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CASE STUDY BY: ADDAI FRED

SUPERVISORS NAME: MR. AMANKWA


HOSPITAL: SDA HOSPITAL KWADASO
WARD: SURGICAL WARD
PATIENTS PARTICULARS
NAME: MRS D.O
AGE: 43 YEARS
SEX: FEMALE
DIAGNOSIS: UTERINE FIBRIOD
TYPE OF OPERATION: TOTAL ABDOMINAL HYSTERECTOMY
DATE OF ADMISSION: 10/9/2013
TIME OF ADMISSION: 11: 30AM
DATE OF SURGERY: 11/9/2013
OCCUPATION: TRADER
RELIGION: CHRISTIAN
LOCALITY: KWADASO
NEXT OF KIN: MR A.D
LANGUAGE SPOKEN: TWI AND FANTE
WARD IN-CHARGES NAME: COMFORT ADU BOOBI
SIGNATURE..

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.

LITERATURE REVIEW ON UTERINE FIBRIOD


DEFINITION
Uterine fibroid is a noncancerous growth of the uterus that often appears during childbearing
years. It is not associated with an increased risk of uterine cancer and also never develops into
cancer.
CAUSES/RISK FACTORS
-Hereditary or family history.
-Race and ethnicity
-Age
-Other factors
Hereditary or family history: uterine fibroids are the most common tumor found in female
reproductive organs. If your mother or sister had fibroid, you are at increased risk of developing
them.
Race and ethnicity: black women are more likely to have fibroids than women of other racial
groups. Also black women have fibroids at younger ages and they are likely to have more or
larger fibroids.
Age: fibroids are more common in women who are their 30s through early 50s. [After
menopause, fibroids tend to shrink]. About 20-40percent of women age 35 and over have
fibroids.
Other factors: onset of menstruation at an early age, having a diet higher in red meat and lower
in green vegetables and fruits, and drinking alcohol such as beer appears to increase risk of
developing fibroid.

LOCATION OF FIBROIDS
-Sub mucosal fibroids: fibroids that grow into the inner cavity of the uterus are more likely to
cause prolonged, heavy menstrual bleeding and sometimes problem for women attempting
pregnancy.
-Subserosal fibroids: fibroids that projects to the outside of the uterus can press on the bladder
causing one to have urinary symptoms.
-Intramural fibroids: some fibroids grow within the muscular uterine wall. If large enough,
they can distort the shape of the uterus and cause prolonged, heavy periods as well as pain.
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.

-History from the patient.


-Signs and symptoms.
SPECIFIC MEDICATIONS
Medications for uterine fibroid target hormones that regulates menstrual bleeding and pelvic
pressure. They do not eliminate fibroid but may shrink them. Medications include;
-Gonadotropin releasing hormone [Gn-RH] agonist. Example; Lupron, synarel and others are
used to treat fibroid by blocking the production of estrogens and progesterone putting a person
into a temporally postmenopausal state.
-Progestin releasing intrauterine device [IUD] to help relieve heavy bleeding caused by fibroid. It
provides symptom relieve only and does not shrink fibroid or make them disappear.
-Non steroidal anti-inflammatory drugs [NSAIDS] may be effective in relieving pain but not to
reduce bleeding caused fibroid.
-Oral contraceptives or progestin can help control menstrual bleeding but do not reduce fibroid
size.
-Intravenous fluids such as dextrose saline, normal saline may be given to correct fluid and
electrolyte loss.

SPECIFIC SURGICAL TREATMENT


Surgery is usually the curative treatment of uterine fibroid and the type of surgery is total
abdominal hysterectomy or subtotal abdominal hysterectomy.
HYSTERECTOMY
A hysterectomy is the surgical procedure whereby the uterus [womb] is removed. Or it can be
define as the surgical removal of the uterus to treat cancer, dysfunctional uterine bleeding,

endometriosis, non-malignant growths, persistent pain, pelvic relaxation and prolapsed and
previous injury to the uterus.
TYPES OF HYSTERECTOMIES
-Total abdominal hysterectomy
-vaginal hysterectomy
-Assisted vaginal hysterectomy
-Supracervical hysterectomy
-Laparoscopic supra cervical hysterectomy
-Radical hysterectomy
-Oophorectomy and salpingo-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

