: I dnt think
this is right
Route :Oral, intravenous
Patient:500mg tds x5days, intravenouslyAntiprotozoa,
AmoebicideTo treat infection
11/09/13Dextrose SalineDosage depends on calorie and fluid
requirement
Route: intravenousPatient: 2 litres for 48hours,
intravenouslyFluid and electrolytes replacement Provides
supplementary calories and fluids
11/09/13Normal SalineHighly individualized
Route: intravenous
Patient: 1 litre for 8hours, intravenouslyFluid and electrolyte
replacementComment by Amankwaa: What type of fluid is it?Restores
normal sodium and chlorine level
11/09/13Ringers lactateDepends on the rate of dehydration
Route: intravenous
Patient: 1.5 litres for 48 hours, intravenouslyFluid and
electrolyte replacementRestores the normal fluid and electrolyte
imbalance
11/09/13Tablet FlagylComment by Amankwaa: Indicate the generic
nameAdult dose:250-500mg tdsComment by Amankwaa: How can tablet
flagyl be dispensed in 500mg formulation?
Child dose:30-50mg tdsComment by Amankwaa: ????
Route: oral
Patient:400mg tds x 5, orallyAntiprotozoa, AmoebicideTo treat
infection
11/09/13Tablet ZincovitAdult dose:1 tablet daily
Child dose: 1tablet dailyComment by Amankwaa: ?? are u sure?
Route: oral
Patient:1 tablet daily x 30, orally
HaematimicsTo stimulate red blood cell production
11/09/13Atropine Adult dose:0.4-0.6mg in single dose
45-60minutes before anesthesia
Child dose:0.4mgComment by Amankwaa: incomplete
Route: intravenous
Patient:1 mg given 35minutes before anesthesia,
intravenouslyAntisecretory agentComment by Amankwaa: wrongDries
secretions and decreases sweating
11/09/13Comment by Amankwaa: if this was not given in the ward
then take it outSuxamethionum Adult dose:1-2mg
Child dose: 0.04mg per kg
Route: intravenous
Patient: 2.5mg ,intravenouslyAnesthetic drugRelaxes skeletal
muscles
11/09/13CiprofloxacinComment by Amankwaa: are we dealing with
tab or IV?Adult dosage: 400mg bdComment by Amankwaa: For how
long?
Child dosage:10-15mg per kg
Route: intravenous
Patient: 400mg bd x 5, intravenouslyAntibiotics Comment by
Amankwaa: What type of antibioptic?Kills susceptible bacteria and
prevent infection
Comment by Amankwaa: Where is patient problems and strength? And
other stuffs
CHAPTER THREE PLANNING FOR PATIENT AND FAMILY CARENursing care
plan is a step by step process designed to enhance delivery of
nursing care on individual. It is the third step in nursing process
which is an approach to patients care and serves as communication
between patient and the entire health team. Nursing care plan
ensures that, the nursing team work efficiently to bring out a
holistic goal oriented and individual care to patient.Comment by
Amankwaa: What space is that?PRE OPERATIVE PROBLEMSComment by
Amankwaa: Your problems must match the strengthComment by Amankwaa:
This is supposed to be in chap 21. Fever.2. Abdominal pain.3.
Knowledge deficit (Partial).4. Anxiety.POST OPERATIVE PROBLEMS5.
Acute pain (incision pain).6. Incision wound.7. Risk for urinary
tract infection.8. Inability to perform her personal
hygiene.PATIENT AND FAMILY STRENGHTSComment by Amankwaa: How can u
be having 8 problems and 5 strength1. Patient had support from
family.2. Patient expresses the desire to learn more about the
condition.3. Patient was oriented to time, place and person and
could communicate her pain.4. Patient and family fully participate
in the planning of her care.5. Patient had cordial relationship
with other patients on the ward as well as the staff.PRE OPERATIVE
NURSING DIAGNOSIS1. Altered in body temperature (38.4C) related to
inflammatory process.2. Altered body comfort (abdominal pain)
related to inflammatory process secondary to uterine fibroid.3.
Knowledge deficit (partial) related to inadequate information on
the causes and management of uterine fibroid.4. Anxiety related to
unknown outcome of impending surgery. POST OPERATIVE NURSING
DIAGNOSIS5. Altered body comfort (incision pain) related to wound
at the incision site.6. Altered skin integrity (incision wound)
related to surgical manipulation on the abdomen.7. High risk for
urinary tract infection related to urethral catheter in situ.8.
Self care deficit (bathing, mouth care, etc.) related to post
operative restrictions.PRE OPERATIVE NURSING OBJECTIVES1. Patients
body temperature will be reduced within to the normal range (36.2C-
37.2C) within 12 hours as evidenced by:a. Nurse observing that
patients temperature has reduced to the normal range (36.2C- 37.2C)
by reading from the clinical thermometer.b. Patient verbalizing a
reduced body temperature.
