CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment is the deliberate, systematic and logical collection of data, about the patient and

family to enable the health worker plan and provide quality nursing care to the patient and

family. Assessment is the first and essential aspect of data collection on the patient’s current and

past health status. The data collected were both subjective and objective. They were directly

from the patient and indirectly taken from the medical records, family and other health team

members. The data collected included patient particulars, patient medical history, patient hobbies

ad lifestyle and literature review. Interviews, observations, consultations, diagnostic reports and

physical examination were among the tools employed for the data collection on Mr. AU.

PATIENT’S PARTICULARS

Mr. AU is a 19 year old male born on the 3 rd march 2003 at Elubo to Madam H and Mr. A. Mr.

AU is a Ghanaian by nationality and hails from Elubo in the Jomoro District in the Western

Region of Ghana. Mr. AU is single and currently staying with his Auntie at Kweikuma in

Sekondi. Mr. AU is the fourth born among seven children of his parents. Mr. AU is a student in

Fijai Senior High School in Sekondi and he is in his final year. Mr. AU is dark in complexion,

about 5.0 feet tall and weighs 62kg on admission. Mr. AU is an intelligent boy who likes

studying at his leisure time. Mr. AU is a Muslim and prays to Allah or visit the Mosque when

the time is due. Mr. AU speaks both English and Twi alongside his native language, Kusaase.

Mr. AU’s next of kin is his brother Mr. A who is 20years old. Mr. AU is a National Health

Insurance Scheme( NHIS ) subscriber.

1
PATIENT'S FAMILY MEDICAL AND SOCIOECONOMIC HISTORY

Upon my interaction with Mr. AU and his Father, Mr. A, there is no chronic communicable or

hereditary diseases such as diabetes mellitus, sickle cell disease, mental illness, leprosy or

tuberculosis in the family. Mr. AU also admitted that there are no food allergies in the family but

they do take over the counter drugs when they fall sick of minor illness like malaria, headache,

body pains etc. Mr. AU’s father said their only source of income is from farming. Mr. AU and

his family live in their own five(5 ) bedroom house with one(1) hall and a kitchen. All members

in the family are insured under the National Health Insurance Scheme and there is also good

interpersonal relationship among the family members. They support one another when the need

arises.

PATIENT’S DEVELOPMENTAL HISTORY

According to Madam H, AU was born at term, spontaneously per vagina by a traditional birth

attendant. She said he was exclusively breastfed for six(6) month and even went beyond for

3years and was immunized against the six killer diseases now called the vaccine preventable

diseases. He was weaned with porridge and crushed fish when he was two (2) years old. AU

could smile at the third month after birth, sit down at the seventh month, and could walk on his

own by 2years. At the same time, he could call “Mama”, ”Dada” and could follow simple

instructions like sit, come, go, etc. He successfully passed through his infancy, childhood,

adolescent, and now in adulthood. Mr. AU started growing his secondary sexual characteristics

at the age of thirteen. He started growing pubic hair, broadening of the chest and development of

deep voice.

2
PATIENT’S LIFESTYLE AND HOBBIES

Mr. AU is a strong and active boy who socializes quite easily. He usually wakes up around

4:00am, says a word of prayer before getting out of bed and after make his bed neatly. He

washes his face, brushes his teeth with both toothpaste(pepsodent) and toothbrush and sometimes

visit the toilet. He fetches water and wash his clothes, takes a bath and prepares for class on

normal school days. When he is home on vacation he does the regular morning routine but he

wakes up at 6:00am. He takes tea and bread, tom brown and local porridge(kooko) for breakfast

around 9:30am, at lunch break he takes normally rice or ‘gari’ and beans and waakye with sauce

and egg at 1:30pm, he takes a short nap then goes for supper at 5:00pm. He takes kenkey and

pepper with fish or sardine and sometimes rice with kontomire stew and Jollof. He brushes his

teeth twice daily before going to bed. He sleeps early around 9pm after studying. At his leisure

time he play and watches football especially in the evening and dislike mingling with girls.

PATIENT’S PAST MEDICAL HISTORY

Mr.AU said he has been hospitalized before and this is his second time of being admitted into a

hospital. According to Mr. AU’s father he had an abdominal surgery at age six with a similar

condition (condition unknown) and ever since then he hasn’t experienced any major medical

conditions again aside minor illnesses such as headache and stomach pains, etc. He also made it

clear that he resorted to over the counter drugs such as paracetamol, chloroquin and other pain

killers for the treatment.

3
PATIENT’S PRESENT MEDICAL HISTORY

According to Mr.AU all was well until early morning on Monday 24 th of January, 2022 when he

started complaining of severe abdominal pains after eating ‘Kenkey’ with pepper in the evening

on Sunday 23rd of January ,2022 at the school dinning hall. He said the pain was associated with

vomiting and defaecation on the next day. The vomiting was effortless and contains previously

eaten food. He was sent to the school nurse for treatment but the school nurse saw his condition

to be critical so she took him to Holy Child Hospital at fijai where he was given medication

(names of drugs unknown).The abdominal pain became severe on 26 th of January, 2022 in the

morning so the school nurse called his father to come to the hospital. On arrival he was told to

take his son to Effia Nkwanta Regional Hospital for further management at the accidents and

emergency unit. The medical officer upon assessment asked them to go for an abdominal x-ray.

They took the results back to the doctor after which Mr.AU was diagnosed of Intestinal

Obstruction.

