CHAPTER ONE ASSESSMENT OF PATIENT / FAMILY Assessment is the process of collecting data from a patient and his/her family.

It is the first step in the nursing process. The information or data can be collected through physical examination, health history, laboratory investigations, text books and family. Analysis is made from the information to arrive at the health problems and appropriate nursing interventions are put in place to solve the problems noticed. From the first day of meeting the patient and family, assessment begins. And this continues throughout clients stay on the ward. PATIENTS PARTICULARS Mrs. R. A. is a 34year old woman, born to Mr. J. M, a policeman and Mrs. E. M, a trader at La in the Greater Accra region of Ghana. Mrs. R is a Ga and a Ghanaian by nationality. She is fair in complexion. She weighs 60kg and 172cm tall. Out of three (3) siblings, two (2) girls and (1) boy, she is the second ( 2nd) born. She is married to Dr. R A, with 2 kids. She stays at high tension last stop, Awomaso in Kumasi. Mrs. R.A is a Christian and worships at Lighthouse Chapel international Bantama branch. She completed Tamale Nursing Training College in the year 2002 and now is a nurse by profession. She speaks Twi, Ga and English language. She has no known allergy to drugs and food. Dr R. A is her next of kin. FAMILYS MEDICAL AND SOCIO-ECONOMIC HISTORY Information gathered from Mrs. R.A and her family revealed that there is no known hereditary disease such as hypertension, asthma, epilepsy, diabetes, and mental disorders and no known chronic disease such as tuberculosis in the family but occasionally, they do have slight fever and headache which are treated with drugs purchased over the counter but if it is severe they seek treatment from the KNUST Hospital. Mrs. R lives with her husband, two children, mother and a niece. She is unemployed at the moment with 2 dependants. Her husband, the bread winner, is a Nutritionist and a lecturer at the Kwame Nkrumah University Of Science and Technology. Mrs. R. neither smokes nor drinks alcohol. She attends funerals and weddings of family and friends. Mrs. R. does not belong to any social clubs.

PATIENTS DEVELOPMENTAL HISTORY According to client, she was told by the mother that she was delivered spontaneously by vaginal delivery at full term in a nearby clinic in La in the Greater Accra region of Ghana. She was also told that, she was immunized against all the childhood immunizable diseases like BCG, Polio, Diphtheria, Influenza, Yellow Fever and Measles during infancy and was exclusively breastfed. A physical examination of her right shoulder revealed an injection scar on the deltoid region which confirms BCG vaccination as she said earlier. According to clients mother, at 4 months, Mrs. R. A. could sit with pillows at her back and at 6 months, she could sit her without support. At the seventh month, she was able to drag objects toward herself, start crawling and the first pair of tooth began to grow. She started saying "mama" or "dada at 8 months and could stand while holding onto something at 9months. Furthermore, she was able to jump with both feet, Opens doors and started to recognize ABCs when she was about 27-28 months old. At age of three she was able to brush her teeth with help, wash and dry hands own her own. At the age of 13, her secondary sex characteristics began to develop as well as menarche. She went through the developmental milestone without any complication. PATIENTS LIFESTYLE AND HOBBIES Mrs. R wakes up every day at 4:00am to brush her teeth with pepsodent tooth paste, have her quiet time for an hour after which she sweeps the house and its environs. At 5:45am, she wakes the kids up and prepares them for school. At 6:30am she prepares and serves breakfast. When 7:30 she sees her kids off to school after which she goes to take her bath. According to client, she uses warm water, sponge and prefers to use any other bathing soap to Keysoap when bathing. If there is a need for shopping for cooking in the house, she does that after having a nap. At 3:30pm, she starts preparing supper so as dinner could be served at early. In the evenings, Mrs. R.A either attends church service if there is any or watches television. On weekends she prefers to stay indoors and watch movies, listen to music, do the laundry or attend weddings or any church programme of her interest. Furthermore, she loves to take tea or coffee with bread for breakfast, rice and stew or beans and fried plantain for lunch, and fufu or banku with groundnut or palmnut soup for supper.

PAST MEDICAL HISTORY

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Client said she has never been hospitalized until her present condition. She stated that, she occasionally experiences minor ailments such as headache, malaria, body weakness, cold and cough but are treated with drugs purchased from the chemical shops. She has neither undergone surgery nor been blood transfused before. She also does not go for periodic medical checkup. PRESENT MEDICAL HISTORY Client stated that she was faring well until 26th December, 2011 when she experienced a vague generalized pain which settled in the lower abdomen after a day. The abdominal pain was constant, particularly worsens with movement and relieved when she lies still in bed. On 28th December, 2011, when she woke up from bed in the morning, the pain had become so severe and was accompanied with rise in body temperature, nausea and vomiting. She was immediately rushed to KNUST hospital where she received first aid and was transferred to the Accident and Emergency Unit of Komfo Anokye Teaching Hospital. She was then diagnosed of Acute Abdomen based on her clinical manifestations by Doctor Amoah of General Surgery Team A and detained for further treatment.

ADMISSION OF PATIENT
On 29th December, 2010, at 11:40am client was admitted to the Komfo Anokye Teaching Hospital ward C4, a female surgical ward with urology and gastrointestinal cases with the diagnosis, Acute Abdomen on account of Dr. Amoah. She was brought to the ward in a semi conscious state in a wheelchair client and accompanied by the admission team and her husband. She was made comfortable in bed after her folder was collected from the admission team and had been checked to confirm that she was to be admitted to the ward whiles her husband was given a seat at the nurses station while patients particulars to be entered into the admission and discharge book and the daily ward state sheet. Her particulars from her folder were taken and recorded. These included her full name, address, age, occupation, religion and next of kin. Her vital signs were checked and recorded as follows; Temperature Pulse Respiration 37.30C 72 beats per minute (bpm) 18 cycles per minute (cpm)

Blood Pressure -100\60 mmhg

Clients husband was informed that time of visit was 3:30pm and visiting time over at 5:00pm. He was also asked to bring along clients personal toiletries such as towel, sponge, soap for bathing, pail and other personal items which will be needed by client while on admission. Client was orientated to the ward by showing her the sluice room, Nurses station and also introduced to other clients in the ward when condition was fair. She was reassured that she was in the hands of competent staff and that everything possible will be done for her to recover soon. She was allowed to ask any question she wanted and was answered politely. Client complained of pain in her right iliac region, feeling hot and weakness which was written down in the nurses note for continuity of care. After being reviewed by Dr Amoah, She was placed on the following treatments which were administered and recorded as ordered. IV Buscopan IV Metronidazole Inj. Diclofenac IV Cefuroxime 40mg bd x 24hours 500mg tid x 48hours 75mg bd x 24hours 1.5g tds x 48hours

He also requested the following laboratory investigations so he was assisted to collect samples:
Liver function test, Complete Blood Count,

Blood urea nitrogen,

Creatinine

Serum electrolyte level The sample was labeled and sent to the lab. PATIENTS CONCEPT OF HER ILLNESS According to my client, she believes that her disease condition does not have any spiritual cause but she believes that prayers and medical intervention will make her recover soon.

LITERATURE REVIEW ON ACUTE ABDOMEN DEFINITION Acute abdomen or peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localized or generalized, and may result from infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process. TYPES OF PERITONITIS The two main types of acute abdomen
1. PRIMARY SPONTANEOUS PERITONITIS

Primary spontaneous peritonitis is the development of peritonitis (infection in the abdominal cavity) despite the absence of an obvious source for the infection. It occurs almost exclusively in people with portal hypertension (increased pressure over the portal vein), usually as a result of cirrhosis of the liver. It can also occur in patients with nephrotic syndrome. The diagnosis of primary spontaneous peritonitis requires paracentesis (aspiration of fluid with a needle) from the abdominal cavity. If the fluid contains bacteria or large numbers of neutrophil granulocytes (a type of white blood cells), infection is confirmed and antibiotics are required to avoid complications. In addition to antibiotics, infusions of albumin are usually administered.

2. SECONDARY PERITONITIS
Secondary peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Secondary means it is due to another condition, most commonly the spread of an infection from the digestive tract.

AETIOLOGY
The most common risk factors of primary spontaneous peritonitis include:
1. Liver disease with cirrhosis. Such disease often causes a buildup of abdominal fluid (ascites) that

can become infected.

