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CHAPTHER ONE
ASSESSMENT OF PATIENT AND FAMILY
Assessment is the first step in the nursing process in which the nurse carries out a complete and
holistic nursing assessment of every patients needs. Psychological, sociological, physiological
and spiritual statuses are all forms of information gathered about patient. Assessment is done
through observation, physical examination, interview of patient and family, medical investigation
and laboratory investigation. The information gathered serve as a foundation upon which
appropriate nursing intervention will be established for speedy patients recovery.
PATIENTS PARTICULARS
Mrs. D.O is 43 year woman born to Mr. O.O and Mrs. R.T. she hails from cape coast in the
central region of Ghana but stays at Kwadaso in the Ashanti region of Ghana. She is half Ashanti
and half Fanti. Mrs. D.O is 5.4feet tall and weighs 68kg. Mrs. D.O is married to Mr. A.D a 55
year old man with five children, three girls and two boys. The husband is the next of kin. She is
an alcohol [local gin] seller and also a farmer. She is a Christian and worship with the
Presbyterian church of Ghana at Kwadaso. Mrs. D.O had no formal education.
FAMILYS MEDICAL AND SOCIO-ECONOMIC HISTORY
There are no known hereditary illnesses like asthma, diabetes mellitus, hypertension and absence
or mental illness in their family. The family sometimes experiences headache, slight stomach
aches which are mostly managed by taking paracetamol and sometimes flagyl tablets. There are
no food and drugs allergies. She gains her income from the products from her farm and selling of
local gin [apteshie]. She is sociable and adapt to situations that are challenging.
PATIENTS DEVELOPMENTAL HISTORY
According to patients mother she was born by vaginal delivery with an assistance of a
traditional birth attendant at the house on the last week of the ninth month of her pregnancy .she
started sitting at the sixth month, crawling at the eighth month ,standing at the eleventh month
walking and running after one year. She was immunized against the six childhood killer diseases
now known as childhood vaccine preventable diseases. She experienced her secondary sexual
characteristics such as breast enlargement, growing of pubic hairs, menstrual flow and
enlargement of hips at the age of 14years. Client had no formal education. She traditionally got
married to her husband at the age of 24 and gave birth to her first child at the age of 26.
PATIENTS LIFESTYLE AND HOBBIES
Patient normally goes to bed at 10:00pm and wakes up around 4:30am and prays to God for
protecting her throughout the night. She maintains her personal hygiene and goes to the farm at
6:30am. She normally closes from the farm around 1:00pm and come to continue her selling of
local gin [apteshie] at the house. She watches television, maintains her personal hygiene and
goes to bed at 10:00pm. Patient baths twice daily with soap, sponge and warm water. She cleans
her teeth twice daily with toothpaste and brush and before and after going to bed. She empties
her bowel once daily. Her favorite food is banku and okro stew. She does not smoke but drinks
alcohol. Mrs. D.O favorites hobby is music and often likes to dance to her children sight.
PATIENTS PAST MEDICAL/SURGICAL HISTORY
Patient had never experienced any medical conditions like diabetes mellitus, hypertension etc.
she had no known allergies. She has, had no surgical condition which might have needed her
admission to any hospital; this was her first surgery to be done. Total abdominal hysterectomy
was done for uterine fibroid. Prior to that, she was admitted at SDA hospital Kwadaso to be
taking care of.
PATIENTS PRESENT MEDICAL HISTORY
Patient was apparently well until 6 th day of September 2013 when she started experiencing
profuse bleeding and abdominal pains that was associated with her menstruation. It was later
confirmed that patient was having uterine fibroid of which she was to undergo total abdominal
hysterectomy.
ADMISSION OF PATIENT
Mrs. D.O was admitted to the surgical ward at the S.D.A hospital Kwadaso on the 10th
September, 2013 at 11:30am with the diagnosis of uterine fibroid. She was in the company of
two relatives, the husband and the child. Patient and her family were warmly received and given
seats to make them comfortable and were reassured that all the necessary measures would be put
in place to ensure her comfort throughout her hospitalization. The patients folder was collected
from the admission nurse and patients name and other particulars were mentioned to confirm
whether she was the right patient. Patient was put on a comfortable bed and quick assessment
from head to toe was done to ascertain her general condition.
