CHAPTER FOUR

IMPLEMENTATION OF PATIENT/FAMILY CARE PLAN

The fourth (4th) phase of the nursing process is the implementation of patient and family care

plan and the given of actual nursing care. It aims at making patient comfortable, avoidance of

complications and promotion of speedy recovery.

SUMMARY OF ACTUAL NURSING CARE

This involves the actual implementation of the nursing orders in the nursing care plan. The

nursing care given to the patient started on 27th January, 2022 and ended on 5th February,

2022.The nursing procedure/care has been summarized on daily basis as they were implemented.

FIRST DAY OF ADMISSION( 27TH JANUARY, 2022)

Mr. AU was admitted to ward 4 through the Accident and emergency centre of Effia Nkwanta

Regional Hospital at 12:00pm. Upon entering to the ward, Mr. AU and his father were

welcomed by the nurse in-charge and he was admitted into an already prepared bed. The folder

was collected and routine assessment such as general appearance of the patient began. He was

nursed in a semi fowler’s position based on his signs and symptoms. The position was chosen to

facilitate easy respiration. Ventilation was provided and Nasogastric tube was passed to aspirate

fluid in the stomach to reduce vomiting. Urinary catheter was passed to eliminate the urine

produced into the bladder. The need for surgery and post operative measures were made known

to the patient. These include deep breathing exercise, placing the hand on the incision site when

coughing and strict observation of the drug regimen. The education was given in simple

language to facilitate his understanding. The patient was ordered to be put on nil per os.

Admission papers were handed over to the nurse in-charge and Mr. AU’s particulars were
recorded into the admission and discharge book. Nurse’s notes were written on his admission.

Vital signs checked and recorded throughout the day range as:

Temperature= 36.0℃ － 37.7℃ (degree Celsius)

Pulse= 80 －108 beats per minute

Respiration = 20 － 24 cycles per minute

Blood pressure= 130/70 － 130/90mmHg

During admission, vital signs were checked at 12:00pm it was detected that temperature recorded

37.70 C was above the normal range therefore nursing measures were employed to solve the

problem. The patient and father were reassured that measures are being executed to bring the

temperature to normal. His clothing were removed to facilitate tepid sponging intervention and to

encourage tissue circulation. He was tepid sponged with sweeping strokes for 10 minutes leaving

water droplets on the skin to evaporate to cool down the body temperature. Nearby windows

were opened and the ceiling fans switched on for fresh air to improve circulation. Prescribed

medication injection Paracetamol 1g was administered as prescribed, it was then recorded in the

drug administration chart. His vital signs especially temperature was rechecked and it was

detected that it falls within the normal range of (36.2-37.2degree Celsius).

On that same day at 1:30pm patient complained of tenderness on palpation of the abdomen and

on doctor’s assessment and observation he requested to change the catheter because it was

blocked from allowing easy flow of urine from the urinary bladder.. Patient’s catheter was

changed and he was made comfortable in bed and reassured of competent nursing care.

Prescribed injection morphin 10mg was administered to patient to ease his abdominal pain and
injection metoclopramide 10mg was also administered to induce the vomiting.

SECOND DAY OF ADMISSION (28TH JANUARY, 2022)

Mr. AU woke up very early in the morning around 5:30am and was assisted to bath in bed, and

to assume a comfortable position. Due medication were served and recorded. Vital signs were

also checked and recorded as well within the ranges of ;

Temperature= 36.9℃－37.6℃

Pulse= 104－108beats per minute

Respiration= 20－24cycle per minute

Blood Pressure= 125/80 － 140/80mmHg

At 6:00pm the blood pressure went high so patient was served IV fluid of normal saline 500ml to

stabilize the pressure. At 7:00am it was discovered that patient was looking anxious due to the

impending surgery and it outcome .The patient and his family were briefly prepared

psychologically towards the surgery and it outcome. All questions pertaining to the surgery were

answered in simple language to clear all misconceptions about the outcome of surgery .A patient

who has undergone similar operation was invited to share his experience with patient. He was

witnessed to sign the consent form as a sign of agreement towards the surgery. Patient was also

introduced to some of the equipment that are being used in the theatre to alley his fear at the time

of entering the theatre. The laboratory results were collected from the laboratory department to

be sure of hemoglobin level estimation, urea and creatinine level. He was reviewed by Dr.