-Bleeding at the surgical area

SPECIFIC NURSING MANAGEMENT


PRE-OPERATIVE NURSING MANAGEMENT
PSYCHOLOGICAL CARE
a. Reassure the patient and the relative by explaining the type of surgery to be performed for
her and explain the disease condition to patient. This will help to relieve her of anxiety
and fears.
b. Introduce people who have undergone such operation to her to allay anxiety.
c. Allow her to ask questions about her condition and this will help her gain knowledge and
understand her condition.
REST AND SLEEP
a. Her bed should be free from creases and crump to prevent her being uncomfortable.
b. Reduce noise at the ward: make sure all procedures are performed in bulk to prevent
procedures destructing her sleep.
OBSERVATION
a. Vital signs such as temperature, pulse, respiration and blood pressure are observed to
serve as a baseline to evaluate the patients condition.
b. Patient must be observed for pain, and to be encouraged to assume the position she find
comfortable which is not contradicted to her condition.
CONSENT OF PATIENT
After all the explanations necessary for the patient to gain knowledge, understand the surgery, a
consent form is signed by the patient and this give the legal right for the operation to be
performed on her.

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.

Blood for hemoglobin level estimation.


Blood for red blood cell count.
Blood for white blood cell count.
Blood for serum calcium level.
Blood for serum potassium level.
Blood for serum chloride level.

TABLE ONE: DIAGNOSTIC INVESTIGATION ON MRS. D.O


DATE

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

Red blood cell count

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

White blood cell


count
Serum calcium level

Vitamin B12 was


prescribed for patient.
Patient advised on
nutritious diet
Tablet zincovit was
prescribed for patient.
No treatment was given.

2.45mmol/l

2.15-2.55mmol/l

Normal

No treatment was given.

07/08/13

Blood

3.8mmol/l

3.5-5.5mmol/l

Normal

No treatment was given.

07/08/13

Blood

Serum potassium
level
Serum chloride level

98mmol/l

90-100mmol/l

Normal

No treatment was given.

TABLE TWO: COMPARISON OF CLINICAL MANIFESTATION FROM CLINICAL MANIFESTATION EXHBITED BY


PATIENT
CLINICAL MANIFESTATION OUTLINED IN
LITERATURE REVIEW

CLINICAL MANIFESTATION EXHBITED BY


PATIENT

.Heavy menstrual bleeding

Patient experienced heavy menstrual bleeding

.Prolonged menstrual bleeding

Patient had prolonged menstrual bleeding

.Pelvic pressure or pain

There was a complain of pelvic pressure

.Frequent urination

She had frequent urination

.Constipation

Patient had constipation

.Low backache

She experienced low backache

.Dehydration

Patient was dehydrated

SPECIFIC TREATMENT GIVEN TO PATIENT


The following treatments were given to Mrs. D. O.
SURGICAL TREATMENT
1. Total abdominal hysterectomy was done for patient.
PRE OPERATIVE TREATMENT
1. Intravenous normal saline 1litre
2. Intravenous ringers lactate 1litre
3. Intravenous ciprofloxacin 400mg bd x2
INTRA OPERATIVE TREATMENT
1. Intravenous Atropine 0.5mg
2. Intravenous Suxamethionum
POST OPERATIVE TREATMENT
1. Intramuscular pethidine 50mg bdx24hours
2. Intramuscular Diclofenac 75mg bd x48hours
3. Intravenous metronidazole 500mg 8hourly x24
4. Intravenous Dextrose saline 3L
5. Intravenous Normal saline 3L
6. Intravenous Ringers lactate 3L
7. Tablet Zincovit 1 tablet daily x15
8. Intravenous Ciprofloxacin 500mg bd x 48hours
9. Intramuscular Buscopan 20mg bd x 24hours

TABLE THREE: PHARMACOLOGY OF DRUGS PRESCRIBED TO MRS. D.O

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

Depends on the rate


of dehydration

Intravenous
fluid for Fluid
and
electrolyte
replacement

Fluid and
electrolyte

It is used for the


replacement of lost
fluid and electrolyte.

