PATIENT AND FAMILY CARE STUDY

(A NURSING PROCESS APPROACH)

ON

A PATIENT WITH

HYPOSPADIAS

SAMANTHA FLOWERS ………………………..

INDEX NUMBER: ……………………

A FINAL YEAR STUDENT OF NURSES' TRAINING COLLEGE, SAMPA

SUBMITTED TO THE NURSING AND MIDWIFERY COUNCIL OF GHANA IN

PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF

REGISTRERED GENERAL NURSING DIPLOMA CERTIFICATE

JULY, 2019.
 PATIENT AND FAMILY CARE STUDY

(A NURSING PROCESS APPROACH)

ON

A PATIENT WITH

HYPOSPADIAS

BY

SAMANTHA FLOWERS ………………………..

INDEX NUMBER: ……………………

A FINAL YEAR STUDENT OF NURSES' TRAINING COLLEGE, SAMPA

SUBMITTED TO THE NURSING AND MIDWIFERY COUNCIL OF GHANA IN

PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF

REGISTRERED GENERAL NURSING DIPLOMA CERTIFICATE

JULY, 2019.
 TABLE OF CONTENTS

TABLE OF CONTENTS……………………………………………………………….

LIST OF TABLES……………………………………………………………………...

PREFACE………………………………………………………………………………

ACKNOWLEDGEMENT……………………………………………………………..

INTRODUCTION……………………………………………………………………..

CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY………………………………………….…

1.0 Introduction………………………………………………………………...

1.1 Patient Particulars……………………………………………………….....

1.2 Patient and Family Medical History………………………………………

1.3 Patient’s/Family Socio-Economic History………………………………..

1.4 Patient’s Developmental History…………………………………………..

1.5 Patient’s Lifestyle/Hobbies………………………………………………...

1.6 Patient’s Past Medical History…………………………………………….

1.7 Patient’s Present Medical History…………………………………………

1.8 Admission of Patient………………………………………………………

1.9 Patient’s Concept about Condition……………………………………….

1.10 Literature Review ………………………………………………………..

1.11 Validation………………………………………………………………..

i
CHAPTER TWO

ANALYSIS OF DATA……………………………………………………………...

2.0 Introduction …………………………………………………………..

2.1 Comparison of Data with Standards…………………………………

2.2 Patient/ Family Strengths………………………………………………

2.3 Patient’s Health Problems……………………………………………..

2.4 Nursing Diagnosis……………………………………………………..

CHAPTER THREE

PLANNING FOR PATIENT AND FAMILY CARE…………………………….

3.0 Introduction…………………………………………………………….

3.1 Patient/Family Care Objectives………………………………………..

CHAPTER FOUR

IMPLEMENTATION OF PATIENT/ FAMILY CARE PLAN…………….….

4.0 Introduction……………………………………………………………

4.1 Summary of the Actual Nursing Care…………………………………

4.2 The Preparation of the Patient / Family for

Discharge and Rehabilitation………………………………………………

4.3 Follow-up / Home Visit / Continuity of Care…………………………

ii
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT/ FAMILY …..………

5.0 Introduction ………………………………………………………………

5.1 Statement of Evaluation………………………………………………….

5.2 Amendment of Nursing Care for Partially

Met or Unmet Outcome Criteria……………………………………………

5.3 Termination of Care…………………………………………...………...

5.4 Summary…………………………………………………………...…….

5.5 Conclusion……………………………………………………..………...

APPENDIX………………………………………………………………………………

BIBLIOGRAPHY…………………………………………………………………………

SIGNATORIES…………………………………………………………………………….

iii
LIST OF TABLES

Table one diagnostic investigations carried out on patient compared with those in literature

review …………………………………………………..………………………………….

Table two Details of Diagnostic Investigations Carried out On Patient……………………

Table three Comparison of clinical manifestation presented by patient to those in the

literature review……………………………………….……………………………………

Table four Comparison of treatment outlined in literature review with those ordered for

patient………………………………………………………………………………………

Table five Pharmacology of drugs prescribed for patient …………………………………..

Table six Family/patients care plan for patient…….……………………………………...

Table seven Vital signs of patient ……………………………………………………………

iv
 PREFACE

Nursing now a profession has evolved through time to be the nursing known today. Nursing

started with the use of herbal medicine and naturopathy which was not clinically proven.

Nursing was based on observation and experience from our successes. The patient and family

care study forms part of the academic programme for Diploma Nursing students which

requires the student to carry out total nursing care to patient/family from time of admission to

time of discharge and home care. It takes into account the physical, psychological, social and

spiritual needs of the patient and family.

The patient/family care study forms part of the assessment of every final year student. It is

essential for every candidate in order to partially fulfill the award of diploma certificate in

Registered General Nursing by the Nursing and Midwifery Council of Ghana. The

patient/family care study is a comprehensive account of the nursing care rendered to the

patient and family from the day of admission through the day of discharge, review and follow

up visits.

Patient /family initials were used instead of their full names to ensure confidentiality. The

care is designed to promote, maintain and prolong life as well as alleviating pain and meet

client’s psychological needs.

A patient/family care study enables the student nurse to put into practice all the knowledge

and skills he/she acquires during his or her three year training to give comprehensive nursing

care to his or her client, relatives as well as the entire community by using the nursing

process approach.

v
 ACKNOWLEDGEMENT

This study wouldn’t have being a success if not for the efforts of these personalities who

contributed in diverse ways.

My first and foremost greatest gratitude goes to the Almighty God for His knowledge,

understanding, wisdom, protection, guidance and patience granted me throughout the study.

I wish to express my sincere gratitude to my client, Master K.P and his especially his mother

Mrs. G.A family for their co-operation, support, consent to interact with me and necessary

information given to me during their stay at the hospital and the home visit.

I would also wish to express my gratitude to the staff of the Nurses’ Training College for

their guidance and time especially …………………. under whose supervision this study

became a success.

Again my appreciation goes to the doctors and nursing staff of the Urological Unit of the

Wenchi Methodist Hospital for their support and guidance that has made this scripts a reality.

I also express my gratitude to the authors and publishers of various books from which I took

valuable information to write this script.

Finally, special thanks go to my mother, Mrs. ……………..and my father

Mr.……………….. for her unconditional support and encouragement and all my friends,

especially………………………………………………………………………………………

……………………………………………………. who supported and inspired me.

May the Good Lord richly bless you all! Amen.

vi
 INTRODUCTION

Patient/family care study is a written report of the care rendered to the patient/family which is

required by The Nursing and Midwifery Council of Ghana in partial fulfillment for the award

of License to practice as a Professional Registered General Nurse. This is an approach in

nursing where a comprehensive and holistic nursing care is given to the patient/family from

the time of admission to discharge, and ensuring continuity of care through follow-ups or

home visits before the care is terminated.

The study was conducted on Master K.P, a two year old boy who was admitted to the Wenchi

Methodist Hospital on the 1/10/2018 with a diagnosis of hypospadias. Patient had been

scheduled for hypospadias repair the following day. Patient was accompanied by the mother

to the ward. Upon assessment of patient, it was realised patient had an abnormal opening

under the penis and such urine leaked through the opening when urinating.

His vital signs was checked and recorded and charted.

Laboratory investigations requested were done.

Drugs prescribed were collected from pharmacy and administered.

Pre-operative preparations such as signing of consent form by patient’s mother, ensuring nil

per os, eliminating of his bowel and bladder before surgery, grouping and cross matching of

blood, insertion of an intravenous cannula and filling of surgical checklist were done.

On the day of surgery (02/10/2018), patient was sent to the theater at 9am after he had been

seen by the anesthetics and the urologist early in the morning.

Master K.P returned from theatre after hypospadias repair had been done under general

anaesthesia. He was put in the recovery position and vital signs was checked and recorded

vii
every 15 minutes for the first one hour, thirty minutes for another hour till patient was stable.

Intake and output chart was maintained.

Post-operative medications were collected and started. Throughout patient’s period of

hospitalisation, daily wound dressing and catheter care was done to prevent infection of the

wound.

During their stay at the hospital, 5(five) main health problems were identified and a care

plan was drawn to solve them. They were anxiety (mother), knowledge deficit, pain, wound

and body image disturbance. A goal was set to ensure patient and family were relieved of the

health problems identified. Due to the holistic care rendered and the cooperation of patient

and mother, all set goals were achieved within the set time frame and none of the objective

were amended.

Patient was discharged on the 12/10/2018. In all three home visit were made to patient’s

house. Patient and mother came for review on the 18/10/2018. During the last home visit

care rendered to Master K.P and his family was terminated as they were handed over to a

community health nurse.

This script has been divided into six chapters following the components of the nursing

process;

Chapter one is the assessment on patient and family.

Chapter two is the analysis of data collected by comparing them with standard as indicated in

the literature review.

Chapter three which is planning for patient/family care. It includes the use of care plan which

entails nursing diagnosis, objectives/outcome criteria, nursing orders, interventions and

evaluation.

Chapter four gives an implementation of patient/family care plan.

Chapter five evaluates the entire care rendered to patient and family, followed by

viii
Chapter six summary and conclusion of care study.

CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

1.0 Introduction

Assessment involves the gathering of information about the health status of the patient,

analysis and synthesis of the data and the making of clinical nursing judgment (Weller, 2015).

Assessment is the first phase and an essential tool in the nursing process. It deals with

gathering of data from the patient/family through observation, direct interviews of the patient,

family and health workers who rendered care to the patient, from medical records, laboratory

investigations, physical examinations and review of literature. The assessment will covers

the patient’s particulars, family medical/surgical history, family socio-economic history,

patient’s developmental history, patient’s lifestyle and hobbies, patient’s past

medical/surgical history, the present medical/surgical history of the patient, admission

process of the patient/ family’s concept of his illness, literature review on the condition and

validation of data. This information gathered from patient will help identify patient/family’s

problems and the appropriate and recommended nursing intervention rendered to patient.

1.1 Patient’s Particulars

Patient’s particulars are the details of information of the patient that has been recorded which

includes name, sex, date of birth and religion.

Master K.P is the name of the patient chosen for this case study. Master K.P is a 2 year old

boy born to Mr. K.A and Mrs. G.A on the 4/01/2016. He comes from Banda in the Brong

Ahafo Region of Ghana. Master K.P is the second born of his parents and has one sibling,

ix
Miss A.B who is seven years. His next of kin is his mother, Mrs. G.A. Master K.P lives in

Wenchi with his mother and his sibling, Miss A.B in a house with number WN 126 B. He is a

Christian by religion and attend the Church of Christ at Wenchi with his mother and sibling.

They normally go to church on Sundays. He is Bono by ethnic group and he speaks Twi and

Banda. Master K.P attends preschool at the Methodist School in Wenchi. Physically, Master

K.P weighs 12 kg, his height is 0.39 meters. He is fair in complexion, has well shaved black

hair and does not have any facial marking or any physical disability.

1.1 The Patient/Family’s Medical History

The Patient/Family’s Medical History provides information about illness which has a genetic

of families’ tendency (Weller, 2014)

According to patient’s mother, there are no known genetic or hereditary disorder such as

sickle cell disease, hypertension, diabetes, mental illness as well as any chronic disease such

as, chronic heart failure and chronic renal failure in her family. She also added that there are

no communicable diseases like tuberculosis or leprosy existing in their family.

Mrs. G.A said occasionally, master K.P and his sister Miss A.B suffer attacks of headache,

chills and fever which they go for over-the-counter (OTC). According to Mrs. G.A, her son

has never being admitted before. The sibling of Master K.P is in good condition of health.

According to Mrs. G.A they occasionally use herbal medicine to treat ailments. There are no

known allergies to drugs, food or any substances in her family. I educated the patient and

relative about buying (over-counter-drug) since it was not prescribed by the medical officer

because it can lead to another health complication. According to Mrs. G.A, the maternal and

paternal grandparents of Master K.P are all alive and doing well. Mrs. G.A confirmed that

aside the normal ailments that comes with old age, none of her paternal or maternal

grandparents are sick or living with any chronic disease.

2
1.2 The Patient/Family’s Socio-Economic History

According to Weller (2014), a family is a system in which each member had a role to play

and rules to respect. Members of the system are expected to respond to each other in a certain

way according to their role, which is determined by relationship agreements.

Upon observations made on patient and family it can be said that Mrs. G.A has cordial

relationship with her neighbours. This was evidenced as some of them came to visit her when

she was on admission. The relationship between Mrs. G.A and patient’s father, Mr. K.A is

not cordial. Mrs. G.A complain that he has abdicated his duty of caring for Master K.P and

his sister Miss A.B.

Mrs. G.A also said she is the main bread winner of the family. According to her, she is a

farmer and also trade in clothes. She does all these in order to raise the necessary money

needed to take care of Master K.P and his sibling, Miss A.B. Mrs. G.A said the money raised

from her economic activities are mostly not sufficient enough to pay family’s bills such as up

keeping of the family, school fees and hospital bills. She relies on her siblings, parents and

friends in times of financial difficulties. She also said that Mr. K.A, rarely and occasionally

send them money which is mostly not adequate. Mr. K.A is a “galamsay” operator in the

Ashanti region. They belong to the lower socio-economic class of the society.

Because all members of the family are Christians, Master K.P attends church with his family

every Sunday. The family and Master K.P have registered with the National Health Insurance

Scheme (NHIS), this enables them to get free medical treatment when they fall sick. Patient’s

mother said she believes there are family values, taboos and cultural practices in their

community such as respecting the elderly in the society and working hard.

3
1.3 Patient’s Developmental History

Development is defined as the process of growth and differentiation. Growth as well is the

progressive development of a living thing, especially the process by which the body reaches

its point of complete physical development. (Weller, 2015)

According to Mrs. G.A, she experienced normal pregnancy for a period of nine months and

did not experience any complication during that period. She attended antenatal clinic

regularly at Wenchi Methodist Hospital and had Spontaneous Vaginal Delivery (SVD) at the

Wenchi Methodist Hospital, on the 4/01/2016. Mrs. G.A said she had no complications

during birth or after birth of Master K.P.

