Planning is the next step in the nursing process after nursing diagnosis has been established. This is where the nurse formulates the nursing strategies or interventions required to prevent, reduce or eliminate the patient’s health problem gathered during analysis. The planning phase of the nursing process includes;
- Identification of patient’s problem
- Setting priorities
- Establishing patient’s goal and outcome criteria
- Planning nursing measures
- Writing out a care plan comprising of nursing diagnosis, objectives/outcome criteria, nursing orders, nursing intervention and evaluation of care for patient.
OBJECTIVES OF CARE
- Patient’s pain will be relieved within 48 hours as evidenced by
- Patient verbalising the absence of pain.
- Nurse observing patient to be cheerful in bed.
- Patient’s electrolyte level will be maintained throughout the course of hospitalisation.
- a) Patient verbalising the absence of vomiting.
- b) Nurse observes patient’s skin for good skin turgor, moist lips and mucous membrane.
- Patient and family will express a reduction in the anxiety level within 48 hours as evidenced by:
- a) Patient stating a reduction in her anxiety level.
- b) Nurse observing patient to be conversing with other patients.
- Patient will maintain her nutritional status throughout hospitalization as evidence by
- a) Patient having normal body weight in relation to her age
- b) Nurse observing that patient eat all of her meals served
- Patient’s elimination pattern will be restored with 48 hours as evidenced by
- a) Patient stating that she is passing semi formed stool.
- b) Nurse observing that patient spends patient less time in the toilet.
- Patient’s sleep pattern will be restored within 24 hours as evidenced by:
- a) Patient stating that she slept well
- b) Nurse observing that patient sleeps uninterruptedly.
- Patient will gain adequate knowledge into the cause and management of peptic ulcer disease within 48 hours as evidenced by:
- Patient’s ability to give accurate feedback on the information given on the condition.
- Nurse observes patient answer at least 3 out of 5 questions asked.
Implementation refers to putting into action, the nursing orders outlined in the nursing care plan to relieve patient and family of their health-related problem. It involves carrying out both medical and surgical nursing interventions. The patient and relatives are encouraged to participate by playing their part for the patient’s speedy recovery.
The actual nursing care rendered to Madam R.A., was aimed at meeting patient’s recovery. The nursing care started on the day of admission which was 7th November, 2019 to the time of discharge on 13th November, 2019 till care was terminated.
Madam R.A was admitted to the Female Ward of Ho Municipal Hospital through the Emergency Unit by Dr Osei on 7th November, 2019 with the diagnosis of Peptic Ulcer Disease.
Patient was wheeled into the ward in a fully conscious state with two (2) relatives accompanied by the admission team member from the Emergency Unit. She and her family were warmly welcomed and were made comfortable on seats close to the nurse’s station. Patient’s documents were collected from the admission team member. The staff who received them introduced herself and other staffs present to the patient and family. On admission, Madam R.A was neatly dressed, could give good account of herself but was in pain.
Patient was reassured and made comfortable in an already prepared bed. Her particulars were obtained from her relatives.
Temperature – 36.8 degree Celsius
Pulse – 98 beats per minute
Respiration – 22 cycle per minute
Blood Pressure – 120/80 millilitres of mercury
Patient was given IM Metoclopramide 10mg stat, IV Omeprazole stat and IV Ringers Lactate was set up after an intravenous line was secured as ordered by the doctor.
The following problems were identified:
- Patient complained of abdominal pain
- Patient complained of persistent vomiting for two days
- Patient complained of body weakness
- Patient was anxious
The above problems were managed by; patient being reassured, nurse patient relationship was established, the need for hospitalisation was explained to her, her needs were attended to promptly, vital signs were monitored, Client’s level of pain was assessed and was made to assume comfortable positions. Fluid intake was encouraged, items were kept within her reach, bulk nursing was practiced in order for her to rest.
Client’s National Health Insurance was explained to her and her relatives that the scheme will take care of her hospital bills but they would pay for medications that are not covered by the scheme.
Client was put on the following medications;
- Caps Omeprazole 20 milligram bd x 14 days
- Tablet Clarithromycin 500 milligram bd x 14 days
- Caps Amoxicillin 500 milligram tid x 14 days
- Tablet Paracetamol 1-gram tds x 7 days
- Tablet Metoclopramide 10 milligram daily x 5 days
- IV Ringers Lactate 1litreover 12 hours
- IV Dextrose normal saline 4litres over 48 hours
Client’s medications were served and recorded on the medication chart and documented in the nurse’s note.
Client’s belongings were collected and sent to her bedside. Client and relatives were oriented to the ward. The hospital and ward protocols such as visiting hours and ward rounds were explained to them. I informed patient that I wanted to use her for my patient and family care study and because of this I will be the one taking care of her during her stay in the hospital. I also made it known to her that I would need information about her and her family to aid in my writing to which she agreed.
The following laboratory investigations were requested;
- Full blood count
- BUN level estimation
- Blood creatinine
- Routine Stool Examination
Client’s samples were taken and sent to the laboratory. At 6:00pm routine vital signs were checked and due medications were served. Client was asked to watch television , this was to divert her attention from the pain. After an hour, all forms of disturbance were restricted to allow client rest. She slept at 10:30pm.