Her vital signs were checked and recorded as follows;
Temperature = 38.4 degree Celsius
Pulse = 80 beats per minute
Respiration = 20 cycles per minute
Blood pressure= 130/80 mmHg
Tepid sponging was done to reduce patients body temperature to 37.5 degree Celsius.
Family members were educated on visiting hours and the meal time and all ward policies were
explained to them. They were also shown to the bathroom and toilet. They were also and
introduced to doctors, nurses and other staff on the ward as well as other patients.
Anxiety level of patients rose up due to the impending surgery, so she was reassured that she will
have a successful surgery. This helped to allay anxiety and wins her cooperation. She was
introduced to other patients who have undergone similar surgery successfully, this helped relieve
her psychologically. She was also allowed to express her fears through questioning. Her
questions were answered in simple terms to clear any misconception.
Patient had inadequate knowledge on the condition (uterine fibroid) and so the definition, causes,
signs and symptoms and treatment of the condition were explained to patient. Clients and
familys questions were answered in simple and appropriate terms to aid in the full understanding
of the condition.
Bed rest was ensured and quit environment provided. Assisted bed bath and oral care were given.
Clients vital signs was checked and recorded and all measures were put in place to relieve pain.
Nil per oS was instituted due to the impending surgery. Patient went to bed around 7:20pm to
prepare for the operation on the following day, (11th September 2013). Procedures done were
recorded and documented in the nurses notes.
PATIENTS CONCEPT OF ILLNESS
Patient does not know what actually contributed to her illness. She believes that with God on her
side and with care rendered she would be able to pass through the surgery successfully.
LOCATION OF FIBROIDS
-Sub mucosal fibroids: fibroids that grow into the inner cavity of the uterus are more likely to
cause prolonged, heavy menstrual bleeding and sometimes problem for women attempting
pregnancy.
-Subserosal fibroids: fibroids that projects to the outside of the uterus can press on the bladder
causing one to have urinary symptoms.
-Intramural fibroids: some fibroids grow within the muscular uterine wall. If large enough,
they can distort the shape of the uterus and cause prolonged, heavy periods as well as pain.
PATHOPHISIOLOGY
Uterine fibroids develop from the smooth muscular tissue of the uterus [myometrium]. A single
cell divides repeatedly, eventually creating a firm, robbery mass distinct nearby tissues. The
growth patterns of uterine fibroids vary, grow slowly or rapidly, remain the same size, some
fibroids go through growth sports and some may shrink on their own. Many fibroids that present
during pregnancy shrink or disappear after pregnancy as the uterus goes back to a normal size.
They can be single or multiple expanding the uterus so much it that it reaches the rib cage.
CLINICAL FEATURES
-Heavy menstrual bleeding
-Prolonged menstrual periods
-Pelvic pressure or pain
-Frequent urination
-Difficulty emptying the bladder
-Constipation
-Lows backache
COMPLICATIONS
-Infertility
-Pregnancy loss
-Anemia
-Urinary tract infection
-Uterine cancers
DIAGNOSTIC INVESTIGATION
-Ultrasound: the ultrasound device [transducer] is moved over the abdomen [Trans abdominal]
or places it inside the vaginal [transvaginal] to get images of the uterus.
-Laboratory tests: These might include a complete blood count to determine if there is anemia
due to chronic blood loss and other blood test to rule out bleeding disorders.
Other imaging test
-Magnetic resonance imaging [MRI]: this shows the size and location of the fibroid, identify
different types of tumors and help determine appropriate treatment options.
-Hysterosonography: Also called a saline infusion sonogram, uses sterile saline to expand the
uterine cavity making it easier to get images of the cavity and endometrium. It is useful when
one has heavy bleeding.
-Hysterosalpingography: Uses a dye to highlight the uterus and fallopian tube on x-ray images
to determine if the fallopian tubes are opened.
-Hysteroscopy: A small lighted telescope called a hysteroscope is inserted through the cervix
and into the uterus.
Other diagnosis
-Physical examination.
endometriosis, non-malignant growths, persistent pain, pelvic relaxation and prolapsed and
previous injury to the uterus.