2. Patient will experience reduced abdominal pain within 24
hours as evidenced by:a. Patient feeling comfortable in bed and
verbalizing absence of pain.Comment by Amankwaa: How can one know
that patient is comfortable?b. Nurse observing that patient is
relaxed with cheerful facial expression.
3. Patient will have adequate knowledge about uterine fibroid
within 24 hours as evidenced by:a. Patient and family verbalizing
their full understanding of the condition and how to take care of
surgical wounds.b. Patient and family able to answer some questions
asked by the nurse.Comment by Amankwaa: What do u mean by some? Be
specific
4. Patient will be relieved of anxiety within 4 hours as
evidenced by:a. Patient verbalizing that she is relieved of
anxiety.b. Nurse observing that patient have cheerful facial
expression.
POST OPERATIVE NURSING OBJECTIVES1. Patient will experienced a
reduction in pain level within 72 hours as evidenced by:a. Patient
verbalizing relief of pain.b. Nurse observing patient having a
cheerful facial expression and looking relaxed in bed.
2. Patient will have intact skin throughout the period of
hospitalization as evidenced by:Comment by Amankwaa: I think the
attention should be able the risk that wound would be infected.
There had been incision, so u cant talk abt pt having intact skina.
Patient verbalizing her skin has minimal scar at incision site.b.
Nurse observing that patients wound will heal by first
intension.
3. Patient will be free from urinary tract infections within the
period of catheterization hospitalisation as evidenced by:a. Nurse
observing no signs of redness and discharge at the site of the
catheter.b. Patient verbalizing that she feels no pain at the
site.
4. Patient will be able to meet her self careself-care needs
within 72 hours as evidenced by:a. Nurse observing patient taking
her bath, grooming and caring for her mouth without assistanceTABLE
FOUR: PRE OPERATIVE NURSING CARE PLAN OF MRS D.ODATE
ANDTIMENURSINGDIAGNOSISOBJECTIVES/OUTCOMECRITERIANURSINGORDERSNURSING
INTERVENTIONSEVALUATION
10/9/2013
at
12:00pmAltered in body temperature (38.4C) related to
inflammatory process.Comment by Amankwaa: Make sure all corrections
made to above reflects here too. Am not reading this part again
Patients body temperature will be reduced within the normal
range (36.2C-37.2C) within 12 hours as evidenced by:
a. Nurse observing that patients temperature has reduced to the
normal range (36.2C-37.2C) by reading from the clinical
thermometer.
b. Patient verbalizing that her temperature has reduced.1. Check
patients body temperature and record.
2. Tepid sponge patient.
3. Open nearby windows.
4. Re-checks patients body temperature every 15 minutes.1.
Patients body temperature was checked and recorded to serve as
baseline for treatment.
2. Patient was tepid sponged to reduce body temperature.
3. Nearby windows were opened to allow for circulation of
air.
4. Patient body temperature was rechecked every 15 minutes to
determine reduction in body temperature.Goal fully met as patient
verbalized that her temperature has reduced(37.5C)
10/09/2013.
6:30pm
A.F
DATE ANDTIMENURSINGDIAGNOSISOBJECTIVE/OUTCOMECRITERIANURSING
ORDERSNURSING INTERVENTIONSEVALUATION
10/09/13
at
1:15pm
Altered body comfort (abdominal pain) related to inflammatory
process secondary to uterine fibroid.Patient will be reduced of
pain within 24 hours as evidenced by:Comment by Amankwaa: This cant
be 24 hours
a. Nurse observing that patient is relaxed with cheerful facial
expression.
b. Patient feeling comfortable in bed and verbalizing absence of
pain.1. Reassure client.
2. Perform pain assessment.
3. Assists patient to assume a comfortable position.
4. Reduce noise
5. Provide diversion therapy.1. Patient was reassured that pain
will subside after implementation of all nursing procedures.
2. Assessment of pain was done before and 30 minutes after
analgesics were served.
3. Patient was assisted to assume prone position on which was
comfortable for her on a bed free from creases and cramps.
4. Staff was asked to minimized noise and visitors were also
restricted.
5. Patient was engaged in conversation to divert her attention
from the painGoal fully met as patient was seen relaxed and
cheerful in bed.
10/09/13
8:10pm
DATE ANDTIMENURSINGDIAGNOSISOBJECTIVE/OUTCOME CRITERIANURSING
ORDERSNURSING INTERVENTIONEVALUATION
10/09/13
at
2:00pmInadequate knowledge (partial) related to information on
the causes and management of uterine fibroid.Patient will have
adequate knowledge about uterine fibroid within 24 hours as
evidenced by:
a. Patient and family verbalizing their full understanding of
the condition and how to care of surgical wounds.1. Reassure client
and family.