Restores the normal


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

For the relieve of


pain.

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

None of the above


was observed.

None of the above


was observed.

To stimulate red
blood cell production.

There was a
stimulation of
red blood cell
production.

Diarrhea
,abdominal
distress

None of the above


was observed.

11/09/1
3

Atropine

Adult dose:0.40.6mg in single dose


45-60minutes
before anesthesia

Muscle
relaxant

Relaxes the muscle.

Patient muscles
were relaxed
before surgical
operation.

Child dose:0.050.4mg in single dose


45-60minutes
before anesthesia

Tachycardia,
photophobia, dry
mouth, blurred
vision.

None of the above


was observed.

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.

No side effect was


observed.

intramuscular

PRE OPERATIVE PROBLEMS


1.
2.
3.
4.

Fever.
Abdominal pain.
Knowledge deficit (Partial).
Anxiety.

POST OPERATIVE PROBLEMS


5.
6.
7.
8.

Acute pain (incision pain).


Incision wound.
Risk for urinary tract infection.
Inability to perform her personal hygiene.

PATIENT AND FAMILY STRENGHTS


1.
2.
3.
4.
5.
6.
7.
8.

Patient can tolerate tepid sponging.


Patient can verbalize the location of her pain.
Patient is willing to be educated about her disease condition.
Patient is not irritable.
Patient is can verbalize pain at the incision site.
Patient can tolerate wound dressing.
Patient can tolerate catheter care.
Patient can cooperate and tolerate assisted bath.

PRE OPERATIVE NURSING DIAGNOSIS


1. Altered in body temperature (38.4C) related to inflammatory process.
2. Altered body comfort (abdominal pain) related to inflammatory process secondary to
uterine fibroid.
3. Knowledge deficit (partial) related to inadequate information on the causes and
management of uterine fibroid.
4. Anxiety related to unknown outcome of impending surgery.
POST OPERATIVE NURSING DIAGNOSIS
5.
6.
7.
8.

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.

POST OPERATIVE NURSING OBJECTIVES


1. Patient will experienced a reduction in pain level at the incision site within 72 hours as
evidenced by:
a. Patient verbalizing relief of pain.

b. Nurse observing patient having a cheerful facial expression and looking relaxed in
bed.
2. 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

TABLE FOUR: PRE OPERATIVE NURSING CARE PLAN OF MRS D.O


DATE
AND
TIME
10/9/2013
at
12:00pm

NURSING
DIAGNOSIS

OBJECTIVES/OUTCOME
CRITERIA

NURSING
ORDERS

Altered in body
temperature
(38.4C) related to
inflammatory
process.

Patients body temperature will


be reduced to the normal range
(36.2C-37.2C) within 12
hours as evidenced by:

1. Check patients body 1. Patients body temperature


temperature and record. was checked and recorded to
serve as baseline for treatment.

a. Nurse observing that


patients temperature has
reduced to the normal range
(36.2C-37.2C) by reading
from the clinical thermometer.

2. Tepid sponge
patient.

EVALUATION

Goal fully met


as patient
verbalized that
her temperature
has reduced
(37.5C)

2. Patient was tepid sponged to


reduce body temperature.
10/09/2013.

3. Open nearby
windows.
b. Patient verbalizing that her
temperature has reduced.

NURSING
INTERVENTIONS

3. Nearby windows were


opened to allow for circulation
of air.

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.

1. Patient was reassured


that pain will subside
after implementation of
all nursing procedures.

Goal fully met as patient


was seen relaxed and
cheerful in bed.

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.

3. Patient was assisted to


assume prone position
on which was
comfortable for her on a
bed free from creases
and cramps.

4. Reduce noise

4. Staff was asked to


minimized noise and
visitors were also
restricted.

5. Provide diversion

5. Patient was engaged

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.

Patient 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 care of
surgical wounds.

1. Reassure client and


family.

1. Client and family were


reassured that all necessary
information about the condition
would be provided to help them
understand the condition.

Goal fully met as


client and family
verbalized their full
understanding on the
condition.

2. Put client in a
comfortable position.

2. Client was put in a sitting up


position to seek for her alertness

10/09/13

3. Educate client on
condition.

3. Education was provided to client 2:30pm


that helped her to understand the
causes and the management of
A.F
fibroid.

4. Allow patient and


family to ask questions.

4. Patient and family were given


the opportunity to ask questions on
the condition.

5. Give appropriate
answers to client and
family.

5. Appropriate answers were given


to the questions asked by the 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

1. Patient and family were reassured that


she in the hands of competent nurses or
staff to reduce her anxiety.

Goal fully met as


patient seen relaxed
and had a good
relaxed facial
expression.

2. The facial expression and posture of


family and patient were observed in
attempt to assess their level of anxiety.

10/09/13
5:00pm
3. The theater environment, dressing of
workers and equipment were explained to
allay her anxiety.

4. Patient and family were allowed to


express their concern by asking questions
and appropriate answers were given to
correct misconception about uterine
fibroid.
5. Patient was engaged in diversional
therapy such as conversation to allay her
fears on the impending surgery

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.

1. Patient was reassured that the


pain and discomfort will be
relieved with effective nursing
measures.

Goal fully met as


patient verbalized
that she has a reduced
pain.

a. Patient
verbalizing that
she is relieved of
pain.

2. Assist patient to
assume a comfortable
position that relieves
her pain.

2. The patient was assisted to


assume a comfortable position to
help reduce 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.

3. The patient was engaged in


conversation to turn her attention
from pain.

4. Teach patient to
support incision site
when coughing or
laughing.

4. Patient was taught to support the


site with the hands when coughing
or laughing to relief tension, on
incision site to reduce pain.

5. Administer

5. Analgesic was served to reduce

A.F

analgesics.
TABLE FOUR:

DATE
AND
TIME
12/09/13
At
10:00am

pain.

POST OPERATIVE NURSING CARE PLAN OF MRS D.O

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.

1. Patient was reassured that strict


technique will be employed during
hospitalization to prevent wound
infection.

Goal fully met as it was


observed that patient
wound healed by first
intension.

a. Patient verbalizing
that there is no
discharge at incision
site.

2. Change soiled
dressing as per
hospital policy and
aseptically.

2. Soiled dressing was frequently


changed three times daily to
prevent moisture and infection.

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.

3. Patient was instructed not to


touch the wound site to avoid
infection of the wound.

4. Administer
prescribed antibiotics.

4. Prescribed antibiotics such as


flagyl were administered to
prevent infection.

DATE AND TIME

NURSING
DIAGNOSIS

12/09/13

High risk for


urinary tract

OBJECTIVE/
OUTCOME
CRITERIA
Patient will be free
from urinary tract

NURSING
ORDERS

NURSING
INTERVENTION

EVALUATION

1. Reassure client.

1. Patient was
reassured that the

Goal fully met as


nurse observed

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. Care for catheter


daily with antiseptic
lotion.

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.

DATE AND NURSING


TIME
DIAGNOSIS

3. Monitor flow rate


of urine.

3. Urine flow rate was


monitored to determine
fluid balance.

4. Assist patient to
perform personal
hygiene such as
bathing and care of
mouth.

4. Patient was assisted


to perform personal
hygiene as bathing and
mouth care to promote
her comfort.

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.

Patient will be able to meet


her self-care needs within
72 hours as evidenced by:
a. Nurse observing patient
taking her bath, caring for
her mouth without
assistance.

1. Reassure
patient.

1. Patient was reassured


that her personal hygiene
would be taken care of until
her condition allows her to
perform them by herself.

Goal fully met


as patient was
able to bath and
care for her
mouth without
assistance.

2. Assist patient to
bath twice daily.

2. Patient was assisted in


bed to bath twice daily with
warm water to refresh her
and remove dirt and also
stimulate circulation.

15/09/13
7:00am

A.F
3. Treat pressure
areas as such.

3. Pressure areas such as


heels and scapula were
inspected and treated to
prevent the development of
bedsores.

4. Give oral care


twice daily.

4. Patients mouth was


cared twice daily with tooth
brush and tooth paste to
prevent oral infection.
Vaseline was applied to the
lips to prevent cracks.

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.

SUMMARY OF ACTUAL NURSING CARE


The actual nursing care rendered to Mrs. D.O in the management of her condition started on the
day of admission (10th September, 2013) through to the time when the third home visit was
made.

DAY OF ADMISSION (10TH SEPTEMBER, 2013)


Mrs. D.O was admitted to the surgical ward at the S.D.A hospital Kwadaso on the 10 th
September, 2013 at 11:30am with the diagnosis of uterine fibroid. She was in the company of
two relatives, the husband and the child. The patients folder was collected from the admission
nurse and patients name and other particulars were verified to confirm whether she was the right
patient. Patient and her family were warmly received and given seats to make them comfortable
and were reassured that all the necessary measures would be put in place to ensure her comfort
throughout her hospitalization. Patient was put in a comfortable bed and quick assessment from
head to toe was done to ascertain her general condition.
Her vital signs were checked and recorded as follow:
Temperature = 38.4 degree Celsius

Pulse = 80 beats per minute


Respiration = 20 cycles per minute
Blood pressure = 130/80 millimeter per mercury
Tepid sponging was done to reduce patients temperature to 37.5 degree Celsius.
Family members were educated on visiting hours and the meal time and all ward policies were
explained to them. They were also shown to the bathroom and toilet. They were also introduced
to doctors, nurses and other staff on the ward as well as other patients.
Anxiety level of patient rose up due to the impending surgery, so she was reassured that she will
have a successful surgery. This helped to allay anxiety and wins her cooperation. She was
introduced to other patients who have undergone similar surgery successfully and it helped to
release her psychologically. She allows expressing her fears through questioning and her
questions were answered in simple terms to clear any misconception.
Patient had inadequate knowledge on the condition (uterine fibroid) and so the definition, causes,
signs and symptoms and treatment of the condition were explained to her. Clients and familys
questions were answered in simple and appropriate terms to aid in the full understanding of the
condition.
Bed rest was ensured and in a quite environment. Clients vital signs were checked and recorded
and all measures were put in place to relieve pain. Nil per OS was instituted due to the
impending surgery. Patient went to bed around 7:20pm to prepare for the operation on the
following day, (11th September, 2013). Procedures done were recorded and documented in the
nurses notes.
Vital signs checked and recorded for the ranges within:
Temperature = 37.5-38.4 degrees Celsius
Pulse = 78-80 beats per minute
Respiration = 18-20 cycle per minute

Blood pressure = 120/70-130/80 millimeter per mercury

FIRST DAY OF ADMISSION (DAY OF SURGERY) 11TH SEPTEMBER 2013


IMMEDIATE PRE-OPERATIVE CARE
Mrs. D.O woke up around 5:35am and had a cheerful facial expression. Her personal hygiene
such as bathing and mouth care was done. Patient was reassured again that she was in the hands
of competent health personal and she would recover successfully. The area to be operated was
cleaned with antiseptic solution and covered with a sterile towel. Nil per OS was still instituted
and was well explained to patient as to help prevent aspiration during the time of surgery. The
relatives were given the chance to be with the patient until it was about time for her to be sent to
the theatre. The patient folder was checked to ensure that all necessary documents were intact
and the consent form was signed to confirm the surgery.
Mrs. D.O was dressed in a theatre gown and all materials such as necklace; rings were removed
and placed safely in the property room. A urethral catheter was in-situ to make easily empting of
the bladder. She was sent to the theatre on a stretcher at 12:45pm. Oxygen
apparatus, suction machine and drip stand were at the side of the patients bed to be
used when the need arises.
The vital signs of the patient were checked and recorded to ensure that patient is fit for the
operation.
Temperature = 36.5 degree Celsius
Pulse = 78 beats per minute
Respiration = 20 cycle per minute
Blood pressure = 120/70millimeter per mercury

IMMEDIATE POST OPERATIVE CARE [11TH SEPTEMBER, 2013]


After the surgery, patient was brought back to the ward on a stretcher in the company of two
theatre nurses at 2:45pm. She was semi-conscious and had 500ml of Ringers lactate in place that
was dripping well. Patency of urethral catheter was ensured
Vital signs were checked 15 minutes, then 30 minutes and hourly till her condition was stable.
This helped to allay fears and anxiety. A resuscitation tray (containing galipot with sterile swabs,
spatula, ventilators, and tongue holding forceps, mouth gag and receiver for used swab) was set
and placed at patients bed side to be used when the need arises. Patient finally slept at 9: 05pm.
Vital signs were checked and recorded for the day ranges within:
Temperature = 36.2-36.8 degree Celsius
Pulse = 74-78 beats per minute
Respiration = 22-24 cycles per minute
Blood pressure = 120/70-130/70 millimeter of mercury

FIRST DAY POST OPERATIVE [12TH SEPTEMBER, 2013]


Patient woke up in the morning around 7: 00am and complained of incision pain and she was
reassured. She had an assisted bed bath, oral hygiene and was given toothbrush and paste to
clean the mouth to promote physical comfort and also prevent oral infection. She was reassured
that the pain was temporal and will be relieved through effective medical and nursing
interventions. Nil per OS was still ensured and her catheter cared for. Patients bed linen was
changed to promote rest and sleep.
Wound dressing of patient was inspected for discharges and none was seen. She was instructed
not to touch the wound with her hand to prevent infection. Patient was also taught to support the

incision site when coughing, sneezing, or getting out of bed to prevent wound gabbing. The
doctor came for review around 10: 25am 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

SECOND DAY POST OPERATIVE [13TH SEPTEMBER, 2013]


Around 7: 15am patient woke up from bed and was assisted to take her bath in bed. She also had
her oral hygiene because there was an improvement in her condition. She was encouraged to
engage in passive exercise to ensure improvement in her health state. She had no complaints, her
wound was assessed for drainage and discharges and was dressed using aseptic technique to
prevent infection. She took her porridge and due medications were served in the morning. Patient
had a cheerful facial expression and went to bed around 7:00pm after taken her personal hygiene.
Vital signs checked and recorded for the day ranges within;
Temperature = 36.4-37.2 degree Celsius
Pulse = 80-84 beats per minute
Respiration = 20-22 cycles per minute
Blood pressure = 110/70-110/90 millimeters of mercury

THIRD DAY POST OPERATIVE [14TH SEPTEMBER, 2013]


On the third day post-operative, patient woke up at 7:00am and was having a cheerful facial
expression. Patient was assisted to take her personal hygiene thus brushing the teeth, taking her
bath and dressing neatly. She took her breakfast and due medications were served.
Vital signs checked and recorded for the day ranges within;
Temperature = 36.2-37.4 degree Celsius
Pulse = 78-80 beats per minute
Respiration = 18-22 cycles per minute
Blood pressure = 120/70-130/70 millimeters of mercury
Patient dressing was inspected and dressing was changed to prevent infection and promote
healing. She was educated to ensure personal hygiene by not touching the wound to prevent
infection. She was also advised to eat nourishing diet as well as fruits rich in vitamins to promote
wound healing. Mrs. D.O was seen interacting with other patients at the ward. She had her
supper, took her medications and bathed in the evening and went to bed around 8:00pm.

FOURTH DAY POST OPERATIVE [15TH SEPTEMBER, 2013]


Patient slept well during the night according to the night nurses report. Her condition now was
improving. All prescribed medications were served and recorded. Patients vital signs were
checked and recorded. Wound of patient was inspected for abnormalities such as pus and
swelling. The wound was dressed with normal saline from inside out under aseptic technique as
the hospital policy. .She was not to touch the wound site to prevent infection and also was
advised to adhere to all medications to promote wound healing.

Patient was taught how to get out of bed without putting pressure on the incision site and was
also encouraged to walk around the ward to improve circulation and prevent joint stiffness. She
was served with light porridge in the morning, rice balls with light soup in the afternoon and
slice yam with light soup in the evening. Patient was made comfortable in bed and her relatives
were reassured of her speedy recovery.
Vital signs checked and recorded for the day ranges within;
Temperature = 36.6-36.9 degree Celsius
Pulse = 78-80 beats per minute
Respiration = 22-24 cycles per minute
Blood pressure = 120/70-130/80 millimeters of mercury

FIFTH DAY POST OPERATIVE [16TH SEPTEMBER, 2013]


Client woke up in the morning with no complaints and she was looking cheerful. She maintained
her personal hygiene without assistance. Alternate stitches were removed and the wound was
dressed aseptically using methylated spirit. On ward rounds, client was finally discharged after
she had undergone physical examination. She was asked to report on 23 rd of September, 2013 for
removal of other stitches. She was also told to come for review on 27th September, 2013.
Mrs. D.O was again advised on the importance of taking her medications regularly and also the
need of taking in nutritious diet to enhance wound healing. She was advised on promoting
dryness of the wound by not wetting the wound dressing. The families including the patient were
happy to go home due to as no complication was observed.
The patients folder was sent to the accounts department for assessment and payment of bills and
all debts were settled by patients relatives. Madam D.O and the family expressed their profound
gratitude to me and the entire health team for the cared rendered. Clients name and date of
discharged were documented into the admission and discharge book as well as the daily ward
state. Patient and family said goodbye to other patients on the ward and left to the house around

3:30pm. Bed linen of patient was stripped off and bedstead, lockers were clean with disinfectants
and were made ready for the next admission.

PREPARATION

OF

PATIENT

AND

FAMILY

FOR

DISCHARGE

AND

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.

FOLLOW UP/ HOME VISITS/ CONTINIUTY OF CARE


Home visit is a purposeful visit to the home of the patient with the aim of preventing diseases,
promoting and maintaining health. The follow up is also to assess the use of available resources
at the house as well as in the community that can be used to solve patients problems. Follow up
was to assess the health status of patient after discharge.
FIRST HOME VISIT [14TH SEPTEMBER 2013]
The first follow up home visit was made on 14 th September, 2013 when patient was still on
admission. Its purpose was to know the patients environment and how well it will contribute to
the health status of the patient and also to educate them on how to support the patient after
discharge. I went to the house together with the husband.
They live at Kwadaso in Kumasi. We were there around 11:45am and were warmly welcomed by
some of the family members present at that time. On arrival to the house, observation was made
regarding cleanness of the surroundings. They lived in a family house. Their main water supply
was pipe borne water and was also having electricity. The community was well equipped with
portable roads.
Cement blocks were used to build the house and was roof with iron sheets. The house was well
painted and had no fenced wall. They have well ventilated rooms which aid in air circulation.
They store their refuse in an aluminum dustbin and empty it each morning into the communitys
refuse dumping site. I congratulated them for good environment and encouraged them to
continue it. Not forgetting, I advised them to always visit the hospital for medical checkups and

also to take in well nutritious meal to aid in their bodys functioning. Assurance was given to
them concerning my next home visit after discharged of patient.

SECOND HOME VISIT [20TH SEPTEMBER 2013]


The second home visit was made on 20th September, 2013. The aim was to check how patient
was faring, how she was adhering to her treatment regimen and also to remind her of the date for
review. Mrs. D.O and family welcomed me to their house. I asked for patient drugs to see if she
was adhering to treatment regimen. Patient was given the mandate to verbalize how she feels and
I observed the wound for any complication of which none was observed. Mrs. D.O had no
complained and the wound was well clean.
The patient was reminded of the review date which comes on 27 th September, 2013. She was
adviced to take in well-balanced diet to help prevent infection and also promote early wound
healing. She was also educated to avoid putting much pressure on her wound through lifting of
heavy objects. It was made clear to the patient that if she encounters any problem she should
report to the hospital before the review date. Termination of care was explained to them and that
would be possible on the third home visit. Another home visit was promised. Permission was
granted for me to leave.

