CHAPTER 3: SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT AND FAMILY

By | July 11, 2021

IMPLEMENTING PATIENT/FAMILY CARE PLAN

Implementing is the fourth stage in the nursing process. It investigates actual nursing care given to the patient and family. It aims at making patient comfortable, avoiding complication, and promoting early recovery.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT AND FAMILY

Miss Akosua Naa was admitted on the 4th of January 2010, at around 8:40pm with a provisional diagnosis of Generalised peritonitis as a referred case from Mampong Government Hospital. Some of the signs and symptoms she exhibited were high temperature, abdominal pain and distention, headache and malaise.

A good interpersonal relationship was established by introducing myself to client and mother. After acceptance by client and mother to use client for my care study, I asked few questions to enable me carry out the study.

After admission process client and mother were reassured that client was in the hospital which has modern machinery, equipment and competent staffs who are willing to help her recover successfully. The client was also introduced to other patients who had similar condition and were recovering.

Tempid sponging was done after checking vital signs and client having pyrexia from 38.0ºC to 37.5 ºC. All nearby windows were opened to ensure ventilation, visitors were restricted to avoid interruption and also volume of radio and television set were reduced. Client attention was diverted by engaging her in a conversation with the nurses to take her mind off the pain and to ensure rest and sleep.

Client was attended promptly by the doctor on duty and series of examinations and investigations were performed on her alongside nursing cares.

She was finally diagnosed of Typhoid fever with perforation. Prescribed medications were administered and client was advised not to take anything by mouth as she might possibly undergo surgery.

Nursing procedures and doctors’ orders were explained to client and mother, they were allowed to ask questions about the condition and the operation and all misconceptions were cleared to relieve them of anxiety.

CHAPTER 3: SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT AND FAMILY

PHYSIOLOGICAL PREPARATION

Laboratory investigations were carried out on client to assess her for surgery. The doctor was assisted to collect blood specimen for fasting blood sugar, and grouping and cross matching to ensure safe blood transfusion when the need be. Test for malaria parasite, Hemoglobin level (HB) estimation and sickling has already been checked at Mampong Hospital where she was referred from and all these were negative with HB within normal range.

The client was taken to the x-ray department for x-ray of the abdomen, and chest. Her medications were collected from the dispensary. The doctor on duty was also assisted to pass nasogastric tube to empty the stomach contentand avoid vomits during the surgical procedure. Client was allowed to assume a suitable position and prescribed analgesic was given. Female urethral catheter was passed for drainage of urine.

Client has a potent intravenous line and it wasmaintained andobserved for infiltration, swelling and flow rate. IV infusions were given prescribed to prevent dehydration.

 

SOCIO-ECONOMIC PREPARATION

Upon assessment and interview, it was noticed that client came from a less than average socio-economic background but fortunately client had joined the National Health Insurance Scheme which catered for her hospital bills.

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