PATIENT AND FAMILY CARE STUDY ON MRS G.A.WITHINTESTINAL OBSTRUCTION SECONDARY TO POST OPERATIVE ADHESIONS(BOWEL RESECTION AND ANASTAMOSIS DONE)

PRESENTED BY

DANKWA BETAH AMA

CHAPTER ONEASSESSMENT OF PATIENT AND FAMILY

Assessment of patient and family is the first step in the nursing process which involves a careful and systematic collection of data from the patient, family, friends and community through examination, observation, interview, laboratory investigations and x-rayThe purpose of this study is to identify the patients problem which is expresseds as actual or potential. The information serves as a foundation upon which appropriate nursing intervention will be established and implemented for the speedy recovery of the patient.PATIENTS PARTICULARSMrs. G.A. is a 68year-old woman born on 11th March 1946 to Opanin Kofi Boakye and Maame Yaa Nsia; who are both deceased. dead and may their soul rest in perfect peace; on 11th March 1946 at Oduom in the Ashanti Region of Ghana. She is dark in complexion and stays at Nyankyirenease. Mrs G. A. is about 5.2 feet tall and weighs about 52kg. She is the third (3rd) among eleven (11) siblings, and the only female. She was married to O. A. Opanin Akwasi Prah and have givenave birth to nine (9) children; five(5) male and four(4) female. Two females are deceased. and two(2) among the four (4) females are dead. She is a Christian and worships with the Methodist Church at NyankyireneaseComment by RENE: Do away with all namesNext of kin?

FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORYAccording to Mrs. G.A. there is no known chronic or hereditary diseases like hypertension, asthma, or mental illness in the family. diabetes mellitus and also no known history of mental illness and communicable disease like tuberculosis, leprosy, epilepsy in their family. She also could not remember any food allergies. admitted that there are no food allergies. Members of the family usually take over- the- counter drugs to cure treat minor illness like malaria, headache and , bodilty pains, etc. She depends on her grown children for financial support.Type of accommodation?Is she employed or what was the previous jobSource of drinking waterRefuse disposalEconomic class???PATIENTS DEVELOPMENTAL HISTORYAccording to client, she was born at term by spontaneous vaginal delivery with the help of a Ttraditional Bbirth Aattendant (TBA) at home. Clients mother then sent her to a nearby clinic for other treatment. Client went through a normal developmental milestone without any complains. . She began teething at age 5 months, started to crawl at age 9 months and started walking at age 14 months. She feeds on the normal family diet such as fufu and light soup, rice and stew, banku and okra stew or palm nut soup.Comment by RENE: You need to be specific, was she sick, else deleteComment by RENE: Something comes before thisComment by RENE: I dont think this shd be here. Not clear what u want to writeYour developmental history must contain the following (you have already written some)a. Immunisation statusb. B.feeding historyc. Developmental milestone; summaryd. Educational historye. Secondary sexual characteristicsf. Marital history if married

PATIENT LIFESTYLE AND HOBBIESMrs. G.A .usually wakes up at 5:30 a.m. and says a word of prayer before getting up from bed. She washes her his face, brushes her teeth with tooth paste and tooth brush then shower down. She then takes in breakfast. She then goes out to take a walk and comes back to the house to watch television then sleeps when feeling tired. . She normally takes her supper at 6:30pm. She watches television, maintains her personal hygiene and goes to bed at 9pm. According client, she baths twice daily with soap, sponge and warm water. She cleans her teeth twice daily with toothpaste and brush before and after going to bed. She empties her bowel twice daily. Does your patient go to work? Active/social/introvert???

PATIENTS PAST MEDICAL HISTORYAccording to client, she had never experienced any medical condition like, hHypertension, diabetes, tuberculosis etc. She had never received any blood transfusion and had no known allergies. According to client, sShe was however admitted at Suntreso Government Hospital a year ago at the Female Surgical Ward with the diagnosis of appendicitis and appendectomy was done and was discharged.

PATIENTS PRESENT MEDICAL HISTORYPatient was well until 4th October 2014, when she experienced stomach ache, which was colicky in nature and of a sudden onset., it had relieving factors. Her vomitus contained food eaten previously and was yellowish in colour. She was subsequently then admitted to Suntreso Hospital on 9th October 2014. An X-ray was taken which showed distended bowel. She was then transferred to Komfo Anokye Teaching Hospital on 10th October 2014 and she was admitted at the Accident and Emergency Center. After examination, she was diagnosed of intestinal obstruction and was trans-out to the female surgical ward C4 to be prepared for surgery.Comment by RENE: Was your patient at home for abt 5 days? What happened during this time that the patient did not visit the hospital, did she get some treatment for herslf?