Mr.A, the father was made aware that Mr.AU would be relieved with surgical intervention. After

reassurance and explanation, they consented to signing of the consent form for the surgery and

Mr. AU was booked on Sunday the 30TH of January, 2022.

ADMISSION OF PATIENT

On the 27th of January, 2022 at 12:00pm, Mr. AU was admitted into ward 4 (male surgical ward)

at Effia Nkwanta Regional Hospital on a wheel chair diagnosed of intestinal obstruction. Patient

was under the care of Dr. Amoabeng, Dr. Aboagye and Dr. Marfo .

On admission he complained of severe abdominal pain, nausea and vomiting, patient had

distended abdomen on examination, experienced abdominal tenderness on palpation and also

4
complained of having constipation and on attempt he could pass dark stools and he was anxious.

Immediately after taking his history and vital signs, he was put on an already prepared bed.

Patient and his Father were made comfortable and reassured of the competent health team and

officials and the very best of treatment will be offered to him. This was done to alley fear and

anxiety.

The necessary documents and admission notes were collected from the father. His particulars

such as name, age, sex, marital status and next of kin were entered in his folder, after cross

checking and confirmed by the mother it was entered into the admission and discharge book as

well as the daily ward state.

On assessment of AU’s general condition and appearance, his vital signs were checked and

recorded as follows;

Temperature – 36.6degree Celsius

Pulse – 108beats per minutes

Respiration – 24cycles per minutes

Blood pressure – 130/80mmHg

Patient’s vital signs were within normal range and he was encouraged to rest to maintain the

range. Urinary catheter was passed to assess the colour of urine and to maintain the normal

elimination pattern, cannula was also in situ for the administration of intravenous medication as

well as blood samples taken, and nasogastric tube was also passed to aspirate fluids in the

stomach. His father was told not to feed him because his abdomen was distended. He was

reassured again and was asked to present his insurance form so no deposit was instructed to be

paid. The Father was orientated to the ward environment, the bathroom, toilet and the nurses’

station. He was told of the visiting time, 5:00am to 6:00am in the morning and 5:00pm to

5
6:00pm in the evening ,ward rounds by the Doctors at 10am everyday, and ward activities such

as routine vital signs checking and serving of medication were all explained to them . His father

was to bring along sponge, towel, pomade, comb, rubber, toothpaste and tooth brush and

bathroom sandals. He was told of the impending surgery to be carried out on AU to relieve

symptoms.

Blood specimen were taken by the doctor for investigations on hemoglobin level estimation, urea

creatinine, electrolyte estimations(sodium,potassium, chloride) and also abdominal x-ray were

requested.

Patient was booked for surgery then to be transferred back (male surgical ward) after the surgery.

Patient’s condition on admission was ill-looking. Patient and family were made to understand

that the patient will be discharged after recovery to continue care at home.

The following drugs prescribed by the doctor were collected from the pharmacy and put on his

bedside.

Pre-operative drugs prescribed;

1. Injection Paracetamol 1g tid x 24hours

2. Injection Morphine 10mg x 24hours

3. Normal Saline 2 Liters x 48hours

4. Dextrose Saline 2 litres x 24hours

5. Intravenous Ringers Lactate 2Litres x 48hours

6. Injection Metronidazole (Flagyl) 500mg tid x 24 hours

7. Injection Ciprofloxacin 500mg tid x 24hours

8. Jnjection Metoclopramide 10mg x 24hours

PATIENT’S CONCEPT OF ILLNESS

6
Patient has no knowledge about the cause, signs and symptoms, treatment or prevention of

intestinal obstruction. He did not attribute it to spiritual forces but believe it is a natural

occurrence. He was worried about the outcome of his condition. However, he was hopeful that,

he will get well with the help of Allah and the competent health team attending to him.

LITERATURE

Intestinal obstruction is when blockage prevents the normal flow of intestinal contents through

the intestinal tract ( Suzanne C. Smeltzer and Brenda, 2004).

TYPES

1. Partial obstruction

2. Total obstruction

3. It can be classified as acute or chronic

CLASSIFICATION ACCORDING TO AETIOLOGY

There are two types

Mechanical obstruction

Non mechanical obstruction (paralytic or dynamic ileus)

MECHANICAL OBSTRUCTION

This occurs where there is intraluminal obstruction or mural obstruction pressure on the

intestinal walls.

CAUSES

1. Intussusceptions (the invagination of one section of the bowel into the next section)

7
 2. Polypoid tumors and neoplasm

3. Compression of the bowel wall from stenosis

4. Volvulus(twisting of the intestine/bowels)

5. Bowel Strictures usually from crohn’s disease and congenital malformation

6. Adhesions

7. Hernias

8. Abscess

9. Atresia

10. Foreign bodies in the bowel, mass of parasitic worms

11. Gall stones

NON MECHANICAL OR PARALYTIC ILEUS OR ADYNAMIC ILEUS

This is common to neuromuscular defect and it is the most common of all intestinal obstructions.

1. Muscular dystrophy

2. Vascular defect

3. Hypokalaemia

4. Pneumonia

5. Peritonitis

6. Abdominal surgery

7. Myocardiac infarction and trauma

8
PATHOPHYSIOLOGY

Intestinal content, fluids and gas accumulate above the intestinal obstruction. The abdominal

distention and retention of fluid reduce the absorption of fluids and stimulate more gastric

secretions. With increasing distention pressure within the intestine, lumen increases causing a

decrease in venous return and arteriolar capillary pressure. This causes oedema, congestions,

necrosis, and eventuary rapture or perforation of the intestinal wall resultant peritonitis. Reflux

vomiting may be caused by abdominal distention. Vomiting results in a loss of hydrogen ions

and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood

and to metabolic alkalosis. Dehydration and acidosis develops from loss of water and sodium.

