CASE STUDY BY: ADDAI FREDSUPERVISORS NAME: MR. AMANKWAHOSPITAL: SDA HOSPITAL KWADASOWARD: SURGICAL WARDPATIENTS PARTICULARSNAME: MRS D.OAGE: 43 YEARSSEX: FEMALEDIAGNOSIS: UTERINE FIBRIODTYPE OF OPERATION: TOTAL ABDOMINAL HYSTERECTOMYDATE OF ADMISSION: 10/9/2013TIME OF ADMISSION: 11: 30AMDATE OF SURGERY: 11/9/2013OCCUPATION: TRADERRELIGION: CHRISTIANLOCALITY: KWADASONEXT OF KIN: MR A.DLANGUAGE SPOKEN: TWI AND FANTEWARD IN-CHARGES NAME: COMFORT ADU BOOBISIGNATURE..CHAPTHER ONEASSESSMENT OF PATIENT AND FAMILYAssessment is the first step in the nursing process in which the nurse carries out a complete and holistic nursing assessment of every patient 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. and also to identify patients problems which are expressed as actual or potential.PATIENTS PARTICULARSComment by Amankwaa: Next of kin?, marital statusMrs. D.O is 43 year woman born to Mr. O.O and Mrs. R.T. sshe hails from cape coast in the central region of Ghana. She but stays at Kwadaso. She is half Ashanti and half Fanti. Mrs. D.O is 5.4feet tall and weighs 68kg. 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 HISTORYThere are no known hereditary illnesses like asthma, diabetes mellitus, hypertension and absence of or mental illness in their family. The family sometimes experiences headache, slight stomach aches which are mostly managed by taking paracetamol and sometimes flaggly 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 HISTORYComment by Amankwaa: Was she born at term?Comment by Amankwaa: The whole of this part is incomplete. U need to wrk more herePatient was born by vaginal delivery with an assistance of a traditional birth attendantce at the house. She experienced her secondary characteristics such as breast enlargement, menstrual flow and enlargement of hips at the age of 14years. Mrs. D.O is currently living with her husband with five children, two males and three females.Comment by Amankwaa: This section should be chronological, u How can a child start having secondary sexual characteristics soon after birth?Comment by Amankwaa: How does this become development?She was immunized against the six childhood killer diseases now known as childhood preventable diseases. Client had no formal education.Comment by Amankwaa: Never entered the classroom?PATIENTS LIFESTYLE AND HOBBIESPatient 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 HISTORYPatient had never experienced any medical conditions like diabetes mellitus, hypertension etc. she had no known allergies. She hasd, 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.PATIENTS PRESENT MEDICAL HISTORYPatient was apparently well until 6th day of September 2013 when she started experiencing profuse bleeding and, abdominal pains that was associated with her when she got into menstruation. Prior to that, she was admitted at the SDA Hospital Kwadaso to be taking care of. It was later confirmed that patient was having uterine fibroid of which she was to undergone total abdominal hysterectomy.Comment by Amankwaa: Why was she admitted? I think this should be part of the past medical historyADMISSION OF PATIENTMrs. 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. The patients folder was collected from the admission nurse and patients name and other particulars were verified mentioned 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 on a comfortable bed and quick assessment from head to toe was done to ascertain her general condition.Comment by Amankwaa: This shd be done before verifying pts identityHer vital signs were checked and recorded as follows;Temperature = 38.4 degree CelsiusPulse = 80 beats per minuteRespiration = 20 cycles per minuteBlood pressure= 130/80 mmHgTepid 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 introduced to doctors, nurses and other staff on the ward as well as other patients.Comment by Amankwaa: Is this admission of patient or summary of actual care rendered to patient?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 and it helped to release relieve her psychologically. She was also allowed tos expressing her fears through questioning. and Hher 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 in a quit environment provided. Assisted bed bath and oral care were given. Clients vital signs were 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. Vital signs checked and recorded for the ranges within;Temperature= 37.5-38.4 degrees CelsiusPulse = 78-80 beats per minuteRespiration = 18-20 cycles per minuteBlood pressure= 120/70-130/80millimetre per mercury PATIENTS CONCEPT OF ILLNESSPatient 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 FIBROIDComment by Amankwaa: This shd start on a fresh pageDEFINITIONUterine 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 factorsHereditary 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.PATHOPHISIOLOGYUterine 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 backacheCOMPLICATIONS-Infertility-Pregnancy loss-Anemia-Urinary tract infection-Uterine cancersDIAGNOSTIC 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 MEDICATIONSMedications 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 TREATMENTSurgery is usually the curative treatment of uterine fibroid and the type of surgery is total abdominal hysterectomy or subtotal abdominal hysterectomy.HYSTERECTOMYA 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-oophorectomyTOTAL ABDOMINAL HYSTERECTOMYThis 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 MANAGEMENTPRE-OPERATIVE NURSING MANAGEMENTPSYCHOLOGICAL CAREa. 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 SLEEPa. 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.OBSERVATIONa. 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 PATIENTAfter 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.INVESTIGATIONAll investigations must be done on the patient to correct any abnormalities related to blood, hemoglobin estimation, white blood cell count, and etc.NUTRITIONServe 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 PREPARATIONThe 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 MANAGEMENTOBSERVATIONa. 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 INJURYSince patient is unconscious, she needs to be protected from injury by ensuring that all procedures are done using the right technique.WOUND CAREa. 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 HYGIENEPersonal hygiene such as oral care, bed bath should be done regularly to prevent harboring of microbes, thereby preventing secondary infection.EDUCATIONa. 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.DRUGSPrescribed 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 DATAComment by Amankwaa: The whole of this portion is not clear to me. Can u write it again?With reference to the data collected clinical features of uterine fibroid were confirmed by the literature review of the condition. Data collected from the patient and relatives were cross checked with patients folder, laboratory investigations and assessment. All these proved that patient was suffering from uterine Comment by Amankwaa: ??

