Care Study

CHAPTER ONE

ASSESSMENT OF PATIENT / FAMILY

Assessment is the process of collecting data from a patient and his/her family. It is the first step in the

nursing process.

The information or data can be collected through physical examination, health history, laboratory

investigations, text books and family. Analysis is made from the information to arrive at the health

problems and appropriate nursing interventions are put in place to solve the problems noticed.

From the first day of meeting the patient and family, assessment begins. And this continues throughout

clients stay on the ward.

PATIENT’S PARTICULARS

Mrs. R. A. is a 34year old woman, born to Mr. J. M, a policeman and Mrs. E. M, a trader at La in the

Greater Accra region of Ghana. Mrs. R is a Ga and a Ghanaian by nationality. She is fair in complexion.

She weighs 60kg and 172cm tall. Out of three (3) siblings, two (2) girls and (1) boy, she is the second (2nd)

born.

She is married to Dr. R A, with 2 kids. She stays at high tension last stop, Awomaso in Kumasi. Mrs. R.A

is a Christian and worships at Lighthouse Chapel international Bantama branch. She completed Tamale

Nursing Training College in the year 2002 and now is a nurse by profession. She speaks Twi, Ga and

English language.

She has no known allergy to drugs and food. Dr R. A is her next of kin.

FAMILY’S MEDICAL AND SOCIO-ECONOMIC HISTORY

Information gathered from Mrs. R.A and her family revealed that there is no known hereditary disease

such as hypertension, asthma, epilepsy, diabetes, and mental disorders and no known chronic disease such

as tuberculosis in the family but occasionally, they do have slight fever and headache which are treated

with drugs purchased over the counter but if it is severe they seek treatment from the KNUST Hospital.

Mrs. R lives with her husband, two children, mother and a niece. She is unemployed at the moment with 2

dependants. Her husband, the bread winner, is a Nutritionist and a lecturer at the Kwame Nkrumah

University Of Science and Technology. Mrs. R. neither smokes nor drinks alcohol. She attends funerals

and weddings of family and friends. Mrs. R. does not belong to any social clubs.

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PATIENTS DEVELOPMENTAL HISTORY

According to client, she was told by the mother that she was delivered spontaneously by vaginal delivery

at full term in a nearby clinic in La in the Greater Accra region of Ghana. She was also told that, she was

immunized against all the childhood immunizable diseases like BCG, Polio, Diphtheria, Influenza,

Yellow Fever and Measles during infancy and was exclusively breastfed. A physical examination of her

right shoulder revealed an injection scar on the deltoid region which confirms BCG vaccination as she

said earlier.

According to client’s mother, at 4 months, Mrs. R. A. could sit with pillows at her back and at 6 months,

she could sit her without support. At the seventh month, she was able to drag objects toward herself,

start crawling and the first pair of tooth began to grow. She started saying "mama" or "dada” at 8 months

and could stand while holding onto something at 9months. Furthermore, she was able to jump with both

feet, Opens doors and started to recognize ABCs when she was about 27-28 months old.

At age of three she was able to brush her teeth with help, wash and dry hands own her own.

At the age of 13, her secondary sex characteristics began to develop as well as menarche. She went

through the developmental milestone without any complication.

PATIENT’S LIFESTYLE AND HOBBIES

Mrs. R wakes up every day at 4:00am to brush her teeth with pepsodent tooth paste, have her quiet time

for an hour after which she sweeps the house and its environs. At 5:45am, she wakes the kids up and

prepares them for school. At 6:30am she prepares and serves breakfast. When 7:30 she sees her kids off to

school after which she goes to take her bath. According to client, she uses warm water, sponge and prefers

to use any other bathing soap to Keysoap when bathing. If there is a need for shopping for cooking in the

house, she does that after having a nap. At 3:30pm, she starts preparing supper so as dinner could be

served at early. In the evenings, Mrs. R.A either attends church service if there is any or watches

television. On weekends she prefers to stay indoors and watch movies, listen to music, do the laundry or

attend weddings or any church programme of her interest. Furthermore, she loves to take tea or coffee

with bread for breakfast, rice and stew or beans and fried plantain for lunch, and fufu or banku with

groundnut or palmnut soup for supper.

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http://www.babycenter.com/0_developmental-milestones-crawling_6501.bc

http://www.babycenter.com/0_developmental-milestones-grasping_6578.bc

http://www.babycenter.com/0_developmental-milestones-sitting_6505.bc

PAST MEDICAL HISTORY

Client said she has never been hospitalized until her present condition. She stated that, she occasionally

experiences minor ailments such as headache, malaria, body weakness, cold and cough but are treated

with drugs purchased from the chemical shops. She has neither undergone surgery nor been blood

transfused before. She also does not go for periodic medical checkup.

PRESENT MEDICAL HISTORY

Client stated that she was faring well until 26 th December, 2011 when she experienced a vague

generalized pain which settled in the lower abdomen after a day. The abdominal pain was constant,

particularly worsens with movement and relieved when she lies still in bed. On 28 th December, 2011,

when she woke up from bed in the morning, the pain had become so severe and was accompanied with

rise in body temperature, nausea and vomiting. She was immediately rushed to KNUST hospital where

she received first aid and was transferred to the Accident and Emergency Unit of Komfo Anokye

Teaching Hospital.

She was then diagnosed of Acute Abdomen based on her clinical manifestations by Doctor Amoah of

General Surgery Team A and detained for further treatment.

ADMISSION OF PATIENT

On 29th December, 2010, at 11:40am client was admitted to the Komfo Anokye Teaching Hospital ward

C4, a female surgical ward with urology and gastrointestinal cases with the diagnosis, Acute Abdomen on

account of Dr. Amoah.

She was brought to the ward in a semi conscious state in a wheelchair client and accompanied by the

admission team and her husband. She was made comfortable in bed after her folder was collected from

the admission team and had been checked to confirm that she was to be admitted to the ward whiles her

husband was given a seat at the nurse’s station while patient’s particulars to be entered into the admission

and discharge book and the daily ward state sheet.

Her particulars from her folder were taken and recorded. These included her full name, address, age,

occupation, religion and next of kin. Her vital signs were checked and recorded as follows;

Temperature - 37.30C

Pulse - 72 beats per minute (bpm)

Respiration - 18 cycles per minute (cpm)

Blood Pressure -100\60 mmhg

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Client’s husband was informed that time of visit was 3:30pm and visiting time over at 5:00pm. He was

also asked to bring along client’s personal toiletries such as towel, sponge, soap for bathing, pail and other

personal items which will be needed by client while on admission.

Client was orientated to the ward by showing her the sluice room, Nurses’ station and also introduced to

other clients in the ward when condition was fair.

She was reassured that she was in the hands of competent staff and that everything possible will be done

for her to recover soon. She was allowed to ask any question she wanted and was answered politely.

Client complained of pain in her right iliac region, feeling hot and weakness which was written down in

the nurse’s note for continuity of care.

After being reviewed by Dr Amoah, She was placed on the following treatments which were administered

and recorded as ordered.

IV Buscopan 40mg bd x 24hours

IV Metronidazole 500mg tid x 48hours

Inj. Diclofenac 75mg bd x 24hours

IV Cefuroxime 1.5g tds x 48hours

He also requested the following laboratory investigations so he was assisted to collect samples:

Liver function test,

Complete Blood Count,

Blood urea nitrogen,

Creatinine

Serum electrolyte level

The sample was labeled and sent to the lab.

PATIENT’S CONCEPT OF HER ILLNESS

According to my client, she believes that her disease condition does not have any spiritual cause but she

believes that prayers and medical intervention will make her recover soon.

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LITERATURE REVIEW ON ACUTE ABDOMEN

DEFINITION

Acute abdomen or peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of

the abdominal cavity and viscera. Peritonitis may be localized or generalized, and may result from

infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or

from a non-infectious process.

TYPES OF PERITONITIS

The two main types of acute abdomen

1. PRIMARY SPONTANEOUS PERITONITIS

Primary spontaneous peritonitis is the development of peritonitis (infection in the abdominal cavity)

despite the absence of an obvious source for the infection. It occurs almost exclusively in people with

portal hypertension (increased pressure over the portal vein), usually as a result of cirrhosis of the liver. It

can also occur in patients with nephrotic syndrome.

The diagnosis of primary spontaneous peritonitis requires paracentesis (aspiration of fluid with a needle)

from the abdominal cavity. If the fluid contains bacteria or large numbers of neutrophil granulocytes (a

type of white blood cells), infection is confirmed and antibiotics are required to avoid complications. In

addition to antibiotics, infusions of albumin are usually administered.