2. Peritoneal dialysis. This technique involves the implantation of a catheter into the peritoneum to

remove waste products in the blood of people with kidney failure. It's associated with an increased risk of peritonitis due to accidental contamination of the peritoneum by way of the catheter.
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Common causes of ruptures that lead to peritonitis include: Medical procedures, such as peritoneal dialysis A ruptured appendix, stomach ulcer or perforated colon Pancreatitis Diverticulitis Trauma

Common causes of secondary peritonitis include:

A ruptured appendix, diverticulum, or stomach ulcer Digestive diseases such as Crohn's disease and diverticulitis Pancreatitis Pelvic inflammatory disease Perforations of the stomach, intestine, gallbladder, or appendix Surgery Trauma to the abdomen, such as an injury from a knife or gunshot wound Noninfectious causes of peritonitis include irritants such as bile, blood, or foreign substances in the abdomen, such as barium.

PATHOPHYSIOLOGY Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity, usually as a result of inflammation, ischemia, trauma, or tumor perforation. Bacterial proliferation occurs resulting in edema of the tissues and exudation of fluid develops in a short time. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris and blood. The immediate response of the intestinal tract is hypermotility, soon followed by paralytic ileus with an accumulation of air and fluid in the bowel.

CLINICAL MANIFESTATIONS The first symptoms of peritonitis are poor appetite and nausea, and a dull abdominal ache that quickly turns into persistent, severe abdominal pain, which is worsened by any movement.
6

Other signs and symptoms related to peritonitis may include:

Abdominal tenderness or distention Chills Fever Fluid in the abdomen Extreme thirst Not passing any urine, or passing significantly less urine than usual Difficulty passing gas or having a bowel movement Vomiting

DIAGNOSTIC INVESTIGATION Diagnostic tests for acute abdomen may include:

Blood and urine tests Imaging studies such as X-rays and computerized tomography (CT) scans Exploratory surgery

Leukocytes (elevated) complete blood count, hemoglobin, hematocrit, and serum electrolytes (altered potassium, sodium and chloride). Abdominal radiographs, computer tomography (CT) scan, and peritoneal aspiration with culture and sensitivity studies.

MANAGEMENT SURGICAL MANAGEMENT

7

Surgery (laporotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage that may have caused peritonitis. The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance. If the peritonitis is due to a perforated appendix, then appendix is removed and suturing is done to close or join the incision together again. GENERAL NURSING MANAGEMENT Position

Position patient for comfort (e.g. on side with knees flexed to decrease tension on abdominal organs) to reduce pain. Raise bedside rails to prevent patient from falling Observation Assess nature of pain, duration, location in the abdomen, and shifts of pain. Check and record vital signs every 4hourly. Monitor patients intakes and output to prevent fluid overload. Observe and record character of any surgical drainage. Observe for decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic sounds, and passage of flatus and bowel movements, which indicate peritonitis is subsiding. Observe and record character of drainage from postoperative wound drains if inserted; take care to avoid dislodging drains. Nutrition

Increase food and oral fluids gradually, and decrease parenteral fluid intake when peritonitis subsides. Encourage client to take fruits to boost immunity and aid in wound healing. Drug Administer prescribed antibiotics and analgesic medications Administer and monitor intravenous fluids closely. Educate Postoperatively, prepare patient and family for discharge; teach care of incision and drains if still in place at discharge.

SPECIFIC NURSING MANAGEMENT PRE OPERATIVE NURSING MANAGEMENT Psychological Care Reassure the client and the relative by explaining the type of surgery to be done on her and the disease. Make it known to her that she is in the hands of competent staff and so by complying with staff 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. After all the explanation necessary for the patient to gain knowledge and understand her surgery, a consent form is given to client to be signed, this gives the legal right for the operation to be performed on the patient.

Rest and Sleep

Clients bed should be free from creases and crumbs to prevent her being uncomfortable. Reduce or if possible, eliminate noise in the ward; make sure all procedures are performed at a Client must be kept in a Semi Fowlers position. It is the appropriate position she must be kept

goal to prevent procedures destructing her sleep. in this position as much as possible to promote pulmonary ventilation and ease respiratory distress from any abdominal distension. Observation

Vital signs such as temperature, pulse, respiration and blood pressure are observed every four hours to serve as a baseline for evaluating whether the patients condition is progressing or improving.

Assess client for pain to know the location intensity, frequency, and duration. Monitor clients intakes and output chart, if abdomen is distended, abdominal girth is measured and patient must be weighed daily. Clients emotional state must be observed and patient reassured Site of intravenous fluids must be observed for bleeding, blockage of the line and rate of flow to rule out any fluid over load to client.
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Side effects of drugs must be observed and recorded.

Pain management

Client must be observed for pain and pain management given Diversional therapy may be done to distract the patients mind from pain Cold compresses may be applied at the site of distension which can help relax the muscles. Client must be encouraged to assume the position she finds comfortable which is not contraindicated to her condition. Administration of preceded analgesics such as Diclofenac 50 mg bd x 24hr must be given to relive pain.

Investigation All investigation must be done on the patient to correct any abnormalities related to blood, Hemoglobin level, white blood cell count, sickling, Blood grouping and cross matching.

Nutrition Serve fluid diet the night before the surgery. Intravenous fluids such as dextrose saline normal saline, ringers lactate may be given to correct Nothing is given by mouth on the morning of the operation.

fluid and electrolyte loss.

Skin Preparation
The area to be shaved must be washed and dried Wash the operation site again after shaving and dry with bath towel. Clean the shaved area again with an antiseptic lotion, apply sterile dressing towel and secure in

position with an adhesive tape.

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POST OPERATIVE MANAGEMENT Under the post operative intervention, we have; a) Immediate post-operative intervention and b) Subsequent intervention

IMMEDIATE POST OPERATIVE CARE

This begins after the last stitch is done until the patient gains consciousness. A resuscitation tray which should have a mouth gag, tongue forceps, tongue depressor, vital signs tray etc. is set. Other things like, drip stand, vomit bowl, suction machine, fluid chart, oxygen cylinder are placed at the bed side. All these are made ready on the recovery ward including a well made operation bed.

First, Check patient for the up and down movement of the chest or breathing to know if patient is alive. Surgeons notes are read and patient is placed on his or her back with head turned to one side to prevent the tongue from falling back. Position

Place patient in a semi-fowlers position. Turned the head to the side to facilitate easy emptying of the contents of mouth since patient is unconscious. Maintain the patients safety by ensuring that the patients airway is patent, and prevention of injury by lifting the side rails Maintenance of Airway

The 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.

Observation Observe 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
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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. Incision site is then observed for bleeding and if any reported at once. Observe for cyanosis, if present, is a sign of hypoxia. Prevention from Injury Since patient is unconscious and cannot complain of pricking from needles, clamp that is exerting pressure and burn from hot water bottle, patient needs to be protected from injury by ensuring that all procedures are done using the right technique.

Subsequent Care
Wound Care Dressing 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 according to the surgeons preference. The wound must be observed for infection, bleeding and pain. Personal Hygiene Oral toileting and bed bath needs to be done regularly to prevent harboring of microbes, thereby preventing secondary infection. Drugs Administer Intravenous fluids and blood component therapy, if prescribed. Prescribed drugs such as injection Pethedine 50mg 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.

Ambulation

12

Early ambulation is also encouraged as soon as patient gains consciousness. Patient is encouraged to sit up in bed and also to put his/her hand on the incisional site when coughing or sneezing to prevent wound from gaping. Nutrition

When bowel sounds are heard, sips of water or tea is given and nasogastric tube if any are removed as ordered by the surgeon. Administer prescribed stool softener if there is constipation.

Patient Education

1.
2. 3. 4. 5.

Patient is educated on the disease condition including its definition, types, causes, signs and symptoms and complications, as well as management. Patient should be taught on how to care for the wound and if she is taking a surgical dressing in place home, she can take it to a near by health centre for dressing. Patient is educated on how, to observe the incision site for swelling, redness, bleeding and warmth daily. Patient should be educated on all medications and see to it that, she can administer each drug according to the physicians order and knows its effect and adverse effect. Post operative activity must be discussed with patient by telling him to avoid lifting heavy objects for 6 weeks after the surgery in other to prevent strain on the abdominal muscle until healing is completed.

6.

Patient is educated on how necessary to care for follow ups and treatment.