CHAPTER TWOANALYSIS OF DATAComment by Amankwaa: It appears you have left out lots of information in the introductory section of the care study. See that of ur friends.Analysis of data is the interpretation of data collected to identify patients specific needs and strengths, which help in the information of an appropriate nursing diagnosis. It includes actual and potential identified needs. It also covers diagnostic investigations, causes, clinical features, treatment, complications and pharmacology of drugs.

TABLE ONE: DIAGNOSTIC INVESTIGATION ON MRS. D.ODATE SPECIFIC/ BODY PART INVOLVEDINVESTIGATIONRESULTSNORMAL VALUEINTERPRETATIONREMARKS

07/08/13BloodHemoglobin level estimation10.1gldlMale: 14-18gldl Female: 12-16gldlComment by Amankwaa: You may reduce the font size of all information in table to abt 10 or 11 so that it can fit well into the tableBelow normalVitamin B12 was prescribed for patient.Patient advised on nutritious diet

07/08/13BloodRed blood cell count4.21[106/ul]4.50-5.50[106/ul]Below normalTablet zincovit was prescribed for patient.

07/08/13BloodWhite blood cell count3.65[10/ul]2.60-8.50[10/ul]NormalNo treatment was given.

07/08/13Blood Serum calcium level2.45mmol/l2.15-2.55mmol/lNormalNo treatment was given.

07/08/13BloodSerum potassium level3.8mmol/l3.5-5.5mmol/lNormalNo treatment was given.

07/08/13BloodSerum chloride level98mmol/l90-100mmol/lNormalNo treatment was given.

TABLE TWO: COMPARISON OF CLINICAL MANIFESTATION FROM CLINICAL MANIFESTATION EXHBITED BY PATIENTCLINICAL MANIFESTATION OUTLINED IN LITERATURE REVIEWCLINICAL MANIFESTATION EXHBITED BY PATIENT

.Heavy menstrual bleedingPatient experienced heavy menstrual bleeding

.Prolonged menstrual bleedingPatient had prolonged menstrual bleeding

.Pelvic pressure or painThere was a complained of pelvic pressure

.Frequent urinationShe had frequent urination

.ConstipationPatient had constipation

.Low backacheShe experienced low backache

.DehydrationPatient was dehydrated

SPECIFIC TREATMENT GIVEN TO PATIENTAccording to the literature review on the treatment for uterine fibroid, the following treatment was given to patient;Comment by Amankwaa: This part is not clear. Must literature review be done before u get to know the treatment given to your patient?SURGICAL TREATMENT1. Total abdominal hysterectomy was done for patient.PRE OPERATIVE TREATMENT1. Intravenous normal saline 1litre2. Intravenous ringers lactate 1litre3. Intravenous ciprofloxacin 400mg ads x2INTRA OPERATIVE TREATMENT1. Intravenous Atropine 0.5mg2. Intravenous Suxamethionum POST OPERATIVE TREATMENT1. Intramuscular pethidine 50mg bdx24hours2. Suppository Diclofenac 100mg bdx5/73. Intravenous metronidazole 500mg 8hourly x244. Intravenous Dextrose saline 3L5. Intravenous Normal saline 3L6. Intravenous Ringers lactate 3L7. Tablet flagyl 400mg tdsx58. Tablet Zincovit 1 tablet daily x159. Intravenous Ciprofloxacin 400mg bd x 5