2. SECONDARY PERITONITIS

Secondary peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the

abdomen and covers most of the abdominal organs.

Secondary means it is due to another condition, most commonly the spread of an infection from the

digestive tract.

AETIOLOGY

The most common risk factors of primary spontaneous peritonitis include:

1. Liver disease with cirrhosis. Such disease often causes a buildup of abdominal fluid (ascites) that

can become infected.

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2. Peritoneal dialysis. This technique involves the implantation of a catheter into the peritoneum to

remove waste products in the blood of people with kidney failure. It's associated with an increased

risk of peritonitis due to accidental contamination of the peritoneum by way of the catheter.

Common causes of ruptures that lead to peritonitis include:

Medical procedures, such as peritoneal dialysis

A ruptured appendix, stomach ulcer or perforated colon

Pancreatitis

Diverticulitis

Trauma

Common causes of secondary peritonitis include:

A ruptured appendix, diverticulum, or stomach ulcer

Digestive diseases such as Crohn's disease and diverticulitis

Pancreatitis

Pelvic inflammatory disease

Perforations of the stomach, intestine, gallbladder, or appendix

Surgery

Trauma to the abdomen, such as an injury from a knife or gunshot wound

Noninfectious causes of peritonitis include irritants such as bile, blood, or foreign substances in

the abdomen, such as barium.

PATHOPHYSIOLOGY

Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity, usually as a

result of inflammation, ischemia, trauma, or tumor perforation. Bacterial proliferation occurs resulting in

edema of the tissues and exudation of fluid develops in a short time. Fluid in the peritoneal cavity

becomes turbid with increasing amounts of protein, white blood cells, cellular debris and blood. The

immediate response of the intestinal tract is hypermotility, soon followed by paralytic ileus with an

accumulation of air and fluid in the bowel.

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CLINICAL MANIFESTATIONS

The first symptoms of peritonitis are poor appetite and nausea, and a dull abdominal ache that quickly

turns into persistent, severe abdominal pain, which is worsened by any movement.

Other signs and symptoms related to peritonitis may include:

Abdominal tenderness or distention

Chills

Fever

Fluid in the abdomen

Extreme thirst

Not passing any urine, or passing significantly less urine than usual

Difficulty passing gas or having a bowel movement

Vomiting

DIAGNOSTIC INVESTIGATION

Diagnostic tests for acute abdomen may include:

Blood and urine tests

Imaging studies such as X-rays and computerized tomography (CT) scans

Exploratory surgery

• Leukocytes (elevated) complete blood count, hemoglobin, hematocrit, and serum electrolytes

(altered potassium, sodium and chloride).

• Abdominal radiographs, computer tomography (CT) scan, and peritoneal aspiration with culture and

sensitivity studies.

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MANAGEMENT

SURGICAL MANAGEMENT

Surgery (laporotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to

correct any gross anatomical damage that may have caused peritonitis. The exception is spontaneous

bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the

first instance. If the peritonitis is due to a perforated appendix, then appendix is removed and suturing is

done to close or join the incision together again.

GENERAL NURSING MANAGEMENT

Position

Position patient for comfort (e.g. on side with knees flexed to decrease tension on abdominal

organs) to reduce pain.

Raise bedside rails to prevent patient from falling

Observation

Assess nature of pain, duration, location in the abdomen, and shifts of pain.

Check and record vital signs every 4hourly.

Monitor patient’s intakes and output to prevent fluid overload.

Observe and record character of any surgical drainage.

Observe for decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic

sounds, and passage of flatus and bowel movements, which indicate peritonitis is subsiding.

Observe and record character of drainage from postoperative wound drains if inserted; take care to

avoid dislodging drains.

Nutrition

Increase food and oral fluids gradually, and decrease parenteral fluid intake when peritonitis

subsides.

Encourage client to take fruits to boost immunity and aid in wound healing.

Drug

Administer prescribed antibiotics and analgesic medications

Administer and monitor intravenous fluids closely.

Educate

Postoperatively, prepare patient and family for discharge; teach care of incision and drains if still

in place at discharge.

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SPECIFIC NURSING MANAGEMENT

PRE OPERATIVE NURSING MANAGEMENT

Psychological Care

Reassure the client and the relative by explaining the type of surgery to be done on her and the disease.

Make it known to her that she is in the hands of competent staff and so by complying with staff she will

get well within few days. This will help to relieve her of anxiety and fears. Introduce people who have

undergone such operation to her. Allow her to ask any question about her condition and this will help her

gain knowledge about and understand her condition.

After all the explanation necessary for the patient to gain knowledge and understand her surgery, a

consent form is given to client to be signed, this gives the legal right for the operation to be performed on

the patient.

Rest and Sleep

Client’s bed should be free from creases and crumbs to prevent her being uncomfortable.

Reduce or if possible, eliminate noise in the ward; make sure all procedures are performed at a goal to

prevent procedures destructing her sleep.

Client must be kept in a Semi – Fowler’s position. It is the appropriate position she must be kept in

this position as much as possible to promote pulmonary ventilation and ease respiratory distress from

any abdominal distension.

Observation

Vital signs such as temperature, pulse, respiration and blood pressure are observed every four

hours to serve as a baseline for evaluating whether the patient’s condition is progressing or

improving.

Assess client for pain to know the location intensity, frequency, and duration.

Monitor client’s intakes and output chart, if abdomen is distended, abdominal girth is measured

and patient must be weighed daily.

Client’s emotional state must be observed and patient reassured

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Site of intravenous fluids must be observed for bleeding, blockage of the line and rate of flow to

rule out any fluid over load to client.

Side effects of drugs must be observed and recorded.

Pain management

Client must be observed for pain and pain management given

Diversional therapy may be done to distract the patients mind from pain

Cold compresses may be applied at the site of distension which can help relax the muscles.

Client must be encouraged to assume the position she finds comfortable which is not

contraindicated to her condition.

Administration of preceded analgesics such as Diclofenac 50 mg bd x 24hr must be given to relive

pain.

Investigation

All investigation must be done on the patient to correct any abnormalities related to blood, Hemoglobin

level, white blood cell count, sickling, Blood grouping and cross matching.

Nutrition

Serve fluid diet the night before the surgery.

Intravenous fluids such as dextrose saline normal saline, ringers lactate may be given to correct fluid

and electrolyte loss.

Nothing is given by mouth on the morning of the operation.

Skin Preparation

The area to be shaved must be washed and dried

Wash the operation site again after shaving and dry with bath towel.

Clean the shaved area again with an antiseptic lotion, apply sterile dressing towel and secure in

position with an adhesive tape.

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POST OPERATIVE MANAGEMENT

Under the post operative intervention, we have;

a) Immediate post-operative intervention and

b) Subsequent intervention

IMMEDIATE POST OPERATIVE CARE

This begins after the last stitch is done until the patient gains consciousness. A resuscitation tray which

should have a mouth gag, tongue forceps, tongue depressor, vital signs tray etc. is set. Other things like,

drip stand, vomit bowl, suction machine, fluid chart, oxygen cylinder are placed at the bed side. All these

are made ready on the recovery ward including a well made operation bed.

First, Check patient for the up and down movement of the chest or breathing to know if patient is

alive.

Surgeon’s notes are read and patient is placed on his or her back with head turned to one side to

prevent the tongue from falling back.

Position

Place patient in a semi-fowler’s position.

Turned the head to the side to facilitate easy emptying of the contents of mouth since patient is

unconscious.

Maintain the patient’s safety by ensuring that the patient’s airway is patent, and prevention of

injury by lifting the side rails

Maintenance of Airway

The patient must be positioned in a recumbent with the head turned to one side and neck extended

to prevent the tongue from falling back and blocking the airway. This will enhance bronchial and

pharyngeal secretions to drain out. Excessive secretions must be aspirated from her nasopharynx

and oropharynx.

Observation

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Observe and monitor vital signs every thirty (30) minutes till patients condition subsides or stabilizes.

Monitor the intravenous fluids for blood clot in the needle, presence of air bubbles tube kinked, all these

are done to prevent the development of any complication, also type of infusion, amount, time infusion

was set up must be observed and recorded.

The number of drops per minute and time infusion was completed are all recorded in the input and output

chart. Incision site is then observed for bleeding and if any reported at once. Observe for cyanosis, if

present, is a sign of hypoxia.

Prevention from Injury

Since patient is unconscious and cannot complain of pricking from needles, clamp that is exerting

pressure and burn from hot water bottle, patient needs to be protected from injury by ensuring that all

procedures are done using the right technique.