With acute fluid loss, Hypovolemic shock may occur.

INCIDENCE

Of all cases of acute abdomen, 20% constitute intestinal obstruction. It affect all ages but very

common in the aged. 75% occur in the small intestine and 15& occur in the large intestine.

CLINICAL FEATURES

1. Crampy abdominal pain

2. Nausea and vomiting

3. Constipation

4. Hiccups

5. Distended abdomen during inspiration

6. Palpation may disclose abdominal tenderness

9
 7. Cold pale and clammy skin

8. Weak rapid pulse

COMPLICATIONS

1. Perforation

2. Peritonitis

3. Septicemia

4. Secondary infection

5. Metabolic alkalosis

6. Intestinal necrosis

7. Hypovolaemic shock may occur

8. Death if untreated

DIAGNOSTIC INVESTIGATION

1. Plain abdominal x-ray studies will show abnormal qualities of gas, fluid or both in the

bowel.

2. White blood cell count may be normal or slightly elevated if necrosis, peritonitis and

strangulated hernia occur.

3. Serum chloride, sodium and potassium level may fall because of vomiting.

4. Sigmoidoscopy or colonoscopy or barium enema may help determine the cause of

obstruction, however it is contraindicated if bowel perforation is suspected

5. Hemoglobin concentration and haematocrit may increase, indicating dehydration.

SURGICAL AND NON SURGICAL TREATMENT

SURGICAL TREATMENT

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Surgery is usually the treatment choice. Resection and anastamosis of the part involved is

performed. In case of volvulus in adults, operation is done to untwist the intestine.

NON SURGICAL TREATMENT INCLUDE

1. Passing of nasogastric tube to relieve vomiting, reduce abdominal distention and to

prevent aspiration.

2. Colonoscopy may be performed to untwist and decompress the bowel.

3. Analgesics such as pethidine and diclofenac im 75mg tds, is administered to relieve pain.

4. Antibiotics such as injection metronidazole 500mg tds, injection ciprofloxacin 500mg bd

are given as prescribed to combat infections.

5. Sedatives such as Phenobarbitals are given to promote rest and sleep and reduce pain.

6. Intravenous fluids such as Normal saline, Dextrose saline, Ringers lactate are given as

prescribed to compensate for fluid and electrolyte imbalance

NURSING MANAGEMENT

REASSURANCE / PSYCHOLOGICAL CARE

The nurse must build trust for the patient to have confidence in her by ensuring security,

establishing trust and confidentiality. The patient must be reassured of competent nurses in

places and doctors who are willing to put measures in place to help. Patient is encouraged to talk

about his fears concerning the surgery and appropriate answers were given to him.

All the nursing care procedures are explained to the patient and relatives including importance of

hospitalization to gain their cooperation in the treatment. Patient and relatives are given the

opportunity to ask questions and all questions are to be answered correctly and tactfully to clarify

misconceptions.

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REST AND SLEEP

The nurse must make a comfortable bed for the patient free from creases and cramps by

straightening the linen to prevent from patient from developing pressure sores. The environment

must be quiet, adequate ventilation must be ensured by opening nearby windows. Rest and sleep

relaxes the patient, provides energy and reduces anxiety.

OBSERVATION

The nurse must monitor the patient's vital signs temperature, pulse, respiration and blood

pressure and record it the appropriate charts to determine the progress of the patient condition.

Observe and monitor intake and output by measuring and recording the amount taken in and

output into the daily fluid chart. The site of infusion must be observed for possible dislodgement

of needle. Also, the rate of flow of all infusions must be monitored to prevent fluid overload. The

nurse must observe and record the amount, colour consistency of output. The patient’s skin must

be observed for abnormalities and report if any is found. The side effect of medication must also

be observed and reported for the necessary measures to be taken.

NUTRITION

The nurse must ensure that, the patient do not take anything by mouth for 6 to 8 hours before

surgery, intravenous infusions must be monitored.

The amount given must be recorded. The flow of IV infusions must be regulated as prescribed to

avoid fluid overload.

PREVENTION

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The nurse must use aseptic technique throughout care. This includes hand washing with soap

under running before and after attending to a patient. Wear gloves whenever necessary. Dispose

syringes and needles properly after use.

PERSONAL HYGIENE

Assist patient to maintain his personal hygiene. This is done by ensuring that patient’s mouth has

been cared for bathed to promote circulation. The nurse must ensure that the area to be operated

is shaved and antiseptic tuition applied. Apply Vaseline to the patient’s lips to prevent cracking.

ELIMINATION

The nurse must ensure that, Nasogastric tube is in situ to reduce vomiting and prevent aspiration.

A urinary catheter should be in place to empty the bladder and prevent urine retention or

incontinence. Bedpan must be served on request. The amount, odour, colour and consistency are

observed and recorded accordingly.

CHEMOTHERAPY

All prescribed drugs must be served by employing all rights in drug administration and observing

side effects of drugs or medications. The nurse must document all procedures and report any

abnormalities observed.

PATIENT’S EDUCATION

This involves teaching the patient about various activities that relates to the surgery. Inform the

patient that various equipment’s would be used following surgery to help him breathe. Patient

was taught how to perform deep breathing and coughing exercise. The purpose is to promote

exhalation to keep the lungs clear. It prevents pneumonia and collapse of the lungs.

