PATIENT AND FAMILY CARE STUDY

ON
MRS G.A.
WITH
INTESTINAL OBSTRUCTION SECONDARY TO POST OPERATIVE ADHESIONS
(BOWEL RESECTION AND ANASTAMOSIS DONE)

PRESENTED BY

DANKWA BETAH AMA

CHAPTER ONE
ASSESSMENT OF PATIENT AND FAMILY

Assessment of patient and family is the first step in the nursing process which involves a careful
and systematic collection of data from the patient, family, friends and community through
examination, observation, interview, laboratory investigations and x-ray
The purpose of this study is to identify the patients problem which is expresseds as actual or
potential. The information serves as a foundation upon which appropriate nursing intervention
will be established and implemented for the speedy recovery of the patient.
PATIENTS PARTICULARS
Mrs. G.A. is a 68year-old woman born on 11th March 1946 to Opanin Kofi Boakye and Maame
Yaa Nsia; who are both deceased. dead and may their soul rest in perfect peace; on 11th March
1946 at Oduom in the Ashanti Region of Ghana. She is dark in complexion and stays at
Nyankyirenease. Mrs G. A. is about 5.2 feet tall and weighs about 52kg. She is the third (3rd)
among eleven (11) siblings, and the only female. She was married to O. A. Opanin Akwasi Prah
and have givenave birth to nine (9) children; five(5) male and four(4) female. Two females are
deceased. and two(2) among the four (4) females are dead. She is a Christian and worships with
the Methodist Church at Nyankyirenease
Next of kin?

FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY

According to Mrs. G.A. there is no known chronic or hereditary diseases like hypertension,
asthma, or mental illness in the family. diabetes mellitus and also no known history of mental
illness and communicable disease like tuberculosis, leprosy, epilepsy in their family. She also
could not remember any food allergies. admitted that there are no food allergies. Members of the
family usually take over- the- counter drugs to cure treat minor illness like malaria, headache and
, bodilty pains, etc. She depends on her grown children for financial support.
Type of accommodation?
Is she employed or what was the previous job
Source of drinking water
Refuse disposal
Economic class???
PATIENTS DEVELOPMENTAL HISTORY
According to client, she was born at term by spontaneous vaginal delivery with the help of a
Ttraditional Bbirth Aattendant (TBA) at home. Clients mother then sent her to a nearby clinic
for other treatment. Client went through a normal developmental milestone without any
complains. . She began teething at age 5 months, started to crawl at age 9 months and started
walking at age 14 months. She feeds on the normal family diet such as fufu and light soup, rice
and stew, banku and okra stew or palm nut soup.
Your developmental history must contain the following (you have already written some)
a.
b.
c.
d.
e.
f.

Immunisation status
B.feeding history
Developmental milestone; summary
Educational history
Secondary sexual characteristics
Marital history if married

PATIENT LIFESTYLE AND HOBBIES

Mrs. G.A .usually wakes up at 5:30 a.m. and says a word of prayer before getting up from bed.
She washes her his face, brushes her teeth with tooth paste and tooth brush then shower down.
She then takes in breakfast. She then goes out to take a walk and comes back to the house to
watch television then sleeps when feeling tired. . She normally takes her supper at 6:30pm. She
watches television, maintains her personal hygiene and goes to bed at 9pm. According client, she
baths twice daily with soap, sponge and warm water. She cleans her teeth twice daily with
toothpaste and brush before and after going to bed. She empties her bowel twice daily.

Does your patient go to work?

Active/social/introvert???

PATIENTS PAST MEDICAL HISTORY

According to client, she had never experienced any medical condition like, hHypertension,
diabetes, tuberculosis etc. She had never received any blood transfusion and had no known
allergies. According to client, sShe was however admitted at Suntreso Government Hospital a
year ago at the Female Surgical Ward with the diagnosis of appendicitis and appendectomy was
done and was discharged.

PATIENTS PRESENT MEDICAL HISTORY

Patient was well until 4th October 2014, when she experienced stomach ache, which was colicky
in nature and of a sudden onset., it had relieving factors. Her vomitus contained food eaten
previously and was yellowish in colour. She was subsequently then admitted to Suntreso
Hospital on 9th October 2014. An X-ray was taken which showed distended bowel. She was then
transferred to Komfo Anokye Teaching Hospital on 10th October 2014 and she was admitted at
the Accident and Emergency Center. After examination, she was diagnosed of intestinal
obstruction and was trans-out to the female surgical ward C4 to be prepared for surgery.

ADMISSION OF PATIENT

On Friday, 10th October 2014 at 7:25am, Mrs. G.A. was admitted through the Accident and
Emergency Centre (Major and Minor) of Komfo Anokye Teaching Hospital to the Female
Surgical Ward C4. She was brought to the ward on a trolley fully conscious accompanied by a
triage nurse and three relatives, with about 250mls of dextrose saline in situ and , dripping were.
There was also urethral catheter and nasogastric tube in situ. She came to the ward with the
following medications; IV Augumentin 2g stat, Injection Pethedine 10mg stat, IV Flaggyl, IV
Ciprofloxacin, IV Normal Saline and IV Dextrose Saline. They were warmly welcomed and
escorted to the nurses table. Her relatives were given a chair near the nurses table to assist in
providing information about the patient. Clients folder was collected from the accompanying
nurse. She was placed in a recumbent position in a comfortable bed free from creases and
crumbs. Client and relatives were reassured of good medical and nursing intervention and care.
The information about the client in the admission papers was read to gain knowledge about the
patient, her particulars such as name, sex, age, date and time of admission were identified and
recorded. The patients name and other information were entered in the Admission and Discharge
book and daily ward state. Vital signs were checked and recorded as follows:
Temperature = 37.5 C.
Pulse

= 94 beats per minute.