COMPLICATIONS

Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may cause electrolyte disturbances, as well as significant hypovolemia, possibly leading to shock and acute renal failure.

A peritoneal abscess may form above or below the liver, or in the lesser omentum Sepsis may develop, so blood cultures should be obtained. The fluid may push on the diaphragm, causing splinting and subsequent breathing difficulties.

VALIDATION OF DATA
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From the information gathered on the causes, signs and symptoms by the client, including results of her laboratory investigations confirms that client was suffering from acute abdomen when the information was compared with standards in various textbooks, My clients husband also confirmed the information collected from my client. Therefore, the data collected is free from errors and misinterpretations for this study and therefore valid.

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CHAPTER TWO ANALYSIS OF DATA

The second stage in nursing process is analysis, whereby the data collected earlier on are analysed to ensure accuracy of the data. It covers comparison of data with standards, client and family strength, client health problems, nursing objectives and nursing diagnosis.

COMPARISON OF DATA WITH STANDARDS

Information collected from diagnostic investigations, clinical features, treatment as well as complications were compared with standard values in textbooks and stated in the following tables.

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TABLE 1: DIAGNOSTIC INVESTIGATIONS

DATE SPECIMEN INVESTIGATION RESULTS NORMAL VALUES 28/12/11 Blood Liver function test Total protein 59.7 g/L Albumin 39.10 g/L Globulin 20.6 Bilirubin total 20.6 Bilirubin-direct 4.75 umol/L Indirect bilirubin 7.6 13.84 x10 /L 459 x103/uL
9

INTERPRETATI ON Total protein and Globulin level was low whiles direct bilirubin level was high White blood cell count was above normal Platelet count was normal

REMARKS

66.0-87.0 35.00-52.00 25.0-35.0 1.0-17.0 0.00-3.40 1.5-14.0 4 10x109/L 140-440 x103/uL

No treatment was given

28/12/11 28/12/11

Blood Blood

White Blood Cell count (WBC) Platelet count

Antibiotics was prescribed for treatment Treatment was not given

28/12/11

Blood

Differential count, Neutrophils Lymphocytes Monocytes Basophils

86.5% 7.3% 5.4% 0.4%

37.0 - 75.0% 16.0 51.0% 0.0 12.0% 0.0 3.0%

WBC Differential Antibiotic was count was within prescribed for the normal range treatment. except lymphocytes which was below and the neutrophils which was above the normal range. Blood urea nitrogen/Creatinin e level was above Antibiotic was prescribed for treatment

1/1/12

Blood 1. Blood urea Nitrogen / Creatinine Level. 42.0 8.0 36.0

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2. Creatinine 3. Urea 1/1/12 Blood Electrolyte analysis 1. Sodium 2. Potassium 3. Chloride

23mol/l 3.4mmol/l 138mmol/l 2.8mmol/l 99mmol/l

44 80mol/l 2.14 7.14mmol/l 135 145mmol/l 3.5 5.5mmol/l 90 110mmol/l

normal range. Creatinine was normal. Urea was normal. Potassium level was low

No treatment was given Treatment was not given IV KCL 15ml(30mmol) in each 500ml of ringers lactate

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CAUSES
The literature review on acute abdomen stated that it can be caused by a raptured or a perforated appendix, pancreatitis, diverticulitis or Crohns disease. From the post operative notes of the client, her disease was precipitated by a perforated appendix according to the surgical findings.

TABLE 2: CLINICAL FEATURES

CLINICAL FEATURES ACCORDING TO LITERATURE REVIEW 1. Sudden onset 2. Abdominal pain at the right lower quadrant of abdomen 3. pyrexia 4. Tenderness and rigidity at the right iliac fossa. 5. Nausea and vomiting 6. Malaise 7. Constipation may be present 8. There may be diarrhoea 9. Loss of appetite CLINICAL FEATURES PRESENTED BY PATIENT 1. Onset was sudden 2. Client had abdominal pain at his right lower quadrant of the abdomen. 3. Client exhibited pyrexia of 38.0C. 4. On palpation there was tenderness and rigidity at the right iliac fossa of the patient. 5. Client experienced nausea and vomiting 6. Malaise was experienced by patient 7. Client did not complain of constipation 8. Client had diarrhoea 9. Client complained of loss of appetite

TREATMENT

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In the literature review, management of acute abdomen is medically by antibiotics, analgesia and IV fluids if the patient general state is not suitable for surgery and in situations where surgical intervention is paramount then exploratory laporotomy is done.

TREATMENT OF CLIENT
Since patients attack was an acute one, an exploratory laporotomy was the treatment of choice which was done under general anesthesia. All preparations like psychological, physical, physiological and spiritual were made before the surgery. She was put on the following drugs;

IV Normal Saline 3L x 48hours IV Ringers Lactate 3L x 72hours IV Metronidazole 500mg tid x 72hours IV Ciprofloxacin 400mg bd x 72hours Injection Diclofenac 50mg bd x 24hour IV Dextrose Saline 1L x 48hours Injection pethidine 50mg bd x 48hours Tablet flagyl 400mg tid x 5days Tablet ciprofloxacin 250mg bd x 7days

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TABLE 3: PHARMACOLOGY OF DRUGS

DATE 28/12/11 DRUG Normal Saline 0.9% Ringers Lactate DOSAGE/ROUTE OF ADMINISTRATION 2.0 litres x 24hours, Intravenously 28/12/11
2.0 litres x 24hours,

CLASSIFICATION Intravenous fluid and electrolyte Intravenous fluid and electrolyte

DESIRED EFFECT Gives energy and increases blood volume Replaces fluid and supplies important electrolytes such as sodium, calcium and potassium To control or combat infection

ACTUAL ACTION OBSERVED Electrolyte and fluid balance maintained Fluid and electrolytes balance was maintained

SIDE EFFECT/REMARKS Edema, headache, hypernatraemia, irritability. None was observed in client. Hypercalcaemia, fluid over load and electrolyte imbalance, hypercalcaemia. None was observed in client.

Intravenously

28/12/11

Metronidazole (flagyl)

500mg tidx48hours, Intravenously

Antibacterial and Antiprotozoal

Infection was controlled

Dry mouth, headache, dizziness and nausea. Client complained of dizziness. Nausea and vomiting abdominal pain, headache, diarrhoea. These were all observed in client except headache

31/12/11

Ciprofloxacin

400mg bd x 72hours Intravenously

Antibacterial

Destroys bacterial and prevent bacteria DNA replication

Bacterial eliminated from blood and infection was controlled

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DATE 31/12/11

DRUG Injection Diclofenac

DOSAGE/ROUTE OF ADMINISTRATION 75mg bd x 24 hours

CLASSIFICATION Non steroidal antiinflammatory analgesic

DESIRED EFFECT Produces antiinflammatory and antipyretic effect possibly inhibiting prostaglandin synthesis Corrects electrolyte imbalance and provide energy

ACTUAL ACTION OBSERVED Patients pain was relieved and pyrexia reduced.

SIDE EFFECT/REMARKS Drowsiness, anxiety, depression, edema, hypertension, abdominal pain. None of these was observed in patient Confusion, phlebitis, glucosuria and hypovolemia. None was observed in client.

Intramuscularly 31/12/11 Dextrose Saline 2.0 litres for 48hours Intravenously Isotonic solution caloric agent and fluid volume replacement

Energy was restored and fluid balance was maintained

2/1/12

Inj. Pethidine

50mg bd 48hours Intramuscular

Opioid analgesic

Depresses pain impulse at spinal cord level To prevent infection Destroys bacteria

None was observed

Seizures, Dizziness Respiratory depression, Client was relieved of pain Nausea, constipation, headache, dry mouth. None of these was observed in patient. Fatigue, headache, and dizziness. None was observed in patient.

4/1/12

Tablet Metronidazole (flagyl) Tablet ciprofloxacin

400mg tid x 5days Orally 250mg bd x 7days Orally

Antiprotozoal and antibacterial Antibacterial

Patients wound healed without infection Infection was combated.

4/1/12

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COMPLICATIONS
Client did not exhibit any complication due to early detection of her condition, good treatment and nursing care rendered with reference to the complications stated in the literature review.