Patient is taught that before coughing, the wound area is firmly supported with palms padded

with a folded sterile towel.

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PATIENT’S CONSENT FOR THE SURGERY

After all explanations necessary for the patient to gain knowledge, understanding and confidence

on the surgery, a consent form is signed by the patient and this gives the legal right for the

operation to be performed on the patient.

POST OPERATIVE NURSING MANAGEMENT

Maintenance of patent airway

Put patient in a Recumbent position with the head turned to one side and neck extended to help

prevent the tongue from falling back and blocking the airway. This will also enhance bronchial

and pharyngeal secretions to drain out.

1. Aspirate excessive secretions from the nasopharynx and oropharynx by suctioning.

2. Administer oxygen as ordered.

3. Assess the status of the circulatory system

4. Monitor vital signs that is temperature, pulse, 10 minutes, 15 minutes, 30 minutes, hearty

etc until patient’s condition is well stabilized compare pre-operative vital signs with current

readings.

5. Check for cyanosis. If cyanosis is present, it is an evidence of hypoxia. Evaluate the

respiration for any obstruction which is causing the hypoxia and relieve the blockage.

6. Monitor intravenous infusions. Intravenous infusion should be monitored for the

following:

- Blood clot in needle or given set.

- Presence of air bubbles

- Tube may kink

- The flow rate of IV fluids etc.

14
All these are done to prevent the development of any complication. Moreover, the type of

infusion, the amount, the time infusion was set up and the time infusion got completed are all

recorded in the intake and output chart.

PREVENTION FROM INJURY

Since patient may not be fully conscious, and cannot complain of pricking from needles and

other forms of injuries, elevate the side rills of the bed, ensure proper disposal of needles and

syringes. Patient should not be bathed with hot water to prevent burns. The nurse should ensure

that all procedures are done in the right way or ensuring the right technique to prevent the patient

from injury.

EXAMINATION OF INCISIONAL SITE

The dressing is inspected for unexpected bleeding enfaces dressings if any and reports it to the

doctor. Also check the dressings for constriction.

Evaluate patient’s status or orientation periodically.

PERSONAL HYGIENE

Oral toileting and bed bath is done regularly at least twice very day to prevent harbouring of

infection thereby preventing complications.

WOUND CARE

Dressings are normally changed on the third day after the surgery; wound dressing was done

aseptically with normal saline lotion and secured with sterile gauge and adhesive tape. Alternate

stitches were removed on the 7th day and the rest of the stitches are removed on the 10 th day after

surgery as ordered by the doctor or the surgeon. The removal of stitches depends on the

condition of the wound and the drosptal’s policy.

EARLY AMBULATION

15
Encourage early ambulation to prevent post operative complications such as thrombosis.

PATIENT’S EDUCATION

Education may be given based on the causes of intestinal obstruction, signs and symptoms of the

condition, the need for the sugary, preventive measures, the need for periodic medical check-ups,

the need to take medications and to come for review.

All these educations are served to the patient to equip him with the necessary information on

intestinal obstruction so that he can take the necessary precaution to prevent the condition from

re-occurring.

PATIENT’S MEDICATION

1. Prescribed medication such as Injection morphine 10mg x 24hours was given to patient to

relieve pain.

2. Antibiotics such as Injection Rocephin may also be given to prevent secondary infection as

directed by the doctor.

VALIDATION OF DATA

From the information gathered, Mr. AU had intestinal obstruction. He exhibited the signs and

symptoms of abdominal pain, distended abdomen, nausea and vomiting abdominal tenderness

etc.

From the causes, signs and symptoms, literature review proves that data collected were valid and

free from bias and errors.

16
 CHAPTER TWO

ANALYSIS OF DATA

Analysis involves the making of conclusion from data collected from a patient, patient and

relative. The signs and symptoms exhibited are compared to what exist in the literature review

and various laboratory investigations. The nurse analysis such information to deduce the exact

nursing diagnosis to enable him or her to formulate appropriate nursing care plans for the patient.

17
COMPARISON OF DATA WITH STANDARDS

The following tables illustrate the comparison of data collected with standard values.

18
TABLE 1

DIAGNOSTIC INVESTIGATIONS

DATE SPECIMEN INVESTIGATION RESULTS NORMAL INTERPRETATION REMARKS

VALUE

27/01/2022 Abdominal To assess the state of the Bowel No foreign body or Intestinal obstruction Exploratory

x-ray intestines obstruction obstructive part laporatomy.

should be revealed

29/01/2022 Blood Haemoglobin level 12.6g/dl 12-18g/dl = males Within normal range No treatment

estimation 11-16g/dl = was given.

females

29/01/2022 Blood Urea creatinine 1.2mg/dl 0.6-1.4mg/dl Normal No treatment

was given.

29/01/2022 Blood Electrolytes estimations; Within normal No treatment

sodium, 145mmol/l 134-149mmol/l range. was given.

potassium 4.3mmol/l 3.6-5.1mmol/l

chloride 98mmol/l 98-106mmol/l

19
CAUSES OF PATIENT’S CONDITION

With reference to the literature review of the causes of intestinal obstruction Mr. AU’s condition

was as a result of postoperative adhesion. This postoperative adhesion which is a natural

consequence of surgical tissue trauma and healing, commonest cause of small bowel obstruction

that hinders the flow of intestinal content.