Subsequent Care

Wound Care

Dressing are normally changed on the third day post operatively, wound dressing must be done under

aseptic technique. Alternate stitches are removed on the seventh day and remaining stitches removed on

the Tenth day after surgery according to the surgeons preference. The wound must be observed for

infection, bleeding and pain.

Personal Hygiene

Oral toileting and bed bath needs to be done regularly to prevent harboring of microbes, thereby

preventing secondary infection.

Drugs

Administer Intravenous fluids and blood component therapy, if prescribed.

Prescribed drugs such as injection Pethedine 50mg as prescribed may be given to patient to relieve pain.

Antibiotics may also be given to prevent secondary infections.

Desired and side effects of drugs must also be observed.

Ambulation

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Early ambulation is also encouraged as soon as patient gains consciousness. Patient is encouraged to sit

up in bed and also to put his/her hand on the incisional site when coughing or sneezing to prevent wound

from gaping.

Nutrition

When bowel sounds are heard, sips of water or tea is given and nasogastric tube if any are

removed as ordered by the surgeon.

Administer prescribed stool softener if there is constipation.

Patient Education

1. Patient is educated on the disease condition including its definition, types, causes, signs and

symptoms and complications, as well as management.

2. Patient should be taught on how to care for the wound and if she is taking a surgical dressing in

place home, she can take it to a near by health centre for dressing.

3. Patient is educated on how, to observe the incision site for swelling, redness, bleeding and warmth

daily.

4. Patient should be educated on all medications and see to it that, she can administer each drug

according to the physician’s order and knows its effect and adverse effect.

5. Post operative activity must be discussed with patient by telling him to avoid lifting heavy objects

for 6 weeks after the surgery in other to prevent strain on the abdominal muscle until healing is

completed.

6. Patient is educated on how necessary to care for follow ups and treatment.

COMPLICATIONS

Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may

cause electrolyte disturbances, as well as significant hypovolemia, possibly leading to shock and

acute renal failure.

A peritoneal abscess may form above or below the liver, or in the lesser omentum

Sepsis may develop, so blood cultures should be obtained.

The fluid may push on the diaphragm, causing splinting and subsequent breathing difficulties.

VALIDATION OF DATA

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From the information gathered on the causes, signs and symptoms by the client, including results of her

laboratory investigations confirms that client was suffering from acute abdomen when the information

was compared with standards in various textbooks,

My client’s husband also confirmed the information collected from my client.

Therefore, the data collected is free from errors and misinterpretations for this study and therefore valid.

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CHAPTER TWO

ANALYSIS OF DATA

The second stage in nursing process is analysis, whereby the data collected earlier on are analysed to

ensure accuracy of the data. It covers comparison of data with standards, client and family strength, client

health problems, nursing objectives and nursing diagnosis.

COMPARISON OF DATA WITH STANDARDS

Information collected from diagnostic investigations, clinical features, treatment as well as complications

were compared with standard values in textbooks and stated in the following tables.

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TABLE 1: DIAGNOSTIC INVESTIGATIONS

DATE SPECIMEN INVESTIGATION RESULTS NORMAL

VALUES

INTERPRETATI

ON

REMARKS

28/12/11 Blood Liver function test Total protein 59.7 g/LAlbumin 39.10 g/LGlobulin 20.6Bilirubin total 20.6Bilirubin-direct 4.75 umol/LIndirect bilirubin 7.6

66.0-87.035.00-52.0025.0-35.01.0-17.00.00-3.40

1.5-14.0

Total protein and Globulin level was low whiles direct bilirubin level was high

No treatment was given

28/12/11 Blood White Blood Cell count (WBC)

13.84 x109/L 4– 10x109/L White blood cell count was above normal

Antibiotics was prescribed for treatment

28/12/11 Blood Platelet count 459 x103/uL 140-440 x103/uL

Platelet count was normal

Treatment was not given

28/12/11 Blood Differential count, NeutrophilsLymphocytesMonocytesBasophils

86.5%7.3%5.4%0.4%

37.0 - 75.0% 16.0 – 51.0%0.0 – 12.0%0.0 – 3.0%

WBC Differential count was within the normal range except lymphocytes which was below and the neutrophils which was above the normal range.

Antibiotic was prescribed for treatment.

1/1/12 Blood1. Blood urea Nitrogen / Creatinine Level.

42.0 8.0 – 36.0 Blood urea nitrogen/Creatinine level was above

Antibiotic was prescribed for treatment

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2. Creatinine

3. Urea

23µmol/l

3.4mmol/l

44 – 80µmol/l

2.14 – 7.14mmol/l

normal range.Creatinine was normal.Urea was normal.

No treatment was givenTreatment was not given

1/1/12 Blood Electrolyte analysis1. Sodium

2. Potassium

3. Chloride

138mmol/l

2.8mmol/l

99mmol/l

135 – 145mmol/l

3.5 – 5.5mmol/l90 – 110mmol/l

Potassium level was low

IV KCL 15ml(30mmol) in each 500ml of ringers lactate

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CAUSES

The literature review on acute abdomen stated that it can be caused by a raptured or a perforated

appendix, pancreatitis, diverticulitis or Crohn’s disease.

From the post operative notes of the client, her disease was precipitated by a perforated appendix

according to the surgical findings.

TABLE 2: CLINICAL FEATURES

CLINICAL FEATURES ACCORDING TO

LITERATURE REVIEW

CLINICAL FEATURES PRESENTED BY

PATIENT

1. Sudden onset 1. Onset was sudden

2. Abdominal pain at the right lower quadrant of

abdomen

2. Client had abdominal pain at his right lower

quadrant of the abdomen.

3. pyrexia 3. Client exhibited pyrexia of

38.0ºC.

4. Tenderness and rigidity at the right iliac fossa. 4. On palpation there was tenderness and rigidity at

the right iliac fossa of the patient.

5. Nausea and vomiting 5. Client experienced nausea and vomiting

6. Malaise 6. Malaise was experienced by patient

7. Constipation may be present 7. Client did not complain of constipation

8. There may be diarrhoea 8. Client had diarrhoea

9. Loss of appetite 9. Client complained of loss of appetite

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TREATMENT

In the literature review, management of acute abdomen is medically by antibiotics, analgesia and IV

fluids if the patient general state is not suitable for surgery and in situations where surgical intervention is

paramount then exploratory laporotomy is done.

TREATMENT OF CLIENT

Since patient’s attack was an acute one, an exploratory laporotomy was the treatment of choice which was

done under general anesthesia. All preparations like psychological, physical, physiological and spiritual

were made before the surgery.

She was put on the following drugs;

IV Normal Saline 3L x 48hours

IV Ringer’s Lactate 3L x 72hours

IV Metronidazole 500mg tid x 72hours

IV Ciprofloxacin 400mg bd x 72hours

Injection Diclofenac 50mg bd x 24hour

IV Dextrose Saline 1L x 48hours

Injection pethidine 50mg bd x 48hours

Tablet flagyl 400mg tid x 5days

Tablet ciprofloxacin 250mg bd x 7days

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TABLE 3: PHARMACOLOGY OF DRUGS

DATE DRUG DOSAGE/ROUTE OF ADMINISTRATION

CLASSIFICATION DESIRED EFFECT

ACTUAL ACTION OBSERVED

SIDE EFFECT/REMARKS

28/12/11 Normal Saline 0.9%

2.0 litres x 24hours,

Intravenously

Intravenous fluid and electrolyte

Gives energy and increases blood volume

Electrolyte and fluid balance maintained

Edema, headache, hypernatraemia, irritability. None was observed in client.

28/12/11 Ringer’s Lactate

2.0 litres x 24hours,

Intravenously

Intravenous fluid and electrolyte

Replaces fluid and supplies important electrolytes such as sodium, calcium and potassium

Fluid and electrolytes balance was maintained

Hypercalcaemia, fluid over load and electrolyte imbalance, hypercalcaemia. None was observed in client.

28/12/11 Metronidazole (flagyl)

500mg tidx48hours,

Intravenously

Antibacterial and Antiprotozoal

To control or combat infection

Infection was controlled

Dry mouth, headache, dizziness and nausea. Client complained of dizziness.