ADMISSION OF PATIENTOn Friday, 10th October 2014 at 7:25am, Mrs. G.A. was admitted through the Accident and Emergency Centre (Major and Minor) of Komfo Anokye Teaching Hospital to the Female Surgical Ward C4. She was brought to the ward on a trolley fully conscious accompanied by a triage nurse and three relatives, with about 250mls of dextrose saline in situ and , dripping were. There was also urethral catheter and nasogastric tube in situ. She came to the ward with the following medications; IV Augumentin 2g stat, Injection Pethedine 10mg stat, IV Flaggyl, IV Ciprofloxacin, IV Normal Saline and IV Dextrose Saline. They were warmly welcomed and escorted to the nurses table. Her relatives were given a chair near the nurses table to assist in providing information about the patient. Clients folder was collected from the accompanying nurse. She was placed in a recumbent position in a comfortable bed free from creases and crumbs. Client and relatives were reassured of good medical and nursing intervention and care. The information about the client in the admission papers was read to gain knowledge about the patient, her particulars such as name, sex, age, date and time of admission were identified and recorded. The patients name and other information were entered in the Admission and Discharge book and daily ward state. Vital signs were checked and recorded as follows:Comment by RENE: You need to finish receiving the patient, make them comfortable before talking abt some of these things.Temperature = 37.5 C.Comment by RENE: Take out the equal sign and arrange them well. Pulse = 94 beats per minute.Respiration = 22 cycles per minute.Blood Pressure = 130 /60 mmHg.The patient and family were oriented to various areas on the ward such as the toilet, bath room. Patient was also introduced to other patients on the ward. Relatives were educated on the visiting hours. Since patient had the National Health Insurance card, they were not made to deposit any amount of money. They were given health education on Mrs. G.As condition. Other nursing care was performed.She was put on the following treatment;1. Intravenous normal saline 2. 0 litres2. Intravenous Dextrose saline 2.0 litres3. Intravenous Ringers lactate 2.0 litres5. Intravenous Ciprofloxacin 400mg tds 2 daysComment by RENE: Are you sure this drug is given tds?6. Intravenous Flagyl 500mgmls tds 2Comment by RENE: ??? I prefer you write the hours7. Suppository DiclofenacComment by RENE: ????

CommentsI think your admission is poorly done. You failed to: Identify the patient Do a quick and initial assessment on the patient What complaints did she come with and what did you observe?Follow this format to complete your worka. In what state did patient come in? conscious?b. Accompanied by whom?c. Date and time of admissiond. How was the patient received and identified?e. Immediate nursing interventions based on patients conditionf. Vitals checked and recordedg. Physical examinations done and findingsh. Lab investigationsi. Treatment givenj. Orientation of patient to the ward environmentk. Indicate items that has to be broughtl. Make patient/family know that the relationship was a temporal onem. Explain to the patient that they are being used for a study; explain the rationale and the fact that they can decline without it having any effect on their treatment or care.n. Encourage visitationo. Documentation/nursing care plan

PATIENTS CONCEPT OF ILLNESSPatient has no knowledge about the cause, signs and symptoms, treatment or prevention of intestinal obstruction. She did not attribute it to spiritual forces but believe it is a natural occurrence. She was worried about the outcome of her condition. She was however reassured not to be intimidated and that the treatment she was is receiving will help her to recover.

LITERATURE REVIEW ON INTESTINAL OBSTRUCTIONComment by RENE: You need to be consistent on the formatting of your work. why the sudden underline??DEFINITIONIntestinal obstruction is the partial or complete blockage of the small or large bowel lumen, which prevents the normal flow of intestinal contents through the intestinal tract. An obstruction can occur at any point along the bowel.Incidence?

CAUSESThe causes of intestinal obstruction can be grouped into two.A. Mechanical blockage.B. Non mechanical/ neurogenic/ Paralytic blockage.Comment by RENE: Be careful abt these large spaces!!

A. MECHANICAL BLOCKAGEFactors that cause mechanical blockage are divided into three.1. Condition that occur within the intestinal lumen(intramural) such as; Fecal impaction Gall stones in the lumen Other foreign bodies such as fruits seeds, worms or a piece of bone.2. Conditions that occur within the intestinal wall (mural). Intussusceptions. Inflammation of the ileum. Tumours of the large bowel. Stenosis. Polyps.3. Conditions that occur outside the intestinal wall (extramural lesions).These cause compression of the bowel, Strangulated hernia. Volvulus. Tumors of adjacent organs. Adhesions following previous operations e.g. appendicitis, peritonitis, stenosis etc.

B. NON MECHANICAL /NEUROGENIC /PARALYTIC. Muscular dystrophy Endocrine disorders such as diabetes mellitus Neurologic disorders such as Parkinsons diseases Thrombosis or embolism of mesenteric vessels. Paralytic ileus.

FORMS OF INTESTINAL OBSTRUCTION1. Simple- The blockage prevents intestinal contents from passing with no other complication.2. Strangulated: Blood supply to the part or all of the obstructed section is cut off, in addition to the blockage of the lumen.3. Closer looped: Both ends of the bowed section are occluded, isolating if from the rest of the intestine.

PATHOPHYSIOLOGYIn all the three forms, the physiologic effects are similar; when intestinal obstruction occurs, fluid, air and gas are collected near the site. Peristalsis increases temporarily as the bowel tries to force its content through the obstruction at and above the site of the obstruction.The distension blocks the normal absorption processes. As a result, the bowel begins to secrete water, sodium and potassium into the fluid pooled in the lumen.Obstruction in the upper intestine results in metabolic alkalosis from dehydration and loss of gastric hydrochloric acid.Obstruction in the lower intestines causes slower dehydration and loss of intestinal alkaline fluid resulting in metabolic acidosis. Ultimately, intestinal obstruction may lead to ischemia, necrosis and death.

CLINICAL FEATURES.1) Colicky pains in the abdomen.2) Nausea3) Vomiting (vomiting of fecal contents at times.)4) Constipation5) Distended abdomen6) Abdominal tenderness7) Dehydration with electrolyte loss8) Sunken eyes9) Hollow checks10) Dry skin11) Septic absorption12) High pulse rate13) Cold clammy skin14) Pallor15) Delirium in severe cases.

COMPLICATIONS1. Perforation2. Peritonitis3. Septicemia4. Metabolic alkalosis or acidosis5. Hypovolaemic shock6. Death if untreated.