TABLE 2

COMPARISON OF CLINICAL MANIFESTATIONS

CLINICAL FEATURES OUTLINED IN CLINICAL FEATURES EXHIBITED BY

LITERATURE THE PATIENT

1. Severe abdominal pain(crampy) Patient experienced abdominal pain on

admission.

2. Nausea and vomiting Patient complained of nausea and vomiting

on admission.

3. Distended abdomen Patient had a distended abdomen on

examination.

4. Weak rapid pulse Patient’s pulse was within normal range when

his vital signs were checked.

5. Cold, pale and clammy skin Cold, pale and clammy skin was absent in

patient.

6. Tenderness at the abdomen Patient experienced abdominal tenderness on

palpation.

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7. Hiccups Patient did not experience hiccups.

8. Constipation Patient complained of having constipation and

on attempt he pass dark stools.

SPECIFIC TREATMENT GIVEN TO PATIENT

Mr. AU was treated both surgically and medically.

1. Exploratory laparotomy was done.

2. Nasogastric tube was passed to reduce abdominal distention and prevent aspiration.

3. Antibiotics such as injection metronidazole 500mg tid x 48hours, injection ciprofloxacin

500mg bd x24hours were prescribed, served and was later changed to Rocephin 2g dly x 48hours

4. Injection Morphine 10mg tid x 24 hours and Injection Paracetamol 1g tid x 48hours was

administered to relieve pain.

5. Intravenous Infusions such as 2litres Ringer’s lactate x 24hours, 2litres Normal saline x

24hours, and 2litres Dextrose saline x 24hours were administered as prescribed to compensate

for fluid and electrolyte imbalance.

6. Injection Omeprazole 40mg tid x 48hours.

7. Injection metoclopramide 10mg tid x 24hours.

8. Injection Magnesium Sulphate 1g qid x 24hours.

SURGICAL TREATMENT

Exploratory Laparotomy was performed for AU on the 30 TH of January, 2022. According to the

operation notes; AU’s operation was performed under aseptic condition and patient was

positioned supinely under generalized anaesthesia. The operation was done by Dr. Amoabeng

21
and assisted by Dr. Aboagye and general anaesthesia done by Mr. Amissah. Midline incision was

made through the skin to the fascia and adhesion was removed, resection and anastomosis was

done. Muscles, fascia and skin was closed with sutures. The incision was sutured using catgut for

internal suturing and non-absorbable was used to suture the external. It was then cleaned with

antiseptic solution savlon and sterile dressing applied and plastered.

22
 TABLE 3

PHARMACOLOGY OF DRUGS USED ON PATIENT

DATE DRUG DOSAGE/ROUTE OF CLASSIFICATION DESIRED ACTUAL SIDE REMARKS

ADMINISTRATION EFFECT ACTION EFFECTS

OBSERVED

27/01/ Injection 500mg tid x 48hours Antibacteria To combat No infections Nausea and None was

2022 Metronidazole( intravenously Antiprotozoa infection observed and vomiting, observed.

Flagyl) Antiamoebial the wound insomnia,

healed by first headache,

intention. abdominal

cramping,

darkened

urine.

27/01/ Dextrose saline 2litres x 24hours Intravenous fluids To replace Body fluids Fluid None was

2022 intravenously. therapy. body fluids replaced and overload, observed.

and lost energy oedema,

23
 energy. restored. osmotic

diuresis,

glycosuria

27/01/ Normal saline 2litres x 24hours Intravenous fluids To replace Body well Oedema, None was

2022 intravenously. therapy. body fluids rehydrated and loss of observed.

and electrolytes potassium,

electrolyte( maintained. hypernatrem

magnesium, ia.

sodium,

calcium)

27/01/ Injection 500mg bd x 24hours Antibacterial To prevent Bacterial Headache, None was

2022 Ciprofloxacin intravenously. Antiprotozoa bacterial growth restlessness, observed.

Antiamoebial replication arrested and dizziness,

and combat infection palpitation,

infection. controlled. nausea,

vomiting,

rash, back

24
 pain, joint

pain.

270/1/ Injection 1g tid x 24 hours Analgesic and To alleviate Patient was Insomnia, None was

2022 Paracetamol Intravenously antipyretic pain and relieved from fluid observed.

relieve pain and his retention,

pyrexia. temperature flatulence

was protenuria

controlled.

25
27/01/ Ringers lactate 2litres x 24hours Intravenous fluids To replenish Body fluids Fluid None was

2022 intravenously. therapy. body fluids and electrolyte overload, observed.

and maintained. hypertensio

electrolyte(la n,

ctate in the tachycardia,

form of hypercalcae

sodium mia,

lactate,chlori hyperkalae

de). mia.

29/01/ Injection 200mls bd x 5days Cephalosporin Works by Bacteria Chills, None was

2022 Rocephin intravenously Antibiotics stopping the growth was fever, observed.

growth of controlled. mouth

bacteria sores,

diarrhoea

that is

watery or

26
 bloody.

27/01/ Injection 10mg bd x 24hours Opiod narcotic To relieve Pain subsided Insomnia, None was

2022 Morphine Intravenously analgesics. pain and and patient fluid observed.

induce sleep. slept retention,

comfortably. flatulence

and

protenuria.

27/01/ Injection 10mg tid x 24hours Antiemetics and Works by Delayed Headache, None was

2022 Metoclopramid Intravenously prokinetics blocking stomach confusion, observed.

e dopamine. It emptying was dizziness,

speeds up sped up. restlessness,

stomach sleepiness,

emptying exhaustion.

and

movement

of upper

27
 intestines.