31/12/11 Ciprofloxacin 400mg bd x 72hours

Intravenously

Antibacterial Destroys bacterial and prevent bacteria DNA replication

Bacterial eliminated from blood and infection was controlled

Nausea and vomiting abdominal pain, headache, diarrhoea. These were all observed in client except headache

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DATE DRUG DOSAGE/ROUTE OF ADMINISTRATION

CLASSIFICATION DESIRED EFFECT

ACTUAL ACTION OBSERVED

SIDE EFFECT/REMARKS

31/12/11 Injection Diclofenac

75mg bd x 24 hours

Intramuscularly

Non – steroidal anti-inflammatory analgesic

Produces anti-inflammatory and antipyretic effect possibly inhibiting prostaglandin synthesis

Patient’s pain was relieved and pyrexia reduced.

Drowsiness, anxiety, depression, edema, hypertension, abdominal pain. None of these was observed in patient

31/12/11 Dextrose Saline 2.0 litres for 48hours

Intravenously

Isotonic solution caloric agent and fluid volume replacement

Corrects electrolyte imbalance and provide energy

Energy was restored and fluid balance was maintained

Confusion, phlebitis, glucosuria and hypovolemia. None was observed in client.

2/1/12 Inj. Pethidine 50mg bd × 48hours

Intramuscular

Opioid analgesic Depresses pain

impulse at

spinal cord

level

None was

observed

Seizures, Dizziness

Respiratory depression,

Client was relieved of

pain

4/1/12 Tablet Metronidazole (flagyl)

400mg tid x 5days

Orally

Antiprotozoal and antibacterial

To prevent infection

Patients wound healed without infection

Nausea, constipation, headache, dry mouth. None of these was observed in patient.

4/1/12 Tablet ciprofloxacin

250mg bd x 7days

Orally

Antibacterial Destroys bacteria

Infection was combated.

Fatigue, headache, and dizziness. None was observed in patient.

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COMPLICATIONS

Client did not exhibit any complication due to early detection of her condition, good treatment and

nursing care rendered with reference to the complications stated in the literature review.

PATIENT/FAMILY STRENGTH

Definition: This is the ability of client and family to participate in the care for the achievement of set

goals on their strength.

On admission, client was conscious and communicated with both health care providers and family

members.

Client and family were co-operative and provided all necessary information needed.

Client’s family members and friends visited her regularly when she was on admission and brought her

food as well. Family members were able to foot client’s bill even though she did not register for National

Health Insurance Scheme.

Client got out of bed, third day after surgery and could maintain her personal hygiene with little

assistance.

She was well oriented to time, place and person. The family of the client helped her cope with the

situation by providing her both spiritual and material support.

HEALTH PROBLEMS

At the time of admission till discharge the following problems were identified during the care of my

patient;

PREOPERATIVE:

1. Client experienced pain at the right lower abdomen on 29/12/11 at 11:45am

2. Client experienced pyrexia (38.0°C) on 29/12/11 at 12:50pm

3. Client was vomitting on 31/12/11

4. Client was anxious on 1/1/12

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POST-OPRATIVE:

5. Client experienced pain at the incisional site on 2/1/12

6. Client has wound on 5/1/12

7. Client was unable to care for herself 3/1/12

8. Client was prone to developing infection on 2/1/12

NURSING DIAGNOSES

A nursing diagnosis is a clinical judgment about individual, family or community’s response to actual or

potential health problems. It provides the basis for selection of nursing interventions to achieve objectives

for which the nurse is accountable.

The following nursing diagnosis was drawn from the patient’s health problems presented;

PRE-OPRATIVE:

1. Pain, related to inflammation at the right lower abdomen.

2. Hyperthermia (38.2°C) related to infection.

3. Risk for fluid volume deficit related to excessive vomitting.

4. Anxiety related to unknown outcome of disease and surgery.

POST-OPRATIVE:

5. Pain related to surgical incision.

6. Impaired skin integrity related to surgery

7. Self care deficit (Bathing/Hygiene) related to immobility.

8. High risk for infection related to surgical incision on the abdomen.

23

CHAPTER THREE

PLANNING FOR PATIENT/FAMILY CARE

Identification of nursing diagnosis leads to the next stage of nursing process which is planning.

Planning deals with setting of goals and objectives to help eliminate or reduce client’s health problem

and coming up with the appropriate nursing interventions to meet set goals .The client and her family

were actively involved in planning of nursing care.

The nursing care plan comprises of the following nursing diagnosis, objective/ outcome, nursing orders,

nursing interventions and evaluation were used to carryout the nursing care of patient.

OBJECTIVES OF CARE

1. Client will be relieved of abdominal pain within 45minutes as evidenced by

i. Client verbalizing a reduction in the level of abdominal pain.

ii. Nurse observing that client has a relaxed facial expression

2. Client will attain a normal body temperature (36.2 – 37.20C) within 6hours as evidenced by

i. Client verbalizing that she does not feel hot again.

ii. Client temperature within the range of 36.2 – 37.20C

iii. Nurse observing that client has a normal temperature by the use of a clinical thermometer.

3. Client will maintain normal fluid volume within 24 hours as evidenced by:

i. Client having good skin turgor and skin color being normal.

ii. Client’s temperature within the range of 36-37 degrees Celsius.

iii. Client’s pulse rate within the range of 60-100 bpm

4. Client will be less anxious within 2hours as evidenced by.

i. Client verbalizing relief of anxiety

ii. Client having a relaxed facial expression and participating in ward activities

24

5. Client will be relieved of incisional pain within 45 minutes.

i. Client verbalizing reduction of pain.ii. Nurse observing a relaxed facial expression.

6. Client ‘s wound will heal without infection within the period of hospitalization as evidenced byi. Client’s wound healing by first intension

ii. Nurse observing that client’s wound healing with no purulent discharge and minimal scar formation.

7. Client will be able to maintain her personal hygiene needs without assistance within 72hours

as evidenced by.

i. Client verbalizing that she was able to bath and groom without assistance.

ii. Client looking refreshed and relaxed in bed.

8. Client’s wound will heal by first intention without infection within seven days (1week).

i. Wound healing in the absence of signs of infection like purulent discharges and pyrexia

ii. Nurse observing absence of infection like purulent discharges.

25

TABLE 4: NURSING CARE PLAN

DATE & TIME

NURSING DIAGNOSIS

OBJECTIVE /OUTCOME CRITERIA

NURSING ORDERS

NURSING INTERVENTIONS

DATE & TIME

EVALUATION SIGN.

29/12/11

11:50am

Pain related to

inflammation at

the right lower

quadrant of

abdomen

Client will be relieved

of abdominal pain

within 45minutes as

evidenced by

i. Client verbalizing a

reduction in the level

of abdominal pain.

ii. Nurse observing

that client has a

relaxed facial

expression

1. Reassure client

2. Assist client to

assume a

comfortable

position

1. Client was reassured that

she was in the hands of

competent staff and

necessary measures have

been put in place to help

her recover soon.

2. Client was assisted to

assume a left lateral

position with flexion of the

hip to relax the abdominal

muscle to relieve pain

which she said was

comfortable for her.

3. Television sets were turned

to minimal volume and visitors

29/12/11

1:00pm

Goal fully met as

client verbalized

reduction in level

of pain.

26

3. Ensure a quiet

environment

4. Apply cold

compresses to the

inflamed area

5. Give prescribed

analgesics

were restricted as well, to help

client have enough rest to

reduce pain.

4. Ice pack wrapped in towel

was placed at client’s right

lower quadrant (inflamed area)

5. Prescribed analgesic such

as injection Diclofenac 50mg

was administered with a good

effect.

DATE & TIME

NURSING DIAGNOSIS

OBJECTIVE /OUTCOME

NURSING ORDERS

NURSING INTERVENTIONS

DATE & TIME

EVALUATION SIGN.

27

CRITERIA29/12/11

12:50pm

Hyperthermia

(38.0°C) related

to infection

Client will attain a

normal body

temperature

(36.2°C – 37.2°C)

within 6hours as

evidence by

i. Client verbalizing

that she does not feel

hot again.

ii. Client temperature

within the range of

36.2 – 37.20C

iii.Nurse observing

that client has a

normal temperature by

the use of a clinical

thermometer.

1. Reassure the client

2. Check patients

temperature every

2hours and record

3. Remove excess

clothing and serve

cold drink to reduce

temperature.

4. Tepid sponge

client.


her temperature will reduce

to normal with good nursing

care. This was done to allay

fear and win her co-

operation during the

procedure.

2. Client’s temperature was

checked with the

thermometer and recorded

every 2hours.

3. Client’s excess clothing

were removed in order to allow

air circulate around her to

reduce temperature. Client was

served 100mls of cold Fanta

lemon.