According to patient’s mother, Master K.P was breastfed for 3 months and she mother started

introducing supplementary feeds such as porridge, weanimix and ‘tuzaafi’ to his food. She

said she didn’t exclusively breastfeed Master K.P because she had to start working in order to

cater for Master K.P and his sister. Master K.P has been immunized against all the childhood

diseases that are the Bacillus Calmette Guerin (BCG), Polio, Diphtheria, Pertusis, Tetanus,

Hepatitis B, Haemophilus Influenza Type 3, Measles and Yellow Fever. This was evidenced

by the recording in his child heath record card (weighing card) and a mark of his deltoid

muscle.

Mrs. G.A said Master K.P went through the normal developmental milestone and child’s

developmental characteristics. She said, he was able to sit at three (3) to four (4) months, and

at the age of nine (9) months, he started crawling. His milk teeth started erupting at age nine

(9) months and he started walking at the age of twelve (12) months. Patient’s milk teeth are

all intact and have not being replaced by permanent teeth. At about the age of one and half

4
years, she could talk and could play with other children.

According to Erik Erikson’s theory of Psychosexual Development (1959), there are eight (8)

distinct stages with each possible result, thus either success or failure personality. These

theories are.

Trust verses Mistrust (Birth to 12 months).

Astronomy verses Shame and Doubt (1 to 3 years).

Initiative verses Guilt (3 to 6 years).

Industry verses Role Inferiority (6 to 12 years).

Identity verses Roles Confusion (12 to 20 years).

Intimacy verses Isolation (20 to 40years).

Generatively verses Stagnation (40 to 65 years).

Integrity verses Despair (65 to death)

Patient is at the level of trust versus mistrust. This stage centers on the provision of the basic

needs of the child. If the needs and the interactions are met by those around the child, the

child comes to trust them and has a sense of essential trustfulness of others as well as

fundamental sense of child’s own trustworthiness. If child’s needs are not met, the child tend

to have mistrust for the world.

Master K.P started preschool about two months ago. From the interaction with Master K.P

and her mother, it can be said that Master K.P has achieved trust. This is because, according

to Mrs. G.A, life is not easy for her, she tries very hard to provide the needs of Master K.P.

She hopes master K.P becomes a doctor when he grows up.

1.5 Patient’s Lifestyle and Hobbies

Lifestyle section of a patient provides information about health related behaviours. These

behaviours include pattern of sleep, exercise, nutrition and recreation, as well as personal

5
habits such as smoking and the use of illicit drugs, alcohol and caffeine. (Mitchell, et al,

2013)

During the interaction with patient’s mother, Mrs. G.A she said patient is very active during

the day. He goes to bed around 8:00pm and wake up around 6:00am. He does not usually

sleep in the afternoon and enjoys a better sleep at night. In the morning he is assisted by the

mother to perform his activities of daily living such as brushing the teeth and bathing. He

empties his bladder and bowel at least three times daily depending on the kind of fluid/food

taken. According to Mrs. G.A, Master K.P has not started active schooling but she normally

sends him to a preschool near them. She usually does this on days that she goes to farm and

on market days that she will be busy. On days that he goes to school, Mrs. G.A goes for him

after 4pm. According to the mother, patient eats every food that is offered to him. His

favorite food is rice and stew with chicken. On weekends, she takes him to church when she

attends church and she also takes him to ceremonies and social gatherings such as weddings,

naming ceremonies and funerals. According to Mrs. G.A, Master K.P plays with anyone who

he comes into contact with. The game/hobby he likes most is playing football.

1.6 Patient’s Past Medical History

According to Mrs. G.A, shortly after birth of Master K.P, she observed that there was an

abnormal opening under patient’s penis. She was told by the medical team that the opening

can be corrected once patient was age 16 months to 24 months. She was worried but had to

wait for patient to be 2 years.

According to Mrs. G.A, patient has never been admitted to hospital nor has he suffered any

childhood disease condition before, but usually suffer from common illness such as

headaches, fever and cough which are usually treated when she takes her to the clinic or

through the use of over the counter drugs. He has also never suffered from chicken pox

before. According to the mother, patient has no known allergies to drugs, animals or insects.

6
She also added that my patient has not undergone any surgery since he was born and has also

been cared for well which has prevented her from self-injuries and wounds and this is the first

time that Master K.P has been hospitalized.

1.7 Patient’s Present Medical History.

According to Mrs. G.A, on the 10/09/2018, she came to see the urologist at the Wenchi

Methodist Hospital. She was scheduled for hypospadias repair on the 2/10/2018. Patient’s

mother was told to come for admission on the 1/10/2018 for surgery to be done on the

following day. According to Mrs. G.A, patient had an abnormal opening under the penis and

there is abnormal spraying of urine during micturition.

Patient was seen at the O.P.D by Dr. Bosomtwe and was duly admitted and scheduled for

surgery.

1.8 Admission of patient

On the 01/10/2018 at 12pm, Master K.P and her mother walked into the urological ward of

the Wenchi Methodist Hospital. Patient and mother were welcomed and offered seat.

Patient’s folder was taken from mother and patient’s name, age, sex and residential place was

mentioned to confirm the identity of the patient. Patient and mother were introduced to the

other staff around. Patient had been diagnosed of Hypospadias and had been scheduled for

hypospadias repair the following day. They were then made comfortable in an already

prepared simple unoccupied bed and assessment was done. Upon assessment, patient was

conscious and complain of no pain. Upon examination of patient from head to toe, it was

realised that patient had an abnormal opening under the penis. Vital signs were checked and

recorded as

7
Temperature 36.2oC

Pulse 105bpm

Respiration 24cpm

SPO2 98%

Laboratory investigations requested were

Blood for full blood count

Grouping and cross matching against one unit (pint) of blood standby

Blood sample was taken and sent to the laboratory in a well labeled sample bottle for

investigations to be conducted.

The following medications were ordered by the attending physician. Drugs were to be

administered on the morning of surgery

Intravenous Cefuroxime 750mg stat

Infusion Normal Saline (Sodium Chloride) 500mls stat

Infusion Dextrose Saline 500mls for 24 stat.

Drugs were then procured from the pharmacy department and placed by patient’s bed side.

Since Master K.P is a minor, Mrs. G.A was made to sign informed surgical consent form

and it was witness by myself. Patient’s mother was told to keep patient nil per os 6-8 hours

before the surgery time. She was told that patient will be bathed early in the morning, ensure

he empties his bowel and bladder before the surgery. Patient’s perineal area was inspected

for any hair, but none was available. Patient’s mother was then told that the hospital

chaplain was available and that she could request for him anytime she wanted as part of the

spiritual preparation before surgery.

8
Patient and mother were orientated to the ward and its environs such as the toilet, bath and

the playground. Since the ward didn’t have a dining hall, it was explained to Mrs. G.A that

they could eat by their bed side. After that, she was then introduced to other patients in the

ward. Mrs. G.A was informed of the visiting time and hospital payment policies. She was

told that even though, Master K.P had insurance, not all the care will be covered under the

national health insurance. Since it was a planned admission, patient’s mother already had

patient’s personal items that He may need at the ward such as towel, sponge, tooth brush,

toothpaste and bucket from the house. They were asked to talk to any of the nurses around if

they needed anything or help. Patient’s particulars were documented into the admission and

discharge book and daily ward state

After these interventions, I told the ward in-charge of my intention of using the patient and

the family for a case study and I was given the permission. I introduced myself to the

patient/family that, I am a student nurse of Nurses’ Training College, Sampa, conducting a

case study at the hospital. I then made it known to her my wish to render holistic nursing

care to Master K.P for his speedy recovery. Mrs. G.A was informed that, as part of my

training, final year students are to take a patient each, nurse him or her from the time of

admission till time of discharge and home visits. Mrs. G.A accepted and promised her

cooperation and readiness to give me any information needed for my study. Patient’s mother

was informed that admission was temporal and such patient will be discharged in due time

for her to continue the care at home.

They were also informed that, as part of my care, I would visit their home whiles he was on

admission and after he has been discharged. I choose to write my care study on hypospadias

because it is a very rare condition and there are a lot of misconception about it and people

always attribute its causes to spiritual deities. I wanted to know more about this condition

and to holistically nurse a patient and family who was suffering from this ailment.

9
1.9 Patient’s Concept Of Illness

Since patient is a child he had no concept on the illness. His mother, Mrs. G.A could not pin

point the cause of the illness or even speculate the risk factors that may have led to child

developing such abnormality. She also did not attribute child’s illness to any spiritual cause

because she believed illness can occur at any point in time in an individual’s life. She very

anxious though about the unknown outcome of the surgery. She also hoped that the surgery

will be successful for Master K.P to be able to urinate without any complications.

1.10 Literature Review On Hypospadias

Literature review of a condition gives a detailed insight into the condition. It talks about the

established and laid down facts about the disease condition, which aids in the medical and

nursing diagnoses and the appropriate management for that particular disease. It also entails

the standard with which the patient’s clinical manifestations, diagnostic investigations,

treatment and others are compared. It comprises of the following: review of the anatomy of

the male reproductive system, Definition, Types, Incidence, Etiologic/Causes,

Pathophysiology, Clinical features, Diagnostic investigations, Medical/ surgical management,

Nursing management, Prevention and Complication

10
Review of the anatomy of the male reproductive system

Gross structure of the male reproductive system

(Scalon and Sanders, 2014).

The purpose of the organs of the male reproductive system is to perform the following

functions:

1. To produce, maintain and transport sperm (the male reproductive cells) and protective

fluid (semen)

2. To discharge sperm within the female reproductive tract during sex

3. To produce and secrete male sex hormones responsible for maintaining the male

reproductive system.

4. The urethra is also the passageway for urine excretion.

11
Structures

Penis/Urethra: The urethra is the last of the ducts through which semen travels, and its

longest portion is enclosed within the penis. The penis is an external genital organ; its distal

end is called the glans penis and is covered with a fold of skin called the prepuce or foreskin.

Within the penis are three masses of cavernous (erectile) tissue. Each consists of a framework

of smooth muscle and connective tissue that contains blood sinuses, which are large, irregular

vascular channels. When blood flow through these sinuses is minimal, the penis is flaccid.

During sexual stimulation, the arteries to the penis dilate, the sinuses fill with blood, and the

penis becomes erect and firm. The dilation of penile arteries and the resulting erection are

brought about by the localized release of nitric oxide (NO) and by parasympathetic impulses.

The erect penis is capable of penetrating the female vagina to deposit sperm. The culmination

of sexual stimulation is ejaculation, a sympathetic response that is brought about by

peristalsis of all of the reproductive ducts and contraction of the prostate gland and the

muscles of the pelvic floor.

Testicles: The testes hang outside the abdominal cavity of the male within the scrotum. They

begin their development in the abdominal cavity but descend into the scrotal sacs during the

last 2 months of fetal development. This is required for the production of sperm because

internal body temperatures are too high to produce viable sperm.

Scrotum: This is the loose pouch-like sac of skin that hangs behind the penis. It contains the

testicles (also called testes), as well as many nerves and blood vessels. The scrotum acts as a

"climate control system" for the testes. For normal sperm development, the testes must be at a

temperature slightly cooler than body temperature.

12
Special muscles in the wall of the scrotum allow it to contract and relax, moving the testicles

closer to the body for warmth or farther away from the body to cool the temperature.

Definition of Hypospadias

In hypospadias, the urethral opening is a groove on the underside of the penis (Hinkle and

Cheever, 2014)

Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed

urinary meatus (opening) (Scalon and Sanders, 2014). Instead of opening at the tip of the

glans of the penis, a hypospadic urethra opens anywhere along a line (the urethral groove)

running from the tip along the underside (ventral aspect) of the shaft to the junction of the

penis and scrotum or perineum. A distal hypospadias may be suspected even in an

uncircumcised boy from an abnormally formed foreskin and downward tilt of the glans.

(Scalon and Sanders, 2014)

According to Marcovitch (2014) hypospadias is a developmental abnormality in male born,

in which the urethra opens on the undersurface of the penis or in the perineum. The condition

is treatable with surgery, but several operations over a period of years may be required to

ensure normal urinary and sexual functions.

Incidence/ Epidemiology

According to Marcovitch (2014), hypospadias occurs in 1 in 3000 live male birth.

This showed recent increase in incidence, which is believed to be related to increased referral

of minor forms, for which parents would not previously seek medical advice.

Classifications of Hypospadias

Marcovitch (2014) states that there are three main classification of hypospadias

13
Hypospadias is classified according to the position of the meatus on the penis in first, second

and third degree.

First degree hypospadias: In first degree hypospadias the urethral meatus is located on

either the glans (glanular hypospadias) or the corona (coronal hypospadias).

Second degree hypospadias: In cases of second degree, the urethral meatus is located in the

balanopenile furrow or coronal sulcus (subcoronal hypospadias) or in the shaft of the penis

(distal penile, midshaft, and proximal penile hypospadias).

Third degree Hypospadias: In cases of third degree, the urethral meatus is located in the

junction of the penis and the scrotum (penoscrotal or scrotal hypospadias) or the perineum

(perineoscrotal, perineal, or pseudovaginal hypospadias)

Diagram showing the classification of hypospadia

Scalon and Sanders (2014).

Pathophysiology

14
The penis begins to form at approximately the fifth fetal week under the influence of

testosterone. The urethral folds start to fuse over the urethral groove, and by the 14th week

the process is complete. A short in growth from the tip of the glans progresses inward to meet

the urethral tube at the fossa navicularis. The prepuce is then formed at the end of the

development process.

Hypospadias occurs when the fusion of the urethral folds stops proximal to the tip of the

glans penis and can occur anywhere along the urethral groove.

Severe forms of hypospadias are accompanied by shortening of the urethral groove, which

causes ventral tethering of the penis, a condition termed "chordee."

Risk factors/ Predisposing factors

The aetiology is not fully understood but may be due to the following reasons

 Deficient hormonal stimulation: Endocrinological factors include low levels of

androgens (e.g., testosterone, androsterone) and the infant's cells' inability to use these

substances effectively may also result in hypospadias. Androgens are substances that

stimulate the development of male characteristics. Maternal exposure to increased

levels of progesterone, common during in vitro fertilization (IVF), increases the risk

for hypospadias in the infant.