2. Put client in a comfortable position.
3. Educate client on condition.
4. Allow patient and family to ask questions.
5. Give appropriate answers to client and family.1. Client and
family were reassured that all necessary information about the
condition would be provided to help them understand the
condition.
2. Client was put in a sitting up position to seek for her
alertness
3. Education was provided to client that helped her to
understand the causes and the management of fibroid.
4. Patient and family were given the opportunity to ask
questions on the condition.
5. Appropriate answers were given to the questions asked by the
client and family.
Goal fully met as client and family verbalized their full
understanding on the condition.
10/09/13Comment by Amankwaa: This is not 24 hrs. becareful abt
these fine details
5:20pm
A.F
DATE ANDTIMENURSINGDIAGNOSISOBJECTIVE/ OUTCOMECRITERIANURSING
ORDERSNURSING INTERVENTIONEVALUATION
10/09/13
At
3:45pmAnxiety related to unknown outcome of the impending
surgeryPatient and family will be relieved of an anxiety within 4
hours as evidenced by:
a. Nurse observing that patient have a cheerful facial
expression.
b. Patient verbalizing that she is relieved of anxiety.1.
Reassure patient.
2. Assess patient and familys state of anxiety, fear and
concern.
3. Explain to her the theater environment and what she should
expert expect in the theater.
4. Allow patient and family to express concern.
5. Encourage diversional therapy.1. Patient and family were
reassured that she in the hands of competent nurses or staff to
reduce her anxiety.
2. The facial expression and posture of family were observed in
attempt to assess their level of anxiety.Comment by Amankwaa: What
abt the patient?
3. The theater environment, dressing of workers and equipment
were explained to allay her anxiety.
4. Patient and family were allowed to express their concern by
asking questions and appropriate answers were given to correct
misconception about uterine fibroid.
5. Patient was engaged in diversional therapy such as
conversation to allay her fears on the impending surgeryGoal fully
met as patient seen relaxed and had a good facial expression.
10/09/13
5:00pm
A.F
DATE ANDTIMENURSING DIAGNOSISOBJECTIVES/OUTCOMECRITERIANURSING
ORDERSNURSING INTERVENTIONEVALUATION
12/09/13
At
7:00amAltered body comfort (incision pain) related to wound at
the incision site.Patient pain will be reduced within 72 hours as
evidenced by:
a. Patient verbalizing that she is relieved of pain.
b. Nurse observing patient having a cheerful facial expression
and looking relaxed in bed.1. Reassure patient.
2. Assist patient to assume a comfortable position that relieves
her pain.
3. Provide diversional therapy.
4. Teach patient to support incision site when coughing or
laughing.
5. Administer analgesics.1. Patient was reassured that the pain
and discomfort will be relieved with effective nursing
measures.
2. The patient was assisted to assume a comfortable position to
help reduce her pain.
3. The patient was engaged in conversation to turn her attention
from pain.
4. Patient was taught to support the site with the hands when
coughing or laughing to relief tension, on incision site to reduce
pain.
5. Analgesic was served to reduce pain.Goal fully met as patient
verbalizedzing that she has a reduced pain.
14/09/13
10:20am
A.F
TABLE FOUR: POST OPERATIVE NURSING CARE PLAN OF MRS D.O
DATE ANDTIMENURSING DIAGNOSISOBJECTIVE/OUTCOMECRITERIANURSING
ORDERSNURSING INTERVENTIONEVALUATION
12/09/13
At
10:00amAltered skin integrity (incision wound) related to
surgical manipulation on the abdomen.Patient will have intact skin
throughout the period of hospitalization as evidenced by:Comment by
Amankwaa: review
a. Patient verbalizing that her skin has a minimal scar at
incision site.
b. Nurse observing that patient wound will heal by first
intention.1. Reassure patient.
2. Change soiled dressing as per hospital policy frequent and
aseptically.
3. Educate patient to avoid touching the wound site.
4. Administer prescribed antibiotics.1. Patient was reassured
that strict technique will be employed during hospitalization to
prevent wound infection.
2. Soiled dressing was frequently changed to prevent moisture
and infection.Comment by Amankwaa: indicate how often
3. Patient was instructed not to touch the wound site to avoid
infection of the wound.
4. Prescribed antibiotics such as flagyl were administered to
prevent infection.
Goal fully met as it was observed that patient wound healed by
first intension.
15/09/13
9:30am
A.F
DATE AND TIMENURSING DIAGNOSISOBJECTIVE/ OUTCOME CRITERIANURSING
ORDERSNURSING INTERVENTIONEVALUATION
12/09/13
At
12:30pmHigh risk for urinary tract infection related to urethral
catheter in-situ.Patient will be free from infection within period
of catheterization as evidenced by:Comment by Amankwaa: review
a. Patient verbalizing that she feels no pain at the site
b. Nurse observing no signs of redness and discharge at the
catheter site.1. Reassure client.