Respiration

= 22 cycles per minute.

Blood Pressure = 130 /60 mmHg.

The patient and family were oriented to various areas on the ward such as the toilet, bath room.
Patient was also introduced to other patients on the ward. Relatives were educated on the visiting
hours. Since patient had the National Health Insurance card, they were not made to deposit any
amount of money. They were given health education on Mrs. G.As condition. Other nursing care
was performed.
She was put on the following treatment;
1. Intravenous normal saline 2. 0 litres
2. Intravenous Dextrose saline 2.0 litres

3. Intravenous Ringers lactate 2.0 litres

5. Intravenous Ciprofloxacin 400mg tds 2 days
6. Intravenous Flagyl 500mgmls tds 2
7. Suppository Diclofenac

Comments
I think your admission is poorly done. You failed to:

Identify the patient

Do a quick and initial assessment on the patient
What complaints did she come with and what did you observe?

Follow this format to complete your work

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.

In what state did patient come in? conscious?

Accompanied by whom?
Date and time of admission
How was the patient received and identified?
Immediate nursing interventions based on patients condition
Vitals checked and recorded
Physical examinations done and findings
Lab investigations
Treatment given
Orientation of patient to the ward environment
Indicate items that has to be brought
Make patient/family know that the relationship was a temporal one
Explain to the patient that they are being used for a study; explain the
rationale and the fact that they can decline without it having any effect
on their treatment or care.
n. Encourage visitation
o. Documentation/nursing care plan

PATIENTS CONCEPT OF ILLNESS

Patient has no knowledge about the cause, signs and symptoms, treatment or prevention of
intestinal obstruction. She did not attribute it to spiritual forces but believe it is a natural
occurrence. She was worried about the outcome of her condition. She was however reassured not
to be intimidated and that the treatment she was is receiving will help her to recover.

LITERATURE REVIEW ON INTESTINAL OBSTRUCTION

DEFINITION
Intestinal obstruction is the partial or complete blockage of the small or large bowel lumen,
which prevents the normal flow of intestinal contents through the intestinal tract. An obstruction
can occur at any point along the bowel.
Incidence?
CAUSES
The causes of intestinal obstruction can be grouped into two.
A. Mechanical blockage.
B. Non mechanical/ neurogenic/ Paralytic blockage.

A. MECHANICAL BLOCKAGE
Factors that cause mechanical blockage are divided into three.
1. Condition that occur within the intestinal lumen(intramural) such as;

Fecal impaction

Gall stones in the lumen

Other foreign bodies such as fruits seeds, worms or a piece of bone.

2. Conditions that occur within the intestinal wall (mural).

Intussusceptions.

Inflammation of the ileum.

Tumours of the large bowel.

Stenosis.

Polyps.

3. Conditions that occur outside the intestinal wall (extramural lesions).

These cause compression of the bowel,

Strangulated hernia.

Volvulus.

Tumors of adjacent organs.

Adhesions following previous operations e.g. appendicitis, peritonitis, stenosis etc.

B. NON MECHANICAL /NEUROGENIC /PARALYTIC.

Muscular dystrophy

Endocrine disorders such as diabetes mellitus

Neurologic disorders such as Parkinsons diseases

Thrombosis or embolism of mesenteric vessels.

Paralytic ileus.

FORMS OF INTESTINAL OBSTRUCTION

1. Simple- The blockage prevents intestinal contents from passing with no other
complication.
2. Strangulated: Blood supply to the part or all of the obstructed section is cut off, in
addition to the blockage of the lumen.
3. Closer looped: Both ends of the bowed section are occluded, isolating if from the rest
of the intestine.
PATHOPHYSIOLOGY
In all the three forms, the physiologic effects are similar; when intestinal obstruction occurs,
fluid, air and gas are collected near the site. Peristalsis increases temporarily as the bowel tries to
force its content through the obstruction at and above the site of the obstruction.
The distension blocks the normal absorption processes. As a result, the bowel begins to secrete
water, sodium and potassium into the fluid pooled in the lumen.

Obstruction in the upper intestine results in metabolic alkalosis from dehydration and loss of
gastric hydrochloric acid.
Obstruction in the lower intestines causes slower dehydration and loss of intestinal alkaline fluid
resulting in metabolic acidosis. Ultimately, intestinal obstruction may lead to ischemia, necrosis
and death.

CLINICAL FEATURES.
1) Colicky pains in the abdomen.
2) Nausea
3) Vomiting (vomiting of fecal contents at times.)
4) Constipation
5) Distended abdomen
6) Abdominal tenderness
7) Dehydration with electrolyte loss
8) Sunken eyes
9) Hollow checks
10) Dry skin
11) Septic absorption
12) High pulse rate
13) Cold clammy skin
14) Pallor
15) Delirium in severe cases.

COMPLICATIONS
1. Perforation
2. Peritonitis
3. Septicemia
4. Metabolic alkalosis or acidosis
5. Hypovolaemic shock
6. Death if untreated.

