TABLE OF CONTENT CHAPTER| CONTENT | PAGE| | TABLE OF CONTENT| | | LIST OF TABLES| | | PREFACE| | | ACKNOWLEDGEMENT| | | INTRODUCTION| | ONE| ASSESSMENT OF PATIENT AND FAMILY| | | PATIENTS PARTICULARS| | | FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY| | | PATIENT`S DEVELOPMENTAL HISTORY| | | PATIENT`S LIFE STYLE AND HOBBIES| | | PATIENT`S PAST MEDICAL HISTORY| | | PRESENT`S MEDICAL HISTORY| | | ADMISSION OF PATIENT| | | PATIENT`S CONCEPT OF ILLNESS| | | LITERATURE REVIEW| | | VALIDATION OF DATA| | TWO| ANALYSIS OF DATA| | | COMPARISON DATA WITH STANDARD| | PATIENT AND FAMILY STRENGTH| | | HEALTH PROBLEMS| | | NURSING DIAGNOSIS| | | | | THREE| PLANNING FOR PATIENT AND FAMILY CARE| | | NURSING CARE PLAN| | | | | FOUR| IMPLEMENTATION OF CARE PLAN| | | SUMMARY OF ACTUAL NURSING CARE| | | PREPARATION OF PATIENT/FAMILY FOR DISCHARGE AND REHABILITATION| | | FOLLOW-UP VISITS/CONTINUITY OF CARE| | | | | FIVE| EVALUATION OF CARE| | | STATEMENT OF EVALUATION| | | AMENDMENT OF NURSING CARE PLAN| | | TERMINATION OF CARE| | | SUMMARY| | | CONCLUSION| | | | | | BIBLIOGRAPHY| | | SIGNATORIES| |
TABLE No| LIST OF TABLES| PAGE| | | | ONE| DIAGNOSTIC INVESTIGATION| | | | | TWO| COMPARISM OF CLINICAL FEATURES OF PATIENT TO THAT OF THE TEXTBOOK| | | | | THREE| PHARMACOLOGY OF DRUGS| | | | | FOUR| NURSING CARE PLAN| | | | | FIVE| AMENDMENT OF CARE PLAN| | PREFACE The patient/family care study is a written document of the nursing care rendered to patient/family from the day of admission throughout his/her stay in the hospital and after discharge. This study adapts the concept of the nursing process approach in managing patient/family health problems.
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With particular focus on independent nursing care interventions and the discharged home health care guidelines. The concept of caring for the patient as an individual gives the student nurse a good insight and knowledge into the psychological, socio-economic and how to take care of them. The patient/family care study also helps the student nurse to improve upon his/her establishment of good interpersonal relation of good interpersonal relationship with the patient, his/her family members and members of the health team. Moreover, it also helps the student to improve upon his/her writing skills.
This can be achieved through effective assessment and analysis of patient’s condition. The patient/family care study is written by student nurse in partial fulfillment for the award of professional certificate, Diploma in General nursing by the Nurses and Midwives’ Council of Ghana. It serves as a Literature Review for other students who would like to research in similar area. It also enables student nurse to put into actions all knowledge acquired both practical and theoretical. For the purpose of confidentiality, my patient will be called Miss M. B and the husband Mr.
J. A throughout the script. ACKNOWLEDGEMENT I wish to express my sincere thanks to the Almighty God because without his help, this work would not have been successful. My profound gratitude also goes to Miss M. B and her family especially her husband Mr. J. A for their cooperation for providing me with the necessary information to bring this work to a success. My next regards also goes to the Nurses and Doctors of the obstetrics and gynecological ward as well as the entire staff of Central Regional Hospital who helped in diverse ways in bringing this work to fruition.
Moreover, my warmest gratitude goes to my supervisors; Sister Victoria Amankwaata and Mr. Kenah, for without them this work would not have been a reality. I also thank the entire tutorial staff of the Nurses and Midwives’ training College, Cape Coast through whose devotion, encouragement, contributions, guidance and supervision made this script a meaningful one. Furthermore, my sincere thanks go to all the authors of the literature used as reference for this study. Finally, my sincere gratitude goes to my family and colleagues who helped in diverse ways during my course of writing, I say God richly bless you all.
INTRODUCTION The advancing nature of nursing in the world today demands a more technological advancement, professionalism and efficiency in approaching nursing. It involves the use of knowledge and skills in caring for the sick or well. In order to ensure a quality health care delivery, the nursing process approach provides the framework for care through the application of the North American Nursing Diagnoses Association (NANDA) standard nursing outcome classification and the Nursing Intervention Classification (NIC) which provide an evidenced based approach to nursing practice.
This special care study emphasizes the detailed nursing care rendered to Miss M. B, Cape Coast from 22nd February to 26th February, 2010. She was seen and admitted by Dr. Keenan through the Out-Patient Department of the hospital at 2:00pm on the 22nd February, 2010 with the history of irregular menstrual bleeding, lower abdominal pain, infertility and was diagnosed as ovarian cyst after an abdominal scan was done. My interaction with her started on the same admission date at 2: 20 pm when she was brought to the ward accompanied by the husband Mr.
J. A and an Out-Patient Department nurse of the hospital. Patient was welcomed together with the husband and seats were offered to them at the nurses’ station. Patient’s history was taken and recorded in the appropriate nurses’ note. After taking all the necessary information from them, I introduced myself as a student nurse and declared my intentions to them as a special nurse and rendered nursing care to her throughout the period of hospitalization and beyond. My proposals were accepted by Miss M.
B and husband and therefore the nursing process continued till the period of termination of care. They were fully assured of confidentiality and only the initial names of my patient and relatives were used in the study throughout. My patient was referred to as Miss M. B and the husband Mr. J. A. For easy presentation, the patient/family care study was organized and written in five chapters using the nursing process which includes: 1. Assessment phase: This is the first phase of the nursing process which involves collection of data about the patient/family and community.
It is the act of reviewing a human situation from a data base in order to affirm the wellness state and diagnose potential client problems, to affirm an illness state diagnosing the client’s prevailing problems and identify the wellness aspect of ill client. 2. Analysis phase This also involves the identification of patient’s potential problems and comparing the collected data with standard from literature. The nurse also uses personal knowledge and physiology, psychology, sociology and past experience when comparing data. 3. Planning phase
The planning component of the nursing process involve the assignment of priorities to the nursing diagnoses, specification of mediate, intermediate and long term goals of nursing actions and specification of expected outcome. It also involves the identification of specific nursing interventions appropriately for attaining the set goals/objectives and how these objectives are to be met. 4. Implementation phase This is the fourth phase of the nursing process which signifies the giving of care in relation to the defined nursing intervention and goals.
It involves initiation and completion of actions necessary to accomplish the defined goal of optimal fulfillment of human needs. It draws heavily on the intellectual, interpersonal and technical skills of the nurse. 5. Evaluation This is the phase where the nurse evaluates whether the outcome criteria and intervention was realistic and achievable within the set period of time. It is the appraisal of the changes experienced by the client in relation to goal achievement as a result of the actions of the nurse. It is always considered in terms of how the client responded to planned action.