2. Care for catheter daily with antiseptic lotion.
3. Monitor flow rate of urine.
4. Assist patient to perform personal hygiene such as bathing
and care of mouth.
5. Administer prescribed antibiotics 1. Patient was reassured
that the catheterization was temporal.
2. Patients catheter was cared for daily with antiseptic lotion
such as salvon and normal saline.
3. Urine flow rate was monitored to determine fluid balance.
4. Patient was assisted to perform personal hygiene as bathing
and mouth care to promote her comfort.
5. Prescribed antibiotics were administered to prevent
infection.Goal fully met as nurse observed no signs and discharges
at the catheter site.
12/09/13
3:10pm
A.F
DATE AND TIMENURSING DIAGNOSISOBJECTIVE/OUTCOMECRITERIANURSING
ORDERSNURSING INTERVENTIONEVALUATION
12/09/13
At
6:20pmSelf-care deficit (bathing and mouth care) related to
post-operative restrictions.Patient will be able to meet her
self-care needs within 72 hours as evidenced by:
a. Nurse observing patient taking her bath, caring for her mouth
without assistance.1. Reassure patient.
2. Assist patient to bath twice daily.
3. Treat pressure areas as such.
4. Give oral care twice daily.1. Patient was reassured that her
personal hygiene would be taken care of until her condition allows
her to perform them by herself.
2. Patient was assisted in bed to bath twice daily with warm
water to refresh her and remove dirt and also stimulate
circulation.
3. Pressure areas such as heels and scapula were inspected and
treated to prevent the development of bedsores.
4. Patients mouth was cared twice daily with tooth brush and
tooth paste to prevent oral infection. Vaseline was applied to the
lips to prevent cracks.
Goal fully met as patient was able to perform her needs without
assistance.Comment by Amankwaa: give specific activities that
patient performed
15/09/13
7:00am
A.F
CHAPTER FOURComment by Amankwaa: what is the heading for the
chapter?Implementation is the fourth stage of the nursing process
and it involves the execution of the proposed plan of care.
Implementation includes specific measurable nursing intervention
and patients activities with emphasis on performing procedures like
administrating of drugs, education, providing comfort, ensuring
safety and prevention of complications.Patients and family are
involved as the nurse assesses the patients response to the nursing
care rendered.Comment by Amankwaa: This sentence have no
meaning
SUMMARY OF ACTUAL NURSING CAREThe actual nursing care rendered
to Mrs. D.O in the management of her condition started on the day
of admission (10th September, 2013) through to the time when the
third home visit was made.
DAY OF ADMISSION (10TH SEPTEMBER, 2013)Mrs. D.O was admitted to
the surgical ward at the S.D.A hospital Kwadaso on the 10th
September, 2013 at 11:30am with the diagnosis of uterine fibroid.
She was in the company of two relatives, the husband and the child.
The patients folder was collected from the admission nurse and
patients name and other particulars were verified to confirm
whether she was the right patient. Patient and her family were
warmly received and given seats to make them comfortable and were
reassured that all the necessary measures would be put in place to
ensure her comfort throughout her hospitalization. Patient was put
in a comfortable bed and quick assessment from head to toe was done
to ascertain her general condition.Her vital signs were checked and
recorded as follow: Temperature = 38.4 degree Celsius Pulse = 80
beats per minute Respiration = 20 cycles per minute Blood pressure
= 130/80 millimeter per mercuryTepid sponging was done to reduce
patients temperature to 37.5 degree Celsius.Family members were
educated on visiting hours and the meal time and all ward policies
were explained to them. They were also shown to the bathroom and
toilet. They were also introduced to doctors, nurses and other
staff on the ward as well as other patients.Anxiety level of
patient rose up due to the impending surgery, so she was reassured
that she will have a successful surgery. This helped to allay
anxiety and wins her cooperation. She was introduced to other
patients who have undergone similar surgery successfully and it
helped to release her psychologically. She allows expressing her
fears through questioning and her questions were answered in simple
terms to clear any misconception.Patient had inadequate knowledge
on the condition (uterine fibroid) and so the definition, causes,
signs and symptoms and treatment of the condition were explained to
her. Clients and familys questions were answered in simple and
appropriate terms to aid in the full understanding of the
condition.Bed rest was ensured and in a quite environment. Clients
vital signs were checked and recorded and all measures were put in
place to relieve pain. Nil per OS was instituted due to the
impending surgery. Patient went to bed around 7:20pm to prepare for
the operation on the following day, (11th September, 2013).