Amoabeng on rounds at 10:30am and confirmed that, the surgery will be done on Sunday 31st of
January, 2022 because he wants to manage him first to know if there will be the need for a

surgery. He was ordered to continue nil per os, intravenous infusion, antibiotics and analgesics.

The patient’s vital signs were checked for the day and recorded in ranges as follows,

Temperature …………………36.6 - 37.9 degree Celsius

Pulse …………………………..80 - 108 beats per minute.

Respiration ……………………20 - 24 cycles per minute

Blood pressure ………………125/80 - 140/80 mmHg.

THIRD DAY OF ADMISSION(29TH JANUARY,2022)

On the third day of admission, 29th January,2022, Mr. AU was assisted to bath in bed, routine

care was performed such as mouth care,vital signs and medications were given and recorded

throughout the day within the ranges below;

Temperature= 36.8℃ － 37.6℃

Pulse= 104－108beats per minute

Respiration= 20－24cycle per minute

Blood Pressure= 125/80－140/80mmHg

Patient was made comfortable in bed after every routine that was carried out.

FOURTH DAY OF ADMISSION (THE DAY OF SURGERY) 30TH JANUARY, 2022.

On the fourth day of admission, which was on the 30th January 2022, Mr. AU was assisted to

bath in bed, routine care such as mouth care, vital signs, and medications were given and

recorded in the nurses’ note. The mouth was inspected to find out if there is denture, to remove

and prevent dislodgement. The patient was assisted to assume a comfortable position after being
groomed into a theatre gown. .Dextrose 5% was set on the patient. Nasogastric tube was insitu to

aspirate the gastric content to avoid vomitus from chocking him during the procedure. The

urinary catheter was insitu to help in draining urine from the bladder. Vital signs which are

temperature, pulse, respiration blood pressure were monitored and recorded. The needed

particulars were taking and handed over to the anesthetist for anaesthetic assessment. After

gaining consciousness at 5; 40pm after the procedure, he was then transferred to ward 4 at

7:50pm for further management.

POST OPERATIVE VITAL SIGNS MONITORING FOR MR AU

DATE / TEMPERATUR PULSE RESPIRAT BLOOD LEVEL OF

TIME E(DEGREE (BEAT ION PRESSURE(MILLIM CONSCIOUS

CELSIUS) PER (CYCLE ETRES PER NESS

MINUTE PER MERCURY)

) MINUTE)

30/01/2 37.6 75 22 140/100 Semi

022@1 conscious

2:00pm

30/01/2 37.6 75 22 140/100 Semi

022@1 conscious

2:25pm
30/01/2 37.4 75 21 140/100 Semi

022@1 conscious

2:40pm

30/01/2 36.8 78 20 130/90 Semi

022@1 conscious

:00pm

30/01/2 36.8 80 20 120/80 Conscious

022@2

:10pm

30/01/2 36.5 80 20 120/80 Conscious

022@4

:20pm

30/01/2 36.5 80 20 120/80 Fully

022@5 conscious

:30pm

At 8:00pm patient complained of incisional pain and was reassured that necessary measures are

put in place to relieve him of pain. He was put in a supine position to enhance easy breathing to

reduce pain. Coughing and deep breathing exercise were taught and to put his hand over the

incision site when coughing and not stretch for any item but call for help. The incision site was

inspected for bleeding and swollen, the wound was inspected for bleeding and signs and

symptom of wound infection but no abnormality was seen. Prescribed analgesics such as
injection morphine 10mg was administered.

Patient was again reassured that his wound will be healed with no signs of wound healing

complications such as infections, haemorrhage, extensive scar formation, abscess formation and

no wound dehiscence.

The wound was observed for signs of infection and overt bleeding. It was opened and dressed

aseptically. Patient was taught not to touch wound to prevent wound infection and was

encouraged to eat a well balanced diet especially food rich in protein and vitamin C which

promotes wound healing and repair of worn out tissues after bowel sound.