29/01/ Injection 1g qid x 24hours Antidysrhythmic, V; To treat low Magnesium Headache, None was

2022 Magnesium Intravenously Electrolytes level of level in the circulatory observed.

Sulphate magnesium body was collapse,

in the sustained flushing,

body(hypom hypothermia

agnesemia) , visual

changes,

hypocalcem

ia,

hyperkalemi

a,

hypophosph

atemia,

confusion.

29/01/ Injection 40mg dly x 48hours Proton Pump Works by Patient Headache, None was

2022 Inhibitors decreasing condition was diarrhoea,

28
Omeprazole Intravenously the amount improved. nausea, observed.

of acid vomiting,

content in acid reflux,

the stomach constipation

29
 COMPLICATIONS

According to the literature review, some of the complications are perforation, peritonitis,

septicemia, metabolic alkalosis or acidosis.

On account of efficient nursing, medical and surgical care, patient did not experience any

form of complication as outlined in the literature review of the disease condition.

PATIENT/FAMILY STRENGTHS

This involves the activities that contributed to the well being of the patient and his family as

well as his speedy recovery. The following were the strength of Mr. AU

1. Mr. AU could verbalize the intensity of pain on admission .

2. He had a patent cannula in situ for intravenous fluids

3. Mr. AU and his family were willing to be educated about the surgical procedure and it

outcome.

4. Mr. AU was willing to take his medications.

5. Mr. AU and family were willing to adhere to hygienic needs to prevent infection.

6. He could rest well in bed.

7. He was conscious.

8. Mr. AU could communicate with the nurses to understand his nutritional needs.

9. He could eat a high fibre diet.

10.. AU was able to pay for his drugs and bills from the National Health Insurance.

11. He could also communicate freely with other patients as well as his relatives when they

visited him.

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12. His dirty clothes were taking home to wash and was provided with all his necessary items he

needed such as toiletries by his relatives.

13. All these activities contributed to the well being and speedy recovery of patient.

HEALTH PROBLEMS

Throughout patient stay at the hospital, the following health problems were identified and the

patient and family accepted to work cooperatively with staffs towards solving those problem.

PREOPERATIVE PROBLEM

27/01/2022

1. Patient was in pain.

2. Patient complained of nausea and vomiting

30/01/2022

3. Patient and family were very anxious because of inadequate information about the

impending surgery and the post operative care.

POSTOPERATIVE PROBLEMS

30/01/2022

4. Patient experienced pain at the incision site after surgery.

5. Patient has wound at the incision site

31/01/2022

31
 6. Patient had insomnia.

2/02/2022

7. Patient could not meet his personal hygiene needs (bath and mouth care).

8. Patient complained of anorexia

04/02/2022

9. Patient was not able to pass stool

NURSING DIAGNOSIS

1. Acute pain(abdomen) related to disease condition.

2. Risk for deficient fluid volume related to vomiting

3.Anxiety related to unknown outcome of the impending surgery and post operative care.

4.Altered body discomfort (incisional pain) related to surgical incision.

5.Impaired skin integrity (incisional wound) related to surgical intervention and

manipulation.

6. Sleep pattern disturbances (insomnia) related to environmental disturbances.

7. Self care deficit(general) related to surgical intervention

8. Imbalance nutrition(less than body requirement) related to anorexia.

9. Altered elimination pattern (constipation) related to immobility after surgery and

nutritional imbalance.

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CHAPTER THREE

PLANNING FOR PATIENT AND FAMILY CARE

Planning is the next step after the nursing diagnosis has been established. It involves

setting up of goals and objectives to prevent and eliminate patient’s health problems and

identifying nursing intervention to meet set goals. The patient and family were involved

in the planning of the patient’s health.

OBJECTIVE/OUTCOME CRITERIA

1. Patient’s pain will subside within 48 hours as evidenced by;

a. nurse observing that patient has cheerful facial expression.

b. patient verbalizing relief of pain and appears relaxed and comfortable in bed.

2. Patient’s normal fluid volume will be maintained within normal levels within 24

hours as evidenced by;

a. nurse observing an increase and less concentrated urine production

3. Patient and family will be relieved of anxiety within 24hours as evidenced;

a. nurse observing patient and family with relaxed facial expression

b. patient verbalizing that he doesn’t feel anxious anymore

4. Patient’s incisional pain will be relieved within 2 hours as evidenced by;

a. patient verbalizing that pain at the incision site has reduced

b. patient showing a cheerful and relaxed position in bed.

5. Patient will regain the integrity of skin within 6 days as evidenced by;

33
a. nurse observing wound healed successfully.

b. patient verbalizing restoration of the integrity of the skin.

6. Patient will have normal sleeping pattern within 24 hours as evidenced by;

a. patient having a sound sleep for at least 7 hours in the night

b. Patient verbalizing that he was able to sleep in the night.

7. Patient’s hygienic needs will be met within 72 hours as evidenced by;

a. nurse observing that the patient is looking refreshed and relaxed in bed.

8. Patient will meet his nutritional requirement within 24 hours as evidenced by;

a. Patient being able to tolerate fluids and light diets.

9. Patient will resume his normal elimination pattern within 24 hours as evidenced by;

a. patient verbalizing that he was able to pass normal semi-solid stools without difficulty.