CHAPTER ONE ASSESSMENT OF PATIENT/FAMILY Assessment is the first step in the nursing process. Its primary purpose is to collect data that may be used to assess a person’s health status and also serve as a foundation for clinical judgment and diagnostic reasoning. This chapter therefore covers the following: 1. The patient’s particulars. 2. Family medical and socio-economic history of the patient. 3. Patient’s developmental history. 4. Patient’s lifestyle/hobbies. 5. Patient’s past medical history. 6. Present medical history of the patient. 7.
Patient’s concept of the disease. 8. Admission of the patient. 9. Literature review on the disease condition. PATIENT’S PARTICULARS Miss M. B is a 30 year old Ghanaian woman who was born on 19th August, 1980 at Effete near Elmina in the Commend Edina Guano Abram district in the Central Region. The parents are Mad. A. A and Mr. A. K all of Effete. Miss M. B is the 5th child among the ten children of Mad. A. A and Mr. K. A. The parents are all farmers and are alive. She speaks Fanti. She is a typical Fanti from the “Anona” clan. Miss M. B is married to Mr. J.
F and lives with the husband at Pease near Esuekyir. She had her formal education at Effutu D /A Primary School up to class 2. Miss M. B is dark in complexion and weighs averagely about 62kg. She is a hair dresser by profession but now into trading. She sells plastic rubbers and its products at Jukwa Market Centre. The next of Kin to Miss M. B is her husband Mr. J. A. FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY Miss M. B verbalized that she is the 5th child to her parent. She said the parents gave birth to ten children (10) of which seven are alive, thus, five females and four males.
She explained that, her mother is a Fanti kenkey seller in addition to farming with the father. Miss M. B is married to the husband for six (6) years but without a child. She explained that, two of her siblings died through unknown sickness and the other one through road traffic accident. According to her, apart from these three deaths, the rest of the family members have not experienced any chronic sickness except minor ailments such as headache, malaria, malaise and arthritis for which they are managed by over the counter drugs and herbal medicine. Miss M.
B earns income from the polythene or plastic bag business. She supports the family’s up-keep with the income she receives from the trading activities. She explained that, she can afford the three square meals with the support of the husband who pays the rent and the utility bills. Miss M. B further explained that she is in good relationship with the in-laws and she is enjoying happy marital life. PATIENT’S DEVELOPMENTAL HISTORY Miss M. B was born at term through spontaneous vaginal delivery under the supervision of her late grandmother who was a Traditional Birth Attendant (TBA).
She was born and raised at Effutu near Jukwa and was breastfed for two years but exclusive breast feeding was not observed by the mother. She had a scar at the left deltoid (shoulder) muscle showing that she had an immunization against at least tuberculosis. According to Miss M. B, her mother told her that she was very small in her infant stage but went through the normal developmental stages. By the sixth (6) month, she could sit without a support and by the tenth (10) month, she could crawl, stand and walk alone with good coordination. She had eruption of teeth at that same time.
When she was twenty four (24) month old, she could talk meaningfully. Miss M. B lamented that, on her fifth year of life, she fell from a chair and broke one of her legs which healed completely within one month with the aid of herbs from her grandmother. She explained that, her father always referred to her as a clever girl but he could not afford to educate her. She started schooling at Effutu D /A Primary School at the age of six. She dropped out of school at class two at the age of eight years because of the Aunt who took her to Accra to stay with her, with the pretence of helping her education.
But she explained that, the aunt never enrolled her at any school but lured her into child labour until at the age of twenty-two (22) years when she came back from Accra to Effutu. She said, after coming back from Accra, she enrolled herself as a hairdressing apprentice but could not complete due to financial constraints. She then met her husband at the age of twenty three (23) years when they tied the knot. Though they have married for more than six years, they have no child. Presently, Miss M. B is thirty years old.
She is able to perform all household chores and although illiterate, she understands English Language when spoken with the Fanti language. She is also abreast with time and current issues. PATIENT’S LIFESTYLE/HOBBIES Miss M. B is a person who usually wakes up at 4:30am every day except weekends to sweep her compound. She maintains her oral hygiene with tooth paste and brush. She baths, grooms and prepares breakfast for the family of three i. e. the husband, the step son and herself. She moves the bowel every morning and has family morning devotion on Saturdays and Sundays.
Miss M. D does not have specific time for eating but during the afternoon in her cradling activities, she buys fried yam with pepper or a ball kenkey with fish and hot pepper. Her favorite meal is fufu and light soup or groundnut soup. She normally comes back home from work at 4:00pm to prepare supper for the family. She explained that at most by 6:00pm. The supper is ready and served to the family which normally includes fufu with light soup or groundnut soup, banku with okro soup or stew or ampesi. Miss M. B does not drink alcohol neither the husband.
She habitually drinks a cup full of water 15 minutes after meal. She again maintains her personal hygiene and goes to bed at 8:00pm after watching Television. The last thing she does in the day is to pray and sleep. Since they are Christians, they always go to church on Sundays to worship at Mpeasem Deeper Life Bible Church. On Tuesdays, they go for bible study. She likes playing Ludo and although a female, she is interested in football. Her favorite local team in Ghana is Accra Hearts of Oak. PATIENT’S MEDICAL HISTORY Miss M. B had been well throughout her childhood without any allergy.
However at puberty, she always had a painful menses every month which she use two tablets of paracetamol with good effects. She explained that occasionally, she had heavy menstrual flow but did not report to any health facility for treatment because she thought it was the pattern of her menstrual cycle. But when she realized that the condition was aggravating, she resorted to herbal medicine. She lamented that, last two (2) years, she had a miscarriage for 4-5 months after conception. Miss M. B then talked about otitis media. She had she had last year for which she went for ear irrigation at the Central Regional Hospital, Cape Coast.
Apart from this illness, she normally has minor ailment such as headache, body aches, stomach ache and diarrhea for which she manages them with either herbal medicine or over the counter drugs. Moreover, she explained that since she is looking for a child, she has been moving from one herbal medicine centre to another for the past rears with the intention of getting a child. PATIENT’S PRESENT MEDICAL HISTORY Miss M. B explained that she has been experiencing heavy and irregular menstrual flow, lower abdominal pain and intermittent amenorrhea since 2008.
She lamented that, the menstrual flow lasts from 8-10 days coupled with abdominal pains. She further explained that in September, 2008, she did not have menstrual flow for almost five months therefore, she taught it was pregnancy. But for about a week to five months she experienced bleeding per vaginum suggesting miscarriage. With all these experience, she did not attend or visit any hospital except jumping from one herbal centre to the other. She was therefore introduced to Dr. Ekenam, a gynecologist in the central Regional Hospital by a friend on January, 2009 when she was diagnosed as having ovarian cyst.
She was then put on hormonal therapy but the condition kept on aggravating. Therefore, on 15th February, 2010, she was again ordered to go for abdominal scan which confirmed a left ovarian cyst of 7. 5cm. Hence, she was booked for cystectomy on 23/2//2010 after she was educated on the need to go through the surgical procedure. ADMISSION OF PATIENT Miss M. B was admitted to the Obstetric and Gynecological unit of the Central Regional Hospital on 22/2/2010 at 2:10pm by Dr. Ekenam through the Out-Patient Department (OPD) with the history of heavy and irregular menses and abdominal with the diagnoses of ovarian cyst.