Procedures done were recorded and documented in the nurses
notes.Vital signs checked and recorded for the ranges within:
Temperature = 37.5-38.4 degrees Celsius Pulse = 78-80 beats per
minute Respiration = 18-20 cycle per minute Blood pressure =
120/70-130/80 millimeter per mercury
FIRST DAY OF ADMISSION (DAY OF SURGERY)Comment by Amankwaa:
Date?Mrs. D.O woke up around 5:35am and had a cheerful facial
expression. Her personal hygiene such as bathing and mouth care was
done. Patient was reassured again that she was in the hands of
competent health personal and she would recover successfully. The
area to be operated was cleaned with antiseptic solution and
covered with a sterile towel. Nil per OS was still instituted and
was well explained to patient as to help prevent aspiration during
the time of surgery. The relatives were given the chance to be with
the patient until it was about time for her to be sent to the
theatre. The patient folder was checked to ensure that all
necessary documents were intact and the consent form was signed to
confirm the surgery.Comment by Amankwaa: I think there shd be
appropriate headings for how patient was prepared for OP. e.g.
immediate pre-op careMrs. D.O was dressed in a theatre gown and all
materials such as necklace, rings were removed and placed safely in
the patients own locker. A urethral catheter was in-situ to make
easily empting of the bladder. She was sent to the theatre on a
stretcher at 12:45pm. Oxygen apparatus, suction machine and drip
stand were at the side of the patients bed to be used when the need
arises.Comment by Amankwaa: These things are valuable and must be
kept in the nurses custody for safe keepingComment by Amankwaa: If
u copy and paste someones work, u must make sure the font type and
size matches the original textThe vital signs of the patient were
checked and recorded as follows:Comment by Amankwaa: Give a
rationale for taking this vital signs prior to surgery Temperature
= 36.5 degree Celsius Pulse = 78 beats per minute Respiration = 20
cycle per minute Blood pressure = 120/70millimeter per
mercuryComment by Amankwaa: You havent stated when and how patient
was taken to the Op room
IMMEDIATE POST OPERATIVE CARE [11TH SEPTEMBER, 2013]Comment by
Amankwaa: Patient was operated on this day, but the care plan does
not indicate known problems associated with post of care such pain
etc.After the surgery, patient was brought back to the ward on a
stretcher in the company of two theatre nurses at 12:45pm. She was
was taken back to the surgical ward as ordered by the surgeon at 2:
45pm in a semi-conscious and had state with 500ml of Ringers
lactate in place that was driping well.in-situ, accompanied by two
theatre staff nurses and patency of urethral catheter was
ensured.She was reassured that measures would be put in place to
ensure effective breathing pattern. Vital signs were checked 15
minutes, then 30 minutes and hourly till her condition was stable.
This helped to allay fears and anxiety. A resuscitation tray
(containing galipot with sterile swabs, spatula, ventilators, tong
holding forceps, mouth gag and receiver for used swab) were was set
at and placed at patients bed side to be used when the need arises.
Patient finally slept at 9: 05pm.Comment by Amankwaa: Was she
having problems with breathing? If so then this shd be made clear.
Comment by Amankwaa: ???Vital signs were checked and recorded for
the day ranges within: Temperature = 36.2-36.8 degree Celsius Pulse
= 74-78 beats per minute Respiration = 22-24 cycles per minute
Blood pressure = 120/70-130/70 millimeter of mercury
FIRST DAY POST OPERATIVE [12TH SEPTEMBER, 2013]Patient woke up
in the morning around 7: 00am and complained of incision pain and
she was reassured. She had an assisted bed bath, oral hygiene and
was given toothbrush and paste to clean the mouth to promote
physical comfort and also prevent oral infection. She was reassured
that the pain was temporal and will be relieved through effective
medical and nursing interventions. Nil per OS was still ensured and
her catheter cared for. Patients bed linen was changed to promote
rest and sleep.Wound dressing of patient was inspected for
discharges and none was seen. She was instructed not to touch the
wound with her hand to prevent infection. Patient was also taught
to support the incision site when coughing, sneezing, or getting
out of bed to prevent wound gabbing. The doctor came for review
around 10: 25am, ordered the following; analgesic injection
Pithidine 500mg., starting sips of water, removal urethral catheter
and to discontinue the infusion. The patient was given sips of
water and there was no complication and catheter was cared for,
removed and infusion was discontinued. Relatives were urged to
prepare a light soup the next day and she went to bed around 8:
00pm. Due medications were served as ordered.Comment by Amankwaa:
Are u sure of this dose? And did u include this in your
pharmacology of drugs?Comment by Amankwaa: Construct sentence
wellVital signs were checked and recorded for the day ranges
within; Temperature = 36.5-37.6 degree Celsius Pulse = 78-80 beats
per minute Respiration = 18-20 cycles per minute Blood pressure =
110/70-120/70millimeters of mercury
SECOND DAY POST OPERATIVE [13TH SEPTEMBER, 2013]Around 7: 15am
patient woke up from bed and was assisted to take her bath in bed.