PATIENT/FAMILY STRENGTH
Definition: This is the ability of client and family to participate in the care for the achievement of set goals on their strength. On admission, client was conscious and communicated with both health care providers and family members. Client and family were co-operative and provided all necessary information needed. Clients family members and friends visited her regularly when she was on admission and brought her food as well. Family members were able to foot clients bill even though she did not register for National Health Insurance Scheme. Client got out of bed, third day after surgery and could maintain her personal hygiene with little assistance. She was well oriented to time, place and person. The family of the client helped her cope with the situation by providing her both spiritual and material support.

HEALTH PROBLEMS
At the time of admission till discharge the following problems were identified during the care of my patient; PREOPERATIVE:
1. Client experienced pain at the right lower abdomen on 29/12/11 at 11:45am 2. Client experienced pyrexia (38.0C) on 29/12/11 at 12:50pm

3. Client was vomitting on 31/12/11

4. Client was anxious on 1/1/12

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POST-OPRATIVE:
5. Client experienced pain at the incisional site on 2/1/12 6. Client has wound on 5/1/12 7. Client was unable to care for herself 3/1/12

8.

Client was prone to developing infection on 2/1/12

NURSING DIAGNOSES
A nursing diagnosis is a clinical judgment about individual, family or communitys response to actual or potential health problems. It provides the basis for selection of nursing interventions to achieve objectives for which the nurse is accountable. The following nursing diagnosis was drawn from the patients health problems presented;

PRE-OPRATIVE:
1. Pain, related to inflammation at the right lower abdomen.

2. Hyperthermia (38.2C) related to infection. 3. Risk for fluid volume deficit related to excessive vomitting. 4. Anxiety related to unknown outcome of disease and surgery. POST-OPRATIVE: 5. Pain related to surgical incision. 6. Impaired skin integrity related to surgery 7. Self care deficit (Bathing/Hygiene) related to immobility. 8. High risk for infection related to surgical incision on the abdomen.

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CHAPTER THREE PLANNING FOR PATIENT/FAMILY CARE

Identification of nursing diagnosis leads to the next stage of nursing process which is planning. Planning deals with setting of goals and objectives to help eliminate or reduce clients health problem and coming up with the appropriate nursing interventions to meet set goals .The client and her family were actively involved in planning of nursing care. The nursing care plan comprises of the following nursing diagnosis, objective/ outcome, nursing orders, nursing interventions and evaluation were used to carryout the nursing care of patient.

OBJECTIVES OF CARE
1. i. ii.

Client will be relieved of abdominal pain within 45minutes as evidenced by

Client verbalizing a reduction in the level of abdominal pain. Nurse observing that client has a relaxed facial expression
2. i. ii. iii.

Client will attain a normal body temperature (36.2 37.20C) within 6hours as evidenced by Client verbalizing that she does not feel hot again. Client temperature within the range of 36.2 37.20C Nurse observing that client has a normal temperature by the use of a clinical thermometer.

3. Client will maintain normal fluid volume within 24 hours as evidenced by:

i. ii. iii.

Client having good skin turgor and skin color being normal. Clients temperature within the range of 36-37 degrees Celsius. Clients pulse rate within the range of 60-100 bpm

4. i. ii.

Client will be less anxious within 2hours as evidenced by. Client verbalizing relief of anxiety Client having a relaxed facial expression and participating in ward activities

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5. Client will be relieved of incisional pain within 45 minutes.

i.
ii.

Client verbalizing reduction of pain. Nurse observing a relaxed facial expression.

6.

Client s wound will heal without infection within the period of hospitalization as evidenced by i. Clients wound healing by first intension ii. Nurse observing that clients wound healing with no purulent discharge and minimal scar formation.

7. Client will be able to maintain her personal hygiene needs without assistance within 72hours as

evidenced by.
i. ii.

Client verbalizing that she was able to bath and groom without assistance. Client looking refreshed and relaxed in bed.

8. Clients wound will heal by first intention without infection within seven days (1week). i. ii.

Wound healing in the absence of signs of infection like purulent discharges and pyrexia Nurse observing absence of infection like purulent discharges.

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TABLE 4: NURSING CARE PLAN

DATE & TIME 29/12/11 11:50am NURSING DIAGNOSIS Pain related to inflammation at the right lower quadrant of abdomen OBJECTIVE /OUTCOME CRITERIA Client will be relieved of abdominal pain within 45minutes as evidenced by i. Client verbalizing a reduction in the level of abdominal pain. ii. Nurse observing that client has a relaxed facial expression
2. Assist client 2. Client was assisted to

NURSING ORDERS
1. Reassure

NURSING INTERVENTIONS
1. Client was reassured

DATE & TIME 29/12/11 1:00pm

EVALUATION Goal fully met as client verbalized reduction in level of pain.

SIGN.

client

that she was in the hands of competent staff and necessary measures have been put in place to help her recover soon.

assume a left lateral position with flexion of the hip to relax the abdominal muscle to relieve pain which she said was comfortable for her. 3. Television sets were turned to minimal volume and visitors were restricted as well, to help
26

to assume a comfortable position

client have enough rest to reduce pain. 3. Ensure a quiet environment 4. Ice pack wrapped in towel was placed at clients right lower quadrant (inflamed area) 5. Prescribed analgesic such as injection Diclofenac 50mg was administered with a good 4. Apply cold compresses to the inflamed area effect.

5. Give prescribed analgesics

DATE & TIME

NURSING DIAGNOSIS

OBJECTIVE /OUTCOME

NURSING ORDERS
27

NURSING INTERVENTIONS

DATE & TIME

EVALUATION

SIGN.

CRITERIA 29/12/11 12:50pm Hyperthermia (38.0C) related to infection Client will attain a normal body temperature (36.2C 37.2C) within 6hours as evidence by i. Client verbalizing that she does not feel hot again. ii. Client temperature within the range of 36.2 37.20C iii.Nurse observing that client has a the use of a clinical thermometer. 4. Tepid sponge
28

1. Reassure the client

1.

Client was reassured

29/12/11 6:00pm

Goal fully met as client temperature was 370C on the clinical thermometer.

that her temperature will reduce to normal with good nursing care. This was done to allay fear and win her cooperation during the procedure. 2. Check patients temperature every 2hours and record 3. Remove excess clothing and serve temperature. 2. Clients temperature was checked with the thermometer and recorded every 2hours. 3. Clients excess clothing were removed in order to allow air circulate around her to reduce temperature. Client was served 100mls of cold Fanta lemon. 4. Client was tepid sponged to

normal temperature by cold drink to reduce

client. 5. Ensure adequate ventilation

reduce her body temperature. 5. Nearby windows were opened initially and tight clothing removed to provide fresh air to reduce the bodys temperature.

6.Serve prescribed antipyretics

6. Suppository Diclofenac 75mg inserted as prescribed and recorded.

DATE &

NURSING DIAGNOSIS

OBJECTIVE /OUTCOME

NURSING ORDERS

NURSING INTERVENTIONS
29

DATE & TIME

EVALUATION

SIGN .

TIME 31/12/11 8:00am

Risk for Fluid volume deficit related to excessive vomiting.

CRITERIA Client will maintain normal fluid volume within 24 hours as evidenced by: i. Client having good skin turgor and skin color being normal. ii. Clients temperature within the range of 36-37 degrees Celsius. iii. Clients pulse rate within the range of 60-100 bpm

i. Reassure client.

i. Client was reassured that vomiting will subside with treatment.

1/1/12 7:35am

Goal fully met as client showed no sign of dehydration.

ii. Assess clients skin severity of dehydration.

ii. Clients skin, eyes, and lips, were observed for signs of hydration; client was mildly dehydrated

iii. Remove all nauseating objects in clients environment iv.Monitor and record vital signs to rule out abnormalities like tachycardia, dyspnoea.

i. Clients environment was freed of vomitus bowl. ii. Clients vital signs was monitored and recorded to rule out abnormalities like pyrexia, tachycardia, dyspnoea Prescribed Normal Saline and Ringers
30

v. Administer prescribed iii. intravenous infusions.

Lactate administered. vi. monitor clients intakes and outputs and record in the daily intakes and output to prevent client from dehydrating. iv. Clients intakes and output was charted by measuring urine output, vomitus, and intravenous infusions administered.