She was brought into the ward in the company of the husband and on OPD nurse. On reaching the ward, they were welcomed and offered a seat to feel comfortable especially Miss M. B who was in pain. Relevant information and documents including admission notes were collected, verified and entered into the admission and discharges book and the ward daily state. A comfortable bed was provided. Vital signs checked and recorded after being helped to change into the ward gown. She was introduced to the ward mates and oriented to the ward routines, environment and staff.
Patient and her husband were reassured that with time, treatment and her cooperation, she will be fine. The husband bid the wife goodbye and left the ward since the visiting time was over. Whilst in bed, a quick assessment was made and on her from head to toe. No abnormality was observed. A brief explanation of the disease process and the treatment regimen was explained to the patient to gain his cooperation. I introduced myself once again and informed her of my intension of adopting her as my patient for care study. I assured them that, every information given to me will be respected and treated with confidentiality.
Patient and husband gladly accepted my request. A systematic and comprehensive assessment was conducted on her to obtain data to serve as a baseline from which to evaluate the effectiveness of nursing care and facilitate care planning. The vital signs checked and recorded on admission were as follows: Temperature – 36. 8 degree Celsius Pulse – 80 beats per minute Respiration – 24 cycles per minute Blood pressure -110/70 millimetres per mercury All the laboratory investigations reports were organized and filled with the following results. Hemoglobin level – 12. 1 decilitre White blood cell count – 6. Neutrophils – 67 Lymphocyte – 31 Eosinophils – 1 Basophils – 1 Pre-operative care commenced right away for the pending cystectomy on the next day. Patient was therefore prepared systematically, thus, physically, physiologically and psychologically. PATIENT’S CONCEPT OF HER ILLNESS Miss M. B perceives her condition as normal physiological changes in the body which can affect the body at anytime. Moreover, she did not attribute her illness to any spiritual cause. She explained that her prime concern was to be relieved of her pains and irregular menses and have children. LITERATURE REVIEW
The ovaries are a pair of almond-like structure, dull white in colour with corrugated surface which lie within the peritoneal cavity in a small depression of the posterior wall of the broad ligament. They are specifically situated at the fimbriated end of the fallopian tube at about the level of the pelvic brim. SIZE:The average size of each ovary is 3cm long, 2cm wide and 1 cm thick. It weighs 5-8kg. Macroscopically, the ovaries consist of the following structures: 1. THE MEDULLA : The medulla is the supporting framework which is made up of fibrous and elastic tissues serving as a point of entry for blood vessels, lymphatics and nerves.
It’s the central and inner portion of the ovary. 2. THE CORTEX This is the functional part of ovary which contains the ovarian follicles in different stage of development surrounded by stroma. The graffian follicles are embedded in the stroma. The outer layer forms a fibrous tissue known as Tunica Albuginea. Over this lies the germinal epithelium which is a modification of the peritoneum. It encloses the ovary. The follicles contain an ovum (female egg) and can be found at varying degrees of development. The Corpus Luteum is the scar which forms after the follicle has ruptured.
It is filled with blood clots and then fibroses begins. Corpus Albicans is the name given to the structure as it continues to fibrose. Corpus Fibrosum is the final stage of fibroses FUNCTIONS . The functions of ovary are, to produce ovum or formation of a mature ovum in a graafian follicles i. e. Oogenesis, expulsion of ovum from the follicles into the pelvic cavity usually known as Ovulation and also secretes hormones such as estrogen and progesterone. DEFINITION OF OVARIAN CYST An ovarian cyst is any collection of fluid surrounded by a very thin wall within an ovary.
Any ovarian follicle that is larger than about two (2) centimeters is referred to as ovarian cyst. An ovarian cyst can be as small as a pear or larger than an orange. PROGNOSIS Most ovarian cysts are functional in nature and are harmless (benign). INCIDENCE It affects all women of all ages but is mostly common in women of child bearing age. It is also found in nearly all premenopausal women with about 14. 8% post menopausal women. CLASSIFICATION OF OVARIAN CYST The ovarian cyst is classified into two (2) main groups; functional ovarian cyst and demoid or pathological ovarian cyst. A. FUNCTIONAL OVARIAN CYST
These are the simple cysts which form part of the normal process of menstruation. This type of cyst occurs during ovulation. If the ovum is not released, the ovary can be filled up with fluid such as blood. Usually, this cyst will go or disappear after a few period or cycles. Examples of functional ovarian cysts are: 1. GRAAFIAN OVARIAN CYST This is the most common functional cyst. They are usually small and arise from follicles that over distend instead of going through atretic stage of menstrual cycle. They appear as semi transparent and are filled with a watery fluid visible through their thin walls.
When such cyst persist into menopause, they secrete excessive amount of estrogen in response to the hyper secretion of follicle stimulating hormone and luteinizing hormone that normally occur during menopause 1. GRANULOSA LUTEIN/CORPUS LUTEUM CYST This occurs within the corpus luteum. They are normally non-neoplastic enlargement of the ovaries caused by excessive accumulation of blood during menstruation. It may rupture about the time of menstruation and takes up to three months to disappear entirely. 2. HAEMORRHAGIC CYST This is also called blood cyst, haematocele or haematocyst.
It occurs when a very small blood vessel in the wall of the cyst breaks and the blood enters the cyst. It is associated with abdominal pain at one side of the body usually at the right side. The bleeding may occur quickly and rapidly, stretching the covering of the ovary causing pain. It may lead to bleeding per vaginum or into the peritoneal cavity causing peritonitis. B. THE DEMOID OR PATHOLOGIC CYST THEY are tumours that are believed to arise from parts of ovum that disappear normally as ripening takes place. Demoid ovarian cysts are made up of undifferentiated embryonic cells.
They grow slowly and are found during surgery to contain a thick, yellow sebaceous material arising from a skin lining. Hair, teeth, bone, brain, eyes and many other tissues often are found in a rudimentary state within the cyst. Examples of demoid ovarian cyst are: I. ENDOMETROID CYST/CHOCOLATE CYST This is caused by endometriosis and is formed when a tiny patch of endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wall) bleeds, sloughs off, becomes transplanted and grows and enlarges inside the ovaries. II. PATHOLOGICAL CYST These are cyst caused by carcinoma/malignant cancer.
It affects approximately 15 cases per 100,000 women per year. Other pathological cyst is the polycystic ovary syndrome which is associated with tumours. This is thought to occur in 4-7% of women of reproductive age and also associated with an increased risk of endometrial cancer. AETIOLOGY OF OVARIAN CYST The exact cause of ovarian cyst is unknown but with predisposing factors. PREDISPOSING FACTORS 1. Women on hormonal therapy such as Bromocriptine (Parlodel) which inhibit the release of prolactin causing anovulation. 2. Women undergoing ovulation induction therapy. . Sex: Females are predisposed. 4. Multiple pregnancy or multiparity. 5. Patient or women with molar pregnancy. 6. Patient with hyperthyroidism. 7. Gestational Diabetes PATHOPHYSIOLOGY Each month, normal functioning ovaries develop small cyst called Graffian follicles. At mid cycle, a single dominant follicle up to 2. 8cm in diameter reaches maturity or a matured oocyte and ruptures. The ruptured follicle becomes corpus luteum which at maturity is 1. 5-2cm structured with cystic centre. In the absence of fertilization of the oocytes, it undergoes progressive shrinkage.