She also had her oral hygiene because there was an improvement in
her condition. She was encouraged to engage in passive exercise to
ensure improvement in her health state. She had no complaints, her
wound was assessed for drainage and discharges and was dressed
using aseptic technique to prevent infection. She took her porridge
and due medications were served in the morning. Patient had a
cheerful facial expression and went to bed around 7:00pm after
taken her personal hygiene.Vital signs checked and recorded for the
day ranges within; Temperature = 36.4-37.2 degree Celsius Pulse =
80-84 beats per minute Respiration = 20-22 cycles per minute Blood
pressure = 110/70-110/90 millimeters of mercury
THIRD DAY POST OPERATIVE [14TH SEPTEMBER, 2013]On the third day
post-operative, patient woke up at 7:00am and was having a cheerful
facial expression. Patient was able to take her personal hygiene
thus brushing the teeth, taking her bath and dressing neatly. She
took her breakfast and due medications were served.Comment by
Amankwaa: I dont think this is a correct statmeVital signs checked
and recorded for the day ranges within; Temperature = 36.2-37.4
degree Celsius Pulse = 78-80 beats per minute Respiration = 18-22
cycles per minute Blood pressure = 120/70-130/70 millimeters of
mercuryPatient dressing was inspected and dressing was changed to
prevent infection and promote healing. She was educated to ensure
personal hygiene by not touching the wound to prevent infection.
She was also advised to eat nourishing diet as well as fruits rich
in vitamins to promote wound healing. said by the doctor during
ward rounds. Mrs. D.O was seen interacting with other patients at
the ward. She had her supper, took her medications and bathed in
the evening and went to bed around 8:00pm.
FOURTH DAY POST OPERATIVE [15TH SEPTEMBER, 2013]Patient slept
well during the night according to the night nurses report. Her
condition now was improving. All prescribed medications were served
and recorded. Patients vital signs were checked and recorded. Wound
of patient was inspected for abnormalities such as pus and
swelling. The wound was dressed with normal saline from inside out
under aseptic technique as ordered by the surgeon. She was advised
not to touch the wound site to prevent infection and also was
advised to adhere to all medications to promote wound
healing.Comment by Amankwaa: Is that the normal practice in the
hospital?Patient was taught how to get out of bed without putting
pressure on the incision site and was also encouraged to walk
around the ward to improve circulation and prevent joint stiffness.
She was served with light porridge in the morning, rice balls with
light soup in the afternoon and slice yam with light soup in the
evening. Patient was made comfortable in bed and her relatives were
reassured of her speedy recovery.Vital signs checked and recorded
for the day ranges within; Temperature = 36.6-36.9 degree Celsius
Pulse = 78-80 beats per minute Respiration = 22-24 cycles per
minute Blood pressure = 120/70-130/80 millimeters of mercury
FIFTH DAY POST OPERATIVE [16TH SEPTEMBER, 2013]Client woke up in
the morning with no complaints and she was looking cheerful. She
maintained her personal hygiene without assistance. Alternate
stitches were removed and the wound was dressed aseptically using
methylated spirit. On ward rounds, client was finally discharged
after she had undergone physical examination. She was asked to
report on 23rd of September, 2013 for removal of other stitches.
She was also told to come for review on 27th September, 2013.Mrs.
D.O was again advised on the importance of taking her medications
regularly and also the need of taking in nutritious diet example
protein to enhance wound healing. She was advised on promoting
dryness of the wound by not putting water on the dressing. The
families including the patient were happy to go home due to no
complication observed.Comment by Amankwaa: And u were putting
normal saline on it?The patients folder was sent to the accounts
department for assessment and payment of bills and all debts were
settled by patients relatives. Madam D.O and the family expressed
their profound gratitude to me and the entire health team for the
intensive cared rendered. Clients name and date of discharged were
documented into the admission and discharged book as well as the
daily ward state. Patient and family said goodbye to other patients
on the ward and left to the house around 3:30pm. Bed linen of
patient was stripped off and bedstead, lockers were clean with
disinfectants and were made ready for the next admission.