DIAGNOSTIC INVESTIGATION
1. Abdominal x rays confirm obstruction and reveals the presence and location of
intestinal gas fluid.
2. White blood cell count may be slightly normal if necrosis, peritonitis or strangulation
occurs.
3. Sigmoidoscopy, colonoscopy or barium enema may help determine the cause of
obstruction.
4. Hemoglobin concentration and haematocrit may increase indicating dehydration.
5. Serum sodium, chloride and potassium level may fall because vomiting.
6. Serum amylase level may increase possibly from irritation of the pancreas by distended
abdomen.
7. Physical exams may reveal distended abdomen.
8. History from the patient.
9. Signs and symptoms.

SPECIFIC MEDICAL TREATMENT

Although surgery is usually the treatment of choice, conservative treatment or measures can be
carried out if for any reason the operation cannot be done immediately.
The following conservative measures can be done;
1. Nasogastric tube can be used for decompression of the bowel.
2. Decompression to with a Nasogastric tube attached to low pressure continuous suction.
3. Administration of broad spectrum antibiotics such as ciprofloxacin 500mg 6 hourly x 24
hours saved to prevent infection as prescribed by the surgeon.
4. Analgesics like diclofenac 50mg 8 hourly x 24 hours may be given to relieve pain.
5. Intravenous fluids such as dextrose saline, normal saline may be given to correct fluid
and electrolyte loss.

SPECIFIC SURGICAL TREATMENT

Surgery is usually the curative treatment of intestinal obstruction and the surgery appears in three
forms. The type of surgery to be performed depends on the cause of the obstruction.
1. With this form of surgery, laparotomy is performed and the obstructed bowl or adhesions
or strangulation. The bands and adhesions strangulating the bowel are resected.
2. This is when there are complications such as gangrene or tumor. The gangrenous intestine
is resected and anastomosis is done.
3. When the obstruction is due to cancer of the rectum, palliative measures may be done by
performing colostomy.

COMPLICATIONS OF SURGICAL TREATMENT

1. Shock
2. Hemorrhage
3. Retention of urine
4. Infection

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 condition make it known to her that she is in the hands of competent staff and so by her
complying with 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.
Rest and Sleep
Her bed should be free from crumbs and creases to prevent her being uncomfortable. Eliminate
noise at the ward; make sure all procedures are performed at a goal to prevent procedures
destructing her sleep.
Semi Fowlers position is the appropriate position she must be kept in this position as much as
possible to promote pulmonary ventilation and ease respiratory distress form abdominal
distension.
Observation

Vital signs such as temperature, pulse, respiration are observed every four hours while blood
pressure observed every hourly to serve as a baseline for evaluating whether the patients
condition is progressing or improving.
She must be observed for pain and monitor input and output chart, if abdomen is chastened,
abdominal girth is measured, patient must be weighed daily, her emotional state must be
observed and patient reassured site of intravenous fluids must be observed for bleeding, swatting,
blockage of the line and rate of flow to present any cardiac over load.
Side effects of drugs must be observed and recorded.

Pain relieve
Patient must be observed for pain and pain management given, diversional therapy may be done
to distract the patients mind from pain, and cold compresses may be applied at the site of
distension which can help relax the muscles. Patient must be encouraged to assume the position
she finds comfortable which is not contraindicated to her condition. Administration of preceded
analgesics such as diclofenac 100 mg must be given to relive pain.

Consent of Patient
After all the explanation necessary for the patient to gain knowledge, understand her surgery a
consent form is made to be signed by the patient and this gives the legal right for the operation to
be performed on the patients.

Investigation

All investigation must be done on the patent to correct any abnormalities related to blood,
hemoglobin estimation, white blood cell count, sickling, 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 shave from 3 inches above the nipple of the
breast to middle thigh including the pubic, clean the shaved area again with an antiseptic lotion.

POST OPERATIVE MANAGEMENT

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
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. Vital signs that are temperature, pulse, respiration and blood pressure are also
checked for signs of complications like bleeding. 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 born from hot water bottle, patient needs to be protected from injury by
ensuring that all procedures are done using the right technique

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. The removal of the stitches depends on the
condition of the wound and hospital policy. 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.

Education
Education may be given based on the causes of intestinal obstruction, signs and symptoms of the
condition, the need for the surgical intervention preventive measures, the need for periodic
medical exams, the need to take drugs and for review
All these are given to direct and to equip her with the necessary information on intestinal
obstruction so that she can take the necessary precaution to prevent the condition from
reoccurring.

Drugs
Prescribed drugs such as pethedine 50 mg 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.

VALIDATION OF DATA
With reference to the data collected, signs and symptoms which patient presented are the actual
clinical features of intestinal obstruction as confirmed by the literature review of the condition.
Data collected from the client and relatives were cross checked with client's folder, laboratory
investigation and assessment.

Therefore, all these proved that client was suffering from intestinal obstruction secondary to
postoperative adhesions.

CHAPTER TWO
ANALYSIS OF DATA
Analysis of data is the interpretation of assessment data collected to identify patients specific
needs and strengths, which helps in the formulation of an appropriate nursing diagnoses. It
includes both actual and potential identified needs.
This consists of:
(a) Comparison of data with standards. This covers diagnostic investigations, causes, clinical
features, treatment, complications and pharmacology of drugs.
(b) Patient/ family strengths
(c) Health problems
(d) Nursing diagnosis.

COMPARISON OF DATA WITH STANDARDS

TABLE ONE: DIAGNOSTIC INVESTIGATION ON MRS. GIFTY OKYERE.