But if fertilization occurs, the corpus luteum initially enlarges and then gradually decreases in size during pregnancy. If the ovarian follicle fails to rupture in the course of follicular development and ovulation, a follicular cyst lined by one or more layers of granulose cells may develop. Similarly, a luthein cyst may develop if the corpus luteum becomes cystic or haemorrhagic and fails to regress normally after 14 days. It may also occur with abnormally high serum levels of human chorionic gonadotropins (HCG) in association with patients with hydatidiform mole or chorion carcinoma.
Also in patient with infertility and ovulation induction therapy with gonadotropins, it results to ovarian hyper stimulation syndrome. In neoplastic cyst, there is an inappropriate overgrowth of cells within the ovary which may be malignant or benign. Malignant neoplasm may arise from all cell types and tissues most especially mesothelium and most of these are partially cystic lesions. These cysts may reach a very large size of about 10-15cm and rotate on their stalks thus cutting their blood supply and causing severe abdominal pain and vomiting known as Torsion which is a surgical emergency.
Rupture may occur and stimulate a variety of acute abdominal emergencies such as appendicitis or ectopic pregnancies. Larger cyst may also produce abdominal swelling and pressure on adjacent abdominal organs. CINICAL MANIFESTATION Most of the functional or ovarian cysts do not produce symptoms except torsum or rupture occurs. In pathological cyst, the following clinical features are presented by the patent. 1. Dull aching or severe sudden and sharp pain or discomfort in the lower abdomen, pelvis, vagina and thighs. The pain may be constant or intermittent. 2.
Anovulation 3. Fullness, heaviness, pressure, swollen or bloated abdomen. 4. Dyspareunia 5. History of miscarriage 6. Menorrhagia 7. Frequency in urination 8. There may be constipation. 9. Excessive hair growth or increased level of hair growth 10. Secondary amenorrhea 11. Dysmenorrhea 12. Oligomenorrhoea 13. Nausea and vomiting 14. Fatigue 15. Strange pain in the ribs 16. Weight gain as a result of the disruption of the hormones, estrogen and progesterone. 17. Breast tenderness 18. Strange nodules that feel like bruises under the skin layer. DIAGNOSTIC INVESTIGATION ) Ultrasonography to reveal the cyst. b) Laparascopy: this involves viewing the abdominal cavity by passing an endoscope through the abdominal wall. c) Intravenous pyelogram: used to detect urethral compression resulting in hydronephrosis. d) Colposcopy: this is an examination of the vagina and cervix using colscope to detect any malignant change. A colscope is a speculum that employs the use of magnifying glass in identifying malignant characteristics. e) Magnetic resonance imaging (MRI): This make detailed images of the ovary showing the location of the cyst. ) Basal body temperature graph to reveal an increased level of human chorionic gonadotropin hormones. g) Endometrial biopsy: a tissue sample is removed from the ovarian lining for microscopic examination. h) Urine 17-Ketosteroid concentration level estimation. A slight elevation reveals accompany polycystic ovarian disease. i) Presenting signs and symptoms j) Physical examination through palpation of the abdominal region. k) Human chorion gonadotropin hormone tilter reveal elevation MANAGEMENT The management of ovarian cyst depends largely on the following: 1. The type of cyst . The size and location of the cyst 3. Onset of complication About 95% of all the functional ovarian cysts are benign and may disappear or treated with hormonal regulation therapy. For small asymptomatic cysts, the wait and see approach with regular check-ups are recommended. If the cyst is less than 5cm in diameter and appear to be filled with fluid in young healthy patient, oral contraceptives are frequently used in attempt to suppress the activities of the ovary and resolution of the cyst. CONSERVATIVE MANAGEMENT This involves the use of drugs to induce medical ovulation.
This is seen to be helpful in shrinking or eliminating the chorion carcinoma. Some of the drug management includes: 1. Administration of clomiphene citrate to induce ovulation. This regulates the gonadotropins releasing hormone receptors thereby stimulating the release of follicle stimulating hormones and luteinizing hormone resulting in maturation of the ovarian follicles, ovulation and development of corpus luteum. It also turns to inhibit the growth of the cyst. 2. Cetrorelix acetate 3mg stat or single dose. This also inhibits premature luteinizing hormone surge. 3.
Combined methods of hormonal contraception or anti-hormonal agents such as mifepristone depovera may also be given to regulate the menstrual cycle, prevent the formation of follicles that can turn into cyst and possible shrink an existing cyst. 4. Analgesics such as acetaminophere 650mg-975mg or 500mg-1g tdsx94hrs. Anti-inflammatory drugs such as IV hydrocortisone 50mg, Tab Ibuprofen (motrin) 400mgx94-96hrs are administered to reduce pain. Injection/intramuscular Pethidine 100mg stat can also be given to reduce pelvic pain. Non-steroidal anti-inflammatory drugs usually work best when taken at the first signs of pain. . A warm bath or heating pad or hot water bottle can also be applied to the lower abdomen near the ovaries to relax tensed muscles and relieve cramping lessen discomfort and stimulate circulation and healing in the ovaries. 6. Ice bags covered with towels can also be used alternatively as cold treatment to increase local circulation. 7. Administration of antibiotics such as tetracycline capsules 250mg qidx7days 8. Also limiting strenuous activity may also reduce the risk of cyst rupture. SUGICAL MANAGEMENT 1. Cystectomy: This is a surgical removal of an ovarian cyst through an incision into the lower abdomen’ 2.
Ooprectomy/Ovariectomy: This is also the surgical removal of the ovary. 3. Oophoro Salpingectomy: This is also a surgical removal of an ovary and its associated fallopian tube. 4. Wedge resection INDICATIONS FOR CYSTECTOMY 1. A cyst which remains after one menstrual cycle or period. 2. A cystic mass that is larger than 5cm. 3. A cyst that persist longer than 4 hours. 4. A solid mass or adnexal mass after menopause. COMPLICATIONS 1. Infertility 2. Chronic amenorrhea 3. Peritonitis 4. Painful micturition 5. Intra-Peritoneal hemorrhage 6. Shock 7. Infection 8. Obesity
VALIDATION OF DATA Miss M. B was diagnosed as having ovarian cyst. To ensure that the data obtained from her and the diagnostic investigations results are free from any biases, errors and misinterpretations. It was compared with that of the literature review. The diagnostic tests and physical examination done proved that Miss M. B is suffering from ovarian cyst since her data; the textbook s and some physical observation on her are the same, revealing that the data collected are valid. It is therefore declared that, information in this study is authentic. CHAPTER TWO
ANALYSIS OF DATA COMPARISON OF DATA WITH STANDARD This is the second phase of the nursing process. It involves the comparison of information gathered from patient through assessment with the standards acknowledged in the textbooks. It helps to identify patient’s problems and solve with the appropriate actions or procedures. It includes: a) Comparison of data collected from patient with standard b) Analysis of patient and family strength c) Health problems d) Formulation of appropriate nursing diagnoses The diagnostic investigations requested for Madam M.
B includes: Blood film for haemoglobin level White blood cell count Sickling grouping and cross-matching Blood film for malaria parasite Urinalysis for sugar, protein or routine examination THE DIAGNOSTIC INVESTIGATIONS CONDUCTED ON MY PATIENT With reference to the literature review, one or two of the following investigations must be conducted to confirm the conditions. These are Ultrasonography, Laparascopy, colsposcopy, intravenous pyelogram, urine 17-ketosteroid concentration level estimation, human chorion gonadotropin hormone estimation and physical examination.