THIRD HOME VISIT [2ND OCTOBER, 2013]


The third home visit was conducted on 2nd October, 2013. The purpose of this visit was to
terminate care. Patient and families were in good health with no complaints. Mrs. D.Os wound
was almost healed. Education on personal and environmental hygiene was emphasized. She was
also reminded to avoid lifting of heavy objects. They were lastly then reminded that in case of
any complication, they should report to the hospital for early treatment and also periodic medical
checkup was instituted.

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

EVALUATIN OF CARE RENDERED TO PATIENT AND FAMILY.


This is the final step of the nursing process that allows the nurse to determine the patient
response to nursing intervention. If a set goal is not met, a new intervention is initiated and
carried out until is met.
By definition, it is the determination of patients response to the nursing interventions and the
extent to which the nursing interventions and outcome have been achieved.
STATEMENT OF EVALUATION
Mrs. D.Os health improved after six days of admission. During the evaluation of care rendered
to her, all the goals and evaluation were fully met. Problems presented by patient and objectives
were related to the evaluation.
10TH SEPTEMBER, 2013
An objective was set at 12:00pm to reduce patient body temperature to the normal range [36.237.2 degree Celsius] within 12 hours. Goal was fully met on 10/09/2013 at 6:30pm as nurse
observed that patients temperature has reduced to the normal range by clinical thermometer
reading.
An objective was set at 1:15pm to reduced patients abdominal pain within 1hour. Goal was
fully met on 10/09/2013 at 2:15pm as nurse observed that patient was relaxed with a cheerful
facial expression, patient feeling comfortable in bed and had no pain.
Another objective was set at 2:00pm to encourage patient to have adequate knowledge to uterine
fibroid within 30 minutes. Goal was fully met on 10/09/2013 at 2:30pm as patient and family
verbalized their full understanding of the condition and how to take care of surgical wounds.
Lastly,A an objective was set at 3:45pm to reduce patient and family level of anxiety within
4hours. Goal fully met on 10/09/2013 at 5:00pm as nurse observed that patient had a cheerful
facial expression, patient verbalized that she is relieved of anxiety.

11TH SEPTEMBER, 2013


An objective was set on 11th September 2013 at 3:00pm to relieve patients pain within 72hours.
Goal was fully met on 13/09/2013 at 10:20am as nurse observed patient having a cheerful facial
expression and looking relaxed in bed, patient verbalized that she is relieved of pain.
12TH SEPTEMBER, 2013
An objective was set at 10:00am to prevent patient wound from infection throughout period of
hospitalization. Goal fully met on 15/09/2013 at 9:30am as nurse observed that patient wound
healed by first intension.
An objective was set at 12:30pm to prevent patient from urinary tract infection within the period
of hospitalization. Goal fully met on 12/09/2013 at 3:10pm as nurse observed no signs and
discharges at the catheter site.
An objective was set at 6:20pm for patient to meet herself care needs within 72 hours. Goal fully
met on 15/09/2013 at 7:00am as nurse observed patient taking her bath and caring for her mouth.

AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET


OBJECTIVES OUTCOME
All goals were fully met as Nursing care plan for patient were prioritize and rendered aqurately
to Mrs. D.O.
Cooperation of patient and family and nursing and medical care rendered also contributed to the
achievement of her goals, so no nursing care was amended.

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.

SUMMARY OF CARE PROVIDED TO PATIENT AND FAMILY


Mrs. D.O, 43 year woman was admitted to the female surgical ward at SDA Hospital Kwadaso
on 10th September, 2013 and was diagnosed of uterine fibroid.
Patient presented signs and symptoms such as abdominal pain, anxiety, high body temperature
and others.
Total abdominal hysterectomy was done for patient at the theatre on 11th September, 2013 around
12:45pm.
Nursing management such as mouth care, bed bath, vital signs and wound dressing were
rendered. Patient started sips of water on 12th September, 2013.
Client was told to come for removal of stitches on 23rd September, 2013 and reported for review
on 27th September, 2013. Education was given to patient and family on maintaining personal and
environmental hygiene during admission.

Education was given to patient to take in well-balanced diet, encouraging rest and sleep, and
adhering to prescribed drugs to aid in wound healing. Home visits were done after discharge of
patient.

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.