PREPARATION OF PATIENT AND FAMILY FOR DISCHARGE AND
REHABILITATIONComment by Amankwaa: Not gud enough. This patient has
had surgery and must be prepared adequately for discharge. refer to
Brunner and SuddarthMrs. D.O and family were made to understand
that patients hospitalization was a temporal one since she would be
discharged to go home after her condition has improved. The
preparation for discharge started on the day of admission till the
day of discharge. Patient and family were educated on the causes,
signs and symptoms, complications, treatment and prevention of the
disease.The patient and family were educated to keep the mouth
clean at least twice daily to prevent oral infection. They were
educated to bath twice daily to remove dirt and to promote
circulation. Also they were advised to trimmed fingers to prevent
microbes. They were educated to wash their hands with soap and
water before and after eating and after visiting the toilet to
prevent microbes.Comment by Amankwaa: All these points are ok but
doesnt reflect on the aftercare of a patient who have had
surgery.Mrs. D.O and family were educated on their food, thus
washing fruits and vegetables before eating to prevent
contamination of the food. She was educated to take in diet
containing protein, vitamins and mineral salts to aid in promoting
wound healing. The patient was advised to avoid heavy lifting which
could lead to wound gaping. They were educated on the harmful
effects of alcohol and smoking and to avoid the intake of
them.Lastly, Mrs. D.O was educated to adhere to her drugs and also
to take note of the review date 27th September, 2013 and the date
for removal of stitches 23rd September, 2013. Patient was finally
discharged on 16th September, 2013. Rendered procedures were
documented in the nurses note, admission and discharge book, and
daily ward state.
FOLLOW UP/ HOME VISITS/ CONTINIUTY OF CAREHome visit is a
purposeful visit to the home of the patient with the aim of
preventing diseases, promoting and maintaining health. The follow
up is also to assess the use of available resourcesat the house as
well as in the community that can be used to solve patients
problems. Follow up was to assess the health status of patient
after discharge.
FIRST HOME VISIT [14TH SEPTEMBER 2013]Comment by Amankwaa: You
need to educate the family on how to support the patient on her
return frm the hospThe first follow up home visit was made on 14th
September, 2013 when patient was still on admission. Its purpose
was to know the patients locality, its environment and how well it
will contribute to the health status of the patient. I went to the
house together with the husband.Comment by Amankwaa: Nothing like
this was indicated in the actual care rendered to patientThey live
at Kwadaso in Kumasi. We were there around 11:45am and were warmly
welcomed by some of the family members present at that time. On
arrival to the house, observation was done made regarding to
determine cleanness of the surroundings. They lived in a family
house. Their main water supply was pipe borne water and was also
having electricity. The community was well equipped with portable
roads.Cement blocks were used to build the house and was roof with
iron sheets. The house was well painted and had no fenced wall.
They have well ventilated rooms which aid in air circulation. They
store their refuse in an aluminum dustbin and empty it each morning
into the communitys refuse dumping site. I congratulated them for
good environment and encouraged them to continue it. Not
forgetting, I advised them to always visit the hospital for medical
checkups and also to take in well nutritious meal to aid in their
bodys functioning. Assurance was given to them concerning my next
home visit after discharged of patient.
SECOND HOME VISIT [20TH SEPTEMBER 2013]The second home visit was
made on 20th September, 2013. The aim was to check how patient was
faring, how she was adhering to her treatment regimen and also to
remind her of the date for review. Mrs. D.O and family welcomed me
to their house. I asked for patient drugs to see if she was
adhering to treatment regimen. Patient was given the mandate to
verbalize how she feels and I observed the wound for any
complication of which none was observed. Mrs. D.O had no complained
and the wound was well clean.The patient was reminded of the review
date which comes on 27th September, 2013. She was adviced to take
in well-balanced diet to help prevent infection and also promote
early wound healing. She was also educated to avoid putting much
pressure on her wound through lifting of heavy objects. It was made
clear to the patient that if she encounters any problem she should
report to the hospital before the review date. Termination of care
was explained to them and that would be possible on the third home
visit. Another home visit was promised. Permission was granted for
me to leave.
Comment by Amankwaa: Did u terminate care?THIRD HOME VISIT [2ND
OCTOBER, 2013]The third home visit was conducted on 2nd October,
2013. Patient and families were in good health with no complaints.
Mrs. D.Os wound was almost healed. The family and patient were
educated on their personal and environmental hygiene. She was also
advised to avoid lifting of heavy objects. They were lastly
reminded that in case of any complication, they should report to
the hospital for early treatment and also periodic medical checkup
was instituted.The family members and the patient expressed their
maximum thanks to me and the entire health team for intensive the
care given and wish me all the best in my studies and granted me
permission to leave.
CHAPTER FIVE
EVALUATIN OF CARE RENDERED TO PATIENT AND FAMILY.This is the
final step of the nursing process that allows the nurse to
determine the patient response to nursing intervention. If a set
goal is not met, a new intervention is initiated and carried out
until is met.By definition, it is the determination of patients
response to the nursing interventions and the extent to which the
nursing interventions and outcome have been achieved.STATEMENT OF
EVALUATIONMrs. D.Os health improved after six days of admission.