 Genetic disorder: There is also a 20 percent chance that an infant born with

hypospadias has a family member with the condition.

 Maternal factors: such as obesity, drinking, smoking, contact with herbicides or

weedicides, extreme birth age (below 18 years and above 35 years).

Clinical Findings/ Symptoms and Signs

According to Marcovitch, the signs and symptoms of hypospadias may include:

15
 1. Opening of the urethra at a location other than the tip of the penis

2. Downward curve of the penis (chordee)

3. Hooded appearance of the penis because only the top half of the penis is covered by

foreskin

4. Abnormal spraying during urination

Diagnostic Investigations

According to Scalon and Sanders (2014), Diagnosis of hypospadias is clinical and based on

the characteristics or signs of symptoms. Investigations are done to prepare the child for

surgery and to exclude other associated anomalies.

1. Presenting clinical sign and symptoms

2. Physical examination and history of patient

3. A buccal smear and karyotyping is indicated to help establish the genetic sex.

4. Urethroscopy and cystoscopy to determine internal male sexual organs are normal or

abnormal

5. Excretory urography to detect additional congenital anomalies of the kidneys and

ureters

6. Abdominopelvic ultrasound scan to exclude other associated anomalies an also to

exclude cases of ambiguous genitalia.

7. Urine microscopy, culture and sensitivity to exclude Urinary tract infections (UTI)

8. Full blood count and grouping and cross matching to prepare patient for surgery

Hypospadias Associated Anomalies or Birth defects

According to Marcovitch (2014), there are certain abnormalities that may be associated with

hypospadias. Some of them are;

16
 1. Undescended Testis: It occurs when the testicle does not move into the scrotum

before birth.

2. Hypospadias: the protrusion of any part of the internal organ through the structure

enclosing them.

3. Posterior Urethral Valve (PUV) : is an obstructing developmental anomaly in the

urethra and genitourinary system of male born which causes bladder outlet

obstruction

4. Intersex: when a person is born with a reproductive or sexual anatomy that does not

seem to fit the typical definition of female or male.

Complications of Hypospadias

According to Marcovitch (2014), if hypospadias are not treated well, the following

complications may develop

1. Psychological impacts.

2. Difficult intercourse.

3. Abnormal insemination & infertility.

4. Risk of developing recurrent urinary tract infections

5. Fistulas

6. Blockage of the urethra: This caused when hair grows in the urethra blocking the flow

of urine and semen’

7. Stricture: It is the narrowing of the urethra that causes the urine stream to reduce

when voiding.

17
 Management of hypospadias

Medical / Surgical Management

According to Scalon and Sanders (2014), there are no medical management of hypospadias

available. Treatment is by repair of hypospadias.

Medical management/drugs may be given to child to control pain and prevent infection.

Medical management may involve;

Analgesics to control pain eg Pethidine, Paracetamol and Morphine

Antibiotics to prevent infection after surgery e.g Metronidazole, Cefuroxime etc

Intravenous fluid may be prescribed when child is managed nil per os.

Surgical Management of Hypospadias

According to Scalon and Sanders (2014), surgery is usually performed under general

anesthesia, which means that the child is put to sleep with medications. There are many

techniques for hypospadias repair. Although surgical correction can be performed at any age,

most pediatric urologists would do the surgery between 6 and 24 months of age.

Newer methods accomplish the repair in one stage. The repair procedure is fairly simple

when the opening is near the head of the penis. The operation is more complex when the

urethral opening is along the penile shaft.

Goals of surgical treatment

According to Scalon and Sanders (2014), the goal of the reconstructions of hypospadias are

to;

 Straighten the penis (correct chordee)

 Bring the opening meatus to the tip of the penis

18
  Make the penis as cosmetically close to the normal as possible.

Specific Surgical Management of Hypospadias;

According to Marcovitch(2014) the specific procedures involved in hypospadias repair are;

1. Orthoplasty: this involves straightening of the penis

2. Urethroplasty: this involves the rebuilding of the urethra so that urine and semen will flow

as far forward as possible

3. Meatoplasty and Glanuloplasty: Building a new opening and reconstructing the head of the

penis as necessary to accommodate the new opening

4. Scrotoplasty: Repair of the scrotum

5. Skin Coverage: Getting enough skin grafts to complete all necessary hypospadias repairs.

Complications of Hypospadias repair

According to Marcovitch (2014), despite the great advances in hypospadias reconstructive

surgeries, many frustrating complications are still met with:

 Urethrocutaneous fistula: hole in the channel that is reconstructed – diagnosed by

noting urine dripping from a second opening when the child is urinating

 Meatal stenosis: scarring of the new opening – diagnosed by a narrowing of the urine

stream

 Urethrocele: Where there is prolapse of the urethra into the bladder

 Recurrent chordee: when the head of the penis curves downward or upward at

the junction of the head and shaft of the penis after surgery.

 Penile oedema: When there is swelling of the penis

 Wound infection: May be due to infection of the surgical site

19
  Urethral stricture: when there is narrowing of the urethra due to the surgery

performed.

Nursing Management of hypospadias

Nursing management of a patient with hypospadias is group under pre-operative management

and post op nursing management;

Scalon and Sanders (2014) groups’ pre-operative nursing management under the following

headings

 Psychological preparations

 Physiological preparations

 Physical preparations

 Spiritual preparations

Psychological preparations

a. Patient and family are prepared psychologically to allay her fears and anxiety.

b. Allow patient’s family to verbalize any questions bothering the mind and explain

accordingly, discarding and correcting all rumors or false information.

c. Patient’s family is introduced to other patients who have undergone same procedure

and are responding to treatment to chart with in order to win patient’s co-operation.

d. Patient’s family are reassured that skillful personnel are ready to give their best if

patient will be co-operative

e. Explain the nature of surgery and the type of anaesthesia to be given to the patient

f. Explain the need to sign consent form and assist patient’s family or caregiver to sign

the consent form

20
Physical Preparation

a) Skin preparation: observe the area for lesions, scars, wound or infection around the

surgical site and report for action.

b) Assist patient to bath and clean mouth

c) Trim nails short if necessary.

d) Patient’s family is reminded to avoid tea, coffee, cola and other stimulants.

e) Patient’s family are advised to encourage child empty his bowel early in the

morning and immediately the operation begins on the day of operation.

f) Removal of contra surgical items such as rings, jewelries, dentures, hairpins, wigs

and bands.

g) Nil per os is ensured 6 hours to the surgery time

h) Pass NG tube if indicated or ordered

i) Informed consent must be signed by the legal care giver of the patient and

witnessed by nurse.

Physiological Preparation

This comprises of all Laboratory investigations and vital signs done to establish a tolerance

data, detect abnormalities, correct imbalances and determine the fitness of the patient for the

surgery. It includes the following

1. Check vital signs i.e. temperature, pulse, respiration and blood pressure and record.

This serves as a baseline data and also helps to determine the fitness of the patient for

the surgery

2. Laboratory investigations such as hemoglobin level estimation, blood for grouping and

cross-matching are done.

3. Other diagnostic investigations such as Abdominopelvic ultrasound scan, urine culture

and sensitivity, cystoscopy are done to rule out any abnormalities.

21
 4. Blood should be on standby in case patient may need it during or after surgery.

Spiritual preparations

Patient and family spiritual needs should be assessed.

Identify if patient and family are interested in inviting the hospital’s chaplain to pray with

them before surgery.

Respect the cultural and spiritual beliefs of the patient and family.

Morning of surgery (Immediate Pre-operative Care)

 Patient and family should be reassured of positive prognosis of the surgery.

 All contraindicated items such as rings or beads should be removed.

 A theatre gown and head cap or gear should be used to dress the patient.

 Baseline vital signs were checked and recorded and any abnormality should be

reported.

 Theatre checklist should be filled and crosschecked by other nurses on duty

 Administer any pre-operative medications and set up intravenous infusions if

prescribed and monitor its side effects

 Patient should be taken to the theatre with his folder with all requested laboratory

investigations, consents form and theatre checklist.

Post-operative Nursing Management

Immediate post-operative care

Whiles patient was in the theatre, a post-operative bed is prepared to receive the patient. A

vital signs tray, resuscitation equipment such as oxygen cylinder, suction machine, drip stand,

22
and blankets should all be made ready at the bedside of the patient for use in case of

emergency.

1. Assess the patient’s consciousness level and mental status .This helps to evaluate the

effects of anesthesia and any neurological changes.

2. Assess the patient’s cardiovascular status as indicated by by checking the vital signs every

15 minutes for 1 hour and every hourly till patient is stable. This helps to evaluate the

stability of the patient’s condition following the surgery.

3. Assess the patient’s respiratory status as indicated by respiratory rate, oxygen saturation,

and breathe sounds. This helps to evaluate the patient’s oxygenation after the surgery.

4. Assess the patient’s level of pain as indicated by appropriate pain scale and administer

prescribed analgesics. Pain assessment helps to determine the type and amount of medication

and/treatment needed to provide adequate pain control.

5. Assess the surgical site and wound dressing for signs of bleeding and arrest hemorrhage

immediately.

6. Assess the patient’s fluid status by reviewing the intake and output record

7. Assess the neurovascular status of the patient’s extremities to evaluate for possible

perioperative positioning injury.

Others

Position and exercise

Patient is nursed in the supine position to prevent pressure on the surgical site when patient lies

in a prone position.

The head of the patient was turned to one side to ensure patent airway and facilitate normal

breathing pattern.

23
The patient is encouraged in the performance of deep breathing exercise to prevent hypostatic

pneumonia (as a result of stasis of air in the lungs). Patient’s family is educated on early

ambulation which is very necessary to prevent deep vein thrombosis and to promote

circulation of blood to all body parts.

Infant or toddler is restricted from activities (e.g., playing on riding toys) that put pressure on

the surgical site.

Patient’s family are instructed to avoid holding the infant or child straddled on the hip.

Child’s physical activity is limited for 2 weeks.

Observation

Observed the level of patient’s consciousness and the general condition of the patient.

The incisional site is observed periodically for bleeding.

Vital signs are checked and recorded every four hourly and recorded.

The airway is continuously monitored for patency to prevent asphyxiation.

Complications such as hemorrhage, shock, infection, Fistula and deep vein thrombosis should

be monitored.

Watch for signs of infection: fever, swelling, redness, pain, strong smelling urine, or change

in flow of the urinary stream.

Maintain adequate urinary output and patency of the stent.

Hourly documentation of intake and output is essential. Notify the physician if there is no

urine drainage for 1 hour as this may indicate blockage of the stent (catheter)

Nutrition/ Fluid intake

Intravenous fluids is given within the first 24 hours after surgery to maintain energy,

rehydrate patient and balance electrolytes.

24
Sips of water and fluid diet should be gradually encouraged as bowel sounds return.

Normal diet is introduced as ordered by the surgeon.

Encourage the infant or toddler to drink fluids to ensure adequate hydration.

Provide fluids in a pleasant environment or using a special cup.

Offer fruit juice, fruit-flavored ice pops, fruit flavored juices and flavored ice cubes.

Medication

Intravenous antibiotics should be administered according to doctor’s order to prevent

infections.

Analgesics should be administered to control pain

The therapeutic effects as well as the side effects of the drugs were observed and recorded.

Personal Hygiene

The patient was assisted to bath. Wound should be dry at all times.

Mouth care was also given immediately patient recovers from anesthesia.

Bed lining is changed when soiled.

Patient’s family should be educated to change patient clothes as soon as it is dirty to prevent

infection of the wound.

Elimination

Serve patient with bedpan on request and encourage patient to take more fluid and roughages

to prevent constipation.

Use double-diapering to protect the stent (the small tube that drains the urine). The urine will

be blood tinged for several days. Call the physician if urine is seen leaking from any area

other than the penis.

25
Rest and Sleep

It is important the patient has a calm peaceful rest. Bed rest is provided to converse energy.

This can be ensured by providing comfortable bed free from creases and crumps. There must

be less noise on the ward and all procedures organized in such a way to prevent interruption

during sleep. Ensure good ventilation and reduce the number of visitors.

Wound Care

The wound site or incisional site is observed as soon as the patient arrives from the theatre,

for bleeding or any abnormal discharge. The dressings should be changed when necessary.

The wound is dressed strictly under aseptic condition. Note the nature of wound and

discharges for signs of infection and healing.

Discharge education

 Advise mother to follow all the prescribed medications.

 Advice mother to limit child’s activities such as playing. Patient may walk and play

quietly. Patient may not use straddle toys, walkers, or bicycles until it is okayed by the

surgeon.

 Advice patient’s family to always do proper hand washing before touching wound site

and ensure patient has proper hygiene every day.

 Educate patient’s family to always have a regular check up at your nearest health

center, at least once a week to monitor the progress of the treatment. The patient

should report immediately to the physician if there is unusual discharge or if urine

flows from any other part aside the urethral meatus.

 Advice patient’s family to give patient fruit juice, fibre foods and drink lots of water

to prevent constipation and to ensure wound completely heals.

26
1.11 Validation of Data

With reference to the data collected, signs and symptoms which patient presented are the

actual clinical features of hypospadias as confirmed by the literature review of the condition.

Data collected from the patient’s family were also cross checked with patient's folder,

laboratory investigation and during home visit.

Therefore, all these proved that data collected was free from bias and confirm that patient was

suffering from hypospadias.

27
 CHAPTER TWO

ANALYSIS OF DATA COLLECTED

2.0 Introduction

This is the act of examining the information gathered from the patient and family to

determine the specific health problems and to formulate appropriate interventions.

Analysis of data involves;

- Comparison of data with standard

- Patient/family strengths

- Nursing diagnosis

The following tables show the comparison of laboratory investigation, clinical features and

the treatment with that of the patient.