The following investigations were therefore performed on my patient to confirm the presence of ovarian cyst. 1. Abdominal ultrasound scan which confirms the presence of a mass of 7. 5cm at the left ovary. 2. Urinalysis which also revealed the absence of ketone, cast and epithelial cells in the urine. 3. Blood sample was also collected for haemoglobin level estimation, white blood cell count, Sickling, grouping and cross matching as a supportive investigation to rule out the presence of other illness. All these investigations confirmed the presence of ovarian cyst. SPECIMEN| INVESTIGATION| RESULTS| NORMAL VALUES| INTERPRETATION| REMARKS| 27/01/10| Abdominal cavity| Ultrasound scan| A mass of 7. 42cm was seen at the left ovary but no mass was seen at the right ovary. | No mass should be seen or present| The result revealed that patient has ovarian cyst at the left ovary | Cystectomy was ordered| 19//02/10| Blood | Hemoglobin level estimation| 12. 1g/dl| Male – 12. 5-18g/dlFemale – 11. 5-16g/dl| The result showed that the level is within the normal range indicating the absence of anemia | No hematemic given neither blood transfusion indicated | 19//02/10| Blood | White blood cell count| 6. ? 109/l| 3. 0-11. 0| The values showed that the level or count is within normal range| No treatment ordered| 19//02/10| Blood | White blood cell differential count| Neutrophils – 67%Lymphocyte-31%Eosinophils – 1%Monocytes – 1%Basophils – 0%| 40-70%20-45%1-6%2-10%0-1%| Patient’s blood group is ‘O’ positive| No treatment ordered| 19//02/10| Blood | Grouping and cross matching| Blood group – ‘O’Rhesus positive| A,B,O or AB| | No treatment given| 22//02/10| Urine | Routine investigation | Urine colour was amber and free from cast, ketone epithelial cells and blood. Colour should be amber, no blood, ketone and epithelial cells should not be seen. | Within normal range| No specific treatment ordered| 19//02/10| Blood | Blood film for malaria parasite| No malaria parasite seen. | There should not be parasite seen in the blood showing negative| Patient has no malaria parasite present in the blood. | No treatment was prescribed for the patient. | CAUSES OF PATIENT’S CONDITION With reference to the predisposing causes of outlined in the literature review, the cause of Miss M. B’s condition could be attributed to her sex as a woman in her reproductive age.
It could also be as a result of hormonal imbalance. TABLE II OUTLINED UNDER THE LITERATURE REVIEW NO. | CLINICAL MANIFESTATION IN TEXT BOOKS | CLINICAL MANIFESTATION PRESENTED BY MISS M. B| 1| Dull aching or severe abdominal pain| Patient experienced lower abdominal pain| 2| History of miscarriage| Patient has had two miscarriages| 3| Anovulation| Patient usually experience anovulation| 4| Dyspareunia| Patient occasionally experience painful coitus. | 5| Fullness, heaviness or pressure and bloated abdomen| Patient did not show the symptom| 6| Menorrhagia| There was menorrhagia| | Dysmenorrhea| Patient experienced secondary Dysmenorrhea| 8| Frequency in micturition| Patient had normal micturition| 9| Constipation| There was occasional constipation| 10| Excessive hair growth| Patient had normal hair growth| 11| Oligomenorrhoea| Patient had no oligomenorrhoea| SPECIFIC TREATMENT ORDERED FOR MISS M. B The treatment for Miss M. B was aimed at relieving pain, symptoms of the disease and prevents further complications. The treatments are as follows: 1. Intravenous metronidazole 500mg 8hourlyx48hours 2. Intravenous Amoksiclav 600mg 12hourlyx48hours 3.
Intravenous Gentamycin 80mg 8hourlyx72hours 4. Intramuscular Pethidine 100mg stat 5. Intravenous fluid Dextrose saline 2litresx24hours 6. Intravenous fluids Ringers Lactate 1litrex24hours 7. Capsules Nexcofer 1 dailyx30days 8. Suppository Diclofenac 100mg 12hourlyx5/7 9. Capsules Doxycycline 100mg12hourlyx10days 10. Tablet Metronidazole 400mg 8hourlyx6days 11. Tab GVfluc 150mg stat 12. Tab paracetamol 1g 8hourlyx3days SURGICAL INTERVENTION The surgical intervention rendered to Miss M. B was cystectomy. Cystectomy is a surgical removal of ovarian cyst without tempering with anything attached to the ovary.
Instead, an incision is made through the abdomen with subcutaneous tissue and facial muscles dissected. The uterus is mobilized and the ovary incised with the cyst removed. The tissue from the cyst was taken for histopathology at Korle-Bu Teaching Hospital. Rectus muscle was closed with vinyl 20 and the skin closed with nylon 2. 0 in continuous fashion. Cystectomy was preferred in Miss M. B’s case because she had a cyst of 7. 5cm and she also desired to have children. TABLE III PHARMACOLOGY OF DRUGS ORDERED FOR MISS M.
B DATE| DRUG| DOSAGE/ROUTINE OF ADMINISTRARION| CLASSIFICATION| DESIRED EFFECTS| ACTUAL EFFECTS/ACTION OBSERVED| SIDE EFFECTS/REMEDIES| 23/02/10| Metronidazole| 500mg 8hourlyx2daysIntravenous| Antibacterial| 1. For infections caused by anaerobic bacteria and protozoa. 2. For treatment of surgical and gynecological sepsis. 3. Works at both intestinal and extra intestinal sites. | It prevented post operative infections or sepsis by inhibiting protein synthesis causing cell death of microorganisms. It also prevented colonic anaerobic bacteria infections as patient did not experience any sign of infection. Fever, vertigo, rash, headache, dizziness, depression, polyuria, rhinitis. No side effects observed. | 23/02/10| Co-Amoxiclav| 600mg12hourlyx2days| Antibiotics (broad spectrum)| -Prevents surgical and gynecological sepsis. -Prevents infection caused by aerobic and protozoa. | It prevented patient from post-operative sepsis| Dizziness, anxiety, insomnia, agitation, nausea and vomiting. None was observed. | 23/2/10| Gentamycin| 80mg 8hourlyx3days| Anti bacteriaAnti infectiveAnti protozoa| For the treatment of systemic infection and pelvic inflammatory disease.
For suspected infection of immune-compromised patients. | It relieved the patient from systemic infection and pelvic inflammatory diseases. | Fever, headache, vertigo, confusion, encephalopathy, anemia. None was observed. | 23/02/10| Pethidine| 100mg stat intravenous| Narcotic analgesic| | Patient was relieved of pain and was able to sleep well. | Physical dependence, sedation, euphoria, headache, hallucination, hypotension. None was observed. | 23/02/10| Dextrose saline| 2 litresx24hours intravenously 20 drops per minute | Sterile isotonic solution for sodium and glucose. | 1.