DATE

SPECIMEN/
Body

10/10/14

INVESTIGATION

RESULTS

NORMAL VALUE

INTERPRETATION

REMARKS

Haemoglobin level

15.7 g/dl

Male: 14-18 g/dl.

Normal.

No

part

examined
Blood

eEstimation

Female: 12-16 g/dl.

treatment

given.

Patient encouraged on
well-mixed diet

10/10/14

Blood

Red blood Cell count 5.35 (106/uL)

4.50-5.50 (106/uL)

Normal

No treatment given

10/10/14

Blood

White

Cell 7.32(103/uL)

2.60-8.50 (103/uL)

Within normal range

No treatment given

blood

count
10/10/14

Abdominal

To assess the state of Bowel

There shouldnt be intestinal obstruction

Exploratory Laporotomy

x-

the intestine

obstruction

the

And bowel ressection

rayAbdomen

Abdominal x-ray to

bowels.No evidence

(end to end anastomosis)

assess the state of

of bowel obstruction.

obstruction

of

the bowels
10/10/14

Serum

Sodium

134mmol/L

135-145mmol/L

Normal

No treatment given.

Chlorine

102mmol/L

97-110mmol/L

Normal

No treatment given.

Potassium

2.7mmol/L

3.5-5.5mmol/L

Normal

No treatment given.

Calcium

2.49mmol/L

2.15-2.55mmol/L

Normal

No treatment given.

Electrolyte
10/10/14

Serum
Electrolyte

10/10/14

Serum
Electrolyte

10/10/14

Serum
Electrolyte

AUSES OF PATIENTS ILLNESS

With reference to the causes of intestinal obstruction indicated in the literature, Mrs G.A.s
condition was caused by adhesions from the previous operation.

TABLE TWO: COMPARISON OF CLINICAL MANIFESTATION FROM LITERATURE

REVIEW WITH CLINICAL MANIFESTATION EXHIBITED BY CLIENT.

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION

OUTLINED IN LITERATURE
1. Colicky abdominal pain.

EXHIBITED BY CLIENT
1. Client complained of colicky abdominal pain.

2. Nausea and vomiting.

2. Client experienced nausea and vomiting.

3. Abdominal distension and tenderness.

3. On palpation there was distension and

tenderness of the abdomen

4. Weak and rapid pulse.

4. Client exhibited weak and rapid pulse.

5. Cold, pale and clammy skin.

5. There was absence of cold, pale and clammy

skin

6. Constipation.

6. There was constipation

7. Delirium in severe cases.

7. There was no delirium

8. Pallor.

8. Client had pallor.

9. Dehydration.

9. Client was dehydrated

10. Sunken eyes.

10. Client had sunken eyes

11. Hallow cheeks.

11. Client had hollow cheeks

SPECIFIC TREATMENT GIVEN TO CLIENT

With reference to the literature review on the treatment for Intestinal Obstruction, the following
treatment was given to the patient;

SURGICAL TREATMENT
(1) Exploratory Laparotomy, bowel resection and end to end anastomosis done.
(2) Nasogastric tube was passed to reduce abdominal distension and prevent aspiration.

PRE- OPERATIVE TREATMENT

Intravenous Normal saline 2.0 litres
Intravenous Dextrose saline 2.0 litres
Intravenous Ringers lactate 2.0 litres
Intravenous Ciprofloxacin 400mg tds 2
Intravenous Flagyl 500mls tds 2
Intramuscular Pethedine 100mg bd 24 hours.
INTRA OPERATIVE TREATMENT
IV Suxamethionum 80mg
IV Atropine 1.0mg
IV Ketamine 225mg
IV Neostigmin 2.5mg
POST OPERATIVE TREATMENT
Intravenous IV Pethedine 50mg 6hourly 24hours.
Intravenous Dextrose saline 3L.
Intravenous Normal saline 3L.

Intravenous Ringers lactate 3L.

Intravenous Metronidazole 500mg.
Suppository Diclofenac 50 mg bd 5.
Tablet Ciprofloxacin 500mg bd 5

TABLE THREE:
PHARMACOLOGY OF DRUGS ADMINISTERED TO MRS G.A.

DATE

10/10/14

DRUG

Intravenou

DOSAGE AND

DOSAGE AND

ROUTE OF

ROUTE OF

ADMINISTRATION

ADMINISTRATION

PER LITERATURE
Adult Dose: 5-10mg

TO CLIENT
10mg daily 2 days

Tranquilizer,

Relaxes

Client pain was

Blurred vision, nausea,

intravenously.

antianxiety, and

skeletal

relieved.

hypoactivity.

4hours p.r.n

skeletal muscle

muscles and

Child Dose: 0.6mg

relaxant.

relieves

s Diazepam repeated in 3 to

CLASSIFICATION

10/10/14

ACTUAL

SIDE EFFECTS/

EFFECTS

ACTION

REMEDIES

OBSERVED

per kg in 8hours
10/10/14

DESIRED

None was observed.

muscle

Dextrose

Route: Intravenous
Dosage depends on

2 Litres for 48 hours

Fluid and electrolyte

spasms.
Provides

Client was

Confusion, fluid

saline

fluids and calorie

intravenously

replacement.

supplementar

hydrated and

overload, oedema,

requirement

y calories and

energy restored.

glucosuria. None was

(Intravenously)

fluids.