2.1 Comparison of Data with Standards

A. Diagnostic Investigations/Tests

This is comparing the data collected with that of the standards which includes;

 Diagnostic Investigation

 Causes

 Clinical features

 Treatment

 As well as complication associated with disease

A. Diagnostic Investigations

The following were investigations carried out on Master K.P throughout period of admission

to help diagnose patient

28
Blood for full blood count

Blood for grouping and cross matching

Physical examination

The table below compares the various investigations done on patient to those in text books

Table 1: Comparism of Diagnostic Investigations Conducted on patient to that in the

Literature Review

Diagnostic investigations in the Diagnostic investigations conducted on

Literature Review my patient

Physical examination and history of patient Physical examination of patient was done

Buccal smear and karyotyping Test not ordered

Urethroscopy and cystoscopy Test not ordered

Excretory urography Test not ordered

Abdominopelvic ultrasound Test not ordered

Urine microscopy, culture and sensitivity Test not ordered

Full blood count and grouping and cross Full blood count and group and cross

matching matching was ordered and done.

Form the table above diagnostic test such as urethroscopy, abdominal ultrasound, urine

culture and sensitivity test, buccal smear and karyotyping were not done. But the main

diagnostic investigation which was physical examination and history of the patient was done.

The physical examination confirmed the existence of an abnormal opening under the shaft of

the penis. Full blood count and grouping and cross matching were done to ensure patient was

fit for surgery.

Details of the test carried out on patient have been presented in table 2.

29
30
Table 2: Diagnostic Investigations carried out on Master K.P
Date Specimen Investigation Result Normal Value Interpretation Remarks

1/10/2018 Blood Grouping and cross 0 positive A, B,AB, 0 positive Normal blood type compatible Standby 0 positive blood
matching A, B,AB, O negative with a donor blood of 0 was made available for
possible transfusion
positive and 0 negative
1/10/2018 Full White blood cells 6.8 x109/L 4.0-10.0 x109/L Normal No treatment was
Blood ordered

Count
Red blood cell 3.2 3.9 -6.5 x 10/l Normal No treatment was given
count
Neutrophils count 46% 40-75% Normal No treatment was given

Haemoglobin levels 10.2 g/dl 11.0-15.0g/dl Slightly low No treatment was

ordered but patient’s
mother was educated on
good nutrition to
maintain normal
hemoglobin level.
Platelet 275 250-400g/dl normal no treatment ordered

Hematocrit 44% 40-54% Normal No treatment ordered

The table above shows that all test conducted on Master K.P before surgery were all within range.

31
 B). Causes of Patient’s Condition

The cause of hypospadias is unknown but certain factors may predispose the development of

hypospadias. From the history of Master K.P’s mother occupation, it may be that Master

K.P’s hypospadias may have being caused due to contact with weedicides. Mrr. G.A said she

was still into farming when she was pregnant with Master K.P. She had contact with

weedicide on a number of occasion. This may have been predisposing factor for the

development of the hypospadias.

C. Clinical Features/ Signs and Symptoms

Comparison of clinical features exhibited by patient with those listed in the literature review

Table 3: Clinical Features Manifested By Patient Compared With Those In Literature

Review.
Clinical features of literature review. Clinical features exhibited by K.P

Opening of the urethra at a location other than Patient had an abnormal opening under the
shaft of the penis
the tip of the penis

Downward curve of the penis (chordee) Chordee was present

Hooded appearance of the penis because only Penis had hooded appearance

the top half of the penis is covered by foreskin

Abnormal spraying during urination Abnormal spraying of urination was present

The table above shows that patient exhibited all the clinical signs and symptoms of

hypospadias.

D. Treatment of Patient

Treatment (medical/surgical) is referred to as a therapy intended to stabilize or reverse a

morbid process or state. Treatment may be pharmacologic, using drugs; surgical,

32
 involving operative procedures; or supportive, building the patient’s strength. It may be

specific for the disorder, or symptomatic to relieve symptoms without affecting a cure.

Medical Management

Master K.P was managed on the following throughout period of admission

 Intravenous cefuroxime 750 mg stat

 Intravenous Infusion Normal Saline 0.5l stat

 Intravenous Infusion Dextrose Saline 0.5l stat

 Intravenous Cefuroxime 250mg tds for 3 days

 Intravenous Metronidazole 125mg tds for 3 days

 Suppository Paracetamol 250mg qid for 1 day

 Syrup Brufen 125mg tds for 7 days

 Syrup Cefuroxime 125mg bd for 5 days

 Syrup Flagyl 125mg tds for 5 days

 Tablet Oxybutynin 1.25mg tds for 5 days

 Syrup Paracetamol 10mls tds for 5 days

Surgical Management

According to the literature review, surgical management of hypospadias is by hypospadias

repair. This involves five specific procedures. Orthoplasty: this involves straightening of the

penis . Urethroplasty: this involves the rebuilding of the urethra so that urine and semen will

flow as far forward as possible. Meatoplasty and Glanuloplasty: Building a new opening and

reconstructing the head of the penis as necessary to accommodate the new opening.

Scrotoplasty: Repair of the scrotum. Skin Coverage: Getting enough skin grafts to complete

all necessary hypospadias repairs.

33
Hypospadias repair was done for Master K.P on the 2/10/2018. According to the operation

notes, Master K.P’s hypospadias was repaired under general anaesthesia. The wound was

covered with a sterile gauze soaked in povidone iodine solution and strapped with plaster. A

urethral catheter was left insitu to drain patient’s urine. This was to ensure proper monitoring

of urine output and to limit the risk of wound infection from contact with urine.

Table 4 below shows the treatment given to Master K.P compared with those in the literature

review

Table 4: Comparison of treatment outlined in the literature review with those given to

Master K.P

Treatment according to literature review Patient’s drug administered

Analgesics to control pain e.g. Pethidine, Suppository Paracetamol 250mg qid

Paracetamol and Morphine for 1 day, Syrup Brufen 125mg tds

for 7 days, Syrup Paracetamol 10mls

tds for 5 days were prescribed

Antibiotics to prevent infection after surgery Intravenous cefuroxime 750 mg stat,

e.g. Metronidazole, Cefuroxime etc. Intravenous Cefuroxime 250mg tds

for 3 days , Intravenous

Metronidazole 125mg tds for 3 days,

Syrup Cefuroxime 125mg bd for 5

days , Syrup Flagyl 125mg tds for 5

days were prescribed

34
 Intravenous fluid Intravenous Infusion Normal Saline

0.5l stat, Intravenous Infusion

Dextrose Saline 0.5l stat were

ordered

Surgical management , Hypospadias repair Hypospadias repair was done for patient.

According to the literature classifications of drugs such as antibiotics, analgesics and

Intravenous infusions are prescribed. All such drugs were ordered and served during patient’s

stay at the hospital. Even though oxybutynin was not stated in the literature review, it was

prescribed for patient to relieve any urinary and bladder difficulties after the surgery.

Hypospadias repair was done as the surgical treatment for Master K.P.

With reference to the literature review, it can be concluded that Master K.P received all the

treatment regimen required for the treatment and cure of hypospadias.

Below is the pharmacology of the drugs given to Master K.P.

35
 Table 5: Pharmacology of drugs for Master K.P
Date Drug Dosage/route of Classification Desired effect Actual action Side effects/
administration observed Remarks
2/10/18 Cefuroxime 750mg stat, Intravenous Cephalosporin To prevent infection after Patient was free Diarrhoea, dizziness,
250mg tds for 3 days, antibiotic surgery from infection abdominal pain, nausea,
Intravenous after surgery vomiting, headache.
125mg bd for 5days None was observed.
oral
2/10/18 Paracetamol 10mls tds for 5 days, Oral Analgesics, It inhibits the production of Patient was
250mg qid for 1 day, Anal Antipyretics prostaglandins by relieved of pain None was observed
decreasing the activity of post-surgery
enzyme cyclooxygenase.
Thereby reducing pain
3/10/18 Brufen 125mg tds for 5 days Analgesics It inhibits the production of Patient was Constipation, Diarrhoea,
oral prostaglandins by relieved of pain ringing in ears,
decreasing the activity of post-surgery nervousness
enzyme cyclooxygenase. None was observed
Thereby reducing pain.
2/10/18 Metronidazole 125mg tds for 3 days, Synthetic A synthetic antibacterial Patient was free Nausea, vomiting,
Intravenous and antiprotozoal agent from infection diarrhoea, constipation,
Antibiotic,
125mg tds for 7 days, Oral that inhibits the nucleic after surgery loss os appetite, mouth
Antimicrobial sores
acid disrupting the DNA of
None was observed
microbial cells.
Prevents infection after
surgery

36
 Table 5: Pharmacology of drugs for Master K.P continued
Date Drug Dosage/route of Classification Desired effect Actual action observed Side effects/
administration Remarks
2/10/18 Normal Saline 500mls stat, Isotonic solution To correct dehydration and Patient fluid and Circulatory overload,
(Sodium Intravenous
maintain fluid balance electrolyte balance was pulmonary oedema.
Chloride).
maintained None observed
2/10/18 Dextrose 500mls stat, Hypertonic To correct dehydration and Patient fluid and Circulatory overload,
Saline Intravenous
solution maintain electrolyte balance electrolyte balance was pulmonary oedema.
maintained None of these was observed
8/10/18 Oxybutynin 1.25mg tds for 5 days Anticholinergic it relieves urinary and bladder Patient was relived of Dry mouth, blurred vision,
difficulties by decreasing bladder difficulty dizziness, drowsiness,
muscle spasms of the bladder sweating.
None was observed.

37
 Complications

With reference to the preoperative complication stated in the literature review such as

Psychological impacts, difficulty during intercourse, abnormal insemination & infertility, risk

of developing recurrent urinary tract infections, Fistulas, blockage of the urethra and stricture

and post-operative complication such as Urethrocutaneous fistula, Meatal stenosis,

Urethrocele, penile oedema and wound infection, Master K.P did not develop any of them.

This was due to the holistic care rendered by the medical and nursing team.

2.2 The patient/Family strengths

This is explained as the ability of the patient and her family to participate in the care for the

achievement of setting goals and basically what they do for themselves even in the presence

of the disease. The following were identified during the assessment phase as D.K.A and her

family strengths

Pre-Operative Strength

 Patient and family could express their fears and uncertainties about the impending surgery

 Patient and family were willing to learn about the condition

Post-Operative Strength

 Patient’s pain subside with pain medications

 Patient cooperated during wound dressing

 Patient’s mother verbalised her uncertainties about the catheter inserted into patient’s

urethra

38
 2.3 The Patient /Family Problems

These are conditions that affect the individual physically, mentally, socially and hinder

speedy recovery.

Pre-Operative Problems

1. Patient’s mother was anxious about the impending surgery (1/10/2018)

2. Patient’s mother had no knowledge on the causes and treatment plan of the condition

(1/10/2018)

Post-Operative Problems

1. Patient complain of pain after surgery (2/10/2018).

2. Patient had surgical wound on the penis (2/10/2018)

3. Patient had urethral catheter inserted in the urethra (3/10/2018)

4. Patient was at risk of wound infection (04/10/2018)

2.4 Nursing Diagnosis

A nursing diagnosis is a clear and definite statement of the patient’s health status that can be

influenced by nursing interventions. It is derived from a validated, critically analyzed and

interpreted data collected during assessment.

Conclusions are drawn regarding the patient needs and problems. The nursing diagnosis, once

identified, provides a central focus for the remainder of the stages that is based on the nursing

process. The plan of care is designed, implemented and evaluated, hence making it possible to

give a comprehensive health care to the patient. This is done by identifying, validating and

responding to specific health problems. The nursing diagnosis also supplies an efficient method

of handling the patient’s health problems.

The following diagnosis were made on Master K.P and family

39
Pre-operative Nursing Diagnosis

1. Anxiety (mother) related to unknown outcome of impending surgery (1/10/2018)

2. Knowledge deficit (mother) related to inadequate of information on causes and

management on disease condition (hypospadias). (1/10/2018)

Post-Operative Nursing Diagnosis

1. Acute pain related to damage to skin/tissues secondary to surgical incisions and presence of

catheter (2/10/2018)

2. Impaired skin integrity (wound) related to surgical incision (2/10/2018)

3. Body image disturbance related to treatment regimen (inserted catheter). (3/10/2018)

40
 CHAPTER THREE

PLANNING FOR PATIENT AND FAMILY CARE

3.0 Introduction

Planning is the third stage of nursing process. It involves the development of strategies

designed to prevent, minimize or correct problems identified in the nursing diagnosis. It

involves setting clear objectives and outcome criteria and stating specific nursing measures

that are required in order

3.1 Patient and Family Care Objectives / Outcome Criteria

The following objectives and outcome criteria were set for patient

Pre-Operative Objectives / Outcome Criteria

1. Patient’s family will be relieved of anxiety within 48 hours.

2. Patient’s family will have adequate knowledge on the causes and management of disease

condition within 6 hours.

Post-Operative Objective / Outcome Criteria

1. Patient will be relieved of pain within 72 hours

2. Patient’s wound will heal by first intention within period of hospitalisation

3. Patient’s family will accept changes in patient’s body image within period of

hospitalisation.

