THIRD DAY OF ADMISSION AND FIRST DAY OF OPERATION (06-05-10)
This was the first day postoperatively, the client’s general condition was stable and looked a bit cheerful than the previous day. She was reassured that with good nursing and medical intervention she will recover fully like the other healthy ward mates.
The client was served with a warm bedpan on request and she passed black watery stool about 300mls, urine emptied was 800mls and 150mls of aspirated fluid from the nasogastric tube. All documented. She was given a warm bath in bed and her mouth was cared for with toothpaste and a brush. She was groomed and guided to stretch the arms, turn side and side in bed, flex and extend the legs. This was to promote fleshiness, improve circulation and encourage early ambulation respectively.
Vital signs were checked and recorded, values were within the normal range. Prescribed intravenous medications were served with no reaction noticed.
The wound site was inspected for discharge, bleeding, and swelling. Intravenous infusions were served and recorded as shown in table 2 appendix 2.
In the afternoon at around 3:00 pm, the client complained of difficulty in breathing. Her vital signs were checked and it was ensured that no tight clothing or bangs were on patients. She was nursed in a semi-flowers position to aid in breathing with her head turned to one side and to assist in drainage. Prescribed oxygen 4 liters per minute were administered. The client was reassured that the measures underway will ensure and maintain her normal breathing pattern.
FOURTH DAY OF ADMISSION AND SECOND DAY POSTOPERATIVE (07-01-10)
On the morning of the second day post-operatively, basic nursing procedures were performed on the client including bathing and grooming, oral care, and serving of bedpan. The client was encouraged to perform active exercises such as sitting up in bed and on the chair, walking around her bed and in the ward. The urine output and nasogastric tube content were checked and emptied and was recorded accurately. At the time of ward rounds, the client’s condition was satisfactory to the surgeon and he ordered that the urethral catheter and nasogastric tube should be removed but the client should continue IV treatments.
To prevent wound infections the site was inspected for any abnormal discharge. Vital signs were checked regularly and prescribed antibiotics were served and documented.
In the evening, at around 8 pm client complained of sleeplessness. To ensure that she enjoys enough sleep, her bed was made comfortable regularly. The noise was reduced in the ward and nearby curtains were raised to improve ventilation. Prescribed analgesic IM Pethidine 100mg was administered. The client was reassured that she will recover safely.
FIFTH DAY OF ADMISSION AND THIRD DAY POSTOPERATIVE (8-04-10)
According to the night, report the client had a sound sleep. Routine nursing care was rendered to the client and now she looks very cheerful.
The wound was opened and it looked neat and dry. Wound dressing was done with methylated spirit and covered with sterile gauze aseptically
The client was advised not to be touching the wound and to be neat all the time so as not to alter the healing process. She was also educated on what to eat to promote wound healing such as eating fruits and vegetables,
On review, the doctor observed that bowel sound has resumed and ordered that intravenous fluids should be discontinued and start slip of water. As the client can tolerate plain tea could be added, followed by a fluid diet, a soft di, et and then a normal diet.
Vital signs were checked and recorded as ordered and due medication is given. The client slept at 8:00 pm after evening routine care has been rendered,
SIXTH AND SEVENTH DAY OF ADMISSION AND FOURTH AND FIFTH DAY POSTOPERATIVE (9TH AND 10TH JANUARY 2010)
The client’s condition was known to have improved considerably on the sixth day of admission. The usual nursing care was carried out; vital signs were checked and recorded.
The client made no complaints on the review. The surgeon ordered that alternate stitches should be removed and the remaining ones on the 9th day post-operatively. The wound site was inspected and she was put on Tablets ciprofloxacin 500mg, Tablets Diclofenac 625 bd for 7 days, Tab vitamin B 30mg TDS x5 days, Tab fersolate 200mg TDS x 16 days.
Oral feeding was to proceed gradually as the condition improves and the client could tolerate it.
On the 7th day, all routine nursing care was carried out, meals and medication served, vital signs checked and recorded.
Requirements for the removal of stitches and wound dressing were assembled and alternate stitches were removed, the wound was made clean and dressed antiseptically. Instruments were washed and made ready for the next use.
Diet was planned with the client to know her likes and dislikes and to prevent any allergies.
In the evening client meals and drugs were served and personal hygiene was maintained as well, after which rest and sleep were ensured.