DIAGNOSTIC INVESTIGATION1. Abdominal x rays confirm obstruction and reveals the presence and location of intestinal gas fluid.2. White blood cell count may be slightly normal if necrosis, peritonitis or strangulation occurs.3. Sigmoidoscopy, colonoscopy or barium enema may help determine the cause of obstruction.4. Hemoglobin concentration and haematocrit may increase indicating dehydration.5. Serum sodium, chloride and potassium level may fall because vomiting.6. Serum amylase level may increase possibly from irritation of the pancreas by distended abdomen.7. Physical exams may reveal distended abdomen.8. History from the patient.9. Signs and symptoms.

SPECIFIC MEDICAL TREATMENTAlthough surgery is usually the treatment of choice, conservative treatment or measures can be carried out if for any reason the operation cannot be done immediately.The following conservative measures can be done;1. Nasogastric tube can be used for decompression of the bowel.2. Decompression to with a Nasogastric tube attached to low pressure continuous suction.3. Administration of broad spectrum antibiotics such as ciprofloxacin 500mg 6 hourly x 24 hours saved to prevent infection as prescribed by the surgeon.4. Analgesics like diclofenac 50mg 8 hourly x 24 hours may be given to relieve pain.5. 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 intestinal obstruction and the surgery appears in three forms. The type of surgery to be performed depends on the cause of the obstruction.1. With this form of surgery, laparotomy is performed and the obstructed bowl or adhesions or strangulation. The bands and adhesions strangulating the bowel are resected.2. This is when there are complications such as gangrene or tumor. The gangrenous intestine is resected and anastomosis is done.3. When the obstruction is due to cancer of the rectum, palliative measures may be done by performing colostomy.

COMPLICATIONS OF SURGICAL TREATMENT1. Shock2. Hemorrhage3. Retention of urine4. Infection

SPECIFIC NURSING MANAGEMENTPRE OPERATIVE NURSING MANAGEMENT

Psychological CareReassure the client and the relative by explaining the type of surgery to be done on her and the disease condition make it known to her that she is in the hands of competent staff and so by her complying with she will get well within few days. This will help to relieve her of anxiety and fears. Introduce people who have undergone such operation to her. Allow her to ask any question about her condition and this will help her gain knowledge about and understand her condition.

Rest and SleepHer bed should be free from crumbs and creases to prevent her being uncomfortable. Eliminate noise at the ward; make sure all procedures are performed at a goal to prevent procedures destructing her sleep.Semi Fowlers position is the appropriate position she must be kept in this position as much as possible to promote pulmonary ventilation and ease respiratory distress form abdominal distension.

ObservationVital signs such as temperature, pulse, respiration are observed every four hours while blood pressure observed every hourly to serve as a baseline for evaluating whether the patients condition is progressing or improving.She must be observed for pain and monitor input and output chart, if abdomen is chastened, abdominal girth is measured, patient must be weighed daily, her emotional state must be observed and patient reassured site of intravenous fluids must be observed for bleeding, swatting, blockage of the line and rate of flow to present any cardiac over load.Side effects of drugs must be observed and recorded.

Pain relievePatient must be observed for pain and pain management given, diversional therapy may be done to distract the patients mind from pain, and cold compresses may be applied at the site of distension which can help relax the muscles. Patient must be encouraged to assume the position she finds comfortable which is not contraindicated to her condition. Administration of preceded analgesics such as diclofenac 100 mg must be given to relive pain.

Consent of PatientAfter all the explanation necessary for the patient to gain knowledge, understand her surgery a consent form is made to be signed by the patient and this gives the legal right for the operation to be performed on the patients.

InvestigationAll investigation must be done on the patent to correct any abnormalities related to blood, hemoglobin estimation, white blood cell count, sickling, grouping and cross matching.

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 electrolyte loss. Nothing is given by mouth on the morning of the operation.

Skin PreparationThe area to be shaved must be washed and dried shave from 3 inches above the nipple of the breast to middle thigh including the pubic, clean the shaved area again with an antiseptic lotion.

POST OPERATIVE MANAGEMENTMaintenance of AirwayThe patient must be positioned in a recumbent with the head turned to one side and neck extended to prevent the tongue from falling back and blocking the airway. This will enhance bronchial and pharyngeal secretions to drain out. Excessive secretions must be aspirated from her nasopharynx and oropharynx.

ObservationObserve and monitor vital signs every thirty (30) minutes till patients condition subsides or stabilizes. Monitor the intravenous fluids for blood clot in the needle, presence of air bubbles tube kinked, all these are done to prevent the development of any complication, also type of infusion, amount, time infusion was set up must be observed and recorded.The number of drops per minute and time infusion was completed are all recorded in the input and output chart. Vital signs that are temperature, pulse, respiration and blood pressure are also checked for signs of complications like bleeding. Observe for cyanosis, if present, is a sign of hypoxia.

Prevention from InjurySince patient is unconscious and cannot complain of pricking from needles, clamp that is exerting pressure and born from hot water bottle, patient needs to be protected from injury by ensuring that all procedures are done using the right technique

Wound CareDressing are normally changed on the third day post operatively, wound dressing must be done under aseptic technique. Alternate stitches are removed on the seventh day and remaining stitches removed on the Tenth day after surgery. The removal of the stitches depends on the condition of the wound and hospital policy. The wound must be observed for infection, bleeding and pain.

Personal HygieneOral toileting and bed bath needs to be done regularly to prevent harboring of microbes, thereby preventing secondary infection.