Table 6 below shows the nursing care plan for Master K.P and family

41
 Table 6: Nursing Care Plan for Master K.P and family

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
01/10 Anxiety Patient’s mother will 1. Reassure patient and family. 1. Patient and family were reassured that 3/10/18 Goal fully
competent nursing staff will handle his met as
/18 (mother) be relieved of anxiety condition so that no complication would
1pm patient had
2. Allow patient and family to arise after the surgery.
related to within 48 hours as
express their feeling. 2. Patient and family were allowed to relaxed
1pm unknown evidenced by 3. Explain the purpose of the express their feeling. facial
investigations and examinations 3. The purpose of investigation was
expression
outcome of 1.Mother verbalising to patient’s mother explained to patient’s mother and was
4. Explain the importance of the informed about items that will be used on and mother
impending absence of anxiety surgery to patient’s mother. patient. verbalised
4. Patient’ mother was told that the surgery
surgery 2.Nurse observing absence of
5. Introduce other patients who will help correct the abnormality on
have undergone same surgery patient’s penis, so that he could live his anxiety
patient having relaxed
and are recovering well to normal life..
facial expression patient’s mother. 5. Other patients who were successfully
recovering from hypospadias repair were
6. Provide a quiet environment introduced to patient’s mother and was
made to converse with them. This helped
to allay her fears.
6. The volumes of television set, radio set
were turned to a lower volume to relax
patient and also to induce sleep

42
 Table 6: Nursing Care Plan for Master K.P and family continued

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Outcome Criteria Time
01/10/18 Knowledge Patient’s mother 1. Reassure patient and 1. Patient and mother were reassured that all 01/10/18 Goal fully met as
relatives. necessary information on hypospadias
deficit will have adequate
1:15pm would be provided to help them understand 7:15pm patient’s mother
(mother) knowledge on the 2. Establish rapport with the condition.
patient and family. 2. A good interpersonal relationship was answered
related to disease condition
3.Provide a peaceful established with patient and mother to
inadequate of within 6 hours as environment to enhance provide a good atmosphere for learning. questions about
learning 3. Conducive environment with less noise
information evidenced by
4. Assess patient’s mother was created to enhance learning by putting the causes and
on causes and 1. Patient’s mother level of knowledge about the off television and radio.
disease 4. Patient’s mother level of knowledge management of
management answering
5. Educate patient mother on about the disease was assessed and
on disease questions on the causes, signs and education was built on it start. the disease
symptoms, management, 5. Patient’s mother was educated on the
condition hypospadias
complications and prevention causes, signs and symptoms, management, condition
(hypospadias) correctly. of hypospadias. complications and prevention of
hypospadias. This gave her more insight on correctly.
. 2.Patient’s mother
the condition and all misconceptions
verbalizing clarified.
6. Allow time for questions. 6. Patient’s mother was allowed to ask
understanding on
questions and was answered in simple terms
the information to aid in understanding
7. Ask for feedback 7. Patient’s mother was made to repeat what
given her
she has been taught to ensure she
understood the causes and management of
the disease condition.

43
 Table 6: Nursing Care Plan for Master K.P and family continued

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Outcome Criteria Time
02/10/18 Acute pain Patient will be 1. Reassure patient and 1. Patient and mother were reassured that all 5/10/18 Goal fully met as
relieved of pain relatives. measures will be put in place to help relieve
1pm related to evidenced by
within 72 hours as him of the pain.
damage to 2. Use divertional therapy 2. Diversional therapy was provided by 1pm nurse observing
evidenced by;
turning on the television set in the ward.
skin/tissues a. Patient the patient having
3. Restrict visitors and 3. All visitors and relatives were made to go
exhibition of relatives. outside the ward so that the patient could
secondary to relaxed facial
cheerful facial have enough rest.
surgical 4. Apply cold compress. 4. Padded ice packs were applied to the site expression and
expression
incisions. b. Nurse observing of pain every 2 hours. This helped the patient
patient to relax and also ease the pains
that patient remains
5. Help patient to assume a 5. Patient was assisted to assume a supine exhibiting
calm and relaxed
comfortable position position to prevent pressure on the bladder cheerful facial
when lying in a prone position.
6. Monitor vital signs 6. Vital signs were checked and recorded to expression.
ascertain any abnormalities.
7.Encourage rest and sleep to 7. Patient’s bed linen was straightening and
reduce pain sensation free from creases to enhance rest.
8. Serve prescribed analgesics 8. Prescribed analgesics Suppository
Paracetamol and Syrup Brufen were
. administered to relieve him of the pains.

44
 Table 6: Nursing Care Plan for Master K.P and family continued

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Outcome Criteria Time
02/10/18 Impaired skin Patient’s skin 1.Reassure patient and mother 1. Patient and mother were reassured that 12/10/18 Goal fully met as
wound would heal completely without any
integrity integrity will be 8am nurse observed
complications.
1pm (wound) maintained within that patient’s
2. Dress wound as ordered 2. Wound was dressed aseptically as
related to period of aseptically ordered. wound was
3. Assess and observe 3. The color, redness and discharges of
surgical hospitalisation healing by first
patient’s wound for signs of patient’s wound was observed daily and
incision as evidenced by intention and
healing. reported.
1. Nurse observing 4.Maintain adequate nutrition 4. Patient was served with balanced diet to patient was free
and hydration to aid wound aid in wound healing
patient wound heal from infection.
healing
by first intention.
5. Nurse patient in a 5. Patient was nursed in supine position to
2. Patient’s mother comfortable position. prevent pressure on the surgical site when
lying in a prone position.
observing no
6. Administer prescribed 6. Prescribed antibiotics (Cefuroxime and
discharge from the
antibiotics Metronidazole) were served and the
incisional site 7. Educate the patient’s therapeutic effects was observed.
mother to report any 7. Patient’s mother was educated to report
discharges if any any discharges

45
 Table 6: Nursing Care Plan for Master K.P and family continued
Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Outcome Criteria Time
3/10/18 Body image Patient’s mother 1. Encourage patient’s mother to 1. Patient’s mother was encouraged to 12/10/18 Goal fully met as
communicate feelings of verbalise her feelings on the inserted patient’s mother
9am disturbance will accept changes frustration and reassure her catheter as it provides opportunity to 8am
verbalised
deal with misconceptions.
related to in patient’s body
2. Answer all questions 2. All questions asked by patient’s acceptance of
treatment image within period concerning the catheter inserted mother were answered in a simple child’s situation.
and its function to patients’ language
regimen of hospitalisation as mother
3. Teach patient’s mother to dress 3. Patient’s mother was encouraged to
(inserted evidenced by child in loose clothes that does dress patient in loose clothes to prevent
not restrict the urethral catheter restriction of the urethral catheter.
catheter) 1. Nurse observe
4. Provide opportunity for 4. Patient’s mother was involved in the
patient’s mother patient’s mother to participate in care of catheter of patient.
the catheter care of patient.
participating in the 5. Inform mother that catheter 5. Patient’s mother was informed that
will be removed as soon as urethra catheter will be removed as soon
care of patient. wound heals. as surgical wound healed.
6. Discuss sexual functioning and 6. Patient’s mother was told that patient
2. Patient’s mother
potential physical changes that will be able to urinate as soon as
verbalising may occur with patient’s mother catheter is removed and it would not
have permanent effect on him when he
acceptance of grows.
7.Educate mother on the 7. Mother was educated on the
child’s situation.
importance of passing urethral importance of passing the urethral
catheter catheter

46
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT/FAMILY CARE PLAN

4.0 Introduction

This chapter deals with the actual care given to Master K.P and his family. It is based on the

care plan drawn for him and the interventions carried out after the problems have been

identified.

4.1 Summary of the Actual Nursing Care

Day of admission (1/102018).

On the 01/10/2018 at 12pm, Master K.P and her mother walked into the urological ward of the

Wenchi Methodist Hospital. Patient and mother were welcomed and offered seat. Patient’s

folder was taken from mother and patient’s name, age, sex and residential place was mentioned

to confirm the identity of the patient. Patient and mother were introduced to the other staff

around. Patient had been diagnosed of Hypospadias and had been scheduled for hypospadias

repair the following day. They were then made comfortable in an already prepared simple

unoccupied bed and assessment was done. Upon assessment, patient was conscious and

complain of no pain. Upon examination of patient from head to toe, it was realised that patient

had an abnormal opening under the penis. Vital signs were checked and recorded as

Temperature 36.2oC

Pulse 105bpm

Respiration 24cpm

SPO2 98%

Laboratory investigations requested were

Blood for full blood count

Grouping and cross matching against one unit (pint) of blood standby

47
Blood sample was taken and sent to the laboratory in a well labeled sample bottle for

investigations to be conducted.

The following medications were ordered by the attending physician. Drugs were to be

administered on the morning of surgery

Intravenous Cefuroxime 750mg stat

Infusion Normal Saline (Sodium Chloride) 500mls stat

Infusion Dextrose Saline 500mls for 24 stat.

Drugs were then procured from the pharmacy department and placed by patient’s bed side.

Patient and mother were orientated to the ward and its environs such as the toilet, bath and the

playground. Since the ward didn’t have a dining hall, it was explained to Mrs. G.A that they

could eat by their bed side. After that, she was then introduced to other patients in the ward.

Mrs. G.A was informed of the visiting time and hospital payment policies. She was told that

even though, Master K.P had insurance, not all the care will be covered under the national

health insurance. Since it was a planned admission, patient’s mother already had patient’s

personal items that He may need at the ward such as towel, sponge, tooth brush, toothpaste

and bucket from the house. They were asked to talk to any of the nurses around if they needed

anything or help. Patient’s particulars were documented into the admission and discharge book

and daily ward state

After these interventions, I told the ward in-charge of my intention of using the patient and the

family for a case study and I was given the permission. I introduced myself to the

patient/family that, I am a student nurse of Nurses’ Training College, Sampa, conducting a

case study at the hospital. I then made it known to her my wish to render holistic nursing care

to Master K.P for his speedy recovery. Mrs. G.A was informed that, as part of my training,

final year students are to take a patient each, nurse him or her from the time of admission till

time of discharge and home visits. Mrs. G.A accepted and promised her cooperation and

48
readiness to give me any information needed for my study. Patient’s mother was informed that

admission was temporal and such patient will be discharged in due time for her to continue the

care at home.

They were also informed that, as part of my care, I would visit their home whiles he was on

admission and after he has been discharged. I choose to write my care study on hypospadias

because it is a very rare condition and there are a lot of misconception about it and people

always attribute its causes to spiritual deities.

Pre-operative preparations

Since Master K.P is a minor, Mrs. G.A was made to sign informed surgical consent form and

it was witness by myself. Patient’s mother was told to keep patient nil per os 6-8 hours before

the surgery time. She was told that patient will be bathed early in the morning, ensure he

empties his bowel and bladder before the surgery. Patient’s perineal area was inspected for

any hair, but none was available. Patient’s mother was then told that the hospital chaplain was

available and that she could request for him anytime she wanted as part of the spiritual

preparation before surgery. All laboratory investigations were carried out as ordered. The

anesthetics was called to evaluate and assess patient to ensure he was ready for surgery. The

anesthetic evaluation showed patient ready for surgery the following day.

After the initial interventions had been done, a care plan was drawn to enable me ascertain

patient and family’s health problems and to plan and solve them.

At 1pm, patient’s mother was observed to be anxious. This was as a results of the impending

surgery for her son. A nursing diagnosis of anxiety (mother) related to unknown outcome of

impending surgery was formulated. A goal was to be met within 48 hours to ensure patient’s

mother was relieved of anxiety. In order to achieve the set goals the following interventions

were carried out; Patient and family were reassured that competent nursing staff will handle his

49
condition so that no complication would arise after the surgery. Patient and family were

allowed to express their feeling. The purpose of investigation was explained to patient’s mother

and was informed about items that will be used on patient.

Patient’ mother was told that the surgery will help correct the abnormality on patient’s penis, so

that he could live his normal life. Other patients who were successfully recovering from

hypospadias repair were introduced to patient’s mother and was made to converse with them.

This helped to allay her fears. The volumes of television set, radio set were turned to a lower

volume to relax patient and also to induce sleep.

In addition at 1pm, through assessment, it was realised that patient’s mother had inadequate

knowledge on the disease condition. An objective was set to ensure patient’s mother had

adequate knowledge on the disease condition within 6 hours. The following nursing

interventions were carried out within the set time; Patient and mother were reassured that all

necessary information on hypospadias would be provided to help them understand the

condition. A good interpersonal relationship was established with patient and mother to provide

a good atmosphere for learning. Conducive environment with less noise was created to enhance

learning by putting off television and radio. Patient’s mother level of knowledge about the

disease was assessed by asking her what she knew about the disease condition. Patient’s mother

was then educated on the causes, signs and symptoms, management, complications and

prevention of hypospadias. This gave her more insight on the condition and all misconceptions

clarified.

Patient’s mother was allowed to ask questions and was answered in simple terms to aid in

understanding and she was made to repeat what she has been taught to ensure she understood

the causes and management of the disease condition.

At 2pm, Master K.P had yam and kontomire stew as lunch. He also took coca drink afterwards.

Patient and mother were encouraged to relax.

50
At 7pm, goal set to ensure patient’s mother had adequate knowledge about the disease

condition was evaluated. Goal was fully met as Mrs. G.A answered questions about the causes

and management of the disease condition correctly.

Vital signs was checked and recorded at 8pm. Patient’s mother reminded to ensure child

remained nil per os from 12 o’clock midnight. They were then handed over successfully to the

night nurses for continuity of care.

Second day of admission (Day of surgery) 02/10/2018

Patient woke around 5:30am. Patient’s mother still looked anxious. All nursing interventions to

ensure she was relieved of anxiety were continued.

Immediate pre-operative preparations

At 6am, all immediate preoperative preparations were done. Nil per os was ensured as Master

K.P was not given any food to eat. Patient was encouraged to eliminate his bowel and bladder.

He was then bathed and his clothing’s were changed into theater gown. An intravenous cannula

was inserted into patient’s vein and an IV sodium chloride (Normal saline) 0.5litres was set up.

Inspection was again made to see whether patient had any ring, necklace or denture in mouth

but were all found absent. A surgical checklist was then filled. The consent form was also

checked to ensure it was properly signed. Results of all requested laboratory investigations

were reviewed and filed.

His vital signs were checked to serve as baseline for future assessment of the condition. The

vital signs recorded as follows;

Temperature 36.2C

Pulse 90 bpm

Respiration 24cpm

SPO2 99%

51
Patient was reviewed by the surgeon and anesthetic again in the morning. All laboratory

investigations were within range and no problem was found.

At 9am, Master K.P was sent to the theatre together with his folder, consent form, surgical

checklist, drug (IV Cefuroxime 750mg) and infusions which were to be given at the theatre.

Patient’s mother was made to wait at the theatre waiting room.

Immediate post-operative care (management)

The patient was brought from the theatre on her bed at 11:00am to the ward after the surgery

had been done. Master K.P was semi-conscious on return. He was put in the recovery position

with the neck turned to the left side to prevent choking and also to facilitate breathing and

drainage of mucous and saliva. This position also ensured he did nit lye on the catheter to block

the urine from flowing.

The incisional site was inspected and it was clean and dry without blood stains.

The vital signs were monitored every 15 minutes for the first one hour, thirty minutes for

another hour. The first vital signs checked read;

Temperature 35.9C

Pulse 84 bpm

Respiration 24cpm

SPO2 98%

Intravenous fluid and urinary catheter were all observed and recorded 200 mls saline and

100mls respectively. They were all patent and secured.