DATE & TIME 1/1/12 9:33am

NURSING DIAGNOSIS Anxiety related to unknown outcome of

OBJECTIVE OUTCOME Patient will be relieved of anxiety within 2 hours as

NURSING ORDERS 1. Reassure the client

NURSING INTERVENTIONS
1. Client was reassured

DATE & TIME 1/1/12 11:30am

EVALUATION Goal fully met as client verbalized the relief of

SIGN.

that, since she was at the hospital, she will be treated

31

surgery

evidenced by
1. Client

and recover fully, without any complication. This was done to allay her fear and anxiety through and to win her co-operation throughout treatment.

anxiety

verbalizing relief of anxiety within 2. Client having a relaxed facial expression 2. Explain procedure

2. All procedures to be

performed were explained to client to gain her cooperation and allay anxiety 3. Introduce 3. Client was introduced to other clients on the ward who have undergone the same operation to interact with them to relieve her from anxiety.

client to other clients on the ward who have undergone the same operation to
32

interact with her. 4. Television set was

4.

Provide

switched on to divert her attention from the impending surgery which made client less tensed up.
5. Client was informed

diversional therapy.

5. Educate client on the benefits of the surgery.

that surgery is the best solution to her disease and to prevent further complication. 6. Procedure was documented

6. Document procedure. DATE & TIME 2/1/12 6:00pm NURSING DIAGNOSIS Pain related to surgical incision OBJECTIVE OUTCOME Client will be relieved of incisional pain within 45minutes.
33

in the nurses note.

NURSING ORDERS 1. Reassure client

NURSING INTERVENTIONS
1. Client was reassured to

DATE & TIME 2/1/12 8:00pm

EVALUATION Goal fully met as client verbalized a reduction in pain.

SIGN.

have confidence in the staff who will give

1. Client verbalizing reduction of pain. 2. Nurse observing a relaxed facial expression. 2. Assist client to assume a comfortable position 3. Create a quiet environment

effective care to relieve her of pain

2. Client was assisted to

assume a Semi Fowlers position.

3. A quiet environment

was created by reducing the volume of the television and restricting visitors to enable her have enough rest.

4. Provide comfort measures

4. Client was informed to

place her hands on the incisional site whenever coughing or sneezing to prevent pain. Pillow and bed linens were made free
34

from creases to make her comfortable. 5. Administer prescribed antibiotics and analgesics
5. Intravenous

Metronidazole 500mg, intravenous Ciprofloxacin 500mg and injection Diclofenac 50mg administered were as prescribed and recorded.

DATE & TIME 5-1-12 8:00am

NURSING DIAGNOSIS Impaired skin integrity (wound) related

OBJECTIVE OUTCOME Clients wound heal during period hospitalization as

NURSING ORDERS 1. Reassure client

NURSING INTERVENTIONS 1. Client was reassured that, he wound have an intact skin as soon as
35

DATE & TIME 6-1-12 8:00 am

EVALUATION Goals fully met as evidence by Nurse observed

SIGN.

to surgical incision

evidence by 1. Nurses own observation that, clients wound has healed by first intention 2. Client verbalizing that, he has his skin minimal scar tissue formation

2. Explain all procedures to the client. 3. Assess wound for discharges and drainage 4. Remove alternate stitches 5. Dress wound with aseptic condition.

possible 2. Procedures were explained to the client to gain his cooperation to gain his cooperation and support 3. Wound was assessed for drainage and discharge as a sign of infection. 4. Alternate stitches were

that, wound is healing by first intention and there were no signs of infections.

removed. 5. Wound was dressed

with aseptic procedures (technique) to prevent 6. Educate client on nutritious diets wound infection 6. Client was educated on nutrition diets such as promote wound healing

36

7. Ensure personal hygiene 8. Serve

8.

7.

Personal hygiene was

ensured to prevent infection prescribed antibiotics Prescribed antibiotics

were served to promote wound healing and prevent wound infection.

DATE & TIME 4/1/12 6:00am

NURSING DIAGNOSIS Self care deficit (Bathing / grooming) related to

OBJECTIVE OUTCOME Client will be able to maintain her personal hygiene needs without assistance within

NURSING ORDERS 1. Reassure client

NURSING INTERVENTIONS 1. Client was reassured that with assistance from staff, her personal hygiene will be taken care of until she is able to do it
37

DATE & TIME 7/1/12 5:30am

EVALUATION Goal fully met as client was able to perform bath and groom herself

SIGN.

immobility

72hours. As evidenced by
1. Client

herself. 2. Give assisted or bed bath twice daily 2. Client was given bed bath with assistance twice daily with warm water to make her feel refreshed, remove dirt as well as to stimulate blood circulation and with the use of soap, sponge and towel as well.

without assistance.

verbalizing that she was able to bath and groom without assistance. 2. Client looking refreshed and relaxed in bed

3. Assist client in oral care

3. Client was assisted to brush her teeth twice daily with close up and soft brush to prevent halitosis and oral infection.

4. Change bed linen and straighten bed daily

38

4. Clients bed linen was changed daily and made free from creases to make her

comfortable. 5. Care for hands and 5. Clients finger and toe nails feet were cut short to prevent it from harboring microbes which can cause infection and also prevent injury to the client.

DATE & TIME 2/1/12 8:00pm

NURSING DIAGNOSIS High risk for infection related to surgical incision on the

OBJECTIVE OUTCOME Clients wound will heal by first intension without infection within 7days (1week)

NURSING ORDERS 1. Reassure the client

NURSING INTERVENTIONS
1. Client was reassured

DATE & TIME 9/1/12 4:00pm

EVALUATION

SIGN.

Goal fully met as client as evidence by clients wound healing by first

that good techniques for dressing will be used to prevent

39

abdomen.

as evidenced by 1.wound healing in the absence of signs of infection like purulent discharges and pyrexia 2. Nurse observing absence of signs of infection. 2. Advice client to keep hands away from incision site.

infection.
2. Client was advised to

intension and nurse observing the absence of signs of wound infection.

keep her hands away from the incision site since her hands may be contaminated with micro-organisms that can cause infection to the wound.

3. Employ aseptic techniques in dressing clients wound

3. Aseptic techniques like proper hand washing, use of sterile dressings and instruments were used in dressing clients wound to avoid infection.
40

4. Check and record vital signs every 4hours.

4. Vital signs checked and

recorded every 4hours especially temperature to detect any signs of infection.

5 Assess the wound daily for infection

5. Daily assessment of the wound was made to detect any discharges but there was none.

6. Encourage client to take well balanced diet

6. Client was encouraged

to take well balanced diet like rich food in protein and vitamins to aid in early wound healing.

41

7. Administer prescribed antibiotics

7. Tab-Metronidazole

500mg tds and capsule Ciprofloxacin 500mg bd were administered and recorded to combat infections.

42

CHAPTER FOUR IMPLEMENTING PATIENT / FAMILY CARE STRATEGIES Implementation is the fourth stage in the nursing process. It entails the actual nursing care rendered to the client and family from the time of admission till time of discharge. SUMMARY OF ACTUAL NURSING CARE DAY OF ADMISSION (29TH DECEMBER, 2011) Client was admitted to ward C4 of the Komfo Anokye Teaching Hospital at 11:00am with Acute Abdomen queried as her diagnosis. She was accompanied by an admission team from the Accident and Emergency Unit of the hospital and her husband. On observation, client looked weak and in pain. She had an IV line and catheter insitu, the catheter was connected to a urine bag with 100mls urine in it. Client was assisted to change into her night wear with privacy provided and made comfortable in a well made admission bed since she was in pain. Orientation of client was initially with held because client was in pain but later in the day she was oriented to the ward, sluice room and nurses station. Client and husband were reassured that due treatment and nursing care would be given to reduce pain and to relieve her of condition. All necessary data were collected from her husband. Clients name and other personal data were entered in the Admission and Discharge book, and the Daily Ward State. Clients husband was informed about the visiting hours being 3:30pm-5:00pm and was also asked to bring clients personal toiletries such as soap, sponge, bathe towel, bucket, and toilet roll Vital signs were checked and recorded as follows; Temperature Pulse Respiration Blood Pressure 37.3C 72 bpm 18 cpm 100/60 mmHg