EducationEducation may be given based on the causes of intestinal obstruction, signs and symptoms of the condition, the need for the surgical intervention preventive measures, the need for periodic medical exams, the need to take drugs and for reviewAll these are given to direct and to equip her with the necessary information on intestinal obstruction so that she can take the necessary precaution to prevent the condition from reoccurring.

DrugsPrescribed drugs such as pethedine 50 mg as prescribed may be given to patient to relieve pain. Antibiotics may also be given to prevent secondary infections.Desired and side effects of drugs must also be observed.

VALIDATION OF DATAWith reference to the data collected, signs and symptoms which patient presented are the actual clinical features of intestinal obstruction as confirmed by the literature review of the condition.Data collected from the client and relatives were cross checked with client's folder, laboratory investigation and assessment.Therefore, all these proved that client was suffering from intestinal obstruction secondary to postoperative adhesions.

CHAPTER TWOComment by RENE: New page, formatting is ur problem!ANALYSIS OF DATAAnalysis of data is the interpretation of assessment data collected to identify patients specific needs and strengths, which helps in the formulation of an appropriate nursing diagnoses. It includes both actual and potential identified needs.This consists of:(a) Comparison of data with standards. This covers diagnostic investigations, causes, clinical features, treatment, complications and pharmacology of drugs.(b) Patient/ family strengths(c) Health problems(d) Nursing diagnosis.

COMPARISON OF DATA WITH STANDARDSTABLE ONE: DIAGNOSTIC INVESTIGATION ON MRS. GIFTY OKYERE.

DATESPECIMEN/Body part examinedINVESTIGATIONRESULTSNORMAL VALUEINTERPRETATIONREMARKS

10/10/14

Blood

Haemoglobin leveleEstimation15.7 g/dl

Male: 14-18 g/dl.Female: 12-16 g/dl.Normal.

No treatment given. Patient encouraged on well-mixed diet

10/10/14BloodRed blood Cell count5.35 (106/uL)4.50-5.50 (106/uL)NormalNo treatment given

10/10/14Blood

White blood Cell count

7.32(103/uL)

2.60-8.50 (103/uL)

Within normal range

No treatment given

10/10/14Abdominalx-rayAbdomen

To assess the state of the intestineAbdominal x-ray to assess the state of the bowels

Bowel obstruction

There shouldnt be obstruction of the bowels.No evidence of bowel obstruction.

intestinal obstruction

Exploratory LaporotomyAnd bowel ressection (end to end anastomosis)

10/10/14

Serum ElectrolyteSodium

134mmol/L

135-145mmol/L

Normal

No treatment given.

10/10/14Serum ElectrolyteChlorine102mmol/L

97-110mmol/LNormalNo treatment given.

10/10/14Serum Electrolyte

Potassium

2.7mmol/L

3.5-5.5mmol/L

Normal

No treatment given.

10/10/14Serum ElectrolyteCalcium2.49mmol/L2.15-2.55mmol/LNormalNo treatment given.

CAUSES OF PATIENTS ILLNESSWith reference to the causes of intestinal obstruction indicated in the literature, Mrs G.A.s condition was caused by adhesions from the previous operation.TABLE TWO: COMPARISON OF CLINICAL MANIFESTATION FROM LITERATURE REVIEW WITH CLINICAL MANIFESTATION EXHIBITED BY CLIENT.Comment by RENE: Am not happy with your headings. Where from these capitals?

CLINICAL MANIFESTATIONOUTLINED IN LITERATURECLINICAL MANIFESTATIONEXHIBITED BY CLIENT

1. Colicky abdominal pain.2. Nausea and vomiting.3. Abdominal distension and tenderness.

4. Weak and rapid pulse.5. Cold, pale and clammy skin.

6. Constipation.7. Delirium in severe cases.8. Pallor.9. Dehydration.10. Sunken eyes.11. Hallow cheeks.1. Client complained of colicky abdominal pain.2. Client experienced nausea and vomiting.3. On palpation there was distension and tenderness of the abdomen4. Client exhibited weak and rapid pulse.5. There was absence of cold, pale and clammy skin6. There was constipation7. There was no delirium8. Client had pallor.Comment by RENE: Which doesnt correspond with the lab investigations9. Client was dehydrated10. Client had sunken eyes11. Client had hollow cheeks

SPECIFIC TREATMENT GIVEN TO CLIENTWith reference to the literature review on the treatment for Intestinal Obstruction, the following treatment was given to the patient;

SURGICAL TREATMENT(1) Exploratory Laparotomy, bowel resection and end to end anastomosis done.Comment by RENE: We need to talk abt this(2) Nasogastric tube was passed to reduce abdominal distension and prevent aspiration.

PRE- OPERATIVE TREATMENTIntravenous Normal saline 2.0 litresComment by RENE: Dosages must be writing in full, with duration Intravenous Dextrose saline 2.0 litresIntravenous Ringers lactate 2.0 litresIntravenous Ciprofloxacin 400mg tds 2 Intravenous Flagyl 500mls tds 2Intramuscular Pethedine 100mg bd 24 hours.INTRA OPERATIVE TREATMENTIV Suxamethionum 80mgComment by RENE: Stat doses? IV Atropine 1.0mgIV Ketamine 225mgIV Neostigmin 2.5mgPOST OPERATIVE TREATMENTIntravenous IV Pethedine 50mg 6hourly 24hours.Intravenous Dextrose saline 3L.Intravenous Normal saline 3L.Intravenous Ringers lactate 3L.Intravenous Metronidazole 500mg.Suppository Diclofenac 50 mg bd 5.Tablet Ciprofloxacin 500mg bd 5

TABLE THREE:PHARMACOLOGY OF DRUGS ADMINISTERED TO MRS G.A.