Fluid and electrolyte balance and sodium depletion. 2. To correct dehydration. | It increased the patient’s blood and fluid volume to normal and corrected fluid and electrolyte imbalance. | Oedema, hypernatremia, confusion, exacerbation, hypertension, heart failure. None observed| 23/02/10| Ringers Lactate| 1litrex24hours intravenously 20drops per minute| Sterile isotonic solution for sodium, calcium and potassium chloride compounds. | For fluid and electrolyte replacement| It increased the fluid and blood volume of patient. Corrected fluid and electrolyte imbalances| Hypercalcaemia and oedema.
None was observed| 23/02/10| Diclofenac (suppository)| 100mg 12hourlyx5days rectally| Non-steroidal anti inflammatory drugs| For the relieve of severe to moderate pain. | It relieved patient of mild pain| Depression, anxiety, drowsiness, insomnia, rash blurred vision. None was observed| 23/02/10| Nexcofer (capsules)| 1 ddailyx30days| Vitamin and mineral supplement| For vitamins A and D and ascorbic acid deficiency correction. To boost appetite level for food. | Helped patient to eat well by increasing the patient’s appetite level for food. It also aided in the healing of patient’s wound. Overdose may cause skin roughness, dry hair and enlarged liver. None was observed| 24/02/10| Doxycycline (capsules)| 100mg 12hourlyx10days broad spectrum. | Broad spectrum antibiotics| 1. for the treatment of pelvic inflammatory disease. 2. | Prevented post-operative sepsis and pelvic inflammatory disease after treatment | Nausea and vomiting, pericarditis, Dysphagia, anorexia None was observed| 23/02/10| Tab Metronidazole | 400mg 8hourlyx6days| Anti-infectiveAnti-protozoa | Disrupts DNA and protein synthesis| It helped to relieve abdominal pain after treatment| Headache, nausea, abdominal pain, diarrhea, dry mouth.
She complained of having an unpleasant taste in the mouth, oral care was done | 24/02/10| GVFluc (tablet)| 150mg stat orally| Anti fungal agent| Inhibits replication of fungal enzymes | Prevented post operative fungal infection on patient| Nausea, vomiting, abdominal pain, headache. None was observed | 25/02/10| Paracetamol (tablet)| 1g 8hourlyx3days| Analgesicantipyretic| Suppresses inflammation by inhibiting cyclooxygenase enzyme that is responsible for the synthesis of prostaglandins. | Relieved patient of pain and high temperature| Liver damage, jaundice/None was observed. |
PATIENT/FAMILY STRENGHT Despite the fact that Miss M. B was disturbed about the condition and the surgery, she was fully conscious on admission, oriented to person, place and time. She was able to speak out clearly and communicate with staff in a common dialect (Fanti). She had National Health Insurance with Oguaa Mansin Mutual Health Insurance Scheme. She could perform activities of daily living with a minimal support. Miss M. B could tolerate her medication as well as injections. She could also cooperate very well with the staff of and ward mates and was ready to adhere to all instructions given.
Patient’s family members were supportive especially her husband Mr. J. A and they were willing to provide all needed information. She was able to eat well after she was ordered to start meal post-operatively. In contribution, to her speedy recovery were prayers, beliefs and blessings from God on her in addition to all the above mentioned strength. COMPLICATIONS Miss M. B experienced irregular and excessive bleeding during menstrual period. She occasionally experienced amenorrhea, miscarriages and infertility or childless as a result of the ovarian cyst.
Prompt management that is cystectomy was ordered and nursing intervention rendered to prevent further complications. Also due to prompt treatment, other complications such as peritonitis, intra peritoneal haemorrhage and shock as mentioned in the literature review were presented. PATIENT’S HEALTH PROBLEMS 22ND FEBRUARY, 2010 1. Lower abdominal pain 2. Anxiety 3. Inadequate information on ovarian cyst 4. Infertility 23RD FEBRUARY, 2010 5. Dizziness 6. Insomnia 7. Incisional pain 24TH FEBRUARY, 2010 8. Indwelling urethral catheter in site 25TH FEBRUARY, 2010 9. Incisional wound NURSING DIAGNOSES 1.
Alteration in body comfort (lower abdominal pain) related to the effect of ovarian cyst. 2. Anxiety related to uncertainty of the outcome of impending surgical operation (cystectomy). 3. Altered family process (infertility) related to ovarian cyst. 4. High risk for injury (dizziness) related to anesthesia. 5. Knowledge deficit related to lack of exposure to information on ovarian cyst. 6. Sleeping disturbance (insomnia) related to incisional pain. 7. High risk for urinary tract and wound infections related to an indwelling catheter in site and incisional wound. 8. Alteration in body comfort (pain) related to incisional wound or surgery. . Impaired skin integrity related to cystectomy CHAPTER THREE This chapter is made up of nursing care plan including the setting of objectives of outcome criteria. The plan is done in order of priority and emergence with which it was presented and at the end nursing interventions is evaluated to review whether the goals were met or not. PRE-OPERATIVE CARE PLAN FOR MISS M. B DATE/TIME| NURSING DIAGNOSIS| OBJECTIVES/OUTCOME CRITERIA | NURSING ORDERS| NURSING INTERVENTION| DATE/ TIME| EVALUATION| SIGN| 22/2/102:30pm| Alteration in body comfort (lower abdominal pain) related to the effect of ovarian cyst. Patient’s body comfort will improve within 6 hours as evidenced by the patient verbalizing reduced abdominal pain and nurse observing patient’s relaxed facial expression. | 1. Reassure patient of reduction of pain within 6 hours. 2. Put patient in a semi-fowlers position3. Apply warm compresses to the lower abdomen. 4. Serve copious drinks as patient can tolerate. 5. Serve prescribed analgesics. 6. Ensure serene environment. 7. Encourage patient to rest. | 1. Patient reassured that pain will subside within 6 hours. 2. Patient put in a semi-fowlers position to relieve pressure on the abdomen. . Towel soaked in warm water and applied to the patient’s lower abdomen. 4. Patient served with 500mls of cold Fanta and 1000mls of cold water. 5. Prescribed analgesics such as tab. Paracetamol 1g tds? 3 served to patient. 6. Nearby radios and television switched off to ensure quite environment. 7. Patient’s bed remade to encourage patient to rest. | 22/2/108:30pm| Goal met as patient verbalized reduced lower abdominal pain and nurse observed patient’s relaxed facial expression. | | 22/2/102:40pm| Anxiety related to uncertainty of the outcome of impending surgical operation (cystectomy). Patient’s anxiety will be relieved within 5 hours as evidenced by the nurse observing patient’s participation in the pre- operative preparation. 2. Patient signing the consent form. | 1. Reassure patient of the competency of the staff especially the surgical team. 2. Orient patient to the theatre and ward environment. 3. Explain to the patient every procedure and their reasons at the ward. 4. Introduce other patients who have undergone same or similar operation and are recovering successfully. 5. Explain to the patient the need for the surgery. 6. Involve the patient in decision making of her care. . Assist patient to sign the consent form. | 1. Patient reassured of being in the hands of competent staff. 2. Patient oriented into the ward and theatre environments. 3. Checking of vital signs, medication, serving of bed pans and ward dressing procedures explained to the patient. 4. Patient was introduced to other patients who have successfully undergone same or similar operation and are recovering safely. 5. Reasons for the cystectomy as the best line of treating ovarian cyst explained to patient. 6. Patient involved in every decision in her care. 7.
