AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET GOALS AND CONCLUSION

By | July 14, 2021

CHAPTER FIVE (5)

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

Evaluation means judgment of action and the outcome of orders as against previously determined goals. In the nursing process, it is the stage at which the patient’s goals for nursing care have been met. Thus, to initiate the evaluation phase, the nurse must review and reflect on the goals set by the original care plan. In evaluation, the nurse assesses the outcome criteria and identifies if goals were partially or fully met. Evaluation is important because the conclusion reached determines the next nursing intervention

STATEMENT OF EVALUATION

When the patient was admitted a lot of objectives were set to relieve her of her condition. These objectives were fully met as a result of proper nursing and medical care rendered.

  1. The objective set for epigastric pain was fully met as;
  2. The patient verbalized the absence of pain.
  3. The nurse observed that patient was cheerful in bed.
  4. The objective set for electrolyte imbalance was fully met as:
  5. The patient verbalized the absence of vomiting.
  6. The nurse observes the patient’s skin for good skin turgor, moist lips, and mucus membrane.
  7. The objective set for anxiety was fully met as;
  8. The patient’s stated a reduction in her anxiety level.
  9. The nurse observed the patient conversing with other patients.
  10. The objective set for risk for impaired nutrition (less than body requirements) was fully met as:
  11. The patient maintained a normal weight in relation to her age.
  12. The nurse observed that patient ate all of her meals served.
  13. The objective set for impaired elimination pattern (constipation) was fully met as:
  14. The patient stated that she is passing semi formed stool.
  15. The nurse observed that patient spent less time in the toilet.
  16. The objective set for disturbed sleep patterns was fully met:
  17. The patient stated that she slept well.
  18. The nurse observed patient slept uninterruptedly for 2 hours during the day and 6 hours during the night.
  19. The objective set for knowledge deficit on the condition was fully met as:
  20. The patient gave accurate feedback on the information given on Peptic ulcer disease.
  21. The nurse observed the Patient answer 3 out of 5 questions asked.

 

AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET GOALS

With effective nursing care rendered to Madam R.A., coupled with the cooperation and assistance from patient and family, goals were fully met and there was no need for an amendment to the care plan.

TERMINATION OF CARE

Termination is the last phase of the nurse/patient relationship. It is a very difficult step to take after a good interpersonal relationship has been established between the nurse and the patient, for this reason, the reality of separation has to be explained on the first day of admission.

Interaction with the patient and her family began on the day of admission which is 7th November 2019. Home visits were made on different occasions to the patient’s house to see how far she was progressing. Series of health education was given during such visits.

On the day of the last visit, which was made on the 25th of November, 2019, the patient was very well and had no complaints.

Finally, the arrangement was made and the patient was handed over to a public health nurse at Royal Hospital for continuity of care.

AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET GOALS AND CONCLUSION

SUMMARY AND CONCLUSION

SUMMARY OF CARE

Madam R.A was admitted on the 7th of November to the Female Ward of Ho Municipal Hospital for continuity of care from the Emergency Unit. She came with the diagnosis of Peptic Ulcer Disease (PUD). She came with two relatives and a member of the admission team from the Emergency Unit and was warmly welcomed and her particulars and vital signs (temperature, pulse, respiration, and blood pressure) were checked and recorded. Her name was entered into the admission and discharge book as well as the daily wards state. The patient and family were reassured that she would be well taken care of. They were oriented to the ward environment and a comfortable bed was made for her. Throughout the period of hospitalization, and effective nursing care was given to the patient. The patient’s health problems were identified and goals and objectives were set to help solve these problems.

The patient was managed with the following medications

  Caps Omeprazole                            20mg 12 hourly for 14 days

  Caps Amoxicillin                            500mg 8 hourly for 14 days

  Tablet Clarithromycin                       500mg 12 hourly for 14 days

  Tablet Metoclopramide                     10mg 24 hourly for 5 days

  IVF Dextrose Normal Saline             4litres over 24 hours

  Tablet Paracetamol                            1g 8 hourly for 7 days

The following investigations were carried out;

  Full Blood Count

  Albumin Level Estimation

  Globulin

  BUN Level Estimation

  Blood Creatinine

  Routine Stool Examination

She was given appropriate care which facilitated her speedy recovery and she was discharged on the 13th of November, 2019. She spent six (6) days on the ward. She was visited at home and care was finally terminated on the 25th of November, 2019 after she had honored her review visit to the hospital.

All goals and objectives set to resolve identified problems were fully met due to effective nursing care rendered to patients.

CONCLUSION

The patient/family care study has helped me to gain good insight into the disease condition Peptic Ulcer Disease. It has helped me to understand comprehensive nursing care that has to be rendered to the individual patient.

This study has equally helped me to put the knowledge I have acquired from the nursing course into practice. I have also been able to establish a good interpersonal relationship with my patient and family. Patient/family care study has helped me to understand the nursing process well. The experience would enable me to care for patients not only with Peptic Ulcer Disease but other conditions in the future.

I also suggest that every student nurse should make it a point to put the nursing process concept into practice for it enables quality nursing care to be rendered to all patients.

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