DATEDRUGDOSAGE AND ROUTE OF ADMINISTRATION PER LITERATUREDOSAGE AND ROUTE OF ADMINISTRATION TO CLIENTCLASSIFICATIONDESIRED EFFECTSACTUAL ACTION OBSERVEDSIDE EFFECTS/ REMEDIES

10/10/14

Intravenous DiazepamAdult Dose: 5-10mg repeated in 3 to 4hours p.r.nComment by RENE: Are you sure abt this? I suggest you get BNF to be sure of the dosagesChild Dose: 0.6mg per kg in 8hoursRoute: Intravenous10mg daily 2 days intravenously.Tranquilizer, antianxiety, and skeletal muscle relaxant.Comment by RENE: Sure? You need to show me the book u usedRelaxes skeletal muscles and relieves muscle spasms.Client pain was relieved.Comment by RENE: What was the purpose of this drug?Blurred vision, nausea, hypoactivity.None was observed.

10/10/14

Dextrose salineDosage depends on fluids and calorie requirement (Intravenously)2 Litres for 48 hours intravenously

Fluid and electrolyte replacement.

Provides supplementary calories and fluids.Client was hydrated and energy restored.Confusion, fluid overload, oedema,glucosuria. None was observed.

10/10/14

Ringers lactate

Depends on the rate of dehydrationComment by RENE: What do you mean by rate of dehydration?Route: Intravenous

1.5 litres for 48 hours intravenously

Fluid and electrolyte replacement

Restores normal fluid and electrolyte balanceClient regained normal fluid and electrolyte balanceFluid overload, hypertension,hypocalcaemia,hypocalcaemia.None was observed.

10/10/14Normal salineHighly individualised (Intravenously)1 litre for 48 hours intravenously.

Fluid and electrolyte replacement

Restores normal sodium and chloride level

Client sodium and chloride level were normal as she did not exhibit signs of fluid retentionOedema, potassium,Hypocalcaemia.None was observed.

11/10/14

Intravenous PethedineAdult Dose: 25-100mg every3 to 4hours, p.r.n.Chid Dose: 0.5mg per kgRoute: Intramuscular100mg stat intramuscularlyNarcotic analgesic.Relieves painClient was relieved of pain.Nausea, vomiting, hypotension, urine retention. None was observed

11/10/14

Intravenous Ciprofloxa-cin

Adult: 400mg bdChild: 10-15mg per kg body weightRoute: IntravenousComment by RENE: Is that the only route?

400mg bd 5 intravenouslyComment by RENE: I hope this is the same as what you wrote in on the day of admission.

AntibioticComment by RENE: What type of antibiotic?Kill susceptibleComment by RENE: Look for the mechanism of action bacteria toprevent infectionNo infection was noticedGastrointestinaldisturbance, nausea, vomiting, diarrhoea,dry mouth, and depression.None was observed.

11/10/14Intravenous Metronida-zoleAdult: 400mg-500mg tds7daysChild: 200mg tds 7days.Comment by RENE: ????Route: IntravenousComment by RENE: Is that the only route?500mls tds 5days intravenouslyComment by RENE: ??AntiprotozoaAmoebicide

To treat infection.No infection noticed.Vertigo, abdominal cramps.None was observed.

11/10/14

IntravenousKetamine

Adult Dose: 1-4mg per kg adjusted according to responseChild Dose: 0.5-2mg per kgRoute: Intravenous

225mg Intravenously.

Anaesthetic agent.

Acts on the central nervous system to produce tranquilation and sleep.Comment by RENE: Check the spelling

Client slept throughout the surgical procedure.

Flexion of arms, fine tremors, drowsiness, restlessness, hypotension, dystocia.

11/10/14Intravenous Atropine

Adult Dose:0.4-0.6mg in single dose 45-60mins before anaesthesiaChild Dose: 0.4mgComment by RENE: incompleteRoute: Intravenous1mg given 35mins before anaesthesia intravenouslyAntisecretory agent.Comment by RENE: look for the proper classDries secretions, decreases sweating and salivationDecrease secretions were observed during the surgery.Drowsiness, blurred vision, tachycardia, dry mouth, urinary hesitancy.None was observed.

11/10/14Intravenous Suxameth-ionumAdult Dose: 1-2mg to a maximum of 150mgChild Dose: 0.04mg per kgRoute: Intravenous80mg intravenously during surgical procedureAnaesthetic agentRelaxes skeletal muscles.Clients skeletal muscles were relaxed throughout the surgery.Bradycardia, cardiac arrhythmia, cardiac arrest, respiratory depression, apnoea.None was observed

11/10/14Intravenous Neostigmi-ngAdult Dose: 0.5-2mgChild Dose: 0.025-0.08mg per kgRoute: Intravenous

2.5mg intravenously

Cholinergic stimulant and Anti-cholinesteraseTo relax skeletal muscles.Clients muscles were relaxed throughout the surgery.Dizziness, headache, bradycardia, blurred vision, rash. None was observed.

12/10/14

Tablet Ciprofloxa-cin

Adult Dose: 250mg to 500mg bd for 7 to 14days.Child Dose: 10-30mg/kg in two divided doses where benefits overweighs riskRoute: oral500mg bd5days orally

AntibioticComment by RENE: ?Kill susceptibleComment by RENE: ?bacteria toprevent infectionNo infection was noticedGastrointestinaldisturbance,nausea, vomiting,diarrhoea, dry mouth, and depression.None was observed.