The doctor’s note was read and was found out that, Master K.P had hypospadias. The

procedure done to correct the defect was hypospadias repair. Surgery was done under

general anaesthesia. The post-operative medical treatment were Intravenous Cefuroxime

52
250mg tds for 3 days, Intravenous Metronidazole 125mg tds for 3 days, and Suppository

Paracetamol 250mg qid for 1 day. Patient was to resume eating after 1 hour.

Patient’s drugs were taken from the pharmacy and all were administered immediately.

At about 1:00 pm, Master K.P was fully conscious and complained of pain at the incisional site.

A nursing diagnosis of acute pain related to damage to skin/tissues secondary to surgical

incisions was then formulated. An objective was set to relieve Master K.P of the pain within

72 hours. The following nursing interventions were carried out within the stated time. . Patient

and mother were reassured that all measures will be put in place to help relieve him of the

pain. Diversional therapy was provided by turning on the television set in the ward. All

visitors and relatives were made to go outside the ward so that the patient could have enough

rest. Padded ice packs were applied to the site of pain every 2 hours. This helped the patient to

relax and also ease the pains. Patient was assisted to assume a supine position to prevent

pressure on the bladder when lying in a prone position. Vital signs were checked and recorded

to ascertain any abnormalities. Patient’s bed linen was straightening and free from creases to

enhance rest. Prescribed analgesics Suppository Paracetamol and Syrup Brufen were

administered to relieve him of the pains.

Moreover at 1pm, due to the surgical incision made on the patient, the problem of wound was

identified. A nursing diagnosis of impaired skin integrity (wound) related to surgical incision

was made. A goal was set to be met within patient’s period of hospitalisation to ensure

patient’s skin integrity was maintained. The following nursing interventions were carried out;

Patient and mother were reassured that wound would heal completely without any

complications. Wound was dressed aseptically as ordered. The color, redness and discharges

of patient’s wound was observed daily and reported. Patient was served with balanced diet to

aid in wound healing. Patient was nursed in supine position to prevent pressure on the

surgical site when lying in a prone position. Prescribed antibiotics (Cefuroxime and

53
 Metronidazole) were served and the therapeutic effects was observed. Patient’s mother was

educated to report any discharges.

All other interventions to ensure patient’s mother was relieved of anxiety was continued.

At 2pm, patient was fed with porridge. Vital signs were checked and recorded. All medications

served were observed for its therapeutic effect. The urethral catheter was consistently

monitored and output was charted to ensure balance between intake and output. The catheter

was monitored to prevent it from bending and twisting and thereby blocking it.

Patient was encouraged to rest. Patient had rice with stew in the evening. Due antibiotics (IV

Metronidazole, IV Cefuroxime) and analgesic (Suppository paracetamol) were served at 8pm.

The therapeutics and side effects of the drugs were then monitored.

Patient retired to bed at 9pm. Patient was handed over to the night nurses for continuous care.

Third day of admission (1st day post-operative) 3/10/2018

Patient woke up around 6:00am. His self-care activities like brushing his teeth, assisted bathing

were maintained. His clothing were changed and his bed linen were changed. According to

patient’s mother and the night nurses, patient had sound sleep.

Vital signs checked and recorded at 6:00am were as follows;

Temperature………….36.00C

Pulse…………………78bpm

Respiration……………26cpm

SP02 99%

Due medications were served and charted appropriately. Intake and output showed a slight

imbalance of intake of 1litre and an output of 950mls. The colour of the urine was clear.

Incisional site was observed to be clean and dry.

Patient had porridge with bread and egg for breakfast. He looked cheerful after the breakfast.

54
At 8am, Master K.P was reviewed by the urologist. After assessment, syrup brufen 125mg was

prescribed for patient. Patient’s dressing was to be changed anytime it was soaked.

Patient’s mother was informed of the doctors’ orders. The prescribed drug was taken from the

pharmacy and served.

At 9am, during interaction with patient’s mother, she was worried about the duration of the

inserted catheter. A nursing diagnosis of body image disturbance related to treatment regimen

(inserted catheter) was formulated. A goal was set to ensure patient’s mother accepts changes

in patient’s body image within period of hospitalisation. The following nursing orders were

carried out during patient’s stay at the hospital. The following orders were carried out to ensure

the set goal was met; Patient’s mother was encouraged to verbalise her feelings on the inserted

catheter as it provides opportunity to deal with misconceptions. All questions asked by

patient’s mother were answered in a simple language. Patient’s mother was encouraged to dress

patient in loose clothes to prevent restriction of the urethral catheter. Patient’s mother was

involved in the care of catheter of patient. Patient’s mother was informed that urethra catheter

will be removed as soon as surgical wound healed. Patient’s mother was told that patient will

be able to urinate as soon as catheter is removed and it would not have permanent effect on him

when he grows. Mother was educated on the importance of passing the urethral catheter.

All other interventions to ensure Master K.P was relieved of pain, his wound healed well and

his mother was relieved of anxiety were all continued.

Patient was encouraged to ambulate and was also encouraged to rest and sleep. Routine care

such as administration of medication and checking of vital signs were all done and recorded

appropriately.

At 1pm, goal set on the first day of admission to ensure patient’s mother was relived of anxiety

was evaluated. Goal fully met as patient had relaxed facial expression and mother verbalised

absence of anxiety.

55
Master K.P was fed with banku and groundnut soup in the afternoon and rice with stew in the

evening. Patient and mother did not lodge any complain in the afternoon and also in the

evening. In the evening, patient joined the rest of the patient’s on the ward to watch the

television.

Patient retired to bed at 8pm.

Fourth day of admission (2nd Day Post-operative) 4/10/2018

On this day, Master K.P slept well during the night. He woke up in the morning without any

complain from the mother. Patient soiled linen was changed and made comfortable in bed.

Patient was bathed with warm water in the morning. His vital signs during the day ranged as

follows;

Temperature- 36.1degrees Celsius

Pulse - 96 beat per minute

Respiration- 27 cycles per minute

SPO2 98%

During the morning visiting hours, patient and her mother were visited by his grandmother and

some friends. They brought fruits and toys for Master K.P to play with. Master K.P’s sibling,

Miss A.B came with them. He was very happy to have seen his sister and they played around.

Ward rounds was conducted at 9am and patient was to continue with his medications.

After the rounds, patient’s wound was dressed and the covering was changed. Wound looked

very clean and dry. No sign of infection was detected. Wound was covered with povidone

iodine solution. Finding from the dressing was documented. Master K.P was encouraged to

rest.

His lunch was yam and kontomire stew and his supper was rice and stew. Patient retired to bed

at 8pm.

56
5th day of admission (3rd Day post-operative) 5/10/2018

Master K.P slept well during the night without any complain. He woke up in the morning

showing relaxed facial expression. His soiled bed linen was changed and made comfortable in

bed. His personal hygiene activities were maintained. His condition was stable. According Mrs.

G.A, he had weanimix for breakfast.

Vital signs was checked and recorded as

Temperature 36.4oC

Pulse 89bpm

Respiration 28cpm

SPO2 99

Patient’s due medications such as IV Metronidazole 125mg, Syrup Brufen and IV cefuroxime

were all served and charted. The therapeutic and side effects were monitored.

Ward rounds was conducted and the urologist ordered for the wound dressing to be continued.

No new treatment was added to patient’s treatment regimen.

After the rounds patient’s wound was dressed aseptically. Wound looked very clean and dry.

No sign of infection was detected. Wound was covered with povidone iodine solution. Finding

from the dressing was documented. Patient’s catheter was also cared for. No infection was

detected during the catheter care. Routine care such as administration of medication and

checking of vital signs were all done and recorded appropriately.

At 1pm, goal set to ensure patient was relieved of pain was evaluated. Goal fully met as

evidenced by nurse observing patient having relaxed facial expression and patient exhibiting

cheerful facial expression.

All other interventions to ensure patient’s wound healed by first intention and patient’s mother

accepts changes in her son body image were all continued.

57
No complain was lodged by mother or son during the day. Patient was handed over to night

staff in a very healthy state. Patient retired to bed at 8pm.

6th day of admission (4th Day Post-operative) 6/10/2018

On this day, patient woke up at 6:00am. Mouth care and personal hygiene were maintained. His

bed linen were changed and he was groomed nicely. His mother was happy and grateful for the

care which was been rendered. Night report indicated that, the patient had a sound sleep and no

complain was lodged during the night.

They were visited by some friends who live with them in their community. Patient and mother

were happy because of the tremendous improvement in Master K.P condition. Patient looked

cheerful and active as he was seen playing with his toys.

At 6:00am, the vital signs were checked and recorded as follows;

Temperature 36.80C

Pulse 92bpm

Respiration 28cpm

SPO2 99%

At 9am, ward rounds was conducted and new drugs were prescribed for patient. Since patient’s

Intravenous medications had completed. Syrup Cefuroxime 125mg bd for 5 days and Syrup

Flagyl 125mg tds for 5days were prescribed and collected from the pharmacy for patient.

Patient wound was dressed aseptically afterwards and catheter was cared for. No sign of

infection was detected. Findings of wound dressing and catheter care were documented and

explained to patient’s mother.

Routine nursing activities were carried out throughout the day. Patient’s mother was

encouraged to report any problem that she may identify on Master K.P. patient was able to eat

all food served during the day. He had a nap in the afternoon.

58
At 9pm, after watching television with the other patient’s at the ward, he retired to bed in a

stable state.

7th, 8th, 9th of admission (5th, 6th, 7th Post-operative Day) 7th, 8th, 9th of October, 2018

On these day, Master K.P normally woke up at 6am in the morning. His personal hygiene

activities such as bathing, elimination of his bowel, brushing of his teeth and his grooming

were all done. His bed linen were changed daily and his clothes were also changed every

morning. Master K.P’s vital signs were checked and recorded to detect any abnormality.

Patient was able to sleep well in the night and had no complain such as constipation,

sleeplessness or loss of appetite. They were visited by his grandmother every morning during

the visiting hours.

Ward rounds were conducted by the urologist and no new treatment was added to patient’s

treatment regimen. Daily wound dressing and urethral catheter were done. Patient’s wound

showed no sign of infection as there was absence of pus or discharge. The findings from the

catheter care and wound dressing were appropriately documented. He usually watched the

television with the other children on the ward. All interventions to ensure patient’s skin

integrity was maintained and patient’s mother accepted changes in the body image of Master

K.P were continued.

On the 9th of October, 2018, Mrs. G.A was informed of my intention to visit her house the

following day. She agreed and gave me directions to her house. She told me her mother was

home and that I will meet her when I go there.

Due medications were served at the right time. The side and therapeutic effects of the drugs

were monitored.

Master K.P normally took a nap in the afternoon and retired to bed around 9pm in the night.

59
10th day of admission (8th Post-operative Day) 10/10/2018

On this day, patient woke up around 6am. Master K.P slept well during the night without any

complain. He woke up in the morning showing relaxed facial expression. His soiled bed linen

was changed and made comfortable in bed. His personal hygiene activities were maintained.

His condition was stable. According Mrs. G.A, he had porridge and bread for breakfast.

Vital signs was checked and recorded as

Temperature 36.2oC

Pulse 89bpm

Respiration 28cpm

SPO2 99

During ward rounds, new treatment was added to patient’s medication plan. Tablet Oxybutynin

1.25mg tds for 5 days and Syrup Paracetamol 10mls tds for 5 days were prescribed. Due to the

quick healing of the wound, patient’s catheter was to be removed on the following day. Mrs.

G.A was informed of the doctor’s decision. The Syrup paracetamol was collected from the

pharmacy department but the Tablet Oxybutynin was prescribed for Mrs. G.A to buy it from an

outside pharmacy store. Mrs. G.A bought the drug and it was served to patient.

Wound dressing and catheter were done and the findings recorded.

At 11am, Mrs. G.A was informed that I was visiting her house. She reiterated the directions to

her house. She gave me the number of her mother who happened to be in the house. I left the

hospital premises for my first home visit at 11am.

I returned from the home visit around 1pm and informed patient’s mother of the findings made.

She promised to make changes to her house as soon as she was discharged.

Routine nursing activities such as administration of medication and monitoring of vital signs

were carried out throughout the day. Patient’s mother was encouraged to report any problem

60
that she may identify on Master K.P. patient was able to eat all food served during the day. He

had a nap in the afternoon.

At 9pm, after watching television with the other patient’s at the ward, he retired to bed in a

stable state.

11th day of admission (9th Post-operative day) 11/10/2018

Master K.P woke up around 6am. He looked cheerful. According to the night nurses and

patient’s mother, he was able to sleep well. No complain was lodge by the patient or mother

during the night. His soiled bed linen was changed and made comfortable in bed. His personal

hygiene activities were maintained. His condition was stable. According Mrs. G.A, he had

porridge and bread for breakfast.

Vital signs was checked and recorded as

Temperature 36.0oC

Pulse 92bpm

Respiration 27cpm

SPO2 99

Due medications such as Syrup Cefuroxime 125mg, Syrup Metronidazole 125mg, Syrup

Paracetamol 10mls and tablet oxybutynin 1.25mg were all were and the therapeutic effects

monitored.

During ward rounds, the wound was inspected by the medical officer and the catheter was

removed. Patient was to be observed for signs of stricture or difficulty urinating. Patient was

also to be observed for the next 24 hours and that patient may be discharged home if condition

was stable. Patient’s mother was informed of the doctor’s orders. She looked very happy. The

dressing around the penis was changed. Wound looked almost healed and there was no sign of

infection.

61
Throughout the day, Master K.P was monitored for any sign of stricture such as difficulty and

straining on urination, distended abdomen. The underside of the penis was also observed if

urine was leaking from the corrected hypospadias site. None of these observations were present

as Master K.P was able to urinate well with no signs of leaking or straining.

Routine nursing activities were carried out and recorded appropriately.

Master K.P was able to eat all his food served. There was no sign of pain or any discomfort.

Patient’s mother didn’t report any abnormality or lodge any health complain.

Patient retired to bed at 9pm.