At the same day and time patient also did complain of difficulty in sleeping. His sleep pattern

was assessed to know the uninterrupted sleep at day and night and pain assessment done to know

whether pain was provocative, aching, and palliative. It was detected that pain was localized at

the incisional site. The lighting system near patient’s bedside was put off for patient’s preference

to enhance sleep and was made comfortable in the semi fowler’s position on bed to aid

relaxation. Again nearby windows were opened slightly to enhance adequate ventilation and

noise on the ward was regulated by turning the volumes of the radio and television set down.

Prescribed post operative medications include:

1. Injection metronidazole 500mg tid x 48hours.

2. Injection Paracetamol 1g tid x 24hours.

3. Injection ciprofloxacin 400mg bd x 24hours .

4. Injection Rocephin 200mg bd x 3 days.

5. Intravenous ringers lactate 1.5l x 3 days.

6. Intravenous normal saline 1.5l x 3 days.

7. Intravenous dextrose saline 1.5l x 3 days.

Vital signs were checked and recorded as follows:

Temperature : 36.9 degrees Celsius

Pulse : 78 beat per minute

Respiration : 20 cycle per cycle

Blood pressure: 110 / 70 mmHg.

FIFTH DAY OF ADMISSION (FIRST DAY POST OPERATIVE DAY POST) 31ST

JANUARY, 2022.

On the 31ST January, 2022,at 6:00am thus patient’s fifth day of admission and first day post

operative at the ward, he could not perform his normal activities because of pain resulting from

surgery, but the patient was reassured that he will be able to perform his normal activities as his

condition improves. Urine bag was emptied and the amount, frequency, colour and odour of

urine were documented in the folder and the nurses’ note. Passive exercise was encouraged for

proper circulation and to reduce surgical complications like accumulation of fluid in the perinea

cavity. Vital signs were checked and recorded as follows,

Temperature…………………………. 36 – 37.0 degrees Celsius.

Pulse …………………………………..70 – 100 beats per minute

Respiration …………………………… 18 – 22 cycles per minute

Blood pressure…………………………110/70 – 120/80 mmHg

Prescribed intravenous infusions were given to improve rehydration and also to flush the system.

As well as prescribed medications served and he was encouraged to have enough sleep.
SIXTH DAY OF ADMISSION (SECOND DAY POSTOPERATIVE) 1ST FEBRUARY, 2022.

According to the night nurses report, Mr. AU had sound sleep throughout the night. At 6:00am it

was found out that patient could not maintain his personal hygiene needs due to post operative

restrictions. He was reassured that he will be able to perform his normal duties as soon as

possible. Patient was assisted to clean mouth with toothpaste and toothbrush twice daily to

prevent infection, improve appetite and maintain his self esteem and was assisted in bed to bath

with sponge, soap and warm water and dry with a towel twice daily and was subsequently

allowed to maintain his personal hygiene without assistance as condition improves. A clean and

relaxing bed was then ensured to maintain patient’s self esteem. Patient was assisted to walk

around his bed at least twice daily to prevent infection. Prescribed drugs were administered. His

vital signs were monitored and recorded and all was within normal ranges.

After the doctor’s became aware of the return of the bowel sound during the inspection on ward

rounds, they ordered all drainage tubes to be removed and sip of water to start, very light

beverages were served at regular intervals in bits.

Postoperative exercises continued by walking around the bed to prevent post operative

complications. The wound was dressed aseptically to prevent infection.

Vital signs checked and recorded ranged as follows:

Temperature………………………………36.2 – 37.2 degree Celsius

Pulse……………………………………..60 – 100 beats per minute

Respiration………………………………18 – 22 cycles per minute

Blood pressure…………………………110/70 – 120/80mmHg

SEVENTH DAY OF ADMISSION (THIRD DAY POSTOPERATIVE) 2ND FEBRUARY,

2022.

On this day around 7:00am it was discovered that patient has not being able to meet his

nutritional requirement. He was then reassured that he will attain his nutritional requirements as

soon as possible. He was assisted to clean mouth and teeth with tooth brush and tooth paste twice

daily to prevent infections, improve appétit and maintain his self esteem then his lips was wiped

with a moist swab and Vaseline cream applied. The need and importance of nutrition was

emphasized when health education was given. Liquid food; Hausa porridge was served. His vital

signs were checked and recorded. and it was within normal range as well as prescribed

medications served and recorded into drug administration chart.