TABLE THREE: PHARMACOLOGY OF DRUGS PRESCRIBED TO MRS. D.ODATEComment by Amankwaa: Table incomplete, where is the remark section?DRUGDOSAGE AND ROUTE OF ADMINISTRATIONCLASSIFICATIONDESIRED EFFECTS

11/09/13 PethidineAdult dose:25-100mg every 3 to 4 hours

Child dose:0.5mg per kg

Route: Intramuscular

Patient:50mg st, intramuscularly

Narcotic analgesicsRelieves of pain

11/09/13DiclofenacAdult dose: 75-150mg bdComment by Amankwaa: I know adults can be given as low as 50mg

Child dose:30-60mg bd

Route :RectalComment by Amankwaa: The route here should refer to all the possible routes that this drug can be given

Patient: 100mg bd x5, rectallyAntipyretic, sedatives ,NSAIDSComment by Amankwaa: Can u show me the book you are using? How can u refer to diclofenac as a sedative?Relieves inflammation, pain

11/09/13MetronidazoleAdult dose:400-500mg tds x7days

Child dose:200mg tds x 7daysComment by Amankwaa: I dnt think this is right

Route :Oral, intravenous

Patient:500mg tds x5days, intravenouslyAntiprotozoa, AmoebicideTo treat infection

11/09/13Dextrose SalineDosage depends on calorie and fluid requirement

Route: intravenousPatient: 2 litres for 48hours, intravenouslyFluid and electrolytes replacement Provides supplementary calories and fluids

11/09/13Normal SalineHighly individualized

Route: intravenous

Patient: 1 litre for 8hours, intravenouslyFluid and electrolyte replacementComment by Amankwaa: What type of fluid is it?Restores normal sodium and chlorine level

11/09/13Ringers lactateDepends on the rate of dehydration

Route: intravenous

Patient: 1.5 litres for 48 hours, intravenouslyFluid and electrolyte replacementRestores the normal fluid and electrolyte imbalance

11/09/13Tablet FlagylComment by Amankwaa: Indicate the generic nameAdult dose:250-500mg tdsComment by Amankwaa: How can tablet flagyl be dispensed in 500mg formulation?

Child dose:30-50mg tdsComment by Amankwaa: ????

Route: oral

Patient:400mg tds x 5, orallyAntiprotozoa, AmoebicideTo treat infection

11/09/13Tablet ZincovitAdult dose:1 tablet daily

Child dose: 1tablet dailyComment by Amankwaa: ?? are u sure?

Route: oral

Patient:1 tablet daily x 30, orally

HaematimicsTo stimulate red blood cell production

11/09/13Atropine Adult dose:0.4-0.6mg in single dose 45-60minutes before anesthesia

Child dose:0.4mgComment by Amankwaa: incomplete

Route: intravenous

Patient:1 mg given 35minutes before anesthesia, intravenouslyAntisecretory agentComment by Amankwaa: wrongDries secretions and decreases sweating

11/09/13Comment by Amankwaa: if this was not given in the ward then take it outSuxamethionum Adult dose:1-2mg

Child dose: 0.04mg per kg

Route: intravenous

Patient: 2.5mg ,intravenouslyAnesthetic drugRelaxes skeletal muscles

11/09/13CiprofloxacinComment by Amankwaa: are we dealing with tab or IV?Adult dosage: 400mg bdComment by Amankwaa: For how long?