12th day of admission/Day of discharge (10th Post-Operative day) 12/10/2018

Master K.P woke around 6am. His self-care activities like brushing his teeth, assisted bathing

were maintained. His clothing were changed and his bed linen were changed. According to

patient’s mother and the night nurses, patient had sound sleep. Mrs. G.A looked cheerful as she

anticipated to be discharged on this day.

Vital signs checked and recorded at 6:00am were as follows;

Temperature………….36.20C

Pulse…………………89bpm

Respiration……………24cpm

SP02 99%

Due medications such as Syrup Cefuroxime 125mg, Syrup Metronidazole 125mg, Syrup

Paracetamol 10mls and tablet oxybutynin 1.25mg were all were and the therapeutic effects

monitored.

At 8am, goal set on the 2/10/2018 to ensure patient’s skin integrity was maintained was

evaluated. Goal was fully met as healed by first intention and was free from infection.

62
In addition, goal set on the 3/10/2018 to ensure patient’s mother accepted changes in patient’s

body image was evaluated. Goal was fully met as Mrs. G.A verbalised acceptance of child’s

situation.

Master K.P wound was dressed. Wound looked almost healed. No sign of infection was

detected. Patient’s mother said he was able to urinate well without any difficulty or leaking

from the underside of the penis.

Ward rounds was conducted by the urologist around 9am. Patient was discharged home with no

new medications prescribed. Patient was to take the remaining drug that he was on. Since the

wound was not completely healed, patient was to come for dressing every 2 days at the Wenchi

Government Hospital. Review date was set at 1 weeks’ time which was 18/10/2018.

Patient’s mother was told to report any abnormality that may be detected at home such as

difficulty urinating. Mrs. G.A was informed of the doctor’s orders.

The mother was educated and encouraged to give him diets rich in vitamins, iron, protein and

calories to aid in wound healing. She was also encouraged to bring patient to the hospital every

two days to dress wound, till it healed completely. Mrs. G.A was further advised to avoid

applying any homemade concoctions on the wound as it may cause the wound to be infected.

She was also educated on how to serve the medications. The need for review was stressed. She

told that I will be visiting them while they are home to ascertain how he is doing after

discharge.

Patient was then discharged in the admission and discharge book and in the daily ward state.

Patient’s folder was taken to the accounts office for billing to be done for insured and non-

insured services rendered to them. The bills were paid for at the cash office and a receipt was

issued to his mother. They were encouraged to adhere to the education given in order to

promote and maintain their health even after discharge.

63
Patient’s mother was assisted to gather their belongings. Patient’s mother then thanked the staff

around for the care rendered to them. She was reminded on the second home visit and also the

review date. They were accompanied to the road side where she picked a car home. The bed

and its accessories were disinfected with chlorine solution and laid for use by the next patient

who will be admitted.

4.2 Preparation of Patient and Family for Discharge and Rehabilitation

Preparation of the patient and family started on the day of admission, that is 01/10/2018.

On admission, patient and family ware made to understand that, hospitalization is temporal and

patient will improve and will be discharged home. During admission, the patient and family

were reassured of the competency of the staff. Mrs. G.A was informed that the surgery to be

done will help correct the birth defect which will enable master K.P to urinate well and it will

have no effect on him in future. During admission she was educated on the predisposing

factors, signs and symptoms, management and correction of hypospadias.

After the surgery was done, Mrs. G.A also educated on the need to maintain good personal

hygiene such as bathing, oral care and proper hand washing before and after eating and visiting

the toilet. She was advised to change patient’s clothing every morning. Mrs. G.A was also

involved in the care of patient especially catheter care to ensure she accepted the body image

disturbance as a result of the treatment plan. She was advised to cloth patient in loose attire to

prevent blocking of the catheter. On the 11/10/2018, patient’s catheter was removed. His

wound looked clean and dry and was healing by first intention. Patient was observed for

difficulty urination and leaking of urine but none was present.

Patient’s mother was also advised to make sure that patient takes her medications to ensure

continuity of care at home and ensure complete recovery. Mrs. G.A, was informed to bring

64
Master K.P for review on the 18/10/2018 to see the urologist. She also informed to bring

patient for dressing every two days.

Patients’ mother was advice to bring him to the hospital for proper management and

appropriate treatment should any of the illness occur. Finally, Master K.P and his mother, Mrs.

G.A were discharged on the 12/10/2018 after spending 12 days at the hospital.

Her bills were assessed and was paid for. Proper documentation of her name, date, bed number

and final diagnosis were entered in the admission and discharge book as well as the daily ward

state to indicate they have been discharged. Mrs. G.A was reminded of the second home visit.

They were reminded of the review date which was 1 week from the day of discharge. They

were helped to pack their things into their bag. They expressed their profound gratitude to the

nursing staff for the care rendered and said goodbye to the other patients wishing them a

speedy recovery. They were seen off to the road side and promised of the second home visit

after which they left in a taxi.

The bed linen was removed mattress, bed and bed locker were disinfected with 0.5% chlorine

solution and air dried.

4.3 Follow Up / Home Visit/ Continuity 0f Care

This is the act of rendering health service to a patient in his/her home environment to ensure

continuity of care.

Follow up, home visit, and continuity of care plan is an important role in the care of the patient

and family before and after discharge. It helps in observing the health and environmental

conditions of the patient and family as well as helping to know the predisposing factors and

hazards which could be dangerous to the health of patient and the family and to know whether

condition of patient is from the surroundings.

65
First Home Visit (10/10/2018)

The first home visit was done on the 10/10/2018 while Master K.P and her mother were still on

admission. Mrs. G.A was informed of my decision to visit their home on the 9/10/2018 and she

gave directions to her home. The aim of the home visit was to know the home and assess the

facilities of the house and community as a whole and to find any factors that may contribute

negatively to their health. It was also to prepare the home before patient was discharged to

prevent relapse of his condition.

On the 10/10/2018 at 11am, I left the hospital premises to visit patient’s home. Mrs. G.A and

Master K.P live at Wenchi in a house with number WN 126 B. The house is opposite the

Assemblies of God Church, near the Pony Filling station just by the roadside. It is about 15

minutes’ drive from the Wenchi Methodist Hospital.

I took a taxi and alighted at the pony filling station. As per Mrs. G.A description, the house was

easily located without asking anyone.

Since the house does not have a fence, I shouted “agoo” and I was received by patient’s

grandmother who was home. She warmly welcomed me and seat and water was offered.

The reason for the visit was explained to her. Patient’s grandmother’s permission was sought to

inspect the house and its environs. She agreed and took me around the house

The house contains 4 bedrooms. It is built with blocks, plastered but not painted. There is no

fence wall around the house. All the 4 rooms has two windows for ventilation in the rooms.

The house has a kitchen and bathroom which is located inside the house and their toilet which

is located outside. The toilet had a gate to lock it and it was well kept. Their kitchen too was

very neat. Their bathroom was also well kept and they had connected a pipe to drain the

bathing water to outside of the house about 30 meters away to join the main gutter in the area.

Even though the house did not have a pipe born, they fetch water from nearby houses and kept

them in the kitchen. According to patient’s grandmother, they dispose their refuse on the

66
community refuse dump which is about 500 meters away from the house. They kept the refuse

they generate each day temporally in a bucket which was well covered with a lid to prevent

spread of diseases by insects.

There were patches of bushes at the back of the house. She was advised to clear it to prevent

breeding of insects and reptiles.

Back to the house, she said 7 people live in the house. There were 3 other family also residing

in the house with them.

Master K.P shares the same room with his mother and his sibling, Miss A.B. Patient’s

grandmother does not live in the house but had only visited because master K.P had been

admitted and she was taken care of Miss A.B. Their room had two windows, a fan and a

mosquito net was set. The things in the room were well arranged and very tidy.

She was congratulated for keeping such a tidy house. Patient’s grandmother was educated to

clear the small weed that was in the house. She was encouraged to assist Mrs. G.A in taking

care of the house and the children when she was discharged.

She thanked me and promised to do what she has been advised to do. I asked permission to

leave and it was granted. She accompanied me to the road side where I picked a taxi back to the

hospital.

Second Home Visit (15/10/2018).

As scheduled with Mrs. G.A, the second home visit was made to patient’s house on the

15/10/2018. Master K.P had been discharged from the hospital for about three days. The aim of

the visit was to assess the state of health of patient at home, to ensure patient was adhering to

treatment regimen, to remind them of the review date, to inform them about handing them over

to community nurse on the next visit and to ensure the family had implemented the

recommendations made on the first home visit.

67
Mrs. G.A was called in the morning to inform her that I will be visiting her on that day. At

3:30pm, I visited patient’s house.

Upon arriving at the house, I was welcomed by Mrs. G.A and her mother. They looked very

happy for the visit. Master K.P was also happy to see me around. The aim for the visit was

explained to them. Mrs. G.A was asked how patient was doing after discharge and she said he

was doing well. She also lodged no complain. She was then asked to bring her drugs that

patient was discharged on from the hospital. This was to verify whether she had been given

Master K.P the drug and whether he was having any side effects of the drugs. Upon inspecting

the drugs, it was realised she had been administering the drugs as prescribed. They were

congratulated and encouraged to take the drugs as prescribed. Enquiries were then made if she

had gone to the hospital to dress Master K.P’s wound after discharged and she responded in the

affirmative. She said she had gone to the hospital the previous day to dress. Wound site was

inspected and it looked clean and dry and it was almost healed. She was asked whether patient

was having abdominal distension, difficulty urinating or leaking under the penis. Mrs. G.A said

there was nothing like that and that Master K.P was doing very well.

Mrs. G.A had found people to weed the bushes that were found around and at the back of the

house. They congratulated for implementing the health advice that was given. According to

Mrs. G.A, her mother had been helping with the caring of Master K.P and his sibling.

After the inspection, they were reminded of the review date which was on the 18/10/2018.

Finally, they were informed that patient will be handed over to a community health nurse for

continuity of care during the next home visit. They were informed that care will be terminated

on the last home visit. Mrs. G.A and her mother thanked me for the care rendered to Master

K.P throughout his stay at the hospital and also following up to check how he was doing after

discharged.

68
I sought permission to leave and I was escorted to the roadside by Mrs. G.A. I bid her goodbye

and took a taxi home.

Review Date (18/10/2018)

On the 18/10/2018, Master K.P and his mother were met at the O.P.D at 9am. They looked

cheerful and happy. Mrs. G.A said she had come to dress patient’s wound also. They were

welcomed and patient’s folder card was taken to retrieve his folder from the record department.

Patient’s folder was taken from the records department and his vital signs were checked and

recorded as

Temperature -36.7 degree Celsius

Pulse - 80 beats per minutes

Respiration - 20 cycle per minutes

Blood Pressure - 110/70milliters per mercury

Patient was then accompanied to the consulting room of the urologist. At the consulting room,

patient gave no new complaint and she was asked to continue with the prescribed drugs. Upon

inspection, patient’s wound had healed. No dysuria or leaking was reported. Patient was told

not to come for dressing again.

Patient was advised to take good care of Master K.P, continue with the remaining of her drugs.

Patient was reminded of the last home visit and she was informed that I will be terminating care

with her and patient and that they would be handed over to a community health nurse who

would ensure continuity of care. Goodbyes were said as she picked a taxi to go home.

69
Third Home Visit (19/10/2018)

The third home visit was made to Master K.P’s house on the 19/10/2018. This was a day after

the review because we were supposed to complete the clinical on the 19/10/2018 and patient

and mother too had be handed over to community health nurse for continuity of care.

The purpose of the visit was to terminate care and introduce patient to a community health

nurse to continue care.

On the 19/10/2018 at 9am, I went to patient’s house with a Community Health Nurse, who

works at the Wenchi Government Hospital. Upon arriving at the house, we were welcomed and

seat and water were offered. The reason for the visit was explained to them and the community

health nurse was introduced to them. Mrs. G.A lodge no complain. The community Health

Nurse informed them of his role in the care of their family.

Mrs. G.A was told to the hospital whenever Master K.P fall sick. She was to report to the

urologist if Master K.P develops any abnormalities or start experience difficulty urination or

stricture. I encouraged them to accord the same co-operation accorded me to the Community

Health Nurse so that he can help in caring for them. They expressed their appreciation for the

care given to them and I also thanked them for their co-operation and time given to me. We

finally asked permission to leave after they had thanked me for my service and they escorted

me to the road side where we picked a taxi walked backed home around 10:00 am.

70
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT/FAMILY

5.0 Introduction

According to Hinkle and Cheever (2014), evaluation is the determination of patient’s response

to the nursing intervention and the extent to which the outcome have been achieved. Evaluation

is the final stage of nursing process and measures patient and family’s response to nursing

interventions and the extent to which they were achieved.

The chapter gives information about the statement of evaluation, amendment of nursing goals

and the termination of the care rendered to my patient and family.

5.1 Statement of Evaluation

Mrs. G.A was relieved of anxiety within 48 hours

On the day of admission i.e. 1/10/2018 at 1pm, patient’s mother was observed to be anxious.

This was as a results of the impending surgery for her son. A nursing diagnosis of anxiety

(mother) related to unknown outcome of impending surgery was formulated. A goal was to be

met within 48 hours to ensure patient’s mother was relieved of anxiety. In order to achieve the

set goals the following interventions were carried out; Patient and family were reassured that

competent nursing staff will handle his condition so that no complication would arise after the

surgery. Patient and family were allowed to express their feeling. The purpose of investigation

was explained to patient’s mother and was informed about items that will be used on patient.

Patient’ mother was told that the surgery will help correct the abnormality on patient’s penis, so

that he could live his normal life. Other patients who were successfully recovering from

hypospadias repair were introduced to patient’s mother and was made to converse with them.

This helped to allay her fears. The volumes of television set, radio set were turned to a lower

volume to relax patient and also to induce sleep.

71
On the 03/10/2018 at 1pm, goal set on the first day of admission to ensure patient’s mother was

relived of anxiety was evaluated. Goal fully met as patient had relaxed facial expression and

mother verbalised absence of anxiety.

Patient and mother had enough knowledge about the disease condition within 6 hours

Moreover on the day of admission i.e. 1/10/2018 at 1pm, through assessment, it was realised

that patient’s mother had inadequate knowledge on the disease condition. An objective was set

to ensure patient’s mother had adequate knowledge on the disease condition within 6 hours.