34
 TABLE 4 NURSING CARE PLAN MR AU

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME INTERVENTIONS TIME

CRITERIA

27/01/202 Acute pain Patient’s pain 1. Reassure patient. 1. Patient was reassured that 27/01/2 Goal fully met as J.A

2 (abdomen) will subside measures will be executed to 022 at patient appeared

At related to within 1 hour 2. Assess the level of subside the pain. 3:30pm relaxed and

1:30pm disease as evidenced pain. 2. Out of the scale from 0 to 5, cheerful in bed.

condition. by; patient chose 3 which is interpreted

a. a) nurse 3. Assess the nature to be a moderate pain.

observing that of pain. 3. Pain was detected to be localized

patient has 4. Assist patient to at the abdominal region.

cheerful facial assume a comfortable 4. Patient was made comfortable in

expression. position. a lateral position as preferred.

c. b) patient 5. Engage patient in a

verbalizing diversional therapy. 5. Patient was engaged in a

relief of pain conversation to divert his attention

35
 and appears from pain.

relaxed and 6. Administer 6. Injection Morphine 10mg was

comfortable in prescribed analgesics administered as prescribed.

bed.

27/01/202 Risk for a) Patient’s 1. 1. Assess for signs 1. 1. Patient was feeling restless 27/01/2 Goal fully met as J.A

2 At deficient fluid normal fluid of low fluid volume and weak. 022 at the nurse observed

2:30pm volume will be such as 11:00p an increase and

related to maintained restlessness,weakness m less concentrated

vomiting within normal ,etc. urine output.

levels within 2. 2.Assess the skin 2. Break in the continuity of the skin

24 hours as for any break in was absent.

evidenced by; continuity.

b) a)nurse 3. 3.Monitor fluid 3. Total amount of fluid intake was

observing an intake and output. 2500mls and output was 1300mls.

increase and 4. 4. Monitor vital 4. Vital signs were checked and

less signs. recorded as T-36.6℃, P-108bpm, R-

36
concentrated 24cpm and BP-130/70mmHg.

urine 5. Patient’s weight was checked and

production. 5. 5.Monitor patient’s recorded within the range of 60kg to

weight. 62kg.

6. 6. Patient was assisted to care for the

7. 6. Assist patient to mouth using diluted mouth wash

care for his mouth. and gauge.

8. 7. Normal saline 500mls, Dextrose

9. 7. Administer saline 1000mls,Ringers lactate

intravenous fluids and 1000mls were administered

antiemetis as ordered. intravenously as ordered as well as

Injection Metoclopramide 10mg.

8. Total output of urine per 24hrs

10. 8. Measure and was 1300mls and was less

determine the concentrated.

concentration of

urine.

37
 11.

30/01/202 Anxiety Patient and 12. Reassure patient 2. Patient and family were 30/02/2 Goal fully met as J.A

2 At related to family will be and family. reassured that he will come out from 022 At patient and family

5:30AM unknown relieved of the surgery successfully. 7:30pm expressed absence

outcome of anxiety within 2. Explain the 3. 2. Patient and family were told of of being anxious.

the impending 24 hours as surgical procedure to patient undergoing exploratory

surgery evidenced by; patient and family . laparotomy where the surgeon

c) a)nurse makes a cut into the abdomen and

observing examine the abdominal organs under

patient and general anaesthesia.

family with 3. Allow patient and 4. 3. Patient and family understood

relaxed facial family to ask the procedure and had no questions

expression questions and give to ask.

d) b)patient appropriate answers.

verbalizing he 4. Introduce patient to 4. Patient was introduced to a

doesn’t feel recovery patients with patient who had undergone same

anxious surgery with similar condition and

38
 anymore. similar condition. has recovered.

5. Patient and family signed the

5. Guide patient and consent form after acceptance.

family to sign the

consent form.

DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN

39
TIME DIAGNOSIS OUTCOME

CRITERIA TIME

30/01/20 Altered body Patient’s 1. Reassure patient. 1. Patient was reassured of competent 31/01/20 Goal fully met as J.A

22 at discomfort(in incisional nursing management to reduce thecpain. 22 at patient felt that the

8:30am cisional pain) pain will be 2. Explain the cause of 2. Patient was told the pain was as a 10:30am pain has subsided.

related to relieved pain. result of tissue damage at the incision.

surgical within 2 hours 3. Help client to assume a 3. Patient was put in a Semi Fowler’s

incision. as evidenced comfortable position. position as preferred.

by; 4. Provide diversional 4. Patient was engaged in a conversation

a) patient therapy. to divert his attention from the pain.

verbalizing 5. Administer prescribed 5. Prescribed injection morphine 10mg

that pain at analgesics. was administered to patient.

the incision

site has

reduced

b) patient

showing a

40
 cheerful and

relaxed

position in

bed.

30/01/20 Impaired skin Patient will 1. Reassure patient. 1. Patient was reassured that measures 6/02/202 Goal successfully J.A

22 at integrity(incis regain the will be put in place to facilitate wound 2 at met as patient

10:00am ional wound) integrity of healing. 8:00am regained his

related to skin within 2. Assess the 2. The edges of the wound appeared integrity of skin.

surgical 6days as characteristics of the clean,with little sustained tissue loss.

intervention. evidenced by; wound.

a) nurse 3. Monitor vital signs 3. Vital signs checked and recorded

observing within the ranges ;T(36-37.0℃), P(70-

wound healed 100bpm), R(18-22cpm), BP(110/70-

successfully 120/80mmHg).

b)patient 4. Dress wound 4. Patient’s wound was dressed with

verbalizing aseptically normal saline lotion and secured with

41
 restoration of gauge and adhesive tape.

the integrity 5. Educate patient to eat 5. Patient was told to consume diet rich

of the skin. nutritious diet rich in in vitamin C and protein like

protein and vitamin C. oranges,milk, fish,legumes,eggs, etc to

help repair worn out tissues and wound

healing.