According to the night nurse report; Mr. AU had a sound sleep throughout the night. Vital signs

checked and recorded ranged as follows:

Temperature………………………………36.2 – 37.2 degree Celsius

Pulse……………………………………..60 – 100 beats per minute

Respiration………………………………18 – 22 cycles per minute

Blood pressure…………………………110/70 – 120/80mmHg

EIGTH DAY OF ADMISSION (FOURTH DAY POST OPERATIVE) 3RD FEBRUARY 2022.

Mr. AU’s condition on this day had improved but only complained of not been able to pass stool

after the surgery at 8:00am. Patient was reassured of proper nursing procedure to ensure that he

regains his normal elimination pattern. He was encouraged to take in more fluids and light diet to

soften stool in the intestinal tract to facilitate elimination also take in more fruits and high fibre

diet to increase bowel movement and also to boost appetite and also soften stools to aid in

elimination. Utilities were made very clean to make patient feel at home when using the closet
again instructed to perform mild to moderate exercise to facilitate bowel movement.

Vital signs checked and recorded ranged as follows:

Temperature………………………………36.2 – 37.2 degree Celsius

Pulse……………………………………..60 – 100 beats per minute

Respiration………………………………18 – 22 cycles per minute

Blood pressure…………………………110/70 – 120/80mmHg

NINTH AND TENTH DAY OF ADMISSION (FIFTH AND SIXTH DAY POST

OPERATIVE) 4TH AND 5TH FEBRUARY, 2022.

Mr. AU was able to get out of bed to perform his usual activities such as brushing his teeth and

bathing. At 8:00am each morning, medications were served and recorded. Vital signs were also

checked and recorded. During these days, semi-solid diet was given. Alternate stitches were

removed on the 8th day after the operation by doctor’s instructions. He continued with his newly

prescribed drugs such as tablet Ciprofloxacin and tablet paracetamol.

Vital signs checked and recorded ranged as follows:

Temperature………………………………36.2 – 37.2 degree Celsius

Pulse……………………………………..60 – 100 beats per minute

Respiration………………………………18 – 22 cycles per minute

Blood pressure…………………………110/70 – 120/80mmHg

ELEVENTH (11TH) DAY OF ADMISSION (SEVENTH DAY POST OPERATIVE) 6TH

JANUARY, 2022.

On 6th February, early in the morning, Mr. AU had fully gained health and had no complains. At
doctor’s rounds, they ordered the remaining stitches should be removed following discharge and

to continue treatment. The wound was observed and no complications were found, it was dressed

aseptically. The patient was prepared towards discharge.

Vital signs checked and recorded ranged as follows:

Temperature………………………………36.2 – 37.2 degree Celsius

Pulse……………………………………..60 – 100 beats per minute

Respiration………………………………18 – 22 cycles per minute

Blood pressure…………………………110/70 – 120/80mmHg

PREPARATION OF PATIENT AND FAMILY FOR DISCHARGE AND REHABILITATION

Preparation of Mr. AU and his family towards discharge began on the first day of admission and

this was made known to him and his Father that after good medical, surgical and nursing care he

will be discharged home to continue his care. Mr. AU and his brother were informed of the

possible date of discharge; they were educated on the disease condition again. Health education

on nutrition concerning balance diet was given. Protein meals such as agushi, meat, fish, just to

mention few to help build worn out tissues. The patient was encouraged to take Vitamins to

boost up his immune system, vitamin c to help facilitate

wound healing and carbohydrate to provide the required energy as well as minerals. They were

also educated on high fibre and roughage diet to ensure proper elimination pattern. They were

also told of proper disposal of refuse to prevent contamination, the spread of infections and

disease in their home. Mr. AU and his family were educated against self medication and advised

to report any sickness to the hospital. Proper food hygiene was emphasized. They were also

informed about the review date on which the patient should report to the hospital. They were
however informed to report to the hospital whenever he experiences any complication before the

review date. The patient bill was assessed and discharge was entered into the admission and

discharged books as well as the daily ward state. They were discharged on 7th February, 2022 at

11:30pm.

FOLLOW UP/HOME VISIT/CONTINUATION OF CARE.