Blood samples were then taken and sent to the laboratory for analysis WBC and RBC count, blood urea nitrogen and Creatinine test. Client was reassured again that, she was in the hands of competent staff and that every necessary measures will put in place to get her to recover soon since she was in pain. Her bed was made free from creases and a pillow was put on the bed to make her comfortable. Clients drugs were collected from dispensary and a stat dose of IV Ciprofloxacin 500 mg, IV Flagyl 500 mg, were set up and later IV Normal Saline 1 litre. The wards television set was turned to minimal volume and ice packs wrapped in towel was applied to the inflammed area to reduce pain. Prescribed injection Diclofenac 50mg was administered and recorded observing the 7 rights of drug administration, which is right patient, right medication, right

43

dosage, right route, right time, right documentation, and right to refuse drug. Client was fed rice and stew at 12:05pm in bits as tolerated but she was not able to eat enough. Client complained of feeling hot, her top sheet was loosened, excess clothing removed and her temperature checked and recorded as 38.0 degrees Celsius. So she was reassured of good nursing care to reduce her temperature. Client was tepid sponged with tepid water leaving drops of water on the skin to aid in the reduction of her temperature as well as served 100mls cold Fanta lemon juice with the aim of reducing her temperature and adequate ventilation was ensured by opening nearby windows and removing tight clothing. Clients temperature was 37.0 degrees Celsius upon recheck it was recorded on the temperature sheet and the procedures carried out to reduce her temperature were documented in the nurse note as well. All intakes and output of patient were monitored within each 24 hours and it was balanced daily at the start of the day to ensure that there is no fluid overload and to know the amount of fluid retained in the body. Client was also given general care such as feeding, assisted bath, administering prescribed medication, change of infusions and documentation in the daily fluid monitoring chart, and emptying of urine bag. Clients urine was deep yellow in colour and 600mls upon emptying. Clients condition was fair. SECOND DAY OF ADMISSION (30TH DECEMBER, 2011) On the second day of admission, I arrived at the ward at 7:30 am. I went to client and greeted her. Upon questioning, client said that there is a reduction her abdominal pain as well as the high temperature. I went back to the nurses table to read the report book which indicated that she was not able to sleep soundly through the night because of the episodes of pain and loose stools she passed. Client was assisted to take her bath and brush her teeth in the morning and fed oat after which she was made comfortable in bed. Vital signs was checked and recorded within the following ranges; Temperature Pulse Respiration 36.0 C -36.8 C 86bpm -94bpm 18cpm-22cpm

10:45am, client was reviewed during ward rounds by Dr. Ato Quansah, she complained of feeling bloated. Clients urinary catheter was removed and encouraged to rest based on Dr Quansahs orders since was booked for surgery on 2/1/12. At 11:45am, she complained of unbearable abdominal pains, client was reassured, pain assessment was done and it was found out that the pain was stabbing in nature, lasted 5mins for duration, and she was relieved when lying on the left side while in pain when she lied on the right side. She was

44

positioned laterally on the left with hip flexed to relax her abdominal muscles after pain assessment and injection Diclofenac 50mg administered and recorded on the drug administration chart. Client was cooperative during medication administration. Client was also given general care such as feeding, assisted bath, administering prescribed medication, change of infusions and documentation in the daily fluid monitoring chart. Clients condition was fair. THIRD DAY OF ADMISSION (31st December, 2011) On my arrival, I went to my clients to find out how she was doing. I observed that she looked ill and also had a distended abdomen. Dr Aidoo of general surgery team A, was called to see client at 8:00am who was restless, vomitting bile stained vomitus (100mls) thrice accompanied with a distended abdomen. He ordered for nasogastric tube to be passed. Client was assisted to maintain oral hygiene after which the nasogastric tube was passed. 900mls more of bile stained fluid with spots of blood was drained. IV normal saline 500mls was setup at a drop rate of 16 drops per minute. Nil per os was ensured with an exception of ice cube sips according to the orders of Dr Aidoo. He also requested for abdominal ultrasound which was booked to be done later in the day. Clients ultrasound scan was done at 11am. Vital signs was checked and recorded within the following ranges; Temperature Pulse Respiration Blood Pressure 36.0-37.0C 90bpm-100 bpm 16cpm-20 cpm 100-110/70-80 mmHg

Client was assisted to bath after which she was covered with top sheet to keep her warm. Patient was also rendered general nursing care like emptying of the bag connected to the NG tube, serving of bedpan with privacy provided, setting up prescribed IV fluids and recording it into the fluid intake and output chart. Client condition was fair. FOURTH DAY OF ADMISSION (1/1/12) Client woke up at 7:00am. Her condition was ill. She talked of passing watery stool thrice in the night and a reduction in her abdominal pain. Clients bed linens were changed to make her comfortable. She was reviewed by Dr Danso who asked that her blood sample should be obtained and sent to the serology lab for serum electrolyte test. Result was obtained and client was placed on 10mmol of KCL in either Normal saline or Ringers lactate till she got 60mmol. The reason behind this was to improve her serum potassium level because the test showed it was low. Clients Nasogastric tube drainage bag

45

was emptied and the tube, monitored for kinking. Her IV fluids were administered as prescribed and recorded in the fluid intake and output chart. Vital signs was checked and recorded within the following ranges;: Temperature Pulse Respiration 36.2-36.8C 90-100 beats per minute 20-26 cycle per minute

Clients prescribed treatments were administered and she was reassured of recovering soon with good nursing measures put in place. At 9:30am client was anxious. So she was reassured of the safety measures that have been put in place to prevent any possible complications. A member of the surgical team, Dr Davor, came to the ward to talk with the client in order to allay her fear. Other clients who had undergone the same operation were allowed to share their experience with the patient to encourage her on the impending surgery. He also confirmed of the surgery the next day at 10am so pre-operative preparation was started. Client was prepared for exploratory laporotomy under the following headings; 1. Psychological Preparation. 2. Physical Preparation. 3. Rest and sleep 4. Physiological preparation Client, husband and mother were reassured that the surgery was going to be successful. They were assured to allay fear or anxiety. The expected outcome of the surgery was also explained to them. She was also made aware of the post operative pain, but told that analgesics will be given to take care of the pain. Client was taken through the consent form and made to sign. Client was told about what to expect in the theatre; the staff dressed in theatre gowns, face mask, an anaesthesia machine, an operation table, a ventilator, cardiac monitors an adjustable operating lamp hanging above the operating table with the aim of orienting her to the theatre. She was also informed that she would be put to sleep prior to the operation by injection. Client was assisted to maintain person hygiene which includes bathing, brushing of teeth and cutting of finger nails. She was also shaved from above the umbilical area through to the pubic region. The site was cleaned with savlon in order to prepare her for surgery. Clients bed was made free from creases and crumbs to prevent her being uncomfortable. The volume of the wards television was lowered to reduce noise. All procedures were grouped and performed to prevent destructing her sleep. Client was placed in a Semi Fowlers position Clients laboratory results were collected and made ready for surgery the next day.

46

( 2/1/12 ) OPERATION DAY Client woke up at 6:30am. She was provided privacy served bedpan and asked to empty her bowels but could not move her bowels because she had been on nil per os except ice cube sips for two days. She was assisted to take her bath and made comfortable in bed. At 9:45am, clients operation site was cleaned with savlon in spirit, covered with sterile towel and secured in position with adhesive tape. An indwelling urethral catheter was passed and connected to a urine bag for continues drainage. She was assisted to change into a theatre gown and cap. All jewelleries on her like the wrist watch and ring were removed and given to the husband in her presence for safe keeping. 500mls of intravenous Ringers lactate was set up 10:00am. Vital signs checked and recorded on the temperature chart as follows to serve as a baseline; Temperature Pulse Respiration Blood pressure 37.0C 80bpm 20cpm 100/70 mmHg

Client was prayed with to boost her spiritual titre. She was then sent to the theatre at 10:30am with her folder, lab results and ultrasound result. IMMEDIATE POST OPERATIVE CARE Client was brought back to the recovery ward around 3:00pm in a semi-conscious state with 200mls of Dextrose Saline on and dripping well. . Client was observed for chest movement and pulse to make sure she was alive Urethral catheter, NG tube and a drainage bag containing 500mls of offensive pus drained from the abdomen were all in position .She was put in a supine position with the head turned to one side to enhance drainage of secretion from the mouth. She was comfortable in an operation bed. The incisional site was observed for bleeding, swelling, skin discoloration and discharges, but none was seen. A fluid intake and output chart was monitored and the surgeons notes read. Her vital signs were checked and recorded as follows; every 15minutes for first 1hour, 30minutes for 2hours, 1hour for 4hours and 4hourly for 24hours till client gained consciousness and was rechecked every 4hours and recorded accurately. Temperature Pulse Respiration Blood pressure 37.0C 80bpm 20cpm 110/60 mmHg