6. Educate patient not to 6. Patient was told not to touch the

touch the wound wound so as to prevent infection.

7. Administer prescribed 7. Injection ciprofloxacin 500mg was

antibiotic. served

31/01/20 Sleep pattern Patient will 1. Asses patient normal 1. Patient is able to sleep for 7 hours 02/02/20 Goal fully met as J.A

22 at disturbances have normal sleep pattern when uninterrupted at night and 22 the patient was able

8: 00am (insomnia) sleeping sometimes goes beyond if he is tired. at to sleep for about 7

related to pattern within 2. Dim lights during sleep 2. Lighting system near patient was dim 8:00pm. hours each day.

environmental 24 hours as periods. to enhance sleep.

disturbances. evidenced by 3.Keep the environment 3. Noise in the ward was regulated by

(a). Patient quiet during sleep periods. toning down the voices of the staff

42
 having a nurses as well as the volume of

sound sleep television set.

for at least 7 4. Encourage daytime 4. Patient was encourage to take a stroll

hours in the physical activities. or walk in the ward .

night. 5. Provide adequate 5. Nearby windows were opened

(b)patient ventilation slightly for fresh air.

verbalizing 6. Make patient 6. Patient was made comfortable in semi

that he was comfortable in bed. Fowler’s position as preferred.

able to sleep

in the night.

DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN

43
TIME DIAGNOSIS OUTCOME TIME

CRITERIA

02/02/2 Self care Patient’s 1. Reassure Patient. 1. Patient was reassured that he will be 5/02/202 Goal fully met as J.A

022 at deficit hygienic needs able to perform his normal duties as 2 at patient

9:00am (general) will be met soon as possible. 9:00am maintained

related to within 72 2.Explain procedure to 2. Patient was told he will be assisted to personal hygiene

surgical hours as patient. take his bath in bed as well as care for daily with little

intervention. evidenced by; his mouth. assistance in bed

a) nurse 3.Provide privacy. 3.Privacy was provided by screening. after the second

observing that 4. Assist Patient to care for 4. Patient was assisted to clean mouth day post operative

the patient is mouth for the first day and with toothpaste and toothbrush twice and subsequently

looking assist patient in the daily to prevent infection, improve maintained his

refreshed and subsequent days until appetite and maintain his self esteem. hygiene with no

relaxed in bed. condition becomes stable. assistance after

5. Assist Patient to bath in 5.Patient was assisted to bath in bed the 7th day.

bed for three days and with sponge, soap and warm water and

subsequently allow patient dries with a towel for three days and

44
 to bath without an was subsequently allowed to bath

assistance as condition without assistance as condition

improves. improves.

6. Make patient 6. Patient was made comfortable on

comfortable in bed. neatly prepared bed free from creases

and crumps.

DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME TIME

CRITERIA

45
02/02/20 Imbalance Patient will 1. Reassure patient. 1. Patient was reassured that he will attain 05/02/20 Goal fully met as J.A

22 at nutrition (less meet his his nutritional requirements as soon as 22 at patient was able

8:00am than body nutritional possible. 8:00am to tolerate all

requirement) requirement food served.

related to within 24 hours 2. Inspect oral cavity, 2. Patient was assisted to clean mouth and

anorexia as evidenced assist Patient in oral teeth with tooth brush tooth paste twice

by; toileting. daily to prevent infections, improve

a) Patient being appetite and maintain her self esteem.

able to tolerate

fluid and light 3. Treat cracked and 3. Patient lips were wiped with a moist

diets. dry lips. swab and Vaseline cream applied.

4. Encourage patient to 4. Patient was served with 200mls of

start sips of fluids. water.

5. Feed Patient. 5. Liquid food; hausa porridge was

served.

46
DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME TIME

CRITERIA

04/0/202 Altered bowel Patient will 1. Reassure patient. 1. Patient was reassured of proper nursing 05/02/20 Goal fully met as J.A

2 at movement resume his procedure to ensure that he regains his 22 at the patient

8:00 am (Constipation normal normal elimination pattern. 8:00am verbalized that

) immobility elimination he was able to

after surgery pattern within 2. Encourage the 2. Patient was encouraged to take in more pass stool.

and 24 hours as patient to take in more fluids and light diet to soften stool in the

nutritional evidenced by; fluids and light diets as intestinal tract to facilitate elimination.

imbalance. a)patient the condition improves.

verbalizing that

47
he was able to

pass normal 3. Advise the patient to 4. Patient was told to take in

semi solid take fruits and fibre more fruits and high fibre diet

stools without diets. such as pawpaw,oranges,green

difficulty. leafy vegetables, cereals, etc

to increase bowel movement

and also to boost appetite and

also soften stools to aid in

elimination.

5.Orientate patient to 5.Patient was shown to the toilet and

the toilet and bathroom.

bathroom.

6. Make sure the utility 6. Toilet and bathroom were made very

is clean. clean for patient to feel at home when

using the closet.

7. Engage patient in 7. Patient was instructed to perform mild

48
passive exercises. to moderate exercises to facilitate bowel

movement like walking.

49
50