Depends on the rate of 1.5 litres for 48 hours Fluid and electrolyte

Restores

Ringers

observed.
Client regained

Fluid overload,

lactate

dehydration

intravenously

replacement

Route: Intravenous

normal fluid

normal fluid

hypertension,

and

and electrolyte

hypocalcaemia,

electrolyte

balance

hypocalcaemia.

balance
10/10/14

None was observed.

Normal

Highly individualised

1 litre for 48 hours

Fluid and electrolyte

Restores

Client sodium

Oedema, potassium,

saline

(Intravenously)

intravenously.

replacement

normal

and chloride

Hypocalcaemia.

sodium and

level were

None was observed.

chloride level

normal as she
did not exhibit
signs of fluid
retention

11/10/14

Intravenou

Adult Dose: 25-

100mg stat

s Pethedine

100mg every3 to

intramuscularly

Narcotic analgesic.

Relieves pain

Client was

Nausea, vomiting,

relieved of pain. hypotension, urine

4hours, p.r.n.

retention. None was

Chid Dose: 0.5mg per

observed

kg

11/10/14

Intravenou

Route: Intramuscular
Adult: 400mg bd

400mg bd 5

Child: 10-15mg per

intravenously

Antibiotic

Kill

No infection

Gastrointestinal

susceptible

was noticed

disturbance, nausea,

Ciprofloxa- kg body weight

bacteria to

vomiting, diarrhoea,

cin

prevent

dry mouth, and

infection

depression.

Route: Intravenous

None was observed.

11/10/14

Intravenou

Adult: 400mg-500mg

500mls tds 5days

Antiprotozoa

To treat

No infection

Vertigo, abdominal

tds7days

intravenously

Amoebicide

infection.

noticed.

cramps.

Metronida-

Child: 200mg tds

zole

7days.
Route: Intravenous

None was observed.

11/10/14

Intravenou

Adult Dose: 1-4mg

sKetamine

225mg Intravenously.

Anaesthetic agent.

Acts on the

Client slept

Flexion of arms, fine

per kg adjusted

central

throughout the

tremors, drowsiness,

according to response

nervous

surgical

restlessness,

Child Dose: 0.5-2mg

system to

procedure.

hypotension, dystocia.

per kg

produce

Route: Intravenous

tranquilation

Dries

Decrease

Drowsiness, blurred

and sleep.

11/10/14

11/10/14

Intravenou

Adult Dose:0.4-0.6mg 1mg given 35mins

s Atropine

in single dose 45-

before anaesthesia

secretions,

secretions were

vision, tachycardia, dry

60mins before

intravenously

decreases

observed during

mouth, urinary

anaesthesia

sweating and

the surgery.

hesitancy.

Child Dose: 0.4mg

salivation

Intravenou

Route: Intravenous
Adult Dose: 1-2mg to

80mg intravenously

a maximum of 150mg

during surgical

Suxameth-

Child Dose: 0.04mg procedure

Antisecretory agent.

Anaesthetic agent

None was observed.

Relaxes

Clients skeletal

Bradycardia, cardiac

skeletal

muscles were

arrhythmia, cardiac

muscles.

relaxed

arrest, respiratory

ionum

11/10/14

per kg

throughout the

depression, apnoea.

Route: Intravenous

surgery.

None was observed

Intravenou

Adult Dose: 0.5-2mg

2.5mg intravenously

Cholinergic

To relax

Clients

Dizziness, headache,

Child Dose: 0.025-

stimulant and Anti-

skeletal

muscles

were bradycardia, blurred

Neostigmi-

0.08mg per kg

cholinesterase

muscles.

relaxed

ng

Route: Intravenous

vision, rash. None was

throughout the observed.

surgery.

12/10/14

Tablet

Adult Dose: 250mg to

Ciprofloxa- 500mg bd for 7 to

cin

500mg bd5days
orally

Antibiotic

Kill

No infection

Gastrointestinal

susceptible

was noticed

disturbance,

14days.

bacteria to

nausea, vomiting,

Child Dose: 10-

prevent

diarrhoea, dry mouth,

30mg/kg in two

infection

and depression.

divided doses where

benefits overweighs
risk
Route: oral

None was observed.

13/10/14

Tablet

Adult Dose: 75-

Diclofenac

Antipyretic,

Relieves

Client was

Anxiety, dizziness,

150mg bd

sedative,

inflammation,

relieved of and

depression, oedema,

Child Dose: 30-60mg

NSAID

pain and

her temperature

drowsiness,

fever.

reduced.

insomnia,

bd
Route: Oral, rectal

50mg bd 5 orally.

irritability,
migraine, headache,
hypertension, taste
disorder.
None was observed.

COMPLICATIONS DEVELOPED BY PATIENT

With reference to the complications stated under the literature review, patient did not develop
any; due to good nursing care and medical treatment given to her.

PATIENT AND FAMILY STRENGTH

Strength is a resource and ability that an individual has which can help her cope with the
stress of her condition.
Patient and family strength includes healthy physiological functioning, emotional health,
cognitive abilities, coping skills, and interpersonal strength. Etc.
These strengths of the client and family will assist the nurse to be able to plan effective
nursing care for the client. These were some of the strength identified;

Client coped well during the pre-operational preparation and also verbalized her fears.
Client was alert and oriented to time, place and person and could communicate her pain.
Client was ready to know more about her condition.
Client was insured with the national health insurance scheme.
Client and family fully participated in the planning of her care and client.
Client was very friendly and co-operative and had a cordial relationship with other clients
on the ward as well as the staff.