Patient assisted to sign the consent form. | 22/2/107:40pm| Goal met as evidenced by the patient participating in her pre-operative preparation and also expressed relaxed face. | | 22/2/103:00pm| Knowledge deficit related to lack of exposure to information on ovarian cyst. | Patient will have knowledge about ovarian cyst and its prognosis within 2 hours as evidenced by the patient able to answer questions on the condition and nurse observing the patient’s willingness to participate in her care. | 1. Reassure patient that she will be educated on her condition. . Establish good rapport with the patient and assess her willingness to cooperate. 3. Create a comfortable learning environment. 4. Review patient’s knowledge on the condition. 5. Educate patient on her condition (ovarian cyst). 6. Allow patient to ask questions on the condition. 7. Ask patient questions to evaluate her knowledge and understanding on lessons discussed. 8. Thank patient and make her comfortable in bed. | 1. Patient reassured that she will be given information to the best of her understanding. 2. Good rapport established with patient through ntroduction and patient’s willingness to cooperate also assessed. 3. Comfortable learning environment such as good ventilation, and proper sitting arrangement offered to enhance effective learning. 4. Questions on ovarian cyst asked from the patient to assess her knowledge on the condition. 5. Patient educated on the meaning, causes, predisposing factors and management of ovarian cyst. 6. Patient encouraged and allowed to ask questions on the condition and appropriate answers given. 7. Questions asked to evaluate patient’s understanding on the lesson discussed. 8. Patient thanked and made comfortable in bed. 22/2/105:00pm| Objective fully met as patient could explain the condition to her husband and also answer all questions on her condition. | | 22/2/106:20pm| Altered sexuality pattern (infertility) related to ovarian cyst. | Patient will express improved satisfaction with sexual patterns within 72 hours as evidenced by the patient1. Expressing the acceptance of the condition as normal. 2. Husband expressing the readiness to adopt a child if all medical interventions fail. | 1. Reassure patient of an improved family process. 2. Explain to the patient and husband the pathophysiology of the ovarian cyst in relation to infertility. . Explain to the patient and family about the causes of infertility. 4. Encourage husband and significant others to participate in the care of the patient. 5. Introduce the couple to other couples who have under gone such situation and have conceived and delivered babies successfully. 6. Educate couples about reproduction and sexual function. 7. Educate couples about other options such as child adoption and artificial insemination. 8. Introduce patient and husband to special psychologist if possible. | 1. Patient reassured that with the will of God, she shall become pregnant and have children. 2.
The pathophysiology of ovarian cyst explained to the patient and husband. 3. Causes of infertility such as endocrine erectile dysfunction, varicocele and genital infections were explained to patient and family. 4. Husband and significant others encouraged to participating in the care of the patient. 5. Couples introduced to other couples who have ever gone through problems of infertility but have had children successfully. 6. Couples educated on reproduction and sexual functions and factors that interferes fertility such as excessive intake of aphrodisiac, stress and sexual transmitted infections. 7.
Couples educated on the options of child adoption and artificial insemination. 8. Couples introduced to special psychologist for further counseling. | 25/2/106:00pm| Goal partially met as patient sexuality pattern could not improve. | | POST-OPERATIVE CARE PLAN FOR MISS M. B | 23/2/1012:20pm| High risk for injury (dizziness) related to anesthesia. | Patient will be free from injury throughout recovery period as evidenced by the nurse observing that patient has no injuries and patient verbalizing that she does not feel dizzy any more. | 1. Reassure patient of injury free recovery. 2. Encourage patient to have complete bed rest. . Encourage patient to call for help whenever necessary. 4. Anticipate the needs of the patient and provide them. 5. Encourage patient to perform all activities in bed. 6. Provide side rails for patient. 7. Monitor vital signs as indicated by the surgical team. | 1. Patient reassured that she will recover from the anesthesia without injuries. 2. Patient’s bed remade and nearby radios switched off to encourage patient to have comfortable bed rest. 3. Patient encouraged to calling for help whenever necessary. 4. Patient’s needs anticipated and provided. 5. Patient encouraged and assisted to perform all activities in bed. . Side rails, bed blocks and sand bars provided to patient’s bed to prevent unnecessary movement and falls. 7. Vital signs checked every 15 minutes for the first 30 minutes, 30 minutes for 1 hour, hourly for 2 hours and 4 hourly as indicated by the surgeon and abnormalities reported. | 23/2/109:20pm| Goal fully met as patient had injury free anesthetic recovery. | | 23/2/106:30pm| Sleep pattern disturbance (insomnia) related to incisional pain| Patient’s sleep pattern will improve within 24 hours as evidenced by the nurse observing patient able to sleep or rest 3 hours in the day and 5-7 hours during the night. | 1.
Reassure patient of an improved sleep pattern. 2. Ask patient to identify factors that make sleeping difficult for her. 3. Maintain well ventilation and serene environment necessary for sleep of patient. 4. Assist patient to take warm bath. 5. Provide patient with sleeping aids. 6. Assess the pain of the patient and manage with prescribed medications. 7. Perform activities at a go and encourage patient to rest. | 1. Patient reassured that she will be able to sleep well within 24 hours. 2. Patient asked and encouraged to identify factors such as excessive noise, poor ventilation and movement in the ward which make sleeping difficult for her. . Nearby doors opened, lights switched off and radio volumes minimized to create conducive environment necessary for sleep at the ward. 4. Patient assisted to have warm bath. 5. Sleeping aids such as magazines provided to patient. 6. Prescribed drugs such as suppository Diclofenac 100mg served with no side effect observed after the pain assessed. 7. Activities performed at a go so as to disrupt patient’s sleep and rest period. | 24/2/106:30pm| Objective met as patient could sleep at least 3 hours in the day and 5-7 hours at night. | 24/2/108:20am| Alteration in body comfort (pain) related to incisional wound| Patient’s pain will reduce within 6 hours as evidenced by the patient verbalizing that pain has reduced and nurse observing patient’s relaxed facial expression. | 1. Reassure patient of a reduction in pain within 6 hours. 2. Assess patient’s pain level. 3. Put patient in a semi fowlers position. 4. Observe the incisional site for discharges and possible signs of infection. 5. Monitor vital signs 4 hourly. 6. Serve copious cold drinks as tolerated by patient. 7.
Set trolley for wound dressing. 8. Encourage early ambulation and deep breathing exercises. 9. Serve prescribed medications. 10. Ensure personal hygiene11. Encourage patient to rest. | 1. Patient reassured that her pain will be reduced within 6 hours. 2. Patient’s pain level assessed through facial expression and tolerance level. 3. Patient put in a semi fowlers level or comfortable position to reduce pressure on the suture line as tolerated by patient. 4. Incisional site observed for drainage, odour, swelling and colour change of the skin to prevent wound infection. 5.
Vital signs such as temperature, pulse, respiration and Blood pleasure monitored 4 hourly and abnormalities reported. 6. Cold drinks such as yoghurt and water served to patient as she could tolerate. 7. Trolley set for and wound dressed aseptically. 8. Early ambulation and deep breathing. 9. Prescribed drugs such as injection Pethidine and Gentamycin served. 10. Patient assisted to bath and mouth cared for, twice daily. 11. Patient encouraged to having enough rest. | 24/2/102:20pm| Goal partially met as evidenced by the patient experiencing intermittent incisional pain. | 24/2/108:00am| High risk for urinary tract and wound infections related to an indwelling catheter and incisional wound. | Patient will be free from urinary and wound infections within 24 hours by the nurse monitoring and observing for signs of infection such as pyrexia, odour, swelling of the wound site and offensive discharges. | 1. Reassure patient she is in competent hands and will receive the maximum care needed. 2. Monitor vital signs 4 hourly. 3. Put patient in a lithotomy position. 4. Set tray and perform catheter care using aseptic technique at least twice a day. 5.