The following nursing interventions were carried out within the set time; Patient and mother

were reassured that all necessary information on hypospadias would be provided to help them

understand the condition. A good interpersonal relationship was established with patient and

mother to provide a good atmosphere for learning. Conducive environment with less noise was

created to enhance learning by putting off television and radio. Patient’s mother level of

knowledge about the disease was assessed by asking her what she knew about the disease

condition. Patient’s mother was then educated on the causes, signs and symptoms,

management, complications and prevention of hypospadias. This gave her more insight on the

condition and all misconceptions clarified. Patient’s mother was allowed to ask questions and

was answered in simple terms to aid in understanding and she was made to repeat what she has

been taught to ensure she understood the causes and management of the disease condition.

On the same day at 7pm, goal set to ensure patient’s mother had adequate knowledge about the

disease condition was evaluated. Goal was fully met as Mrs. G.A answered questions about the

causes and management of the disease condition correctly.

72
Patient was relieved of acute pain within 72 hours

On the second day of admission(02/10/2018), surgical repair of hypospadias was done for

Master K.P. at about 1:00 pm, Master K.P was fully conscious and complained of pain at the

incisional site. A nursing diagnosis of acute pain related to damage to skin/tissues secondary

to surgical incisions was then formulated. An objective was set to relieve Master K.P of the

pain within 72 hours. The following nursing interventions were carried out within the stated

time. Patient and mother were reassured that all measures will be put in place to help relieve

him of the pain. Diversional therapy was provided by turning on the television set in the ward.

All visitors and relatives were made to go outside the ward so that the patient could have

enough rest. Padded ice packs were applied to the site of pain every 2 hours. This helped the

patient to relax and also ease the pains. Patient was assisted to assume a supine position to

prevent pressure on the bladder when lying in a prone position. Vital signs were checked and

recorded to ascertain any abnormalities. Patient’s bed linen was straightening and free from

creases to enhance rest. Prescribed analgesics Suppository Paracetamol and Syrup Brufen

were administered to relieve him of the pains.

On the 5/10/2018 at 1pm, goal set to ensure patient was relieved of pain was evaluated. Goal

fully met as evidenced by nurse observing patient having relaxed facial expression and patient

exhibiting cheerful facial expression.

Patient’s wound healed by first intention throughout his period of hospitalisation

On the day of surgery (02/10/2018) at at 1pm, due to the surgical incision made on the

patient, the problem of wound was identified. A nursing diagnosis of impaired skin integrity

(wound) related to surgical incision was made. A goal was set to be met within patient’s

period of hospitalisation to ensure patient’s skin integrity was maintained. The following

nursing interventions were carried out; Patient and mother were reassured that wound would

73
 heal completely without any complications. Wound was dressed aseptically as ordered. The

color, redness and discharges of patient’s wound was observed daily and reported. Patient

was served with balanced diet to aid in wound healing. Patient was nursed in supine position

to prevent pressure on the surgical site when lying in a prone position. Prescribed antibiotics

(Cefuroxime and Metronidazole) were served and the therapeutic effects was observed.

Patient’s mother was educated to report any discharges.

On the 12/10/2018 at 8am, goal set on the 2/10/2018 to ensure patient’s skin integrity was

maintained was evaluated. Goal was fully met as healed by first intention and was free from

infection.

Patient’s mother accepted changes in her son’s body image within period of

hospitalisation

At 9am, during interaction with patient’s mother, she was worried about the duration of the

inserted catheter. A nursing diagnosis of body image disturbance related to treatment regimen

(inserted catheter) was formulated. A goal was set to ensure patient’s mother accepts changes

in patient’s body image within period of hospitalisation. The following nursing orders were

carried out during patient’s stay at the hospital. The following orders were carried out to ensure

the set goal was met; Patient’s mother was encouraged to verbalise her feelings on the inserted

catheter as it provides opportunity to deal with misconceptions. All questions asked by

patient’s mother were answered in a simple language. Patient’s mother was encouraged to dress

patient in loose clothes to prevent restriction of the urethral catheter. Patient’s mother was

involved in the care of catheter of patient. Patient’s mother was informed that urethra catheter

will be removed as soon as surgical wound healed. Patient’s mother was told that patient will

be able to urinate as soon as catheter is removed and it would not have permanent effect on him

when he grows. Mother was educated on the importance of passing the urethral catheter.

74
On the day of discharge at 8am, goal set on the 3/10/2018 to ensure patient’s mother accepted

changes in patient’s body image was evaluated. Goal was fully met as Mrs. G.A verbalised

acceptance of child’s situation.

5.2 Amendment Of Nursing Care Plan For Partially Met Or Unmet Outcome Criteria

Due to a holistic nursing care and interventions rendered to Master K.P and his family during

the period of admission, all set goals were fully met which contributed to a speedy recovery.

Therefore there was no need for amendment of care plan of any of the set objectives.

5.3 Termination of Patient/Family Care

Termination of care is a therapeutic process that helps patient and the nurse to end their

relationship. It is a gradual process which started from the day of admission to the last home visit.

Throughout the period of hospitalization, Master K.P and family were made aware that the care

is for a period of time after which the nurse-patient relationship will eventually be terminated.

Patient and family were educated on their personal, environmental hygiene, eating of balanced

diet and also ways to prevent infection of the wound.

In all three home visits were made to patient’s house. The actual termination of the interaction

occurred on the last home visit thus on the 19/10/2018 after I had informed patient and family

of the need to return to school and continue with my academic work. They were handed over to

a community health nurse who promised to continue the care which was been rendered to them

The patient and the family showed appreciation for the services I rendered and asked for

continuation of the relationship. I assured them that I would pay them a visit anytime that I

found myself in Wenchi. The termination left separation anxiety effect on the patient and

family, since they were educated from the beginning.

75
 CHAPTER SIX

SUMMARY AND CONCLUSION

6.0 Introduction

This is the final chapter in the patient / Family care study. It deals with the summation of all the

medical and nursing care rendered to the patient and his family as well as the conclusion.

6.1 Summary

According to Webster (2014), summary is a brief statement of the most important information

in a piece of writing or speech.

Master K.P, a two year old boy was admitted to the Wenchi Methodist Hospital on the

1/10/2018 with a diagnosis of hypospadias. Patient had been scheduled for hypospadias repair

the following day. On admission, patient was conscious and ambulatory. Patient was

accompanied by the mother to the ward. Upon assessment of patient, it was realised patient had

an abnormal opening under the penis and such urine leaked through the opening when

urinating.

His vital signs was checked and recorded as

Temperature 36.2oC

Pulse 105bpm

Respiration 24cpm

SPO2 98%

Laboratory investigations requested were

Blood for full blood count

Grouping and cross matching against one unit (pint) of blood standby

Blood sample was taken and sent to the laboratory in a well labeled sample bottle for

investigations to be conducted.

76
The following medications were ordered by the attending physician. Drugs were to be

administered on the morning of surgery

Intravenous Cefuroxime 750mg stat

Infusion Normal Saline (Sodium Chloride) 500mls stat

Infusion Dextrose Saline 500mls for 24 stat.

Drugs were then procured from the pharmacy department and placed by patient’s bed side.

Pre-operative preparations such as signing of consent form by patient’s mother, ensuring nil

per os, eliminating of his bowel and bladder before surgery, grouping and cross matching of

blood, insertion of an intravenous cannula and filling of surgical checklist were done.

On the day of surgery (02/10/2018), patient was sent to the theater at 9am after he had been

seen by the anesthetics and the urologist early in the morning.

Master K.P returned from theatre after hypospadias repair had been done under general

anaesthesia. He was put in the recovery position and vital signs was checked and recorded

every 15 minutes for the first one hour, thirty minutes for another hour till patient was stable.

Intravenous fluid and urinary catheter were all observed and recorded 200 mls saline and

100mls respectively.

Post-operative medications included Intravenous Cefuroxime 250mg tds for 3 days,

Intravenous Metronidazole 125mg tds for 3 days, and Suppository Paracetamol 250mg qid for

1 day.

Throughout patient’s period of hospitalisation, daily wound dressing and catheter care was

done to prevent infection of the wound.

During their stay at the hospital, 5(five) main health problems were identified and a care plan

was drawn to solve them. They were anxiety (mother), knowledge deficit, pain, wound and

body image disturbance. A goal was set to ensure patient and family were relieved of the

77
health problems identified. Due to the holistic care rendered and the cooperation of patient and

mother, all set goals were achieved within the set time frame and none of the objective were

amended.

Patient was discharged on the 12/10/2018. In all three home visit were made to patient’s

house. Patient and mother came for review on the 18/10/2018. During the last home visit care

rendered to Master K.P and his family was terminated as they were handed over to a

community health nurse.

6.2 Conclusion

In conclusion, the patient and family care study has not only broadened my knowledge about

hypospadias, a congenital disease that is rare in male children but also helped me put the

knowledge I have acquired for the three year nursing course into practice. It has also helped me

to understand comprehensive nursing care that has to be given to individual patient and also

improved my interpersonal relationship with patients. It has also benefited my patient and

family so much on the health status and promise to take all the measures given to improve their

health. Though writing of patient /family care study is tedious, I recommend that every student

should write one as it is enriching in knowledge and practice. It should be maintained in the

General Nursing programme by the Nursing and Midwifery Council of Ghana as an essential

tool and part of the training programme. A copy of this study will be kept in the College library

for future references and use for the training of students.

78
 APPENDIX

Table 7.0: Vital Signs Chart of Master K.P throughout period of hospitalization

Date Time Temperature(0c) Pulse(bpm) Respiration(cpm) SPO2 (%)

1/10/18 12:00pm 36.20c 105bpm 24 98

8:00pm 36.40c 82bpm 22 98

2/10/18 6:00pm 36.2 0c 90bpm 24ccpm 99

11am 35.90c 84bpm 24cpm 98

11:15am 35.50c 86bpm 28cpm 99

11:30am 35.60c 80bpm 22cpm 97

11:45pm 35.90c 78bpm 20cpm 98

12:00pm 36.1 0c 78bpm 21cpm 97

12:15pm 36.0 0c 80bpm 21cpm 98

1:45pm 36.1 0c 78bpm 20cpm 99

2:15pm 36.6 0c 80bpm 22cpm 97

6:15pm 36.5 0c 72bpm 16cpm 96

7:15pm 36.60c 78bpm 18cpm 99

8:15pm 36.3 89bpm 24cpm 97

10:00pm 36.0 86bpm 25cpm 95

3/10/18 6:00am 36.0 0c 78bpm 26cpm 99

2:00pm 36.6 0c 80bpm 28cpm 98

10:00pm 36.4 0c 72bpm 26cpm 99

79
04/10/18 6:00am 36.1 0c 96bpm 27cpm 98
2:00pm 36.40c 78bpm 22cpm 98
10:00pm 36.6 0c 80bpm 26cpm 98

05/10/18 6:00am 36.4 0c 89bpm 28cpm 89

2:00pm 36.2 0c 78bpm 24cpm 99
10:00pm 36.1 0c 82bpm 24cpm 97
06/10/18 6:00am 36.8 0c 92bpm 28cpm 99
2:00pm 36.2 0c 78bpm 24cpm 99
10:00pm 36.1 0c 82bpm 24cpm 97
07/10/18 6:00am 36.4 0c 93bpm 27cpm 98
2:00pm 36.7 0c 88bpm 24cpm 99
10:00pm 36.0 0c 83bpm 30cpm 99
08/10/18 6:00am 36.0 0c 90bpm 27cpm 98
2:00pm 35.9 0c 87bpm 27cpm 99
10:00pm 36.1 0c 88bpm 24cpm 99
09/10/18 6:00am 36.8 0c 89bpm 24cpm 98
2:00pm 36.5 0c 88bpm 26cpm 99
10:00pm 36.9 0c 89bpm 25cpm 97
10/10/18 6:00am 36.2 0c 89bpm 28cpm 99
2:00pm 36.5 0c 89bpm 26cpm 99
10:00pm 36.7 0c 82bpm 24cpm 97

11/10/18 6:00am 36.0 0c 92bpm 27cpm 99

2:00pm 36.2 0c 87bpm 26cpm 99
10:00pm 36.1 0c 82bpm 23cpm 97
12/10/18 6:00am 36.2 0c 89bpm 24cpm 99

80
Reference

Harvey Marcovitch (2014), Black Medical Dictionary , 41st edition, A&C Black publication,

London .

Hinkle, J.L., & Cheever, K.H. (2014). Brunner and Saddarth's Textbook of Medical –Surgical

Nursing.( 12 th edition ). London: Wolter's Kluwer Health/ Lippincott

Joint Formulary Committee(2015) , British National Formula (75th edition), London;

BMJ Group and pharmaceuticals press, London

Marilyn E., Mary F.M., & Alice C.M., (2012), Nursing care plans guidelines for

individualizing patient care across the life span, 8th edition, F.A Davis

Company. Philadelphia

Ministry of health /Ghana health service.(2014).standard treatment guidelines 10th edition,

Accra, Ghana.

Waugh, A. and Grant, A. (2014).Ross and Wilson Anatomy and Physiology in Health and

illness. 11th Edition Elsevier limited

Weller, F.B. (2015).Bailliere’s Nurses’ Dictionary for Nurses and Health Workers.

(25thed.) New York: Bailliere Tindal Elsevier.

Valerie C. Scalon and Tina Sanders (2014), Essentials of anatomy and physiology,

5th edition, F.A Davis Company, Philadelphia

Others

Patient’s folder number

81
 SIGNATORIES

NAME OF STUDENT:

SIGNATURE: ……………………………………………….

DATE: …………………………………. ……………………

NAME OF SUPERVISING TUTOR:

SIGNATURE: ……………………………………………….

RANK……………………………………………………………

DATE: ………………………………………………………..

NAME OF WARD-IN-CHARGE: …………………………..

SIGNATURE: …………………………………………………

DATE: ……………………………………………………………

NAME OF PRINCIPAL OF COLLEGE: ……………………………………..

SIGNATURE: ………………………………………………….

RANK……………………………………………………………

DATE: ………………………………………………………….

82