During the evaluation of care rendered to her, all the goals and
evaluation were fully met. Problems presented by patient and
objectives were related to the evaluation.10TH SEPTEMBER, 2013An
objective was set at 12:00pm to reduce patient body temperature to
the normal range [36.2-37.2 degree Celsius] within 12 hours. Goal
was fully met on 10/09/2013 at 6:30pm as nurse observed that
patients temperature has reduced to the normal range by clinical
thermometer reading. An objective was set at 1:15pm to reduced
patients abdominal pain within 24hours. Goal was fully met on
10/09/2013 at 8:10pm as nurse observed that patient is was relaxed
with a cheerful facial expression, patient feeling comfortable in
bed and had no pain.An objective was set at 2:00pm to encourage
patient to have adequate knowledge to uterine fibroid within 24
hours. Goal was fully met on 10/09/2013 at 5:20pm as patient and
family verbalized their full understanding of the condition and how
to take care of surgical wounds.An objective was set at 3:45pm to
reduce patient and family level of anxiety within 4hours. Goal
fully met on 10/09/2013 at 5:00pm as nurse observed that patient
have ahad a cheerful facial expression, patient verbalized that she
is relieved of anxiety.
12TH SEPTEMBER, 2013An objective was set at 7:00am to relieve
patients pain within 72hours. Goal fully met on 14/09/2013 at
10:20am as nurse observed patient having a cheerful facial
expression and looking relaxed in bed, patient verbalized that she
is relieved of pain.An objective was set at 10:00am to prevent
patient wound from infection throughout period of hospitalization.
Goal fully met on 15/09/2013 at 9:30am as nurse observed that
patient wound healed by first intension.Comment by Amankwaa: You
need to carefully differentiate this from the one above, they seem
sameAn objective was set at 12:30pm to prevent patient from
infection within the period of catherization. Goal fully met on
12/09/2013 at 3:10pm as nurse observed no signs and discharges at
the catheter site.An objective was set at 6:20pm for patient to
meet herself care needs within 72 hours. Goal fully met on
15/09/2013 at 7:00am as nurse observed patient taking her bath and
caring for her mouth.
AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET
OBJECTIVES OUTCOMEDue to careful analysis of evaluation of nursing
care rendered to Mrs. D.O all goals were fully met. Cooperation of
patient and family and nursing and medical care rendered
contributed to the achievement of her goals, it brought about no
amendment of nursing care.Comment by Amankwaa: Not clearTERMINATION
OF CAREComment by Amankwaa: Comment by Amankwaa: This part is not
well-written. Cleary state when and how care was terminated. How
did the patient and family feel abt the termination and what
contributed to that?Mrs. D.O and family were made to understand
that patient hospitalization was temporal and that she would be
discharged to go home after her condition had improved. Created
friendship with patient family commenced on the 10th September,
2013 and with a good nursing care, clients condition improved and
was discharged on the 16th September, 2013 and care was terminated
on the 2nd October, 2013.Comment by Amankwaa: ???Also, home visits
were made to patients house and it was found out that the condition
of patient has improved. She was educated on her diet, drugs,
personal and environmental hygiene and also to report any sickness
to nearest hospital which is Kwadaso Sda Hospital. This ended the
interaction and Mrs. D.O hospitalization.
SUMMARY OF CARE PROVIDED TO PATIENT AND FAMILYMrs. D.O, 43 year
woman was admitted to the female surgical ward at SDA Hospital
Kwadaso on 10th September, 2013 and was diagnosed of uterine
fibroid.Patient presented signs and symptoms such as abdominal
pain, anxiety, high body temperature and others.Total abdominal
hysterectomy was done for patient at the theatre on 11th September,
2013 around 12:45pm.Nursing management such as mouth care, bed
bath, vital signs and wound dressing were rendered. Patient started
sips of water on 12th September, 2013.Nursing objectives and orders
were set, implemented for problems of patient during admission. Due
to qualify nursing care goals were fully met.Comment by Amankwaa:
Sentences not clearClient was told to come for removal of stitches
on 23rd September, 2013 and report for review on 27th September,
2013. Education was given to patient and family on maintaining
personal and environmental hygiene during admission.Education was
given to patient to take in well-balanced diet, encouraging rest
and sleep, and adhering to prescribed drugs to aid in wound
healing. Home visits were done after discharge of patient.
CONCLUSIONThis care study has equipped me with the knowledge and
skills to on uterine fibroid, its causes signs and symptoms,
surgical intervention [total abdominal hysterectomy], nursing and
medical management.It was observed that a successful patient and
family care depends on the cooperation of the patient and family
with the nurses willingness to help throughout the
care.Psychological and spiritual wellbeing of patient and family
were promoted all because of their opinions and cooperation given.I
would like to come out with a point that any patient who comes to
the hospital should be given such an individualized and specialized
nursing care which will help improve patients self-image and its
recovery.