4. Client was tepid sponged to

29/12/11

6:00pm

Goal fully met as

client temperature

was 370C on the

clinical

thermometer.

28

5. Ensure adequate

ventilation

6.Serve prescribed

antipyretics

reduce her body temperature.

5. Nearby windows were

opened initially and tight

clothing removed to provide

fresh air to reduce the body’s

temperature.

6. Suppository Diclofenac

75mg inserted as prescribed

and recorded.

DATE &

NURSING DIAGNOSIS

OBJECTIVE /OUTCOME

NURSING ORDERS NURSING INTERVENTIONS

DATE & TIME

EVALUATION SIGN.

29

TIME CRITERIA31/12/11

8:00am

Risk for

Fluid volume

deficit related

to excessive

vomiting.

Client will maintain

normal fluid volume

within 24 hours as

evidenced by:

i. Client having

good skin turgor

and skin color

being normal.

ii. Client’s

temperature

within the range

of 36-37

degrees Celsius.

iii. Client’s pulse

rate within the

range of 60-100

bpm

i. Reassure client.

ii. Assess client’s skin

severity of dehydration.

iii. Remove all

nauseating objects in

client’s environment

iv.Monitor and record

vital signs to rule out

abnormalities like

tachycardia,

dyspnoea.

v. Administer prescribed

intravenous infusions.

i. Client was reassured

that vomiting will

subside with treatment.

ii. Client’s skin, eyes,

and lips, were observed

for signs of hydration;

client was mildly

dehydrated

i. Client’s environment

was freed of vomitus

bowl.

ii. Client’s vital signs

was monitored and

recorded to rule out

abnormalities like

pyrexia, tachycardia,

dyspnoea

iii. Prescribed Normal

Saline and Ringers

1/1/12

7:35am

Goal fully met as

client showed no

sign of

dehydration.

30

vi. monitor client’s

intakes and outputs and

record in the daily

intakes and output to

prevent client from

dehydrating.

Lactate

administered.

iv. Client’s intakes and

output was charted

by measuring urine

output, vomitus, and

intravenous

infusions

administered.

31

1/1/12

9:33am

Anxiety related

to unknown

outcome of

surgery

Patient will be

relieved of anxiety

within 2 hours as

evidenced by

1. Client verbalizing

relief of anxiety

within

2. Client having a

relaxed facial

expression


2. Explain procedure

3. Introduce client to

other clients on the

ward who have

undergone the

1. Client was reassured that,

since she was at the

hospital, she will be treated

and recover fully, without

any complication. This was

done to allay her fear and

anxiety through and to win

her co-operation

throughout treatment.

2. All procedures to be

performed were explained

to client to gain her

cooperation and allay

anxiety

3. Client was introduced to

other clients on the ward

who have undergone the

same operation to interact

1/1/12

11:30am

Goal fully met as

client verbalized

the relief of

anxiety

32

DATE & NURSING OBJECTIVE NURSING NURSING DATE & EVALUATION SIGN.TIME DIAGNOSIS OUTCOME ORDERS INTERVENTIONS TIME

2/1/12

6:00pm

Pain related to

surgical incision

Client will be relieved

of incisional pain

within 45minutes.


reduction of pain.

2. Nurse observing a

relaxed facial

expression.

1. Reassure client

2. Assist client to

assume a comfortable

position

3. Create a quiet

environment

4. Provide comfort

measures

1. Client was reassured to

have confidence in the

staff who will give

effective care to relieve

her of pain

2. Client was assisted to

assume a Semi

Fowler’s position.

3. A quiet environment

was created by

reducing the volume of

the television and

restricting visitors to

enable her have enough

rest.

4. Client was informed to

place her hands on the

incisional site whenever

coughing or sneezing to

2/1/12

8:00pm

Goal fully met as

client verbalized a

reduction in pain.

33


5-1-12

8:00am

Impaired skin

integrity

(wound) related

to surgical

incision

Client’s wound heal

during period

hospitalization as

evidence by

1. Nurses’ own

observation

that, client’s

wound has

healed by first

intention

2. Client

verbalizing

that, he has his

skin minimal

scar tissue

formation

1. Reassure client

2. Explain all

procedures to the

client.

3. Assess

wound for

discharges and

drainage

4. Remove alternate

stitches

5. Dress wound with

aseptic condition.

6. Educate client on

nutritious diets

1. Client was reassured that,

he wound have an intact

skin as soon as possible

2. Procedures were explained

to the client to gain his

cooperation to gain his

cooperation and support

3. Wound was assessed for

drainage and discharge as a

sign of infection.

4. Alternate stitches were

removed.

5. Wound was dressed with

aseptic procedures

(technique) to prevent

wound infection

6. Client was educated on

nutrition diets such as

promote wound healing

6-1-12

8:00 am

Goals fully met as

evidence by

Nurse observed

that, wound is

healing by first

intention and

there were no

signs of

infections.

34


4/1/12

6:00am

Self care deficit

(Bathing /

grooming)

related to

immobility

Client will be able to

maintain her personal

hygiene needs without

assistance within

72hours. As

evidenced by


that she was able

to bath and groom

without assistance.

2. Client looking

refreshed and

relaxed in bed

1. Reassure client

2. Give assisted or

bed bath twice daily

3. Assist client in

oral care


with assistance from staff, her

personal hygiene will be taken

care of until she is able to do it

herself.

2. Client was given bed bath

with assistance twice daily

with warm water to make her

feel refreshed, remove dirt as

well as to stimulate blood

circulation and with the use of

soap, sponge and towel as

well.

3. Client was assisted to brush

her teeth twice daily with close

up and soft brush to prevent

halitosis and oral infection.

7/1/12

5:30am

Goal fully met as

client was able to

perform bath and

groom herself

without

assistance.

35


2/1/12

8:00pm

High risk for

infection related

to surgical

incision on the

abdomen.

Client’s wound will

heal by first intension

without infection

within 7days (1week)

as evidenced by

1.wound healing in

the absence of signs

of infection like

purulent discharges

and pyrexia

2. Nurse observing

absence of signs of

infection.


2. Advice client to

keep hands away

from incision site.

3. Employ aseptic

techniques in

dressing client’s

wound

1. Client was reassured

that good techniques

for dressing will be

used to prevent

infection.

2. Client was advised to

keep her hands away

from the incision site

since her hands may be

contaminated with

micro-organisms that

can cause infection to

the wound.

3. Aseptic techniques like

proper hand washing,

use of sterile dressings

and instruments were

9/1/12

4:00pm

Goal fully met as

client as evidence

by clients wound

healing by first

intension and

nurse observing

the absence of

signs of wound

infection.

36


37

CHAPTER FOUR

IMPLEMENTING PATIENT / FAMILY CARE STRATEGIES

Implementation is the fourth stage in the nursing process. It entails the actual nursing care rendered to

the client and family from the time of admission till time of discharge.

SUMMARY OF ACTUAL NURSING CARE

DAY OF ADMISSION (29TH DECEMBER, 2011)

Client was admitted to ward C4 of the Komfo Anokye Teaching Hospital at 11:00am with Acute

Abdomen queried as her diagnosis. She was accompanied by an admission team from the Accident

and Emergency Unit of the hospital and her husband. On observation, client looked weak and in pain.

She had an IV line and catheter insitu, the catheter was connected to a urine bag with 100mls urine in

it. Client was assisted to change into her night wear with privacy provided and made comfortable in a

well made admission bed since she was in pain. Orientation of client was initially with held because

client was in pain but later in the day she was oriented to the ward, sluice room and nurses station.

Client and husband were reassured that due treatment and nursing care would be given to reduce pain

and to relieve her of condition. All necessary data were collected from her husband. Client’s name and

other personal data were entered in the Admission and Discharge book, and the Daily Ward State.

Client’s husband was informed about the visiting hours being 3:30pm-5:00pm and was also asked to

bring client’s personal toiletries such as soap, sponge, bathe towel, bucket, and toilet roll

Vital signs were checked and recorded as follows;

Temperature - 37.3ºC

Pulse - 72 bpm

Respiration - 18 cpm

Blood Pressure - 100/60 mmHg

Blood samples were then taken and sent to the laboratory for analysis WBC and RBC count, blood

urea nitrogen and Creatinine test.

Client was reassured again that, she was in the hands of competent staff and that every necessary

measures will put in place to get her to recover soon since she was in pain. Her bed was made free

from creases and a pillow was put on the bed to make her comfortable. Client’s drugs were collected

from dispensary and a stat dose of IV Ciprofloxacin 500 mg, IV Flagyl 500 mg, were set up and later

IV Normal Saline 1 litre.

The ward’s television set was turned to minimal volume and ice packs wrapped in towel was applied

to the inflammed area to reduce pain. Prescribed injection Diclofenac 50mg was administered and

recorded observing the 7 rights of drug administration, which is right patient, right medication, right

38

dosage, right route, right time, right documentation, and right to refuse drug. Client was fed rice and

stew at 12:05pm in bits as tolerated but she was not able to eat enough.

Client complained of feeling hot, her top sheet was loosened, excess clothing removed and her

temperature checked and recorded as 38.0 degrees Celsius. So she was reassured of good nursing care

to reduce her temperature. Client was tepid sponged with tepid water leaving drops of water on the

skin to aid in the reduction of her temperature as well as served 100mls cold Fanta lemon juice with

the aim of reducing her temperature and adequate ventilation was ensured by opening nearby windows

and removing tight clothing. Client’s temperature was 37.0 degrees Celsius upon recheck it was

recorded on the temperature sheet and the procedures carried out to reduce her temperature were

documented in the nurse note as well.

All intakes and output of patient were monitored within each 24 hours and it was balanced daily at the

start of the day to ensure that there is no fluid overload and to know the amount of fluid retained in the

body. Client was also given general care such as feeding, assisted bath, administering prescribed

medication, change of infusions and documentation in the daily fluid monitoring chart, and emptying

of urine bag. Client’s urine was deep yellow in colour and 600mls upon emptying. Client’s condition

was fair.

SECOND DAY OF ADMISSION (30TH DECEMBER, 2011)

On the second day of admission, I arrived at the ward at 7:30 am. I went to client and greeted her.

Upon questioning, client said that there is a reduction her abdominal pain as well as the high

temperature. I went back to the nurses table to read the report book which indicated that she was not

able to sleep soundly through the night because of the episodes of pain and loose stools she passed.

Client was assisted to take her bath and brush her teeth in the morning and fed oat after which she was

made comfortable in bed.

Vital signs was checked and recorded within the following ranges;

Temperature - 36.0 ºC -36.8 ºC

Pulse - 86bpm -94bpm

Respiration - 18cpm-22cpm

10:45am, client was reviewed during ward rounds by Dr. Ato Quansah, she complained of feeling

bloated. Client’s urinary catheter was removed and encouraged to rest based on Dr Quansah’s orders

since was booked for surgery on 2/1/12.

At 11:45am, she complained of unbearable abdominal pains, client was reassured, pain assessment

was done and it was found out that the pain was stabbing in nature, lasted 5mins for duration, and she

was relieved when lying on the left side while in pain when she lied on the right side. She was

39

positioned laterally on the left with hip flexed to relax her abdominal muscles after pain assessment

and injection Diclofenac 50mg administered and recorded on the drug administration chart.

Client was cooperative during medication administration. Client was also given general care such as

feeding, assisted bath, administering prescribed medication, change of infusions and documentation in

the daily fluid monitoring chart.

Client’s condition was fair.

THIRD DAY OF ADMISSION (31st December, 2011)

On my arrival, I went to my client’s to find out how she was doing. I observed that she looked ill and

also had a distended abdomen. Dr Aidoo of general surgery team A, was called to see client at 8:00am

who was restless, vomitting bile stained vomitus (100mls) thrice accompanied with a distended

abdomen. He ordered for nasogastric tube to be passed. Client was assisted to maintain oral hygiene

after which the nasogastric tube was passed. 900mls more of bile stained fluid with spots of blood was

drained.

IV normal saline 500mls was setup at a drop rate of 16 drops per minute. Nil per os was ensured with

an exception of ice cube sips according to the orders of Dr Aidoo. He also requested for abdominal

ultrasound which was booked to be done later in the day. Client’s ultrasound scan was done at 11am.

Vital signs was checked and recorded within the following ranges;

Temperature - 36.0-37.0ºC

Pulse - 90bpm-100 bpm

Respiration - 16cpm-20 cpm

Blood Pressure - 100-110/70-80 mmHg

Client was assisted to bath after which she was covered with top sheet to keep her warm. Patient was

also rendered general nursing care like emptying of the bag connected to the NG tube, serving of

bedpan with privacy provided, setting up prescribed IV fluids and recording it into the fluid intake and

output chart. Client condition was fair.

FOURTH DAY OF ADMISSION (1/1/12)

Client woke up at 7:00am. Her condition was ill. She talked of passing watery stool thrice in the night

and a reduction in her abdominal pain. Client’s bed linens were changed to make her comfortable.

She was reviewed by Dr Danso who asked that her blood sample should be obtained and sent to the

serology lab for serum electrolyte test. Result was obtained and client was placed on 10mmol of KCL

in either Normal saline or Ringers lactate till she got 60mmol. The reason behind this was to improve

her serum potassium level because the test showed it was low. Client’s Nasogastric tube drainage bag

40

was emptied and the tube, monitored for kinking. Her IV fluids were administered as prescribed and

recorded in the fluid intake and output chart.

Vital signs was checked and recorded within the following ranges;:


Pulse - 90-100 beats per minute

Respiration - 20-26 cycle per minute

Client’s prescribed treatments were administered and she was reassured of recovering soon with good

nursing measures put in place. At 9:30am client was anxious. So she was reassured of the safety

measures that have been put in place to prevent any possible complications.

A member of the surgical team, Dr Davor, came to the ward to talk with the client in order to allay her

fear. Other clients who had undergone the same operation were allowed to share their experience with

the patient to encourage her on the impending surgery. He also confirmed of the surgery the next day

at 10am so pre-operative preparation was started.

Client was prepared for exploratory laporotomy under the following headings;

1. Psychological Preparation.

2. Physical Preparation.

3. Rest and sleep

4. Physiological preparation

Client, husband and mother were reassured that the surgery was going to be successful. They were

assured to allay fear or anxiety. The expected outcome of the surgery was also explained to them. She

was also made aware of the post operative pain, but told that analgesics will be given to take care of

the pain. Client was taken through the consent form and made to sign.

Client was told about what to expect in the theatre; the staff dressed in theatre gowns, face mask, an

anaesthesia machine, an operation table, a ventilator, cardiac monitors an adjustable operating lamp

hanging above the operating table with the aim of orienting her to the theatre. She was also informed

that she would be put to sleep prior to the operation by injection.

Client was assisted to maintain person hygiene which includes bathing, brushing of teeth and cutting

of finger nails. She was also shaved from above the umbilical area through to the pubic region. The

site was cleaned with savlon in order to prepare her for surgery.

Client’s bed was made free from creases and crumbs to prevent her being uncomfortable.

The volume of the ward’s television was lowered to reduce noise.

All procedures were grouped and performed to prevent destructing her sleep.

Client was placed in a Semi – Fowler’s position

Client’s laboratory results were collected and made ready for surgery the next day.

41

( 2/1/12 ) OPERATION DAY

Client woke up at 6:30am. She was provided privacy served bedpan and asked to empty her bowels

but could not move her bowels because she had been on nil per os except ice cube sips for two days.

She was assisted to take her bath and made comfortable in bed.

At 9:45am, client’s operation site was cleaned with savlon in spirit, covered with sterile towel and

secured in position with adhesive tape.

An indwelling urethral catheter was passed and connected to a urine bag for continues drainage. She

was assisted to change into a theatre gown and cap. All jewelleries on her like the wrist watch and ring

were removed and given to the husband in her presence for safe keeping. 500mls of intravenous

Ringers lactate was set up 10:00am.

Vital signs checked and recorded on the temperature chart as follows to serve as a baseline;


Pulse - 80bpm

Respiration - 20cpm

Blood pressure - 100/70 mmHg

Client was prayed with to boost her spiritual titre. She was then sent to the theatre at 10:30am with her

folder, lab results and ultrasound result.

IMMEDIATE POST OPERATIVE CARE

Client was brought back to the recovery ward around 3:00pm in a semi-conscious state with 200mls of

Dextrose Saline on and dripping well. . Client was observed for chest movement and pulse to make

sure she was alive Urethral catheter, NG tube and a drainage bag containing 500mls of offensive pus

drained from the abdomen were all in position .She was put in a supine position with the head turned

to one side to enhance drainage of secretion from the mouth. She was comfortable in an operation bed.

The incisional site was observed for bleeding, swelling, skin discoloration and discharges, but none

was seen. A fluid intake and output chart was monitored and the surgeons notes read.

Her vital signs were checked and recorded as follows; every 15minutes for first 1hour, 30minutes for

2hours, 1hour for 4hours and 4hourly for 24hours till client gained consciousness and was rechecked

every 4hours and recorded accurately.


Pulse - 80bpm

Respiration - 20cpm


Patient was brought back to the ward from the recovery ward after appendicectomy had been done

under general anesthesia by Dr. Latiff assisted by Dr. Davor. Client had a urethral catheter, an iv line

42

with 400mls of lactated ringers setup, NG tube and a drainage tube connected a drainage bag with 50

mls of blood. She was received into an operation bed and made comfortable in bed at 5:30pm. All post

operative medications were served and recorded. She was protected from injury by raising the side

rails of the bed.

Client complained of incisional pain. She was reassured that measures were being put in place to

relieve her of the pain and complications. The volume of the television set was reduced and visitors

restricted as well to induce sleep. She was advised to put her hand on the incisional site when

coughing or sneezing to reduce stress on the suture line. Client’s drugs were reviewed and changes

made, she was placed on:

IV ceftriaxone 2g dly x3days,

IV 5% Dextrose 2litres daily x 3days,

IV Ringers lactate 1litre with 15 mls of KCL in each pint,

Injection pethidine 100mg dly x 3days

All due medications were administered and recorded, assisted warm bed bath given, fluid intake an

output monitored and KCL administered as prescribed. Client was reassured and made comfortable in

bed. She had a sound sleep throughout the night without any complain. Condition was stable.

FIRST POST-OPERATIVE DAY (3rd January, 2012)

Client woke up at 6:30am and stated a reduction in pain at the incisional site and said she had a sound

sleep.

Her urine bag was emptied and amount recorded in the fluid chart, after which her personal hygiene

was cared for by giving her an assisted bed bath with warm water and assisting her to brush her teeth,

to remove dirt and stimulate circulation in order to make her feel refreshed. Her bed linens was

changed and straightened to make her comfortable, as well as items on her locker were well arranged.

Client was reviewed by Dr. Davor and no changes were made to her treatment except her urethral

catheter was ordered to be removed and nil per os maintained. The same was done.

Client’s wound was assessed for bleeding which was absent and early ambulation was encouraged by

assisting her to sit up in bed and later taken a few steps as tolerated around her bed. The site for the

intravenous line was observed for redness; swelling, flow and amount of fluids to be administered

were also checked.

Vital signs was checked and recorded within the following ranges



Respiration - 20 cycle per minute

Blood pressure - 100-110/70-80 mmHg

43

Due treatments administered and recorded. She was assisted to bath and groom herself. She was made

comfortable in bed. She finally retired to bed at 6:30pm.

Client’s condition was fair.

SECOND POST – OPERATIVE DAY (4th January, 2012)

Client woke at 6:00am. She was given a bed bathed, nasal care and oral care was. Her wound was

assessed for signs and symptoms of infection like pain or tenderness, localized swelling, redness or

heat but none was observed after which the wound was reinforced to keep dressings in place. Her

drainage tube was checked to know if it was in position after which it was cared for. Vital sign was

checked and recorded as follows:

Temperature - 36.0-36.5 oC


Respiration - 19-22 cycle per minute

Due medications were served and recorded in the drug administration chart.

Client’s condition was encouraging as compared to the previous day. Client was reviewed by Dr.

Niraka. She was asked to start sips of tea and to continue with her antibiotics. 100mls of warm tea was

prepared and served client after review, it was well tolerated.

Client was then educated on how to care for the wound to prevent infection. She was advised to keep

her hands away from the incision site and not to temper with the adhesive plaster on the wound too.

Client’s was served bedpan, drainage bag was emptied, due IV fluids setup and recorded into the fluid

intake and output chart. Client’s condition was stable.

THIRD POST – OPERATIVE DAY (5TH January, 2012)

Client woke up and had no complains about the night. She was assisted with bed bath and oral

hygiene; her vital signs were checked and recorded.

Her wound was assessed during dressing for signs of infection high temperature or purulent discharges

but there were none but her wound dressings were soaked with serous fluid. Wound dressing was done

with methylated spirit and sterile gauze under aseptic techniques to prevent infection. Her wound was

packed with more gauze and secured into place with strips of adhesive tape.

She was reviewed by the doctor Niraka; she said client was for possible discharge the next day.

Client’s drainage tube and urinary catheter was asked to be removed and blood sample obtained for

Hb Level and BUE of which all was done as ordered.

Client was asked to continue with light diet and ambulate during ward rounds; oral medications were

served and recorded. All other needed nursing cares were rendered.

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FOURTH POST - OPERATIVE DAY (6th, January, 2012)

Client woke up at 6:45am; she looked cheerful and expressed improvement in her condition. She also

said she had a sound sleep throughout the night. Client got out of bed and maintained personal hygiene

herself. Her wound was clean upon dressing and looked dry.

Vital signs checked and recorded as follows.


Pulse - 72bpm

Respiration - 18cpm


Client was served with light soup and “kafa” for breakfast after which she was assisted to walk

around. On ward rounds with doctor Niraka, client was discharged home on:

Tab Augmentin 1g bd x 7days,

Tab Vitamin C x 30days,

Cap Naclofen 70mg bd x 7days,

Client was asked to come for review on 10TH January, 2012 for the alternate stitches to be removed.

Her wound was then dressed for her aseptically after ward rounds to prevent infection. I read client’s

folder to confirm if she was discharged after which I called client’s husband and told him she was

discharged.

Due medications were served and recorded as ordered. Client was advised to eat more fruits and high

fiber diet to avoid constipation. Client was also encouraged to continue walking around to help in

early wound healing. She was told the need to stick to treatment whiles on discharge and importance

of registering for the National Health Insurance Scheme.

Client’s folder was sent for assessment and payment of her hospital bills when the husband came. Her

name was then entered into the daily ward state, Admission and Discharge (A&D) book. After paying

the bills, I gave her the review card, helped client pack her things and escorted them to the entrance of

the hospital reminding them of my next visit to their home.

After they had left, the bed linens were removed and the mattress decontaminated with parazone 1:10.

The linens were sent to the sluice room for washing and sterilization at Central Sterilization and

Supply Department (CSSD) for reuse.

45

PREPARATION OF PATIENT / FAMILY FOR DISCHARGE

AND REHABILITATION

Client and family were prepared towards discharge on the day of admission. First of all, client and

family were informed that, the hospital was a temporal place to stay when one is sick. Therefore, they

were reassured that after recovery, client will go back to the house or community to continue her

normal life.

She was then advised to co-operate with the health team to ensure her speedy recovery. Client and

family were prepared towards discharge through effective education.

They were reassured that the hospital has competent medical, nursing and other health care providers

who will be available to give her good care. The cause, signs and symptoms, treatment and

complications of her disease were explained to their understanding, since during admission; it was

observed that patient and family were very anxious and disturbed about the disease condition and the

long stay at the hospital.

They were educated on good personal hygiene which facilitated speedy recovery and promote good

health and were informed to make good use of health facilities as well.

Client and family were also educated on the need to adhere to good nutrition especially to include

enough protein to help in early wound healing. Source of good food such as milk, beans, food rich in

vitamin C like oranges were encouraged to be taken. They were also informed to take enough

vegetables and roughage to prevent constipation.

They were educated on the drug prescribed for her and the need to comply with the treatment regimen.

Information was given to them on the need for regular visit to the hospital and also to come for review

on the specific date given to them.

Client and family were informed on how to care for the wound after discharge and also not to engage

in vigorous activities including lifting of heavy objects at least for the first six weeks.

46

FOLLOW-UPS / HOME VISITS / CONTINUITY OF CARE

Follow-up and home visit play a vital role in the care of the client after discharge. It is done to find out

how client and family are faring at home and the use of available resources within the client’s

environment to solve any problem through their own efforts. It also helps to determine if there are any

predisposing factors to client’s condition so that the needed health education will be given to prevent

any recurring disease.

FIRST HOME VISIT (31st DECEMBER, 2011)

This visit was arranged and made possible by the company of client’s husband while client was on

admission. The reason for the visit was to assess the home environment of patient and to detect

predisposing factors and any contributing cause to client’s disease in the environment.

Also, to assess how client will cope with the home environment after discharge.

To meet everybody at home, patient’s husband and I made the visit in the evening after he came

visiting client. We got to high tension last stop, Awomaso where they lived at 4:30pm. It was a 45

minutes drive from Garden City University College.

Client and family of six, lives in a self-contained house built with cement and roofed with aluminum

roofing sheet. On entering the house, it was observed that there were six rooms in all with a kitchen,

three toilets and three baths. Well water was the source of water which they used for cooking, bathing,

washing and even drinking. I was informed that they had a place they burnt their refuse instead of

giving it to refuse trucks to dispose of it properly because they had no such trucks collecting refuse in

the vicinity. Aside that the surroundings were clean with covered drains. The nearest clinic near the

house was the Awomaso Clinic.

They were informed to maintain the clean environment and boil and cool well water for drinking to

avoid any other diseases. After observing the environment, I realized that client can stay in the house

after discharge. I then reassured them of client’s progressing condition and sought permission to leave

after informing them that the next visit will be on the 8th January, 2012.

SECOND HOME VISIT (8th JANUARY, 2012)

On the second home visit, client was met in the house, it was a surprise visit in other to meet the

family in their natural environment and to see how she was faring and responding to treatment after

discharge.

Client and family were in good health with clean surroundings as well. I asked of any problems and

complaints but there was none. The wound was assessed for signs of infection but were all absent. I

told her to keep going for dressing at the Awomaso clinic.

47

I checked her medications and realized she was taking them as prescribed. I encouraged them to keep

to the advice given to them during the discharge.

Client was advised to avoid strenuous exercises and reminded of the review date which was four days

after, for the rest of the stitches to be removed.

Client and family were informed that my next visit I will be my last since am terminating my care.

Client and her husband escorted me to the door, thanked me for my assistance, I bade them goodbye

and left.

DAY OF REVIEW (10TH JANUARY, 2012)

On the day of review, client was accompanied by her husband. Few hours after her arrival, she

complained of weakness in that morning even though she had taken breakfast. She was given fruit

juice to provide her with some energy. Client was assisted to go for her folder and accompanied to the

consulting room 9. She complained of incisional pain when went into the consulting room. The doctor

then prescribed an antibiotic, Dalacin C and Zinc for client to purchase after which he advised that

client continue with her drugs and to report to the hospital if she experienced any other abnormalities

in her state of health.

Client was then sent to the ward for the alternate stitches to be removed after which wound was

dressed. She was asked to come a week later for the remaining stitches to be removed. I escorted client

and husband after wound dressing to the hospital entrance to board a car home.

THIRD HOME VISIT (26TH JANUARY, 2012)

Client was visited for the last time, on arrival at the house; client and family were doing well. They

were advised to maintain good nutrition, complete drug regimen, monitor and report any side effect of

medication and good personal and environmental hygiene, to maintain good health. I also recommend

to client that she could report to the Awomaso clinic, in case of any problem for continuity of care

since her condition was stable.

She said her review date was on 17th January, 2012.

Client and family expressed their gratitude to me for the good nursing care rendered to them.

I also thanked them for their good interpersonal relationship and cooperation during admission and

after discharge, after which I left.

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CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT / FAMILY

Evaluation is the final stage in the nursing process. It focuses on the outcome of the objectives set in

the nursing care plan and the effectiveness of the care given.

It also determines the extent to which goals have been achieved.

STATEMENT OF EVALUATION

The objectives set for client and family were fully met with effective implementation and co-operation

of the family, which contributed to her speedy recovery.

For instance, on 29th December 2011, client complained of abdominal pain at the right lower quadrant.

An objective was set to relieve her of the abdominal pain within 2hours was finally met as client

verbalized a reduction in the level of pain.

Again, on 29th December, 2009, client’s body temperature was high. An objective set to reduce her

temperature to normal 6hours was fully met as her temperature on the clinical thermometer read

37.0°C.

On the 31st of December 2011, client was vomitting excessively. An objective set to maintain his pulse

within 60-100, temperature within 36.2-37.2 degrees Celsius, a good skin turgor and a normal skin

colour was fully met as her skin colour and turgor was normal and his vital signs within the normal

range.

However, on 1st January, 2012, client complained of being anxious due to unknown outcome of

surgery. An objective set to relieve her anxiety within 2hours was fully met as client verbalized the

relief of anxiety.

Also, on 2nd January 2012, client complained of pain at the incisional site. An objective set to enable

her experience minimal pain within 2hours was fully met as client verbalized reduction in pain.

On 5th January 2012, client had wound. An objective set to ensure that client’s wound heals by first

intention within the period of hospitalization was fully met as client’s wound was healing under first

intention.

Also, on 4th January, 2012, client could not maintain her personal hygiene.

An objective set to enable client maintain her personal hygiene needs without assistance within

72hours was fully met as client was able to perform self care activities without assistance.

Again, on 2nd January, 2012, client’s risk for infection was high. An objective set for her wound to

heal by first intension without infection within 7days (1week) was fully met as client’s wound healed

by first intention.

49

AMENDMENT OF NUSRING CARE PLAN FOR PARTIALLY MET OR UNMET

OUTCOME CRITERIA

All the goals and objectives set for client’s care were fully met. There was therefore no amendment

made to any of the nursing care plan.

TERMINATION OF CARE

Termination of care is a gradual process whereby the interaction between the nurse and the

family/patient is withdrawn. Separation can bring anxiety and depression due to its accompanied

psychological pain.

In view of this, client and family were given gradual psychological preparation toward the termination

phase. This started on the day of admission till discharge.

My interaction with client and family started on 29 th December, 2011 at the Komfo Anokye Teaching

Hospital and ended on 26th January, 2012 when I made my final visit to their home.

Client was also informed to report any abnormality in her state of health to the hospital nearby for

further management.

50

CHAPTER SIX

SUMMARY AND CONCLUSION

SUMMARY

Client was admitted on the 29th December, 2011 to ward C4of Komfo Anokye Teaching Hospital with

the diagnosis of Acute Abdomen secondary to perforated appendix. She was booked for surgery on 2nd

January, 2012 for the surgical removal of the perforated appendix and drainage of the accumulated

pus.

She was put on:

Antibiotics

Analgesics

IV infusions

While on admission, during nurses assessment on client, she present the following health problems;

lower abdominal pain, high temperature, pain at incisional site, risk for infection, and self care deficit.

Goals set on all these health problems were fully met, after a good nursing care.

On 6th January, 2012, client’s condition had improved and was finally discharged.

This was as a result of the family’s involvement in the care of client and with adequate nursing

measures given, both pre-operatively and post-operatively.

After her discharge, follow-up visits were carried out to assess her condition at home.

She was seen to be healthy on each visit and adhered to the health education that was given to them on

admission, day of discharge and during home visits.

CONCLUSION

In conclusion, my understanding and knowledge on acute abdomen has been broadened as this care

study has been an educative, challenging and interesting experience to me.

I have gained experience and knowledge on how individualized and holistic care is rendered using the

nursing process. It has also helped me establish good interpersonal relationship with client and family,

and this also helped client to achieve maximum health.

This care study will also serve as a guide or reference document for future student nurses who will

under take similar exercise.

Therefore, it is my hope that the knowledge I have acquired will enable me to care for clients not only

with acute abdomen but other disease conditions as well, and to impart the knowledge acquired to

other colleagues during academic exercises and clinical practice.

51

BIBLOGRAPHY

British Medical Association and Royal Pharmaceutical Society of Great Britain, (2007) British

National Formulary, 53rd edition, BMJ Publishing Group Ltd and RPS Publishing. London.

Chou, J. S.& Chung, C. R. (2007). Pain in the right lower quadrant. American

Family Physician, 1541–1542.

Schaffer, S., & Yucha, C. (2004). Relaxation & pain management: The relaxation re-sponse can play a

role in managing chronic and acute pain. American Journal of

Nursing, 75–82.

Smeltzer, S.C. and Bare, B.G. (2008), Brunner and Suddarth’s, Textbook of Medical Surgical Nursing

11th edition, J.B. Lippincott Company. Philadelphia.

Tucker S. M., Canobbio M. M. , Wells M. F. and Paquette V. E.(2000), Patient Care Standards,7th

edition, Mosby St. Louis, Misourri pg 320,321

Patient’s folder IP number: GSTA 32995

52

SIGNATORIES

NAME OF CANDIDATE: PERCIVAL BRUCE

SIGNATURE: __________________________

DATE: _________________________

NAME OF WARD IN - CHARGE: Mrs GLADYS AMENUEDI

SIGNATURE: __________________________

DATE: _________________________

NAME OF SUPERVISOR: Mrs. VERONICA KWARTENG

SIGNATURE: ________________________

DATE: ________________________

NAME OF PRINCIPAL: MADAM DZIGBORDI KPIKPITSE

SIGNATURE: __________________________

DATE: _________________________

53

Documents

Care Study