Child dosage:10-15mg per kg

Route: intravenous

Patient: 400mg bd x 5, intravenouslyAntibiotics Comment by Amankwaa: What type of antibioptic?Kills susceptible bacteria and prevent infection

Comment by Amankwaa: Where is patient problems and strength? And other stuffs

CHAPTER THREE PLANNING FOR PATIENT AND FAMILY CARENursing care plan is a step by step process designed to enhance delivery of nursing care on 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.Comment by Amankwaa: What space is that?PRE OPERATIVE PROBLEMSComment by Amankwaa: Your problems must match the strengthComment by Amankwaa: This is supposed to be in chap 21. Fever.2. Abdominal pain.3. Knowledge deficit (Partial).4. Anxiety.POST OPERATIVE PROBLEMS5. Acute pain (incision pain).6. Incision wound.7. Risk for urinary tract infection.8. Inability to perform her personal hygiene.PATIENT AND FAMILY STRENGHTSComment by Amankwaa: How can u be having 8 problems and 5 strength1. Patient had support from family.2. Patient expresses the desire to learn more about the condition.3. Patient was oriented to time, place and person and could communicate her pain.4. Patient and family fully participate in the planning of her care.5. Patient had cordial relationship with other patients on the ward as well as the staff.PRE OPERATIVE NURSING DIAGNOSIS1. 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 DIAGNOSIS5. Altered body comfort (incision pain) related to wound at the incision site.6. Altered skin integrity (incision wound) related to surgical manipulation on the abdomen.7. High risk for urinary tract infection related to urethral catheter in situ.8. Self care deficit (bathing, mouth care, etc.) related to post operative restrictions.PRE OPERATIVE NURSING OBJECTIVES1. Patients body temperature will be reduced within 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 (36.2C- 37.2C) by reading from the clinical thermometer.b. Patient verbalizing a reduced body temperature.

2. Patient will experience reduced abdominal pain within 24 hours as evidenced by:a. Patient feeling comfortable in bed and verbalizing absence of pain.Comment by Amankwaa: How can one know that patient is comfortable?b. Nurse observing that patient is relaxed with cheerful facial expression.

3. Patient will have adequate knowledge about uterine fibroid within 24 hours 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 some questions asked by the nurse.Comment by Amankwaa: What do u mean by some? Be specific

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 OBJECTIVES1. Patient will experienced a reduction in pain level 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. Patient will have intact skin throughout the period of hospitalization as evidenced by:Comment by Amankwaa: I think the attention should be able the risk that wound would be infected. There had been incision, so u cant talk abt pt having intact skina. Patient verbalizing her skin has minimal scar at incision site.b. Nurse observing that patients wound will heal by first intension.

3. Patient will be free from urinary tract infections within the period of catheterization hospitalisation 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 careself-care needs within 72 hours as evidenced by:a. Nurse observing patient taking her bath, grooming and caring for her mouth without assistanceTABLE FOUR: PRE OPERATIVE NURSING CARE PLAN OF MRS D.ODATE ANDTIMENURSINGDIAGNOSISOBJECTIVES/OUTCOMECRITERIANURSINGORDERSNURSING INTERVENTIONSEVALUATION

10/9/2013

at

12:00pmAltered in body temperature (38.4C) related to inflammatory process.Comment by Amankwaa: Make sure all corrections made to above reflects here too. Am not reading this part again

Patients body temperature will be reduced within 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 (36.2C-37.2C) by reading from the clinical thermometer.

b. Patient verbalizing that her temperature has reduced.1. Check patients body temperature and record.

2. Tepid sponge patient.

3. Open nearby windows.

4. Re-checks patients body temperature every 15 minutes.1. Patients body temperature was checked and recorded to serve as baseline for treatment.

2. Patient was tepid sponged to reduce body temperature.

3. Nearby windows were opened to allow for circulation of air.

4. Patient body temperature was rechecked every 15 minutes to determine reduction in body temperature.Goal fully met as patient verbalized that her temperature has reduced(37.5C)

10/09/2013.

6:30pm

A.F

DATE ANDTIMENURSINGDIAGNOSISOBJECTIVE/OUTCOMECRITERIANURSING ORDERSNURSING INTERVENTIONSEVALUATION

10/09/13

at

1:15pm

Altered body comfort (abdominal pain) related to inflammatory process secondary to uterine fibroid.Patient will be reduced of pain within 24 hours as evidenced by:Comment by Amankwaa: This cant be 24 hours

a. Nurse observing that patient is relaxed with cheerful facial expression.

b. Patient feeling comfortable in bed and verbalizing absence of pain.1. Reassure client.

