REVIEW OF MISS AKOSUA NAA
On Thursday, the 21st of January 2010 was the review date for Miss Akosua Naa. She came into the company of her mother. They arrived at consulting room 9 at KomfoAnokye Teaching hospital around 9:00 am. I assisted them to collect her folder and by 9:40 am it was their turn to see the doctor. The doctor on duty then was Dr. York. He requested for wider test and malaria parasite but these proved negative when the results came out.
She was also advised to continue her medications given her on the day of discharge till they get finish completely. Akosua was encouraged to report any problem and abnormalities that may arise after reviewing for early interventions.
THIRD HOME VISIT
This took place on the 1st of February 2010, at 3 pm to monitor the continuity of care. Upon reaching the house I was offered a seat and given water to drink.
Akosua was very happy when she saw me. I was asked my mission and I told them as stated above. AkosuaNaa’s condition has improved very well than when she came for the review. Her drugs were checked to find out whether she had taken them or not, how many of the drugs remained, and how she was taking them. It was observed that Akosua has fully completed her medication. I asked how she was fairing and she said that she was doing well. A glance of the environment was done and the whole place was clean and tidy.
In fact, I was glad that health education has really gone down well with them. I told them that, this was my last official visit to them, and they were also appreciative of the care and support rendered during their hospitalization and my home visit.
They promised to use all the advice that had been given to them for good purpose. I handed over AkosuaNaah to the community health nurse Mrs. Prempeh Abigail for the continuity of care.
EVALUATION OF CARE GIVEN
Evaluation is the assessment of the outcome of nursing care rendered to the client. It is the final stage in the nursing process. The patient was diagnosed and a care plan was formulated and implemented.
STATEMENT OF EVALUATION
After the implementation of interventions, it was noticed that objectives and goals set were fully achieved. The client’s condition had improved gradually by the time of evaluation without any complications.
On the 4th of January, 2010, a goal set to reduce high body temperature to normal range within 3 hours was met as the client’s temperature dropped to normal (38.0 – 37.0oC).
On the same day, a goal set to relieve the client’s abdominal pain and distension within 2 days was also achieved as the nurse observed a reduction in abdominal distension, and the client verbalized relief in abdominal pain.
Again, on the 5th of January, 2010, a goal set to reduce anxiety in client and family was achieved after 2 days as evidenced by the client and family having cheerful facial expressions without anxiety and being cooperative.
On the same day, the client was relieved of incisional wound pain as the client verbalized that the pain has subsided and the nurse observed the client having a cheerful facial expression.
On the 6th of January, 2010, a goal set for the maintenance of personal hygiene by the client herself was achieved within 4 days post-operatively as the client verbalized that she could care for her personal hygiene and performs normal daily activities by herself.
Another goal set for a normal breathing pattern was achieved within 4 hours through good nursing management and oxygen therapy as evidenced by the client verbalizing that she could breathe normally and the nurse observing that client have a normal respiration rate.
Again, the goal set to prevent wound infection and contamination was met throughout the period of hospitalization as the nurse observed that client’s wound healed by first intention without infection.
Then on the 7th of January, 2010, the client had a sleeping pattern disturbance and nursing management put it in place to help the client to sleep 3 hours in the day and 6-8 hours in the night. This was a goal met.
Furthermore, a goal set to achieve good nutritional status was achieved gradually 5 days post-operatively as evidenced by the client eating enough amounts of food served and looking healthy.
Again, a goal was set to provide adequate information about the client’s disease condition on the 5th of January, 2010 before discharge and this was met as the client and family were able to give a feedback on health education.
Other nursing goals were also met.