13/10/14Tablet DiclofenacAdult Dose: 75-150mg bdChild Dose: 30-60mg bdRoute: Oral, rectal50mg bd 5 orally.

Antipyretic, sedative,NSAIDRelievesinflammation,pain and fever.Client was relieved of and her temperature reduced.

Anxiety, dizziness,depression, oedema,drowsiness,insomnia,irritability,migraine, headache, hypertension, taste disorder. None was observed.

COMPLICATIONS DEVELOPED BY PATIENTWith reference to the complications stated under the literature review, patient did not develop any; due to good nursing care and medical treatment given to her.

PATIENT AND FAMILY STRENGTHStrength is a resource and ability that an individual has which can help her cope with the stress of her condition.Comment by RENE: Is this a paragraph or a sentence? Try and avoid this. Revise your paragraphing pleasePatient and family strength includes healthy physiological functioning, emotional health, cognitive abilities, coping skills, and interpersonal strength. Etc.These strengths of the client and family will assist the nurse to be able to plan effective nursing care for the client. These were some of the strength identified;

Client coped well during the pre-operational preparation and also verbalized her fears.Comment by RENE: Dont use bullets, number them. You need to re-write all the strength to match the problems stated below. If you are not sure wwe can meet and discuss them. Its VERY IMPORTANT Client was alert and oriented to time, place and person and could communicate her pain. Client was ready to know more about her condition. Client was insured with the national health insurance scheme. Client and family fully participated in the planning of her care and client. Client was very friendly and co-operative and had a cordial relationship with other clients on the ward as well as the staff. Client was willing to be educated on her treatment

HEALTH PROBLEMSA health problem is any stress, be it physical, mental or social in a patient that prevents the client from meeting a certain health standard. Hence client may need some professional services. They were identified as pre-operative and post-operative problems.The following health problems were identified upon assessing Mrs. G.A.;

PRE OPERATIVE PROBLEMS(1)Nausea and vomiting. (patient could tolerate IV fluids)(2)Client was anxious of impending surgery (patient had emotional support from family members).(3)Client had no knowledge of the disease condition and its management (Intestinal obstruction). (client was ready to learn more about condition)(4)Client complained of abdominal pains. (client tolerated analgesics and cooperated with diversion therapy)

POST OPERATIVE PROBLEMS(1)Client was likely to have difficulty in breathing due to the effects of anaesthesia (client was ready to learn pre-operative teaching such as deep breathing exercise and coughing).(2)Client could not perform her personal hygiene ( client understood the importance of good personal hygiene towards her recovery).(3)Client was prone to wound infection (client cooperated with wound dressing procedures and aseptic techniques)(4)Client complained of pain at incision site (client tolerated analgesics).(5)Client was likely to develop urinary tract infection. (???The ones in bracket above should serve as ur strength, in that orderPRE- OPERATIVE NURSING DIAGNOSIS(1)Risk for fluid volume deficit related to nausea and vomitingComment by RENE: Relating problem with problem, change!(2)Anxiety related to impending surgery (Laparotomy) and its outcome.(3)Knowledge deficit related to inadequate information on the disease condition (intestinal obstruction) and its management.(4)Altered comfortation in comfort (abdominal pain) related to iIntestinal oObstruction.Comment by RENE: The nursing diagnosis must be in line with the problems, check the numberingPOST- OPERATIVE NURSING DIAGNOSIS(1)Impaired airway clearance (potential) Potential for dyspnoea related to effects of anesthetic drugsineffective airway clearance due to anaesthesia.(2)Alteration in comfortAltered comfort (abdominal pain) related to surgical incision.(3)Self-care deficit (bathing and grooming) related to general weakness after surgery.(4)Potential for post-operative wound infection related to incisional wound.(5)High risk for infection related to urethral catheter in-situ.

CHAPTER THREEComment by RENE: Formatting of your work is quite poorPLANNING FOR CLIENT AND FAMILY CARENursing care plan is a systematic process designed to enhance delivery of nursing care on individualized basis. It forms the third step in the nursing process, which is an approach to clients care and serves as communication link between client and the health team. This encourages the nurse to use her initiatives in nursing the patient. The nursing care plan is a written guide that directs the efforts of the nursing team to meet health goals. It ensures that, the nursing team works efficiently to deliver holistic, goal-oriented and individualized care to client.PRE OPERATIVE NURSING OBJECTIVES(1) Client will be relieved of anxiety within 30 minutes.Comment by RENE: Is that how you were told to state nursing objectives??(2) Client will have normal fluid volume during the period of Nil per os.(3) Client will have adequate knowledge on the disease condition (Intestinal Obstruction) within 45 minutes. (4) Client will be relieved of abdominal pains within 1 hour.

POST OPERATIVE NURSING OBJECTIVES(1) Client will have a patent airway within 45 minutes.Comment by RENE: ????(2) Client will be relieved of pain within 24 hours.(3) Patient will be able to maintain her personal hygiene without assistance or with minimum assistance within 72 hours.(4) Client wound will be free from infections and heal well within 9 days.(5) Client will be free from urinary tract infections within the period of catheterisation.TABLE FOUR:NURSING CARE PLAN FOR MRS GIFTY OKYEREDATEAND TIMENURSING DIAGNOSISNURSING OBJECTIVE/ OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONDATEAND TIMEEVALUATIONSIGNATURE

10/10/14at8:00amFluid volume deficit (dehydration) related to excessive vomiting.

Client will be relieved of vomiting and will have normal fluid volume within 48 hours as evidenced by;Patient showing no signs of dehydration such as sunken eyes and poor skin turgor.1). Reassure client.

2). Assess the nature and severity of vomiting and report immediately.

3). Provide oral hygiene and remove all nauseating items.

4). Administer prescribed intravenous fluids and monitor strict intake and output chart.

5). Document the procedure.

1). Client was reassured that measures would be put in place to relieve her of vomiting.

2). The nature and severity of vomiting was assessed to render nursing and medical care appropriately.

3). Toothbrush and pepsodent were used to render oral care to client and all nauseating items such as vomitus bowl was removed from clients scene.

4). Prescribed intravenous infusions such as normal saline and dextrose saline were administered and strict intake and output chart was monitored and maintained.

5). Procedure was documented into the nurses notes

12/10/14at8:00pmGoal fully met.

DATEANDTIMENURSING DIAGNOSISOBJECTIVE\ OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONDATEAND TIMEEVALUATIONSIGNATURE

10\10\14at9:20amAlteration in body comfort (abdominal pain) related to Intestinal Obstruction.Client will be relieved of pain within 1 hours as evidenced by;Client feeling comfortable in bed and verbalizing absence of pain.

1). Reassure client

2).Perform pain assessment.

3). Assist client to assume comfortable position.

4). Remove constricting and or tight clothing.

5). Reduce noise.

6). Provide dimensional therapy.

7). Administer prescribed analgesics.

8).Document procedure.

1). Client was reassured that, pain will subside after implementation of all nursing procedures.

2). Assessment of clients pain before and 30 minute after serving analgesics was done.

3). Client was assisted to assume a lateral position which was comfortable for her on a bed free from creases and crump.

4). Tight and constricting clothingwas removed.

5). Staff was asked to minimize noise and visitors were also restricted and patient was screened with a curtain.

6). Client was engaged in conversation to divert her attention from the pain.

7). Injection pethedine 10mg was given intramuscularly as prescribed.

8).All procedures performed to reduce pain were documented in the nurses notes.10\10\14at10:20amGoal fully met.

DATE AND TIMENURSING DIAGNOSISNURSING OBJECTIVE/OUTCOME CRITERIANURSING ORDERNURSINGINTERVENTIONDATEAND TIMEEVALUATIONSIGNATURE

10/10/14 at 11:30am.Anxiety related to impending surgery (Intestinal Obstruction) and its outcome.Client and will be relieved of anxiety within 30 minutes as evidenced by;a). Client verbalizing that she is relieved of anxiety.b). Nurse observing that client have cheerful facial expression.

1).Reassure client.

2).Assess clients state of anxiety, fear and concerns.

3).Explain to her the theatre environment and what she should expect in the theatre.

4).Allow client to express concern.

5).Employ diversional therapy

1).Client was reassured that she is in the hands of competent staff to reduce her anxiety.

2).The facial expression and the posture of client were observed in an attempt to assess her level of anxiety.

3).The theatre environment, dressing of workers and equipment was explained to allay her anxiety.

4).Client was allowed to express her concerns by asking questions. Appropriate answers were given to correct misconception about the condition and treatment plan.

5). Client was engaged in diversional therapy such as conversations to allay fears.

10/10/14 at12:00pm.Goal fully met.

DATEANDTIMENURSING DIAGNOSISNURSING OBJECTIVE/ OUTCOME CRITERIANURSING ORDERS

NURSINGINTERVENTIONDATE ANDTIMEEVALUATIONSIGNATURE

10/10/14at3:00pm.Knowledge deficit related to disease condition (intestinal obstruction).Client and relatives will have knowledge on intestinal obstruction within 45 minutes as evidenced by;a). Client and relatives verbalising that they understand clients condition.

b). Client ability to give correct feedback on the disease condition (Intestinal obstruction).1). Reassure client and family.

2).Ensure quiet environment.

3).Provide a comfortable seat for client and relatives.4).Assess theirprevious knowledge on the condition.

5). Educate them on the disease condition and its management.

6). Allow client and family to ask questions.

7). Access their understanding with feedbacks.

8). Include client and family in planning of care.1).The client and family were reassured that there were available materials to educate them.

2).The environment was made quiet by preventing interference from visitors and staff.

3).Client was put in a comfortable position and relatives offered seats to relax them.4).They were asked to a give brief explanation about the condition.

5). The client and relatives were provided with the needed information concerning the condition and the importance of the surgery.

6). Client and relatives were encouraged to ask questions which in line with the care rendered and answers were provided to their level of understanding.

7). Client and relatives were asked to summarize and explain in their own simple terms as they understand the education. Feedback given was better.

8). They were involved in all procedures and rationale explained to win their maximum cooperation.

10/10/14at3:45pm.Goal fully met.

DATEAND TIMENURSING DIAGNOSISNURSING OBJECTIVE/ OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONDATEAND TIMEEVALUATIONSIGNATURE

11/10/14at6:20amPotential for dyspnoea related to ineffective airway clearance due to anaesthesia.Client will have a patent airway within 45 minutes as evidenced by nurse observing that client has normal respiration pattern and patent airway.1).Reassure client

2).Set a resuscitation tray.

3).Position client in the appropriate position which is not contra indicated.

4). Suction client frequently.

5).Observe client for signs and symptoms for respiratory distress such as dyspnoea and cyanosis.6).Monitor vital signs every 15 minutes, 30 minutes, 1 hour, and every 4 hours as clients condition improve.