2. Perform pain assessment.

3. Assists patient to assume a comfortable position.

4. Reduce noise

5. Provide diversion therapy.1. Patient was reassured that pain will subside after implementation of all nursing procedures.

2. Assessment of pain was done before and 30 minutes after analgesics were served.

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

4. Staff was asked to minimized noise and visitors were also restricted.

5. Patient was engaged in conversation to divert her attention from the painGoal fully met as patient was seen relaxed and cheerful in bed.

10/09/13

8:10pm

DATE ANDTIMENURSINGDIAGNOSISOBJECTIVE/OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONEVALUATION

10/09/13

at

2:00pmInadequate knowledge (partial) related to information on the causes and management of uterine fibroid.Patient will have adequate knowledge about uterine fibroid within 24 hours 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.

2. Put client in a comfortable position.

3. Educate client on condition.

4. Allow patient and family to ask questions.

5. Give appropriate answers to 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.

2. Client was put in a sitting up position to seek for her alertness

3. Education was provided to client that helped her to understand the causes and the management of fibroid.

4. Patient and family were given the opportunity to ask questions on the condition.

5. Appropriate answers were given to the questions asked by the client and family.

Goal fully met as client and family verbalized their full understanding on the condition.

10/09/13Comment by Amankwaa: This is not 24 hrs. becareful abt these fine details

5:20pm

A.F

DATE ANDTIMENURSINGDIAGNOSISOBJECTIVE/ OUTCOMECRITERIANURSING ORDERSNURSING INTERVENTIONEVALUATION

10/09/13

At

3:45pmAnxiety related to unknown outcome of the impending surgeryPatient and family will be relieved of an anxiety within 4 hours as evidenced by:

a. Nurse observing that patient have a cheerful facial expression.

b. Patient verbalizing that she is relieved of anxiety.1. Reassure patient.

2. Assess patient and familys state of anxiety, fear and concern.

3. Explain to her the theater environment and what she should expert expect in the theater.

4. Allow patient and family to express concern.

5. Encourage diversional therapy.1. Patient and family were reassured that she in the hands of competent nurses or staff to reduce her anxiety.

2. The facial expression and posture of family were observed in attempt to assess their level of anxiety.Comment by Amankwaa: What abt the patient?

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 surgeryGoal fully met as patient seen relaxed and had a good facial expression.

10/09/13

5:00pm

A.F

DATE ANDTIMENURSING DIAGNOSISOBJECTIVES/OUTCOMECRITERIANURSING ORDERSNURSING INTERVENTIONEVALUATION

12/09/13

At

7:00amAltered body comfort (incision pain) related to wound at the incision site.Patient pain will be reduced within 72 hours as evidenced by:

a. Patient verbalizing that she is relieved of pain.

b. Nurse observing patient having a cheerful facial expression and looking relaxed in bed.1. Reassure patient.

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

3. Provide diversional therapy.

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

5. Administer analgesics.1. Patient was reassured that the pain and discomfort will be relieved with effective nursing measures.

2. The patient was assisted to assume a comfortable position to help reduce her pain.

3. The patient was engaged in conversation to turn her attention from pain.

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. Analgesic was served to reduce pain.Goal fully met as patient verbalizedzing that she has a reduced pain.

14/09/13

10:20am

A.F

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

DATE ANDTIMENURSING DIAGNOSISOBJECTIVE/OUTCOMECRITERIANURSING ORDERSNURSING INTERVENTIONEVALUATION

12/09/13

At

10:00amAltered skin integrity (incision wound) related to surgical manipulation on the abdomen.Patient will have intact skin throughout the period of hospitalization as evidenced by:Comment by Amankwaa: review

a. Patient verbalizing that her skin has a minimal scar at incision site.

b. Nurse observing that patient wound will heal by first intention.1. Reassure patient.

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

3. Educate patient to avoid touching the wound site.

4. Administer prescribed antibiotics.1. Patient was reassured that strict technique will be employed during hospitalization to prevent wound infection.

2. Soiled dressing was frequently changed to prevent moisture and infection.Comment by Amankwaa: indicate how often

3. Patient was instructed not to touch the wound site to avoid infection of the wound.

4. Prescribed antibiotics such as flagyl were administered to prevent infection.

Goal fully met as it was observed that patient wound healed by first intension.

15/09/13

9:30am

A.F

DATE AND TIMENURSING DIAGNOSISOBJECTIVE/ OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONEVALUATION

12/09/13

At

12:30pmHigh risk for urinary tract infection related to urethral catheter in-situ.Patient will be free from infection within period of catheterization as evidenced by:Comment by Amankwaa: review

a. Patient verbalizing that she feels no pain at the site

b. Nurse observing no signs of redness and discharge at the catheter site.1. Reassure client.

2. Care for catheter daily with antiseptic lotion.

3. Monitor flow rate of urine.

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

5. Administer prescribed antibiotics 1. Patient was reassured that the catheterization was temporal.

2. Patients catheter was cared for daily with antiseptic lotion such as salvon and normal saline.

3. Urine flow rate was monitored to determine fluid balance.

4. Patient was assisted to perform personal hygiene as bathing and mouth care to promote her comfort.

5. Prescribed antibiotics were administered to prevent infection.Goal fully met as nurse observed no signs and discharges at the catheter site.

12/09/13

3:10pm

A.F

DATE AND TIMENURSING DIAGNOSISOBJECTIVE/OUTCOMECRITERIANURSING ORDERSNURSING INTERVENTIONEVALUATION

12/09/13

At

6:20pmSelf-care deficit (bathing and mouth care) related to post-operative 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.

2. Assist patient to bath twice daily.

3. Treat pressure areas as such.

4. Give oral care twice daily.1. Patient was reassured that her personal hygiene would be taken care of until her condition allows her to perform them by herself.

2. Patient was assisted in bed to bath twice daily with warm water to refresh her and remove dirt and also stimulate circulation.

3. Pressure areas such as heels and scapula were inspected and treated to prevent the development of bedsores.

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.

Goal fully met as patient was able to perform her needs without assistance.Comment by Amankwaa: give specific activities that patient performed

15/09/13

7:00am

A.F

CHAPTER FOURComment by Amankwaa: what is the heading for the chapter?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.Patients and family are involved as the nurse assesses the patients response to the nursing care rendered.Comment by Amankwaa: This sentence have no meaning

SUMMARY OF ACTUAL NURSING CAREThe 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 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. 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 mercuryTepid 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)Comment by Amankwaa: Date?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.Comment by Amankwaa: I think there shd be appropriate headings for how patient was prepared for OP. e.g. immediate pre-op careMrs. D.O was dressed in a theatre gown and all materials such as necklace, rings were removed and placed safely in the patients own locker. 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.Comment by Amankwaa: These things are valuable and must be kept in the nurses custody for safe keepingComment by Amankwaa: If u copy and paste someones work, u must make sure the font type and size matches the original textThe vital signs of the patient were checked and recorded as follows:Comment by Amankwaa: Give a rationale for taking this vital signs prior to surgery Temperature = 36.5 degree Celsius Pulse = 78 beats per minute Respiration = 20 cycle per minute Blood pressure = 120/70millimeter per mercuryComment by Amankwaa: You havent stated when and how patient was taken to the Op room

IMMEDIATE POST OPERATIVE CARE [11TH SEPTEMBER, 2013]Comment by Amankwaa: Patient was operated on this day, but the care plan does not indicate known problems associated with post of care such pain etc.After the surgery, patient was brought back to the ward on a stretcher in the company of two theatre nurses at 12:45pm. She was was taken back to the surgical ward as ordered by the surgeon at 2: 45pm in a semi-conscious and had state with 500ml of Ringers lactate in place that was driping well.in-situ, accompanied by two theatre staff nurses and patency of urethral catheter was ensured.She was reassured that measures would be put in place to ensure effective breathing pattern. 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, tong holding forceps, mouth gag and receiver for used swab) were was set at and placed at patients bed side to be used when the need arises. Patient finally slept at 9: 05pm.Comment by Amankwaa: Was she having problems with breathing? If so then this shd be made clear. Comment by Amankwaa: ???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, ordered the following; analgesic injection Pithidine 500mg., starting sips of water, removal urethral catheter and to discontinue the 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.Comment by Amankwaa: Are u sure of this dose? And did u include this in your pharmacology of drugs?Comment by Amankwaa: Construct sentence wellVital 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 able to take her personal hygiene thus brushing the teeth, taking her bath and dressing neatly. She took her breakfast and due medications were served.Comment by Amankwaa: I dont think this is a correct statmeVital 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 mercuryPatient 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. said by the doctor during ward rounds. 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 ordered by the surgeon. She was advised not to touch the wound site to prevent infection and also was advised to adhere to all medications to promote wound healing.Comment by Amankwaa: Is that the normal practice in the hospital?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 23rd 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 example protein to enhance wound healing. She was advised on promoting dryness of the wound by not putting water on the dressing. The families including the patient were happy to go home due to no complication observed.Comment by Amankwaa: And u were putting normal saline on it?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 intensive cared rendered. Clients name and date of discharged were documented into the admission and discharged 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 REHABILITATIONComment by Amankwaa: Not gud enough. This patient has had surgery and must be prepared adequately for discharge. refer to Brunner and SuddarthMrs. 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.The patient and family were educated to keep the mouth clean at least twice daily to prevent oral infection. They were educated to bath twice daily to remove dirt and to promote circulation. Also they were advised to trimmed fingers to prevent microbes. They were educated to wash their hands with soap and water before and after eating and after visiting the toilet to prevent microbes.Comment by Amankwaa: All these points are ok but doesnt reflect on the aftercare of a patient who have had surgery.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. The patient was advised to avoid heavy lifting which could lead to wound gaping. They were educated on the harmful effects of alcohol and smoking and to avoid the intake of them.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 CAREHome 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 resourcesat 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]Comment by Amankwaa: You need to educate the family on how to support the patient on her return frm the hospThe first follow up home visit was made on 14th September, 2013 when patient was still on admission. Its purpose was to know the patients locality, its environment and how well it will contribute to the health status of the patient. I went to the house together with the husband.Comment by Amankwaa: Nothing like this was indicated in the actual care rendered to patientThey 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 done made regarding to determine 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 27th 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.

Comment by Amankwaa: Did u terminate care?THIRD HOME VISIT [2ND OCTOBER, 2013]The third home visit was conducted on 2nd October, 2013. Patient and families were in good health with no complaints. Mrs. D.Os wound was almost healed. The family and patient were educated on their personal and environmental hygiene. She was also advised to avoid lifting of heavy objects. They were lastly reminded that in case of any complication, they should report to the hospital for early treatment and also periodic medical checkup was instituted.The family members and the patient expressed their maximum thanks to me and the entire health team for intensive 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 EVALUATIONMrs. 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, 2013An objective was set at 12:00pm to reduce patient body temperature to the normal range [36.2-37.2 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 24hours. Goal was fully met on 10/09/2013 at 8:10pm as nurse observed that patient is was relaxed with a cheerful facial expression, patient feeling comfortable in bed and had no pain.An objective was set at 2:00pm to encourage patient to have adequate knowledge to uterine fibroid within 24 hours. Goal was fully met on 10/09/2013 at 5:20pm as patient and family verbalized their full understanding of the condition and how to take care of surgical wounds.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 have ahad a cheerful facial expression, patient verbalized that she is relieved of anxiety.

12TH SEPTEMBER, 2013An objective was set at 7:00am to relieve patients pain within 72hours. Goal fully met on 14/09/2013 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.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.Comment by Amankwaa: You need to carefully differentiate this from the one above, they seem sameAn objective was set at 12:30pm to prevent patient from infection within the period of catherization. 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 OUTCOMEDue to careful analysis of evaluation of nursing care rendered to Mrs. D.O all goals were fully met. Cooperation of patient and family and nursing and medical care rendered contributed to the achievement of her goals, it brought about no amendment of nursing care.Comment by Amankwaa: Not clearTERMINATION OF CAREComment by Amankwaa: Comment by Amankwaa: This part is not well-written. Cleary state when and how care was terminated. How did the patient and family feel abt the termination and what contributed to that?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 friendship with patient family commenced on the 10th September, 2013 and with a good nursing care, clients condition improved and was discharged on the 16th September, 2013 and care was terminated on the 2nd October, 2013.Comment by Amankwaa: ???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 Sda Hospital. This ended the interaction and Mrs. D.O hospitalization.

SUMMARY OF CARE PROVIDED TO PATIENT AND FAMILYMrs. 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.Nursing objectives and orders were set, implemented for problems of patient during admission. Due to qualify nursing care goals were fully met.Comment by Amankwaa: Sentences not clearClient was told to come for removal of stitches on 23rd September, 2013 and report 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.

CONCLUSIONThis care study has equipped me with the knowledge and skills to 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 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.