Observe vulva and urethral orifice for any discharge and redness. 6. Serve diet rich in protein, high fibre and vitamins. | 1. Patient reassured that she is in good and competent hands for maximum free from infections. 2. Vital signs such as temperature, respiration, pulse and BP monitored every 4 hourly and abnormalities reported. 3. Patient put in a lithotomy position as she could tolerate to reduce pressure on the suture lines. 4. Tray set and catheter care performed aseptically twice a day. 5. Vulva and urethral orifice observed at least twice daily for discharges, redness and odour to rule out infection. . Agidi and light soup, pineapple and Fanta served as patient could tolerate. | 25/2/108:00pm| Goal met as patient was free from urinary tract infection throughout the period of hospitalization. | | 25/2/109:00am| Impaired skin integrity (incisional wound) related to cystectomy. | Patient’s skin integrity will improved within 10 days as evidenced by the nurse observing patient wound healed by first intention. | 1. Reassure patient that her wound will heal by first intention. 2. Observe wound for signs of wound infection. 3. Educate patient to keep wound dry and also keep her hands away from the wound. . Open the wound and dress using aseptic techniques after third day of operation. 5. Monitor vital signs and report any abnormalities. 6. Remove stitches on the seventh day post operatively. 7. Observe wound for signs of healing. 8. Serve diet rich in proteins and vitamins. 9. Assist patient to ensure personal hygiene. 10. Serve prescribed antibiotics such as Metronidazole. | 1. Patient reassured that her incisional wound will heal by first attention. 2. Wound observed for signs of infections such as redness, swelling, foul odour and colour of skin changes. 3.
Patient educated on the need to keep the wound dry, and hands away from the wound to avoid infection. 4. Wound opened and dressed using aseptic technique after three days of operation. 5. Vital signs such as temperature, respiration, pulse and BP monitored 4 hourly and abnormalities reported. 6. Stitches removed on the 7th day post operatively using aseptic techniques. 7. Wound observed for signs of healing such as presence of itching, apposition of edges, absence of foul smell and absence of pus. 8. Diet rich in protein and vitamins such as oranges and agidi and light soup with fish served. . Patient assisted to bath, perform perineal and oral care at least twice daily. 10. Tab Metronidazole 400mg and other prescribed medications served. | 7/3/109:00am| Goal fully met as wound healed by first intention. | | CHAPTER FOUR IMPLEMENTING PATIENT/FAMILY CARE PLAN This chapter marks the fourth phase of the nursing process which signifies the giving of care in relation to the defined nursing interventions and objectives set. It includes the summary of the actual nursing care rendered to the patient and her family throughout the period of hospitalization and the subsequent home visits.
SUMMARY OF THE ACTUAL NURSING CARE RENDERED TO MISS M. B AND HER FAMILY DAY OF ADMISSION – 22ND FEBRUARY, 2010 On 22nd February, 2010, Miss M. B was admitted into the obstetric and gynaecological ward of the Central Regional Hospital (CRH) at 2:20pm by Dr. Ekenam through the Out-Patient Department (OPD) with a history of abdominal pain, anovulation, and secondary amenorrhea since two years. She was diagnosed of having ovarian cyst at the left ovary and was therefore booked for cystectomy on 23rd February, 2010. She was accompanied by her husband and an OPD nurse.
They were warmly welcomed and seats were offered to them at the nurses’ station. On admission, she looked very anxious and was therefore reassured that she is in competent and safe hands. She and her husband were once again reassured that all the necessary support will be given to them in order to go through the procedure successfully. The necessary document and admission notes were collected from the accompanying nurse. Patient was admitted into an already prepared bed and assisted to change into her hospital gown. Her vital signs were checked and recorded as follows: Temperature – 36. 8 degree Celsius
Pulse – 80 beats per minute Respiration – 24 cycles per minute Blood pressure – 110/70 millimetres of mercury A cheerful and quick assessment from the head to the toe was made on the patient and was observed to have scar on the left arm. When asked about the scar, she explained that she sustained the injury as a result of one of the beatings melted out to her by the auntie at the teenage period when she stayed with her long time ago. I therefore educated her on the need to keep the scar away from further injury to prevent further complications. Again on the assessment, it was realized that Miss M.
B had little knowledge about her condition therefore she was reassured that education would be given to her to get more insight into her condition. Towel soaked in warm water was applied to the lower abdomen of the patient to ease the abdominal pain. 500mls of cold Fanta served and 1000mls of water given within 6 hours of admission. Tab Paracetamol 1g served with nearby radio and television set minimized in volume to ensure quiet environment. Patient encouraged to sleep after taken her bath. At 6:30pm, patient was reassured of an improvement in sexual satisfaction that with the will of God, she will become pregnant and have children.
Education was given on the condition in terms of pathophysiology, causes and complications of the condition. Other causes of infertility such as endocrine disorders, erectile dysfunction and genital infections were explained to patient. Reproductive functions and other factors that interferes with fertility such as excessive intake of aphrodisiac, psychological problems were also explained. Options of child adoption were also explained to patient. DAY OF SURGERY This is the day scheduled for the surgical intervention that is cystectomy for Miss M. B. The night before this day, Miss M.
B had a sound sleep after her anxiety was relieved with continuous reassurance, education on her condition and the encouragement to participate in her care. Opportunity was given to Miss M. B to express her fears and concerns for which she was helped through the explanation of all procedures with their reasons. She was therefore prepared psychologically, physiologically and physically for the safety of the surgery. PSYCHOLOGICAL PREPARATION The psychological preparation started on the day of admission which was 22nd February, 2010. It was explained to Miss M.
B that surgery is the next line of action when all other conservative treatment for her condition has failed. She was reassured of good nursing care and the competency of the health team. The theatre staff were invited and introduced to Miss M. B for which she was told of some of the things she will see on reaching the theatre. What is expected of her so as to cooperate and ensure safety procedure was also explained to her. Her knowledge about the condition was assessed. The purpose and procedure for the surgery were also explained to the patient and family in the Fanti language.
She was informed that anesthesia will be given before the procedure so she would not experience any pain during the surgery but when she returns to the ward, she would experience some pain at the incisional site which will be managed with good nursing care and appropriate drugs. It was also explained to her that, she is on nil per os because during the procedure, she will be given anesthesia which will suppress the brain centres (to make her sleep) so if there is any food, in her stomach for less than 12 hours, she may aspirate the food which can choke her.
All Miss M. B’s questions were answered honestly and tactfully to her as well as all nursing procedures and diagnostic investigations explained. She was also involved in every decision in her care. The consent form was explained to her and the husband as a legal evidence to the surgery so its content were carefully read to them to their understanding and its signing emphasized. Miss M. B was introduced to Mrs. P. D who was recovering from the myomectomy. PHYSIOLOGICAL PREPARATION
A tray was set for blood and urine samples to be taken for the following l