Client was willing to be educated on her treatment

HEALTH PROBLEMS

A health problem is any stress, be it physical, mental or social in a patient that prevents the client
from meeting a certain health standard. Hence client may need some professional services. They
were identified as pre-operative and post-operative problems.
The following health problems were identified upon assessing Mrs. G.A.;

PRE OPERATIVE PROBLEMS

(1)

Nausea and vomiting. (patient could tolerate IV fluids)

(2)

Client was anxious of impending surgery (patient had emotional support from family

members).
(3)

Client had no knowledge of the disease condition and its management (Intestinal
obstruction). (client was ready to learn more about condition)

(4)

Client complained of abdominal pains. (client tolerated analgesics and cooperated with

diversion therapy)

POST OPERATIVE PROBLEMS

(1)

Client was likely to have difficulty in breathing due to the effects of anaesthesia (client

was ready to learn pre-operative teaching such as deep breathing exercise and coughing).
(2)

Client could not perform her personal hygiene ( client understood the importance of good

personal hygiene towards her recovery).

(3)

Client was prone to wound infection (client cooperated with wound dressing procedures

and aseptic techniques)

(4)

Client complained of pain at incision site (client tolerated analgesics).

(5)

Client was likely to develop urinary tract infection. (???

The ones in bracket above should serve as ur strength, in that order

PRE- OPERATIVE NURSING DIAGNOSIS

(1)

Risk for fluid volume deficit related to nausea and vomiting

(2)

Anxiety related to impending surgery (Laparotomy) and its outcome.

(3)

Knowledge deficit related to inadequate information on the disease condition (intestinal

obstruction) and its management.

(4)

Altered comfortation in comfort (abdominal pain) related to iIntestinal oObstruction.

POST- OPERATIVE NURSING DIAGNOSIS

(1)

Impaired airway clearance (potential) Potential for dyspnoea related to effects of

anesthetic drugsineffective airway clearance due to anaesthesia.

(2)

Alteration in comfortAltered comfort (abdominal pain) related to surgical incision.

(3)

Self-care deficit (bathing and grooming) related to general weakness after surgery.

(4)

Potential for post-operative wound infection related to incisional wound.

(5)

High risk for infection related to urethral catheter in-situ.

CHAPTER THREE
PLANNING FOR CLIENT AND FAMILY CARE
Nursing care plan is a systematic process designed to enhance delivery of nursing care on
individualized basis. It forms the third step in the nursing process, which is an approach to
clients care and serves as communication link between client and the health team. This
encourages the nurse to use her initiatives in nursing the patient. The nursing care plan is a
written guide that directs the efforts of the nursing team to meet health goals. It ensures that, the
nursing team works efficiently to deliver holistic, goal-oriented and individualized care to client.
PRE OPERATIVE NURSING OBJECTIVES
(1) Client will be relieved of anxiety within 30 minutes.
(2) Client will have normal fluid volume during the period of Nil per os.
(3) Client will have adequate knowledge on the disease condition (Intestinal Obstruction)
within 45 minutes.
(4) Client will be relieved of abdominal pains within 1 hour.

POST OPERATIVE NURSING OBJECTIVES

(1) Client will have a patent airway within 45 minutes.
(2) Client will be relieved of pain within 24 hours.
(3) Patient will be able to maintain her personal hygiene without assistance or with minimum
assistance within 72 hours.

(4) Client wound will be free from infections and heal well within 9 days.
(5) Client will be free from urinary tract infections within the period of catheterisation.

TABLE FOUR:
NURSING CARE PLAN FOR MRS GIFTY OKYERE
DATE

NURSING

NURSING

NURSING ORDERS

AND

DIAGNOSIS

OBJECTIVE/

AND

TIME

OUTCOME

TIME

10/10/14

Fluid volume

CRITERIA
Client will be

at

deficit

8:00am

1). Reassure client.

NURSING INTERVENTION

DATE

1). Client was reassured that measures

12/10/1

relieved of

would be put in place to relieve her of

at

(dehydration)

vomiting and

vomiting.

8:00pm

related to

will have

excessive

normal fluid

2). Assess the nature

2). The nature and severity of vomiting

vomiting.

volume within

and severity of

was assessed to render nursing and

48 hours as

vomiting and report

medical care appropriately.

evidenced by;

immediately.

Patient showing
no signs of

3). Provide oral

3). Toothbrush and pepsodent were

dehydration such

hygiene and remove

used to render oral care to client and all

as sunken eyes

all nauseating items.

nauseating items such as vomitus bowl

and poor skin

was removed from clients scene.

turgor.
4). Administer

4). Prescribed intravenous infusions

prescribed intravenous

such as normal saline and dextrose

fluids and monitor

saline were administered and strict

strict intake and output intake and output chart was monitored

chart.

5).

and maintained.

Document

the 5). Procedure was documented into the

procedure.

nurses notes

DATE

NURSING

OBJECTIVE\

NURSING

AND

DIAGNOSIS

OUTCOME

ORDERS

TIME
10\10\14

Alteration in

CRITERIA
Client will be

at

body comfort

relieved of pain

will subside after implementation of a

9:20am

(abdominal

within 1 hours as

all nursing procedures.

pain) related

evidenced by;

to Intestinal

Client feeling

2).Perform pain

2). Assessment of clients pain

Obstruction.

comfortable in bed

assessment.

before and 30 minute after serving

1). Reassure client

and verbalizing

NURSING INTERVENTION

T
1). Client was reassured that, pain 1

analgesics was done.

absence of pain.
3). Assist client to

3). Client was assisted to assume a

assume

lateral position which was

comfortable

comfortable for her on a bed free

position.

from creases and crump.

4). Remove

4). Tight and constricting clothing

constricting and or

was removed.

tight clothing.
5). Reduce noise.

5). Staff was asked to minimize

noise and visitors were also
restricted and patient was screened
with a curtain.

6). Provide

6). Client was engaged in

dimensional

conversation to divert her attention

therapy.

from the pain.

7). Administer

7). Injection pethedine 10mg was

prescribed

given intramuscularly as prescribed.

analgesics.
8).Document

8).All procedures performed to

procedure.

reduce pain were documented in the

nurses notes.

DATE

NURSING

NURSING

NURSING

NURSING

DATE

AND

DIAGNOSIS

OBJECTIVE/

ORDER

INTERVENTION

AND

TIME

OUTCOME

TIME

10/10/14

Anxiety

CRITERIA
Client and will be

1).Reassure

1).Client was reassured that she is in

10/10/14

at

related to

relieved of anxiety

client.

the hands of competent staff to

at

11:30am.

impending

within 30 minutes

reduce her anxiety.

12:00pm.

surgery

as evidenced by;

(Intestinal

a). Client

2).Assess clients

2).The facial expression and the

Obstruction)

verbalizing that she

state of anxiety,

posture of client were observed in an

and its

is relieved of

fear and concerns. attempt to assess her level of anxiety.

outcome.

anxiety.
b). Nurse observing

3).Explain to her

3).The theatre environment, dressing

that client have

the theatre

of workers and equipment was

cheerful facial

environment and

explained to allay her anxiety.

expression.

what she should

expect in the
theatre.

4).Allow client to

4).Client was allowed to express her

express concern.

concerns by asking questions.

Appropriate answers were given to
correct misconception about the
condition and treatment plan.

5).Employ

5). Client was engaged in diversional

diversional

therapy such as conversations to

therapy

allay fears.

DATE

NURSING

NURSING

NURSING

NURSING

DATE

AND

DIAGNOSIS

OBJECTIVE/

ORDERS

INTERVENTION

AND

TIME

OUTCOME

TIME

CRITERIA

10/10/14

Knowledge

Client and

1). Reassure client

1).The client and family were reassured

10/10/14 G

at

deficit related

relatives will

and family.

that there were available materials to

at

3:00pm.

to disease

have knowledge

educate them.

3:45pm.

condition

on intestinal

(intestinal

obstruction

2).Ensure quiet

2).The environment was made quiet by

obstruction).

within 45

environment.

preventing interference from visitors

minutes as

and staff.

evidenced by;
a). Client and

3).Provide a

3).Client was put in a comfortable

relatives

comfortable seat for position and relatives offered seats to

verbalising that

client and relatives.

relax them.

they understand

4).Assess their

4).They were asked to a give brief

clients

previous

explanation about the condition.

condition.

knowledge on the
condition.

b). Client

5). The client and relatives were

ability to give

5). Educate them on provided with the needed information

correct

the disease

concerning the condition and the

feedback on the

condition and its

disease

management.

condition

importance of the surgery.

6). Client and relatives were

(Intestinal

6). Allow client and

encouraged to ask questions which in

obstruction).

family to ask

line with the care rendered and answers

questions.

were provided to their level of

understanding.

7). Client and relatives were asked to

7). Access their

summarize and explain in their own

understanding with

simple terms as they understand the

feedbacks.

education. Feedback given was better.

8). They were involved in all

8). Include client

procedures and rationale explained to

and family in

win their maximum cooperation.

planning of care.

DATE

NURSING

NURSING

NURSING

AND

DIAGNOSIS

OBJECTIVE/

ORDERS

TIME

OUTCOME

11/10/14

Potential for

CRITERIA
Client will have a

at

dyspnoea

6:20am

NURSING INTERVENTION

DATE
AND
TIME

1).Reassure client

1).Client was reassured that measures

11/10/14

patent airway

would be put in place to ensure clear

at

related to

within 45 minutes

airway, this helped to allay clients fears

7:05am

ineffective

as evidenced by

and anxieties.

airway

nurse observing

clearance due

that client has

to anaesthesia.

normal respiration

2).Set a

2).A resuscitation tray containing

resuscitation tray.

endotracheal tube, ventilator, ambu bag,

tongue holding forceps, mouth gag,

pattern and patent

gallipots with sterile swabs, spatula and

airway.

receiver for soiled swabs was set and

placed at clients bedside to be used
when the need arises.
3).Position client

3).Client was put in the left lateral

in the appropriate

position with the head turned to one

position which is

side to prevent the tongue from falling

not contra

back to block the airway and to

indicated.

facilitate free drainage of mucus

secretion.

4). Suction client

4). Client was suction frequently to

frequently.

maintain patent airway.

5).Observe client

5).Client was observed for signs and

for signs and

symptoms of respiratory difficulties and

symptoms for

none was observed.

respiratory
distress such as
dyspnoea and
cyanosis.
6).Monitor vital

6).Clients temperature, pulse,

signs every 15

respiration, blood pressure were

minutes, 30

monitored and recorded as clients

minutes, 1 hour,

condition improved. This helped to

and every 4 hours

assess the improvements of clients

as clients

condition.

condition
improve.