Patient was brought back to the ward from the recovery ward after appendicectomy had been done under general anesthesia by Dr. Latiff assisted by Dr. Davor. Client had a urethral catheter, an iv line
47

with 400mls of lactated ringers setup, NG tube and a drainage tube connected a drainage bag with 50 mls of blood. She was received into an operation bed and made comfortable in bed at 5:30pm. All post operative medications were served and recorded. She was protected from injury by raising the side rails of the bed. Client complained of incisional pain. She was reassured that measures were being put in place to relieve her of the pain and complications. The volume of the television set was reduced and visitors restricted as well to induce sleep. She was advised to put her hand on the incisional site when coughing or sneezing to reduce stress on the suture line. Clients drugs were reviewed and changes made, she was placed on: IV ceftriaxone 2g dly x3days, IV 5% Dextrose 2litres daily x 3days, IV Ringers lactate 1litre with 15 mls of KCL in each pint, Injection pethidine 100mg dly x 3days All due medications were administered and recorded, assisted warm bed bath given, fluid intake an output monitored and KCL administered as prescribed. Client was reassured and made comfortable in bed. She had a sound sleep throughout the night without any complain. Condition was stable. FIRST POST-OPERATIVE DAY sleep. Her urine bag was emptied and amount recorded in the fluid chart, after which her personal hygiene was cared for by giving her an assisted bed bath with warm water and assisting her to brush her teeth, to remove dirt and stimulate circulation in order to make her feel refreshed. Her bed linens was changed and straightened to make her comfortable, as well as items on her locker were well arranged. Client was reviewed by Dr. Davor and no changes were made to her treatment except her urethral catheter was ordered to be removed and nil per os maintained. The same was done. Clients wound was assessed for bleeding which was absent and early ambulation was encouraged by assisting her to sit up in bed and later taken a few steps as tolerated around her bed. The site for the intravenous line was observed for redness; swelling, flow and amount of fluids to be administered were also checked. Vital signs was checked and recorded within the following ranges Temperature Pulse Respiration Blood pressure 36.4-36.8C 87-92 beats per minute 20 cycle per minute 100-110/70-80 mmHg
48

(3rd January, 2012)

Client woke up at 6:30am and stated a reduction in pain at the incisional site and said she had a sound

Due treatments administered and recorded. She was assisted to bath and groom herself. She was made comfortable in bed. She finally retired to bed at 6:30pm. Clients condition was fair. SECOND POST OPERATIVE DAY (4th January, 2012) Client woke at 6:00am. She was given a bed bathed, nasal care and oral care was. Her wound was assessed for signs and symptoms of infection like pain or tenderness, localized swelling, redness or heat but none was observed after which the wound was reinforced to keep dressings in place. Her drainage tube was checked to know if it was in position after which it was cared for. Vital sign was checked and recorded as follows: Temperature Pulse Respiration 36.0-36.5 oC 75-85 beats per minute 19-22 cycle per minute

Due medications were served and recorded in the drug administration chart. Clients condition was encouraging as compared to the previous day. Client was reviewed by Dr. Niraka. She was asked to start sips of tea and to continue with her antibiotics. 100mls of warm tea was prepared and served client after review, it was well tolerated. Client was then educated on how to care for the wound to prevent infection. She was advised to keep her hands away from the incision site and not to temper with the adhesive plaster on the wound too. Clients was served bedpan, drainage bag was emptied, due IV fluids setup and recorded into the fluid intake and output chart. Clients condition was stable. THIRD POST OPERATIVE DAY (5TH January, 2012) Client woke up and had no complains about the night. She was assisted with bed bath and oral hygiene; her vital signs were checked and recorded. Her wound was assessed during dressing for signs of infection high temperature or purulent discharges but there were none but her wound dressings were soaked with serous fluid. Wound dressing was done with methylated spirit and sterile gauze under aseptic techniques to prevent infection. Her wound was packed with more gauze and secured into place with strips of adhesive tape. She was reviewed by the doctor Niraka; she said client was for possible discharge the next day. Clients drainage tube and urinary catheter was asked to be removed and blood sample obtained for Hb Level and BUE of which all was done as ordered. Client was asked to continue with light diet and ambulate during ward rounds; oral medications were served and recorded. All other needed nursing cares were rendered.

49

FOURTH POST - OPERATIVE DAY (6th, January, 2012) Client woke up at 6:45am; she looked cheerful and expressed improvement in her condition. She also said she had a sound sleep throughout the night. Client got out of bed and maintained personal hygiene herself. Her wound was clean upon dressing and looked dry. Vital signs checked and recorded as follows. Temperature Pulse Respiration Blood pressure 36.2C 72bpm 18cpm 110/60 mmHg

Client was served with light soup and kafa for breakfast after which she was assisted to walk around. On ward rounds with doctor Niraka, client was discharged home on: Tab Augmentin 1g bd x 7days, Tab Vitamin C x 30days, Cap Naclofen 70mg bd x 7days, Client was asked to come for review on 10TH January, 2012 for the alternate stitches to be removed. Her wound was then dressed for her aseptically after ward rounds to prevent infection. I read clients folder to confirm if she was discharged after which I called clients husband and told him she was discharged. Due medications were served and recorded as ordered. Client was advised to eat more fruits and high fiber diet to avoid constipation. Client was also encouraged to continue walking around to help in early wound healing. She was told the need to stick to treatment whiles on discharge and importance of registering for the National Health Insurance Scheme. Clients folder was sent for assessment and payment of her hospital bills when the husband came. Her name was then entered into the daily ward state, Admission and Discharge (A&D) book. After paying the bills, I gave her the review card, helped client pack her things and escorted them to the entrance of the hospital reminding them of my next visit to their home. After they had left, the bed linens were removed and the mattress decontaminated with parazone 1:10. The linens were sent to the sluice room for washing and sterilization at Central Sterilization and Supply Department (CSSD) for reuse.

50

PREPARATION OF PATIENT / FAMILY FOR DISCHARGE AND REHABILITATION Client and family were prepared towards discharge on the day of admission. First of all, client and family were informed that, the hospital was a temporal place to stay when one is sick. Therefore, they were reassured that after recovery, client will go back to the house or community to continue her normal life. She was then advised to co-operate with the health team to ensure her speedy recovery. Client and family were prepared towards discharge through effective education. They were reassured that the hospital has competent medical, nursing and other health care providers who will be available to give her good care. The cause, signs and symptoms, treatment and complications of her disease were explained to their understanding, since during admission; it was observed that patient and family were very anxious and disturbed about the disease condition and the long stay at the hospital. They were educated on good personal hygiene which facilitated speedy recovery and promote good health and were informed to make good use of health facilities as well. Client and family were also educated on the need to adhere to good nutrition especially to include enough protein to help in early wound healing. Source of good food such as milk, beans, food rich in vitamin C like oranges were encouraged to be taken. They were also informed to take enough vegetables and roughage to prevent constipation. They were educated on the drug prescribed for her and the need to comply with the treatment regimen. Information was given to them on the need for regular visit to the hospital and also to come for review on the specific date given to them. Client and family were informed on how to care for the wound after discharge and also not to engage in vigorous activities including lifting of heavy objects at least for the first six weeks.