1).Client was reassured that measures would be put in place to ensure clear airway, this helped to allay clients fears and anxieties.

2).A resuscitation tray containing endotracheal tube, ventilator, ambu bag, tongue holding forceps, mouth gag, gallipots with sterile swabs, spatula and receiver for soiled swabs was set and placed at clients bedside to be used when the need arises.3).Client was put in the left lateral position with the head turned to one side to prevent the tongue from falling back to block the airway and to facilitate free drainage of mucus secretion.

4). Client was suction frequently to maintain patent airway.

5).Client was observed for signs and symptoms of respiratory difficulties and none was observed.

6).Clients temperature, pulse, respiration, blood pressure were monitored and recorded as clients condition improved. This helped to assess the improvements of clients condition.

11/10/14at7:05amGoals fully met

DATEANDTIMENURSING DIAGNOSISOBJECTIVE/ OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONTIMEAND DATEEVALUATIONSIGNATURE

12/10/14 at 9:00amAlteration in comfort(pain) related to surgical incisionClient will be relieved of pain within 24 hours as evidenced by:a). Client verbalizing that she is relieved of pain.

b). Nurse observes client having a cheerful facial expression and looking relaxed in bed.1). Reassure client.

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

3).Provide diversional therapy.

4).Teach client to support incision site when coughing or laughing.

5). Check vital signs and record.

6). Administer post operative analgesics to relief pain.

7).Document the procedure.1).The client was reassured that the pain and discomfort will be relieved with effective nursing measures.

2).The client was assisted to assume a recumbent position which was not contraindicated to the surgery, to help relieve her of pain.

3).The client was engaged in conversation, to turn her attention from pain.4).The client was taught to support the incisional site with the hands when coughing or laughing to relief tension on incision site to reduce pain.

5).Clients vital signs (temperature, pulse, respiration and blood pressure) was checked and recorded accurately.

6).50mg pethedine was administered to relieve pain and discomfort.

7). The procedure was documented in the nurses notes.13/10/14 at 9:00amGoals fully met.

DATEAND TIMENURSING DIAGNOSISOBJECTIVE/ OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONTIMEAND DATEEVALUATIONSIGNATURE

13/10/14at6:25amSelf care deficit (total) related to incisional wound.Client will be able to meet her self care needs without assistance or with minimum assistance within 72 hours as evidence by;a). Observing client taking her bath, grooming and caring for her mouth without assistance.1).Reassure client.

2).Assist client to bath twice daily.

3).Treat Pressure areas.

4).Give oral toileting twice daily.

5). Encourage early ambulation.

6).Change soiled linen as often as possible and make bed free from crumbs and creases.1).Client was reassured that her personal hygiene would be taken care of until her condition allows her to perform them by herself.

2).Client was assisted in bed to bath twice daily with warm water to refresh her and to remove dirt and also stimulate circulation. Soap and sponge were used.

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

4).Clients mouth was cared for twice daily with tooth brush and toothpaste to prevent oral infection. Vaseline was applied to the lips to prevent cracks.

5).Client was assisted to walk around the ward at least twice daily to improve circulation.

6).Soiled linens were changed regularly and bed made free from crumbs and creases to prevent bed sores and to improve clients comfortability.16/10/14at6:25am.Goals fully met

DATEAND TIMENURSING DIAGNOSISOBJECTIVE\OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONDATEAND TIMEEVALUATIONSIGNA-TURE

13\10\14at8:00amPotential for post operative wound infection related to surgical incision.Client will not develop post operative wound infection throughout the post operative period(9 days) as evidenced by;a).The clients wound looking clean, dry and free from exudates.

b). The clients wound healing by first intention.1).Reassure patient.

2) .Change soiled dressings frequently and aseptically.

3).Educate client to avoid touching the wound site.

4).Administer prescribed antibiotics.

5).Encourage adequate nutrition.

6). Document procedure.1).Client was reassured that strict aseptic technique will be employed during wound dressing to prevent wound infection.

2).Soiled dressing was frequently changed to prevent moisture and infection. Wound was dressed by observing all the necessary aseptic techniques. Sterile instruments were employed in all procedures.

3).The client was instructed to avoid touching the wound site to avoid infecting the wound

4). Prescribed antibiotics such as ciprofloxacin, augumentin and flagyl were administered to prevent infection.

5).Client was frequently served with balanced diet to promote wound healing and replace worn out tissue.

6).Procedure was documented in nurses notes.

16\10\14at8:00amGoals fully met

DATEAND TIMENURSING DIAGNOSISOBJECTIVE\ OUTCOME CRITERIANURSING ORDERSNURSING INTERVENTIONDATEAND TIMEEVALUATIONSIGNA-TURE

14\10\14at8:00amHigh Risk for infection (urinary tract infection) related to catheter insituClient will be free from infection within the period of catheterization as evidenced by;Nurse observing no signs of discharges and redness at the catheter site and absence of dysuria.

1). Reassure client.

2). Care for catheter daily with antiseptic lotion.

3). Keep the drainage bag in a container.

4). Keep drainage bag in a right position for easy drainage.

5). Monitor temperature

1). Client was reassured that the catheterization is temporal.

2). Client catheter was cared for daily with antiseptic lotion such as savlon and normal saline.

3). The drainage bag was kept in a container under the clients bed to prevent the bag from the floor

4).The drainage bag was put under the bed for easy drainage with gravity and preventing obstruction by pressure from the drainage tube.

5).Clients temperature was monitored four hourly for increase in temperature which may indicate presence of infection.15\10\14at8:00amGoals fully met.