On the 29th January, 2022, my first home visit was made to patient house at about 11:30am with

his brother while Mr. AU was still on admission. This was done to familiarize myself to his

living environment of the patient and to collect the practices or habits that may have contributed

to the ill-health of Mr. AU and family. At the house, the compound was neat with little scratches

on the wall of the building which was painted blue and yellow and rubbish was kept in a basket

and it was emptied at the community refuse damp. I congratulated them for that and encourage

the Brother to keep it up. Also all windows have mosquito prove net to prevent the entry of

mosquitoes to the room. The community has social amenities such as nursery primary school,

junior high school and senior high school. They also have a clinic which some members of the

community go to for treatment when they are ill. I thank them for their warm reception and left

around 3:00pm.

SECOND HOME VISIT

The second home visit took place on 12th February 2022 at 12:30pm after the patient was

discharge home. It was a scheduled visit with the aim of seeing whether things have been going

on well with the patient and family after discharge. On reaching the house with Mr. A (the

Father), Mr. AU was strong and could even walk to embrace me as a form of welcome. Food

prepared in the house was under good and hygienic condition. I reminded them of the review

date in case the joy of discharge after going through the surgery had made them forget it. I asked
if Mr. AU was encountering any problem but he said there was none yet experienced. All

education I gave during the admission time was emphasized.

REVIEW OF MR. AU

21st February, 2022 was the review date of the patient. Mr. AU and his Father arrived at

consulting unit at Effia Nkwanta Regional Hospital at about 9:30am and were assisted to collect

his folder. He was accompanied to see the doctor on duty in consulting room 3. His vital signs

were checked and recordings were within normal range. The patient did not have much

complains. He was therefore advised to continue his medication prescribed on the day of

discharge till it gets completed. Mr. AU was encouraged to report any problem that may arise

after his review for early intervention.

THIRD HOME VISIT

This was to monitor continuity of care therefore on 27TH February, 2022 at 8:00am I set off to

Mr. AU’s house. This was not a planned or scheduled visit. Upon the arrival, Mr. AU was in the

room but when he heard I was in the house, he quickly came out to see me. I was given a seat

and asked of my mission. I told them my mission as stated above. Mr. AU’s condition had

improved well than when he came in for review. His drugs were checked to know whether he has

been taking them or not, the remaining drugs and how he was taking them. A quick glance of the

environment was done and the whole place was clean and neat. In fact I was glad that the health

education has gone down with them. I told them that this was my last official visit to them and

that I really appreciate their kind and respectful interaction with me. They were appreciative of

the care and support granted during their hospitalization and my home visit. They promise to use

all the advice that had been given to them for good purpose. I told them to visit the clinic when
there is any problem.

CHAPTER FIVE

EVALUATION OF CARE GIVEN

Evaluation is the assessment of the outcome of nursing care rendered to the client. It is the final

stage in the nursing process. The patient was diagnosed and care plan was formulated and

implemented.

STATEMENT OF EVALUATION

During evaluation, objectives and goals set were fully met. Patient’s ’s condition improved

gradually by the time of evaluation with no complications. On 27th January, 2022 goal set to

reduce pain and to reduce body temperature to normal were also achieved as patient remained

calm in bed and temperature reduced from 36.2 to 37.2 degree Celsius.

On 28th January ,2022, anxiety of the patient and the family were relieved as patient looked

relaxed and cooperative during care rendered.

On the 29th January ,2022, patient had a normal sleep and hygienic needs were met as patient

look refreshed in bed and verbalized that he was able to sleep 7 hours in the night.
On the 30th January, 2022, patient had his surgery done with no complications. He gained

consciousness at 5:40pm and was transferred to the ward at 7:50pm for further management

On 31st February, 2022, patient complained of incisional pain due to the surgical intervention.

Objectives were set and nursing interventions carried out. Goal was fully met on the same day as

patient verbalized that pain at the incisional site has subsided and showed a cheerful and relaxed

position in bed. Patient was cared for by the use of aseptic technique as patient did not

experience any wound infection.

On 1st February, 202 at 7:00am patient was assisted to maintain his personal hygiene needs.

Would was dressed aseptically to prevent infections.