51

FOLLOW-UPS / HOME VISITS / CONTINUITY OF CARE Follow-up and home visit play a vital role in the care of the client after discharge. It is done to find out how client and family are faring at home and the use of available resources within the clients environment to solve any problem through their own efforts. It also helps to determine if there are any predisposing factors to clients condition so that the needed health education will be given to prevent any recurring disease. FIRST HOME VISIT (31st DECEMBER, 2011) This visit was arranged and made possible by the company of clients husband while client was on admission. The reason for the visit was to assess the home environment of patient and to detect predisposing factors and any contributing cause to clients disease in the environment. Also, to assess how client will cope with the home environment after discharge. To meet everybody at home, patients husband and I made the visit in the evening after he came visiting client. We got to high tension last stop, Awomaso where they lived at 4:30pm. It was a 45 minutes drive from Garden City University College. Client and family of six, lives in a self-contained house built with cement and roofed with aluminum roofing sheet. On entering the house, it was observed that there were six rooms in all with a kitchen, three toilets and three baths. Well water was the source of water which they used for cooking, bathing, washing and even drinking. I was informed that they had a place they burnt their refuse instead of giving it to refuse trucks to dispose of it properly because they had no such trucks collecting refuse in the vicinity. Aside that the surroundings were clean with covered drains. The nearest clinic near the house was the Awomaso Clinic. They were informed to maintain the clean environment and boil and cool well water for drinking to avoid any other diseases. After observing the environment, I realized that client can stay in the house after discharge. I then reassured them of clients progressing condition and sought permission to leave after informing them that the next visit will be on the 8th January, 2012. SECOND HOME VISIT (8th JANUARY, 2012) On the second home visit, client was met in the house, it was a surprise visit in other to meet the family in their natural environment and to see how she was faring and responding to treatment after discharge. Client and family were in good health with clean surroundings as well. I asked of any problems and complaints but there was none. The wound was assessed for signs of infection but were all absent. I told her to keep going for dressing at the Awomaso clinic.

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I checked her medications and realized she was taking them as prescribed. I encouraged them to keep to the advice given to them during the discharge. Client was advised to avoid strenuous exercises and reminded of the review date which was four days after, for the rest of the stitches to be removed. Client and family were informed that my next visit I will be my last since am terminating my care. Client and her husband escorted me to the door, thanked me for my assistance, I bade them goodbye and left. DAY OF REVIEW (10TH JANUARY, 2012) On the day of review, client was accompanied by her husband. Few hours after her arrival, she complained of weakness in that morning even though she had taken breakfast. She was given fruit juice to provide her with some energy. Client was assisted to go for her folder and accompanied to the consulting room 9. She complained of incisional pain when went into the consulting room. The doctor then prescribed an antibiotic, Dalacin C and Zinc for client to purchase after which he advised that client continue with her drugs and to report to the hospital if she experienced any other abnormalities in her state of health. Client was then sent to the ward for the alternate stitches to be removed after which wound was dressed. She was asked to come a week later for the remaining stitches to be removed. I escorted client and husband after wound dressing to the hospital entrance to board a car home. THIRD HOME VISIT (26TH JANUARY, 2012) Client was visited for the last time, on arrival at the house; client and family were doing well. They were advised to maintain good nutrition, complete drug regimen, monitor and report any side effect of medication and good personal and environmental hygiene, to maintain good health. I also recommend to client that she could report to the Awomaso clinic, in case of any problem for continuity of care since her condition was stable. She said her review date was on 17th January, 2012. Client and family expressed their gratitude to me for the good nursing care rendered to them. I also thanked them for their good interpersonal relationship and cooperation during admission and after discharge, after which I left.

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CHAPTER FIVE EVALUATION OF CARE RENDERED TO PATIENT / FAMILY Evaluation is the final stage in the nursing process. It focuses on the outcome of the objectives set in the nursing care plan and the effectiveness of the care given. It also determines the extent to which goals have been achieved. STATEMENT OF EVALUATION The objectives set for client and family were fully met with effective implementation and co-operation of the family, which contributed to her speedy recovery. For instance, on 29th December 2011, client complained of abdominal pain at the right lower quadrant. An objective was set to relieve her of the abdominal pain within 2hours was finally met as client verbalized a reduction in the level of pain. Again, on 29th December, 2009, clients body temperature was high. An objective set to reduce her temperature to normal 6hours was fully met as her temperature on the clinical thermometer read 37.0C. On the 31st of December 2011, client was vomitting excessively. An objective set to maintain his pulse within 60-100, temperature within 36.2-37.2 degrees Celsius, a good skin turgor and a normal skin colour was fully met as her skin colour and turgor was normal and his vital signs within the normal range. However, on 1st January, 2012, client complained of being anxious due to unknown outcome of surgery. An objective set to relieve her anxiety within 2hours was fully met as client verbalized the relief of anxiety. Also, on 2nd January 2012, client complained of pain at the incisional site. An objective set to enable her experience minimal pain within 2hours was fully met as client verbalized reduction in pain. On 5th January 2012, client had wound. An objective set to ensure that clients wound heals by first intention within the period of hospitalization was fully met as clients wound was healing under first intention. Also, on 4th January, 2012, client could not maintain her personal hygiene. An objective set to enable client maintain her personal hygiene needs without assistance within 72hours was fully met as client was able to perform self care activities without assistance. Again, on 2nd January, 2012, clients risk for infection was high. An objective set for her wound to heal by first intension without infection within 7days (1week) was fully met as clients wound healed by first intention.

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AMENDMENT OF NUSRING CARE PLAN FOR PARTIALLY MET OR UNMET OUTCOME CRITERIA All the goals and objectives set for clients care were fully met. There was therefore no amendment made to any of the nursing care plan. TERMINATION OF CARE Termination of care is a gradual process whereby the interaction between the nurse and the family/patient is withdrawn. Separation can bring anxiety and depression due to its accompanied psychological pain. In view of this, client and family were given gradual psychological preparation toward the termination phase. This started on the day of admission till discharge. My interaction with client and family started on 29th December, 2011 at the Komfo Anokye Teaching Hospital and ended on 26th January, 2012 when I made my final visit to their home. Client was also informed to report any abnormality in her state of health to the hospital nearby for further management.

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CHAPTER SIX SUMMARY AND CONCLUSION SUMMARY Client was admitted on the 29th December, 2011 to ward C4of Komfo Anokye Teaching Hospital with the diagnosis of Acute Abdomen secondary to perforated appendix. She was booked for surgery on 2nd January, 2012 for the surgical removal of the perforated appendix and drainage of the accumulated pus. She was put on: Antibiotics Analgesics IV infusions While on admission, during nurses assessment on client, she present the following health problems; lower abdominal pain, high temperature, pain at incisional site, risk for infection, and self care deficit. Goals set on all these health problems were fully met, after a good nursing care. On 6th January, 2012, clients condition had improved and was finally discharged. This was as a result of the familys involvement in the care of client and with adequate nursing measures given, both pre-operatively and post-operatively. After her discharge, follow-up visits were carried out to assess her condition at home. She was seen to be healthy on each visit and adhered to the health education that was given to them on admission, day of discharge and during home visits. CONCLUSION In conclusion, my understanding and knowledge on acute abdomen has been broadened as this care study has been an educative, challenging and interesting experience to me. I have gained experience and knowledge on how individualized and holistic care is rendered using the nursing process. It has also helped me establish good interpersonal relationship with client and family, and this also helped client to achieve maximum health. This care study will also serve as a guide or reference document for future student nurses who will under take similar exercise. Therefore, it is my hope that the knowledge I have acquired will enable me to care for clients not only with acute abdomen but other disease conditions as well, and to impart the knowledge acquired to other colleagues during academic exercises and clinical practice.

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BIBLOGRAPHY
British Medical Association and Royal Pharmaceutical Society of Great Britain, (2007) British National Formulary, 53rd edition, BMJ Publishing Group Ltd and RPS Publishing. London. Chou, J. S.& Chung, C. R. (2007). Pain in the right lower quadrant. American Family Physician, 15411542. Schaffer, S., & Yucha, C. (2004). Relaxation & pain management: The relaxation re-sponse can play a role in managing chronic and acute pain. American Journal of Nursing, 7582. Smeltzer, S.C. and Bare, B.G. (2008), Brunner and Suddarths, Textbook of Medical Surgical Nursing 11th edition, J.B. Lippincott Company. Philadelphia. Tucker S. M., Canobbio M. M. , Wells M. F. and Paquette V. E.(2000), Patient Care Standards,7th edition, Mosby St. Louis, Misourri pg 320,321 Patients folder IP number: GSTA 32995

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SIGNATORIES NAME OF CANDIDATE: SIGNATURE: DATE: PERCIVAL BRUCE __________________________ _________________________

NAME OF WARD IN - CHARGE: Mrs GLADYS AMENUEDI SIGNATURE: DATE: __________________________ _________________________

NAME OF SUPERVISOR: SIGNATURE: DATE:

Mrs. VERONICA KWARTENG ________________________ ________________________

NAME OF PRINCIPAL: SIGNATURE: DATE:

MADAM DZIGBORDI KPIKPITSE __________________________ _________________________

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