DATE

NURSING

OBJECTIVE/

NURSING

AND

DIAGNOSIS

OUTCOME

ORDERS

TIME
12/10/14

Alteration in

CRITERIA
Client will be

1). Reassure client.

at
9:00am

NURSING INTERVENTION

TIME
AND

1).The client was reassured that the pain

DATE
13/10/14

comfort(pain) relieved of pain

and discomfort will be relieved with

at

related to

within 24 hours

effective nursing measures.

9:00am

surgical

as evidenced by:

incision

a). Client

2). Assist client to

2).The client was assisted to assume a

verbalizing that

assume a

recumbent position which was not

she is relieved of

comfortable position contraindicated to the surgery, to help

pain.

that relieves her

relieve her of pain.

pain.
b). Nurse
observes client

3).Provide

having a cheerful

diversional therapy. conversation, to turn her attention from

facial expression

3).The client was engaged in

pain.

and looking

4).Teach client to

4).The client was taught to support the

relaxed in bed.

support incision site incisional site with the hands when

when coughing or

coughing or laughing to relief tension on

laughing.

incision site to reduce pain.

5). Check vital signs 5).Clients vital signs (temperature,

and record.

pulse, respiration and blood pressure)

was checked and recorded accurately.

6). Administer post

6).50mg pethedine was administered

operative analgesics to relieve pain and discomfort.

to relief pain.

DATE

NURSING

OBJECTIVE/

AND

DIAGNOSIS

OUTCOME

TIME
13/10/14

7).Document the

7). The procedure was documented in the

procedure.
NURSING

nurses notes.
NURSING INTERVENTION

TIME

ORDERS

AND

Self care

CRITERIA
Client will be able to

1).Reassure

1).Client was reassured that her

DATE
16/10/14

at

deficit (total)

meet her self care

client.

personal hygiene would be taken care of at

6:25am

related to

needs without

until her condition allows her to

incisional

assistance or with

perform them by herself.

wound.

minimum assistance
within 72 hours as
evidence by;
a). Observing client
taking her bath,
grooming and caring

2).Assist client to

2).Client was assisted in bed to bath

bath twice daily.

twice daily with warm water to refresh

her and to remove dirt and also
stimulate circulation. Soap and sponge
were used.

6:25am.

for her mouth

3).Treat Pressure

without assistance.

3).Pressure areas such as sacral region,

heels, and scapula were inspected and

areas.

treated to prevent the development of

bedsores.
4).Clients mouth was cared for twice

4).Give oral

daily with tooth brush and toothpaste to

toileting twice

prevent oral infection. Vaseline was

daily.

applied to the lips to prevent cracks.

5).Client was assisted to walk around

5). Encourage
early ambulation.

the ward at least twice daily to improve

circulation.

6).Change soiled

6).Soiled linens were changed regularly

linen as often as

and bed made free from crumbs and

possible and

creases to prevent bed sores and to

make bed free

improve clients comfortability.

from crumbs and

DATE

NURSING

creases.
OBJECTIVE\

AND TIME

DIAGNOSIS

OUTCOME

NURSING

NURSING

DATE

ORDERS

INTERVENTIO

AND

13\10\14

Potential for

CRITERIA
Client will not

1).Reassure

N
1).Client was reassured that strict

at

post

develop post

patient.

aseptic technique will be employed

8:00am

operative

operative wound

during wound dressing to prevent

wound

infection throughout

wound infection.

infection

the post operative

related to

period

2) .Change soiled

2).Soiled dressing was frequently

surgical

(9 days) as

dressings

changed to prevent moisture and

incision.

evidenced by;

frequently and

infection. Wound was dressed by

a).The clients

aseptically.

observing all the necessary aseptic

wound looking

techniques. Sterile instruments wer

clean, dry and free

employed in all procedures.

from exudates.
3).Educate client

3).The client was instructed to avoi

b). The clients

to avoid touching

touching the wound site to avoid

wound healing by

the wound site.

infecting the wound

4).Administer

4). Prescribed antibiotics such as

prescribed

ciprofloxacin, augumentin and flag

antibiotics.

were administered to prevent

first intention.

infection.

5).Encourage

5).Client was frequently served wit

adequate

balanced diet to promote wound

nutrition.

healing and replace worn out tissue

6). Document

6).Procedure was documented in

procedure.

nurses notes.
NURSING INTERVENTION

DATE

NURSING

OBJECTIVE\

NURSING

AND TIME

DIAGNOSIS

OUTCOME

ORDERS

14\10\14

CRITERIA
High Risk for Client will be free 1). Reassure

1). Client was reassured that the

at

infection

from

catheterization is temporal.

8:00am

(urinary tract

within the period of

infection)

catheterization

related to

evidenced by;

catheter daily

daily with antiseptic lotion such as

catheter

Nurse observing no

with antiseptic

savlon and normal saline.

insitu

signs of discharges

lotion.

infection client.

as 2). Care for

2). Client catheter was cared for

and redness at the

catheter site and

3). Keep the

3). The drainage bag was kept in a

absence of dysuria.

drainage bag in a

container under the clients bed to

container.

prevent the bag from the floor

4). Keep drainage

4).The drainage bag was put under

bag in a right

the bed for easy drainage with

position for easy

gravity and preventing obstruction

drainage.

by pressure from the drainage tube

5). Monitor

5).Clients temperature was

temperature

monitored four hourly for increase

temperature which may indicate

presence of infection.