On 2nd February, 2022 at 8:00am an objective was set and intervened to meet patient’s

nutritional requirement. Goal was fully met as patient was able to tolerate all liquid meals served

as I observed him take his meals

Again, on 3rd February, 2022 at 9: 00am patient was able to pass stool as he verbalized the

absence of constipation and was encouraged to take in more fluids and high fibre diets.

On 4th and 5th February, 2022, patient was introduced to semi-solid foods.

0n 6th February, 2022, patient had fully gained health and had no complications. Patient was

prepared towards discharge.

Goals set for Mr. AU were full met hence, there was no need to amend any goal

AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET AND UNMET

OUTCOME CRITERIA
Upon careful evaluation of the nursing care rendered to Mr. AU and his family, all goals and

objectives set were fully met. Therefore, there was no need for amendment of any of the

objectives set during the care of the patient.

TEMINATION OF CARE

Termination of care is the last phase of interactions of the nurse, patient and relatives.

Termination was very difficult as patient and family showed signs of worry but they were

reassured. However termination was planned even before discharge that one day our relationship

will be terminated. Consequently, during my third home visit, I made them aware that it was my

last official visit to them.

 SUMMARY AND CONCLUTION

SUMMARY

Mr. AU ,18 years Muslim young man was admitted to the ward 4 through the accident and

emergency unit of Effia Nkwanta Regional Hospital l with intestinal obstruction by Dr.

Amoabeng on 27/01/2022 at 12:00pm. He was sent to the theatre on the Fourth day of admission

(30/01/2022) after the various tests and investigations confirmed the diagnosis. The patient

complained of nausea and vomiting, pyrexia and was very anxious. Nursing diagnosis were

made and implemented to ensure patient’s recovery. Vital signs were checked and recorded and

prescribed drugs were served. The drugs prescribed for the patient include analgesics, antibiotics,

Antiemetics drugs, Antidysrhythmic, proton pump Inhibitors, intravenous infusions .Some of

these drugs are ciprofloxacin, Metronidazole, Morphine and Paracetamol, Dextrose, Normal

saline, Ringers lactate, Metoclopramide, Magnesium Sulphate, Omeprazole and Rocephin were

served respectively.

Nursing problems were managed throughout by the use of nursing care plan. Goals set for

management of the patient’s problem were fully met. The patient was discharged after being

declared medically fit by Dr. Amoabeng on 7th February 2022. The patient was reminded of the

review date (21st February, 2022) the patient and the family was informed of the need to take

his medications very regularly throughout hospitalization and after discharge. The patient and

family were given health education on the patient’s condition, good personal hygiene, and good
nutrition. The interactions with the patient and the family lasted for about eight day after the

discharge.

There were three home visits to patient’s home to know how the patient was feeling in his own

environment after and whether all education given were being implemented. Lastly, my study on

Mr. AU has been very successful and smooth. This period has been useful because, patient’s

family learnt about intestinal obstruction, it causes, and clinical features, management,

complication and it’s prevention.

CONCLUSION

The care and help provided by the members of the health team, cooperation of the patient and the

family enhanced a successful patient and family care study with regards to proper nursing care

management.

The study has also broadened my knowledge on the use of the nursing process. I also

recommend the use of the nursing process in our day to day practice as a nurse and that more

seminars should be held to elaborate more on the use of the nursing process and care plan in

caring for our patients.

I thereby agree to the opinion of students writing a holistic care study for a client before

completion of the three (3) year diploma in nursing programs.

 APPENDIX

INTAKE AND OUTPUT FOR MR. AU

Date/Time Intake Date/time Output

27/01/2022 @ Kind of fluid Amount of fluid 27/01/2022@ Kind of fluid Amount of fluid

2:00pm Dextrose 10% 1000mls 4:00pm 600mls

4:30pm Ringers lactate 1000mls 6:30pm Urine 700mls

7:00pm Normal saline 500mls 10:00pm - -

TOTAL 2500mls 1300mls

Total input =2500mls

Total output =1300mls

Balance = 1200mls

Date/Time Intake Date/Time Output

28/01/2022 @ Kind of fluid Amount of fluid 28/01/2022 @ Kind of fluid Amount of fluid
8:00am Normal saline 1000mls 11:00pm Urine 800mls