TYPES OF HYSTERECTOMIES
-Total abdominal hysterectomy
-vaginal hysterectomy
-Assisted vaginal hysterectomy
-Supracervical hysterectomy
-Laparoscopic supra cervical hysterectomy
-Radical hysterectomy
-Oophorectomy and salpingo-oophorectomy
TOTAL ABDOMINAL HYSTERECTOMY
This is the most common type of hysterectomy. During a total abdominal hysterectomy, there is
the removal of the uterus, including the cervix. The scar may be horizontal or vertical, depending
on the reason the procedure is performed, and the size of the area being treated. Cancer of the
ovary[s] and uterus, endometriosis, and large uterine fibroids are treated with total abdominal
hysterectomy. Total abdominal hysterectomy may also be done in some unusual cases of very
severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only
after several attempts at non-surgical treatments. Clearly a woman cannot bear children herself
after this procedure, so it is not performed on women of childbearing age unless there is a serious
condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to
be examined, which is an advantage in women with cancer or investigating growths of unclear
cause.
COMPLICATION OF SURGICAL TREATMENT
-Infection
-Pain
INVESTIGATION
All investigations must be done on the patient to correct any abnormalities related to blood,
hemoglobin estimation, white blood cell count, and etc.
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 electrolytes loss. Nothing is given by
mouth on the morning of the operation.
SKIN PREPARATION
The area to be shaved must be washed and dried, and clean the shaved area with antiseptic
lotion. Sterile procedure of shaving should be done.
POST OPERATIVE NURSING MANAGEMENT
OBSERVATION
a. Observe and monitor vital signs every 15minutes, 30minutes and hourly till patients
condition stabilizes.
b. Monitor the intravenous fluid for blood clot in the needle, presence of air bubbles, all
these are done to prevent any complications.
c. Observe for signs of complication such as bleeding, cyanosis, infection and pain.
PREVENTION FROM INJURY
Since patient is unconscious, she needs to be protected from injury by ensuring that all
procedures are done using the right technique.
WOUND CARE
a. Dressing is normally changed on the third day of post operative; wound dressing must be
done under aseptic technique.
b. Alternate stitches must be removed before the remaining stitches also removed and it
depends on the condition of the wound and the hospital policy.
c. Wound should be observed for signs of bleeding, infection and pain.
PERSONAL HYGIENE
Personal hygiene such as oral care, bed bath should be done regularly to prevent harboring of
microbes, thereby preventing secondary infection.
EDUCATION
a. Assess patient understanding with regard to her condition.
b. Educate her based on the causes of uterine fibroid, signs and symptoms of the condition,
the need for surgical intervention, preventive measures, the need for periodic medical
examination and the need to take drugs.
c. Educate on the review date and the day for removal of stitches.
DRUGS
Prescribed drugs may be given to patient to relieve pain. Antibiotics may also be given to prevent
secondary infections. Desired and side effect of drugs must be observed.
VALIDATION OF DATA
With respect to the information gathered from textbooks, literature review and clinical features
manifested by patient as well as history taken from patient relatives, it was evident that patient
was suffering from uterine fibroid. Information gathered was verified by patient husband, this
proves that all information gathered were valid and free from errors and biases.
CHAPTER TWO
ANALYSIS OF DATA
Data analysis is the second step in the nursing process which involves the breakdown of data
collected in the assessment phase. It also involves the comparison of data with standard, patient
and family strength, health problems and formulation of appropriate nursing diagnoses.
COMPARISON OF DATA WITH STANDARDS
The following were compared with standards
1.
2.
3.
4.
5.
Diagnostic investigations
Causes
Clinical features
Pharmacology of drugs
Complications
DIAGOSTIC INVESTIGATIONS
The following diagnostic investigations were done
1.
2.
3.
4.
5.
6.
SPECIMEN
INVESTIGATION RESULTS
NORMAL
VALUE
INTERPRETATION
REMARKS
07/08/13
Blood
Hemoglobin level
estimation
10.1gldl
Male: 14-18gldl
Female: 1216gldl
Below normal
07/08/13
Blood
4.21[106/ul]
4.50-5.50[106/ul]
Below normal
07/08/13
Blood
3.65[10/ul]
2.60-8.50[10/ul]
Normal
07/08/13
Blood
2.45mmol/l
2.15-2.55mmol/l
Normal
07/08/13
Blood
3.8mmol/l
3.5-5.5mmol/l
Normal
07/08/13
Blood
Serum potassium
level
Serum chloride level
98mmol/l
90-100mmol/l
Normal
.Frequent urination
.Constipation
.Low backache
.Dehydration
DATE
DRUGS
11/09/1
3
Metronidaz
ole
DOSSAGE AND
ROUTE OF
ADMINISTRATION
Adult dose:400500mg tds x7days
CLASSIFICAT
ION
DESIRED EFFECT
ACTUAL
EFFECTS
Antiprotozoa,
Amoebicide
To treat infection.
Patient wound
was not
infected.
SIDE
EFFECT/REMEDI
ES
Dry mouth
abdominal
distress, vomiting.
Child dose:200mg
bd x 7days
None of the above
was observed.
Route: Oral,
intravenous
11/09/1
3
Normal
Saline
Patient:500mg tds
x5days,
intravenously
Highly individualized
Route: intravenous
Patient: 1 litre for
8hours,
intravenously
11/09/1
3
Ringers
lactate
Intravenous
fluid for Fluid
and
electrolyte
replacement
Fluid and
electrolyte
Client was
hydrated before
discharge.
Patient has a
good skin
Overdose causes
circulatory over
load and
pulmonary
oedema.
Patient did not
experience any of
the side effects.
Fluid overload,
oedema,
replacement
imbalance.
Route: intravenous
Patient: 1.5 litres for
48 hours,
intravenously
11/09/1
3
Diclofenac
Adult dose:50200mg
Child dose:12.570mg
11/09/1
3
Tablet
Zincovit
Route: oral
,intramuscular, per
rectum
Patient :75mg bd
x48hours
Adult dose:1 tablet
daily
Child dose: syrup
2.5-5mls per kg
body weight
Route: oral
Patient:1 tablet daily
x 30, orally
Non-steroidal
antiinflammatory
drug
turgor.
This is an
indication of
adequate
hydration.
shortness of
breath.
Patient was
relieved of
abdominal pain.
Anorexia,nausea,d
yspnea
Antipyretic
Haematimics
To stimulate red
blood cell production.
There was a
stimulation of
red blood cell
production.
Diarrhea
,abdominal
distress
11/09/1
3
Atropine
Muscle
relaxant
Patient muscles
were relaxed
before surgical
operation.
Tachycardia,
photophobia, dry
mouth, blurred
vision.
Route: intravenous
11/09/1
3
Pethidine
Patient:1 mg given
35minutes before
anesthesia,
intravenously
Adult dose: 50mg150mg
Child dose:0.5mg
-2mg/kg body
weight
Route:
intramuscularly
Patient dose:50mg
bd daily after
surgical operation
Sedative and
analgesic,
Relieve moderate to
severe pain.
Patient was
relieved of pain
after surgical
operation.
Dizziness, nausea,
dry mouth and
dependence
None of the above
was observed.
11/09/1
3
Ciprofloxaci
n
Adult dose:200500mg
Broad
spectrum
antibiotic
Combats intra
abdominal infection.
Child
dose:10mg/kg/body
weight
Patients
temperature
reduced to
normal as a
result of
reduced level of
infection.
Dizziness
,headache, skin
rashes
Patient was
relieved from
abdominal
spasm which
caused pains.
Headache, dry
mouth, loss of
appetite,
constipation.
None observed in
the patient.
Route :oral,
intravenous
Patient :500mg bd x
48hours
intravenously
11/09/1
3
Buscopan
Adult dose:20mg
4xdaily
Child dose:6-12
years, 10mg 3 times
daily
Route:
Intramuscular,
intravenous, oral.
Patient :20mg bd x
24hours,
Antispasmodi
c.
It is used to relieve
abdominal spasm.
intramuscular
Fever.
Abdominal pain.
Knowledge deficit (Partial).
Anxiety.
Altered body comfort (incision pain) related to wound at the incision site.
Altered skin integrity (incision wound) related to surgical manipulation on the abdomen.
High risk for urinary tract infection related to urethral catheter in situ.
Self care deficit (bathing, mouth care, etc.) related to post operative restrictions.
CHAPTER THREE
PLANNING FOR PATIENT AND FAMILY CARE
Nursing care plan is a step by step process designed to enhance delivery of nursing care on an
individual. It is the third step in nursing process which is an approach to patients care and serves
as communication between patient and the entire health team. Nursing care plan ensures that, the
nursing team work efficiently to bring out a holistic goal oriented and individual care to patient.
PRE OPERATIVE NURSING OBJECTIVES
1. Patients body temperature will be reduced to the normal range (36.2C- 37.2C) within
12 hours as evidenced by:
a. Nurse observing that patients temperature has reduced to the normal range (36.2C37.2C) by reading from the clinical thermometer.
b. Patient verbalizing a reduced body temperature.
2. Patient will experience reduced abdominal pain within 1 hour as evidenced by:
a. Patient verbalizing the absence of pain.
b. Nurse observing that patient is relaxed with cheerful facial expression.
3. Patient/family will have adequate knowledge about uterine fibroid within 30 minutes as
evidenced by:
a. Patient and family verbalizing their full understanding of the condition and how to
take care of surgical wounds.
b. Patient and family able to answer more than 70% of questions asked by the nurse.
4. Patient will be relieved of anxiety within 4 hours as evidenced by:
a. Patient verbalizing that she is relieved of anxiety.
b. Nurse observing that patient have cheerful facial expression.
b. Nurse observing patient having a cheerful facial expression and looking relaxed in
bed.
2. Patients incision wound will be free from infection throughout the period of
hospitalization as evidenced by:
a. Patient verbalizing that there is no discharge at wound site.
b. Nurse observing patients wound healing by first intension.
3. Patient will be free from urinary tract infections within the period of hospitalization as
evidenced by:
a. Nurse observing no signs of redness and discharge at the site of the catheter.
b. Patient verbalizing that she feels no pain at the site.
4. Patient will be able to meet her self-care needs within 72 hours as evidenced by:
a. Nurse observing patient taking her bath, grooming and caring for her mouth without
assistance
NURSING
DIAGNOSIS
OBJECTIVES/OUTCOME
CRITERIA
NURSING
ORDERS
Altered in body
temperature
(38.4C) related to
inflammatory
process.
2. Tepid sponge
patient.
EVALUATION
3. Open nearby
windows.
b. Patient verbalizing that her
temperature has reduced.
NURSING
INTERVENTIONS
4. Re-checks patients
4. Patient body temperature
body temperature every was rechecked every 15
15 minutes.
minutes to determine reduction
in body temperature.
6:30pm
A.F
DATE
AND
TIME
10/09/13
at
1:15pm
NURSING
DIAGNOSIS
Altered body
comfort
(abdominal
pain) related to
inflammatory
process
secondary to
uterine fibroid.
OBJECTIVE/
OUTCOME
CRITERIA
Patient will be
reduced of pain
within 1 hour as
evidenced by:
NURSING ORDERS
NURSING
INTERVENTIONS
EVALUATION
1. Reassure client.
a. Nurse
observing that
patient is relaxed
with cheerful
facial expression.
2. Perform pain
assessment.
2. Assessment of pain
was done before and 30
minutes after analgesics
were served.
10/09/13
b. Patient feeling
comfortable in
bed and
verbalizing
absence of pain.
3. Assists patient to
assume a comfortable
position.
4. Reduce noise
5. Provide diversion
2:15pm
therapy.
DATE
AND
TIME
NURSING
DIAGNOSIS
OBJECTIVE/
OUTCOME
CRITERIA
NURSING ORDERS
in conversation to divert
her attention from the
pain
NURSING INTERVENTION
EVALUATION
10/09/1
3
at
2:00pm
Inadequate
knowledge
(partial) related
to information
on the causes
and
management of
uterine fibroid.
a. Patient and
family verbalizing
their full
understanding of
the condition and
how to care of
surgical wounds.
2. Put client in a
comfortable position.
10/09/13
3. Educate client on
condition.
5. Give appropriate
answers to client and
family.
DATE AND
TIME
NURSING
DIAGNOSIS
10/09/13
Anxiety related
to unknown
outcome of the
impending
surgery
At
3:45pm
OBJECTIVE/
NURSING ORDERS
OUTCOME
CRITERIA
Patient and family 1. Reassure patient.
will be relieved of
an anxiety within 4
hours as evidenced
by:
2. Assess patient and
familys state of
a. Nurse observing anxiety, fear and
that patient have a concern.
cheerful facial
expression.
3. Explain to her the
theater environment
b. Patient
and what she should
verbalizing that
expect in the theater.
she is relieved of
anxiety.
4. Allow patient and
family to express
concern.
5. Encourage
diversional therapy.
NURSING INTERVENTION
EVALUATION
10/09/13
5:00pm
3. The theater environment, dressing of
workers and equipment were explained to
allay her anxiety.
A.F
DATE
AND
TIME
11/09/13
At
3:00pm
NURSING
DIAGNOSIS
Altered body
comfort
(incision pain)
related to
wound at the
incision site.
OBJECTIVES/
OUTCOME
CRITERIA
Patient pain will
be reduced within
72 hours as
evidenced by:
NURSING ORDERS
NURSING INTERVENTION
EVALUATION
1. Reassure patient.
a. Patient
verbalizing that
she is relieved of
pain.
2. Assist patient to
assume a comfortable
position that relieves
her pain.
13/09/13
10:20am
b. Nurse
observing patient
having a cheerful
facial expression
and looking
relaxed in bed.
3. Provide diversional
therapy.
4. Teach patient to
support incision site
when coughing or
laughing.
5. Administer
A.F
analgesics.
TABLE FOUR:
DATE
AND
TIME
12/09/13
At
10:00am
pain.
NURSING
DIAGNOSIS
Altered skin
integrity
(incision
wound)
related to
surgical
manipulation
on the
abdomen.
OBJECTIVE/OUT
COME
CRITERIA
Patient will be free
from wound infection
throughout the period
of hospitalization as
evidenced by:
NURSING ORDERS
NURSING INTERVENTION
EVALUATION
1. Reassure patient.
a. Patient verbalizing
that there is no
discharge at incision
site.
2. Change soiled
dressing as per
hospital policy and
aseptically.
15/09/13
b. Nurse observing
that patient wound
will heal by first
intention.
9:30am
A.F
3. Educate patient to
avoid touching the
wound site.
4. Administer
prescribed antibiotics.
NURSING
DIAGNOSIS
12/09/13
OBJECTIVE/
OUTCOME
CRITERIA
Patient will be free
from urinary tract
NURSING
ORDERS
NURSING
INTERVENTION
EVALUATION
1. Reassure client.
1. Patient was
reassured that the
At
12:30pm
infection related to
urethral catheter insitu.
infection within
period of
hospitalization as
evidenced by:
a. Patient
verbalizing that she
feels no pain at the
site
catheterization was
temporal.
2. Patients catheter
was cared for daily
with antiseptic lotion
such as salvon and
normal saline.
no signs and
discharges at the
catheter site.
12/09/13
3:10pm
A.F
b. Nurse observing
no signs of redness
and discharge at the
catheter site.
4. Assist patient to
perform personal
hygiene such as
bathing and care of
mouth.
5. Administer
prescribed
antibiotics
5. Prescribed
antibiotics were
administered to prevent
infection.
OBJECTIVE/OUTCOME
CRITERIA
NURSING
ORDERS
NURSING
INTERVENTION
EVALUATION
12/09/13
At
6:20pm
Self-care deficit
(bathing and mouth
care) related to postoperative restrictions.
1. Reassure
patient.
2. Assist patient to
bath twice daily.
15/09/13
7:00am
A.F
3. Treat pressure
areas as such.
CHAPTER FOUR
IMPLEMENTING PATIENT/ FAMILY CARE PLAN
Implementation is the fourth stage of the nursing process and it involves the execution of the
proposed plan of care. Implementation includes specific measurable nursing intervention and
patients activities with emphasis on performing procedures like administrating of drugs,
education, providing comfort, ensuring safety and prevention of complications.
incision site when coughing, sneezing, or getting out of bed to prevent wound gabbing. The
doctor came for review around 10: 25am and ordered the following; analgesic injection
Pithidine50mg, Starting sips of water, removal of urethral catheter and discontinuing of infusion.
The patient was given sips of water and there was no complication and catheter was cared for,
removed and infusion was discontinued. Relatives were urged to prepare a light soup the next
day and she went to bed around 8: 00pm. Due medications were served as ordered.
Vital signs were checked and recorded for the day ranges within;
Temperature = 36.5-37.6 degree Celsius
Pulse = 78-80 beats per minute
Respiration = 18-20 cycles per minute
Blood pressure = 110/70-120/70millimeters of mercury
Patient was taught how to get out of bed without putting pressure on the incision site and was
also encouraged to walk around the ward to improve circulation and prevent joint stiffness. She
was served with light porridge in the morning, rice balls with light soup in the afternoon and
slice yam with light soup in the evening. Patient was made comfortable in bed and her relatives
were reassured of her speedy recovery.
Vital signs checked and recorded for the day ranges within;
Temperature = 36.6-36.9 degree Celsius
Pulse = 78-80 beats per minute
Respiration = 22-24 cycles per minute
Blood pressure = 120/70-130/80 millimeters of mercury
3:30pm. Bed linen of patient was stripped off and bedstead, lockers were clean with disinfectants
and were made ready for the next admission.
PREPARATION
OF
PATIENT
AND
FAMILY
FOR
DISCHARGE
AND
REHABILITATION
Mrs. D.O and family were made to understand that patients hospitalization was a temporal one
since she would be discharged to go home after her condition has improved. The preparation for
discharge started on the day of admission till the day of discharge.
Patient and family were educated on the causes, signs and symptoms, complications, treatment
and prevention of the disease.
Mrs. D.O and family were educated on their food, thus washing fruits and vegetables before
eating to prevent contamination of the food. She was educated to take in diet containing protein,
vitamins and mineral salts to aid in promoting wound healing.
Patient was advised to resume activities gradually. This does not mean sitting for long periods,
because doing so may cause blood to pool in the pelvis, increasing the risk of thromboembolism.
She was also advised to avoid straining, heavy lifting, having sexual intercourse which could
lead to wound gaping.
They were educated on the harmful effects of alcohol and smoking and to avoid the intake of
them.
She was instructed to check the surgical incision daily and to contact her primary health care
provider if redness or purulent drainage or discharge occurs. She was informed that she would
not experience monthly menstruation as she used to have her periods were now over but that she
may have a slightly bloody discharge for few days; if bleeding recurs after this time, it should be
reported immediately.
Mrs. D.O was informed that showers were more preferable to tub baths to reduce the possibility
of infection and to avoid the dangers of injury that may occur when getting in and out of the
bathtub.
Vaginal discharge, foul odor, excessive bleeding, any leg redness or pain, elevated temperature
should be reported to the primary health care provider promptly.
Lastly, Mrs. D.O was educated to adhere to her drugs and also to take note of the review date 27th
September, 2013 and the date for removal of stitches 23rd September, 2013. Patient was finally
discharged on 16th September, 2013. Rendered procedures were documented in the nurses note,
admission and discharge book, and daily ward state.
also to take in well nutritious meal to aid in their bodys functioning. Assurance was given to
them concerning my next home visit after discharged of patient.
Mrs. D.O and family were given the opportunity to ask any question pertaining to their health to
clarify any misconception.
They were informed that this was going to be my last visit to them. The family members and the
patient expressed their maximum thanks to me and the entire health team for the care given and
wish me all the best in my studies and granted me permission to leave.
CHAPTER FIVE
TERMINATION OF CARE
Termination of patient care is the last phase of interaction between nurse, patient and family.
Mrs. D.O and family were made to understand that patient hospitalization was temporal and that
she would be discharged to go home after her condition had improved. Created professional
relationship friendship with patient and family commenced on the 10th September, 2013 and
with a good nursing care, clients condition improved and was discharged on the 16 th September,
2013 and care was terminated on the 2nd October, 2013 because patient condition has improved.
Also, home visits were made to patients house and it was found out that the condition of patient
has improved. She was educated on her diet, drugs, personal and environmental hygiene and also
to report any sickness to nearest hospital which is Kwadaso SDAda Hospital. This ended the
interaction and Mrs. D.O hospitalization.
Education was given to patient to take in well-balanced diet, encouraging rest and sleep, and
adhering to prescribed drugs to aid in wound healing. Home visits were done after discharge of
patient.
CONCLUSION
This care study has equipped me with the knowledge and skills on uterine fibroid, its causes
signs and symptoms, surgical intervention [total abdominal hysterectomy], nursing and medical
management.
It was observed that a successful patient and family care depends on the cooperation of the
patient and family with the nurses willingness to help throughout the care.
Psychological and spiritual wellbeing of patient and family were promoted all because of their
opinions and cooperation given.
I therefore recommend that would like to come out with a point that any patient who comes to
the hospital should be given such an individualized and specialized nursing care. which will help
improve patients self-image and its recovery.