10:00am Ringers 1000mls 1:00pm Urine 400mls

lactate

2:00pm Dextrose 10% 1000mls 5:00pm Urine 600mls

6:00pm Normal saline 500mls 8:00pm Urine 400mls

TOTAL 3500mls 2200mls

Total input=3500mls

Total output=2200mls

Balance =1300mls

Date/Time Intake Date/Time Output

29/01/2022 @ Kind of fluid Amount of fluid 29/01/2022 Kind of fluid Amount of fluid

7:00am Dextrose 1000mls 8:00am Urine 900mls

10%

9:00am Ringers 1000mls 11:00am Urine 700mls

lactate

11:30am Normal 1000mls 1:00pm Urine 500mls

saline

6:00pm Ciprofloxacin 500mls 7:30pm Urine 500mls

TOTAL 3500mls 2600mls

Total input=3500mls

Total output =2600mls

Balance =900mls

Date/Time Intake Date/Time Output

30/01/2022 @ Kind of fluid Amount of fluid 30/01/2022 @ Kind of fluid Amount of fluid

5:00am Normal saline 500mls 9:00am Urine 500mls

7:00am Dextrose 5% 500mls 4:00pm - -

10:30am Ringers lactate 500mls 1:00pm Urine 400mls

TOTAL 1500mls 900mls

Total Input= 151500mlspotal output =900mls

Balance=600mls

Date/Time Intake Date/Time Output

31/01/2022 @ Kind of fluid Amount of fluid 31/01/2022 @ Kind of fluid Amount of fluid

8:30pm Ciprofloxacin 500mls 10:45am Urine 700mls

8:15am Metronidazole 500mls 12:00pm Urine 500mls

8:45am Dextrose 10% 500mls 6:00pm Urine 300mls

9:30pm Ringers 500mls 9:00pm Urine 400mls

lactate

6:09pm Dextrose 10% 500mls - - -

6:45pm Metronidazole 500mls 12:00am Urine 500mls

7:00pm Ciprofloxacin 500mls 5:00am Urine 400mls

7:30pm Normal saline 500mls 7:45am Urine 500mls

TOTAL 4000mls 3200mls

Total Input =4000mls

Total Output =3200mls

Balance =800mls

Date/Time Intake Date/Time Output

1/02/2022 @ Kind of fluid Amount of fluid 1/02/2022 Kind of fluid Amount of fluid

8:00am Ciprofloxacin 500mls 10:00am Urine 100mls

12:30pm Normal saline 1000mls 3:40pm Urine 550mls

1:45pm Dextrose 10% 100mls - - -

6:45pm Water 200mls 7:00pm Urine 1000mls

2/02/2022 Hausa 300mls 2/02/2022 - -

@7:30am porridge

12:00pm Light soup 200mls 11:00am Urine 450mls

TOTAL 2300mls 2100mls

Total Iput=2300mls

Total output =2100mls

Balance =200mls

BIBLIOGRAPHY

Baer L. C (1997) Nurses Drug Guide 97, 7th Edition: Springhouse cooperation, Pennsylvania.

Betty L.G and Adrienne R.N (2001) Intravenous Medications, 21ST Edition:

Mosby Inc, California.

Elkin, Perry and Potter, (2000) Nursing Interventions and Clinical Skills, 2nd Edition,

Mosb Inc. Toronto.

Loebs S. Cashill M et al (1994), Handbook Of Medical-Surgical Nursing, 1st Edition,

Springhouse cooperation Pennsylvia.

Sandra M. N, (2002) the Lippincott Manual of Nursing Practice, 7th Edition,

Lippincott Williams and Wilkins Inc. Philadelphia.

Suzanne C. S and Brenda B. (2004) Brunner And Suddarth’s Textbook of Medical and Surgical

Nursing. 10th,12th Edition, Lippincott William and Wilkins Inc. Philadelphia.

SIGNATORIES

………………………………………

NAME OF CANDIDATE: JOSEPHINE AKWANDOH

DATE 13TH OCTOBER, 2022

…………………………………..

NAME OF THE WARD INCHARGE:

DATE:

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NANE OF SUPERVISOR: SISTER BLAY

DATE:

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NAME OF PRINCIPAL: MR. ALHAJI ABOAKYE YIADOM

DATE: