PATIENT/FAMILY CARE STUDY

(A NURSING PROCESS APPROACH)

ON

MADAM D.B

WITH A DIAGNOSIS OF

UMBILICAL HERNIA

AT LEKMA HOSPITAL

WRITTEN BY

ADDAI NYARKO ABIGAIL

INDEX NUMBER: 11423082

NMC NUMBER:

FINAL YEAR STUDENT OF WISCONSIN INTERNATIONAL UNUVERSITY

COLLEGE

SUBMITTED TO THE NURSING AND MIDWIFERY COUNCIL OF GHANA IN

PARTIAL FULFILLMENT FOR THE AWARD OF

REGISTERED GENERAL NURSING

CERTIFICATE

JANUARY, 2025.
 PREFACE

Trends in nursing have undergone systematic development over the years. Currently, the holistic
approach is being emphasized. These stresses that, the patient is a bio-psycho-social entity and
requires that the physical, emotional, social and spiritual needs of the individual, within the
context of his environment must be considered if he is to be helped and cared for to regain
optimal health. The nursing process has become the bed rock of all nursing care activities. It
encompasses the scientific methodology and the holistic approach to patient care. It also
emphasizes the importance of the relationship that develops between the patient, family and
community as a facilitating factor in health care and health recovery.

The Patient/Family Care Study is a detailed written report of nursing care rendered to a patient,
and his family within a specific period of time. It explores nursing care rendered from the time of
encounter to termination of nurse-patient relationship. It gives an in-depth description and
explanation of how a patient’s response to a specific disease condition is diagnosed and given
intervention. This care study is carried out because it is an integral part of the curriculum for
educating nursing students, hence, a prerequisite for completing the nursing course. This care
study is carried out in partial fulfillment of requirement for the award of professional license by
the nurses and midwives’ council of Ghana. Care study offers the nursing student the opportunity
to combine classroom academic work with clinical study of the practices of the nursing
profession.

In order to maintain the confidentiality of this patient, initials will be used to replace the full
name of the patient, thus Madam D.B will be used to identify patient throughout this care-study.

ii
 ACKNOWLEDGEMENT

My heartfelt gratitude goes to the Almighty God for providing me with the knowledge and
strength to get this far. I also want to express my heartfelt appreciation to Madam D.B. and her
family for their help and cooperation during their hospitalization and home visits.

I am also grateful to my supervisor, Mr. John Akoto for his patience and guidance throughout
this project. Sir, may God abundantly bless you.

I would also like to express my heartfelt appreciation to the entire staff of the LEKMA hospital's
Female surgical ward for their assistance most especially sister Racheal Okailey Mensah for
devoting most of her time to help me understand and guide me through my care study, God
richly bless you.

Additionally, I would like to express my gratitude to all of the lecturers at Wisconsin

international university for their assistance and support throughout my entire tertiary education.

Finally, I want to thank all the authors and publishers of the books I used to conduct my
research.

iii
 INTRODUCTION

The Patient/Family Care Study involves the identification of the patient problems and how they
are dealt with by the use of the nursing care plan. It consists of a systematic way of collecting
data,diagnosing, setting objectives, intervening and evaluating the goals set.

The care of Madam D.B a thirty-five (35) years old woman started on the 17th of December
2024 after she was admitted into the female surgical Ward at LEKMA hospital on an account of
an Irreducible Umbilical hernia.

My selection of patient with this diagnosis was because she I wanted to know much about the
causes and management of umbilical hernia.

Patient stayed on the ward for four (4) days, but the whole interaction from the time of admission
till the termination of care lasted for about three weeks (17th December 2024– 7 th January 2025).
Patient had herniorrhaphy done as part of her surgical management. She was seen and reviewed
every day by doctors throughout her stay on the ward. Patient was given series of education on
condition and its management, her nutrition, exercise, rest and sleep, personal hygiene as well as
medications during her stay on the ward. Three visits were made to patient’s home to identify
resources in her environment that could help in her recovery process and also identify any health
problems in the home and community that might lead to the reoccurrence of her condition after
discharge. Again, these visits were aimed at reminding patient of review date and also to
terminate care officially. Patient was reviewed on the 24th December, 2024 after her discharge for
which no problems were identified. Introduction of community health personnel to patient was
made in order to prepare patient to resume living her normal life. Patient and family were
satisfied with the care rendered as they express their profound gratitude for the tremendous and
remarkable effort in providing them with the care deemed. This care study report has been
organized into five chapters in line with the five phases of the nursing process.

Chapter one was on assessment of her biographical, developmental, past and present medical
history, the family’s medical and socioeconomic history, lifestyle and hobbies. Also, literature
was reviewed on umbilical hernia and data was validated.

iv
Chapter two dealt with analysis of data. A comparison was made between the signs and
symptoms experienced by the patient and those obtained in literature review. Diagnostic
investigations, clinical manifestations and pharmacology of drugs are analyzed in tabular form.
Causes of illness, treatment and complications are also discussed.

Chapter three comprises the planning phase of the nursing process and has the tabulated plan of
care for the stated nursing diagnoses spanning the objective criteria, nursing orders, intervention
and evaluation.

Chapter four tackled the actual implementation of the care plan

In chapter five, evaluation of nursing care given to the patient and her family from encounter till
termination of nurse patient relationship is discussed

v
 TABLE OF CONTENTS

PREFACE.......................................................................................................................................ii

ACKNOWLEDGEMENT...............................................................................................................iii

INTRODUCTION...........................................................................................................................iv

TABLE OF CONTENTS.................................................................................................................vi

LIST OF TABLES..........................................................................................................................vii

CHAPTER ONE..............................................................................................................................1

ASSESSMENT OF PATIENT/FAMILY.......................................................................................1

1.1: Patient Particulars / Biographical Data..........................................................................1

1.2: Family’s Medical History.................................................................................................2

1.3: Family’s Socio - Economic History..................................................................................2

1.4: Patient’s Developmental History......................................................................................2

1.5: Patient’s Lifestyle/ Hobbies..............................................................................................4

1.6: Past Medical History........................................................................................................5

1.7: Present Medical History...................................................................................................5

1.8: Admission of the Patient...................................................................................................5

1.9: Patient family’s concept on illness...................................................................................7

1.9.1: Literature Review on Umbilical Hernia........................................................................8

CHAPTER TWO............................................................................................................................15

ANALYSIS OF DATA.................................................................................................................15

2.0 Introduction......................................................................................................................15

2.1: Comparison of Diagnostic investigation........................................................................15

2.2 Patient and Family Problems..........................................................................................22

2.3 Patient and Family Strength............................................................................................23

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 2.4 Nursing Diagnosis............................................................................................................24

CHAPTER THREE........................................................................................................................25

PLANNING OF PATIENT/FAMILY CARE...............................................................................25

3.0 Introduction......................................................................................................................25

3.1 Objective/Outcome Criteria.............................................................................................25

CHAPTER FOUR..........................................................................................................................37

IMPLEMENTATION OF PATIENT AND FAMILY CARE PLAN............................................37

4.0: Introduction....................................................................................................................37

4.1: Summary of Actual Nursing Care Rendered..................................................................37

4.2: Preparation of Patient / Family for Discharge and Rehabilitation...............................45

4.3: Summary of follow up/home visits/continuity of care.....................................................46

CHAPTER FIVE............................................................................................................................49

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY.....................................49

5.0: Introduction....................................................................................................................49

5.1: Statement of Evaluation..................................................................................................49

5.2: Amendment of Nursing Care Plan for Partially Met or Unmet Outcome Criteria........51

5.3: Termination of Care.......................................................................................................51

5.4: Summary.........................................................................................................................52

5.5: Conclusion......................................................................................................................53

BIBLIOGRAPHY...........................................................................................................................54

SIGNATORIES..............................................................................................................................55

vii
 LIST OF TABLES
Table 2.1 Laboratory Investigations Carried out on patient........................................................16
Table 2.2 Clinical Features Manifested by Patient as Compared to the Literature Review........17
Table 2.3: Pharmacology of Drugs Administered to Madam B.D................................................19
Table 2.4: Pharmacology of Drugs Administered to Madam B.D cont’d.....................................20
Table 2.3: Pharmacology of Drugs Administered to Madam B.D cont’d.....................................21
Table 3.1: Pre-Operative Nursing Care Plan for madam D. B....................................................27
Table 3.2: Pre-Operative Nursing Care Plan for madam D. B cont’d.........................................28
Table 3.3: Pre-Operative Nursing Care Plan for madam D. B cont’d.........................................29
Table 3.4: Pre-Operative Nursing Care Plan for madam D. B cont’d.........................................30
Table 3.5: Pre-Operative Nursing Care Plan for madam D. B cont’d.........................................31
Table 3.6: Post Operative Nursing Care Plan for Madam D. B...................................................32
Table 3.7: Post Operative Nursing Care Plan for Madam D. B cont’d........................................33
Table 3.8: Post Operative Nursing Care Plan for Madam D. B cont’d........................................34
Table 3.9: Post Operative Nursing Care Plan for Madam D. B cont’d........................................35
Table 3.9.1: Post Operative Nursing Care Plan for Madam D. B cont’d.....................................36

viii
 CHAPTER ONE
ASSESSMENT OF PATIENT/FAMILY

1.0: Introduction

Whrite (2018) defined Assessment as the systematic collection of information that gets to know
the patient in detail, evaluates their risks and the nature of problems to be identified. It is the first
step in the nursing process. Data collected on Madam D.B was through general observation,
medical records, physical examination, laboratory investigations and interviewing of the patient
and family as well as some personnel in the healthcare team. Some data were also collected
during patient’s home visit.

1.1: Patient Particulars / Biographical Data

According to Haper (2019), patient particulars are facts or details about patients which are
written down and kept as a record. They include patient’s name, age, height, weight, residence,
hometown, parents, languages spoken, complexion, religion, marital status and other basic
information about the patient.

Madam D.B is a 35-year-old woman born on the 14th August 1987. She was born in Konongo in
the Ashanti region of Ghana. She is chocolate in complexion, weighs 105kg and has a height of
165cm. Her parents are Mr. P.O.B and the late Madam. J.P. She is a Ghanaian, an Ashanti and
comes from Konongo in the

Ashanti region of Ghana. She resides at Teshie camp two, near the 31st school in the Greater-
Accra with her husband and children. She speaks Twi and English. She is an entrepreneur and
deals in decor and hampers. She is a Christian and fellowships with the Apostolic church of
Ghana at Spintex. Madam D.B has 1 sibling of which she is the first child of her parents. She is
married to Mr. K.B and blessed with four children. Madam. D.B had her formal education up to
the secondary level. Her next of kin is her sister, Madam. E. O who also resides Tema. Madam
D.B has no physical impairments.
1.2: Family’s Medical History

According to Madam. D. B, her family has no history of inherited conditions like diabetes
mellitus, hypertension, or sickle cell anemia. Despite their advanced age, her dad is still alive and
in good condition, but her mum is deceased. Both her paternal and maternal grandparents are no
more alive, but the cause of their death is unknown to her. Her sibling is also alive and in good
health. She said that her mother was admitted at the Okomfo Anokye hospital in 2019 and
managed for typhoid fever. She also said that some of her family members were also admitted in
other hospitals occasionally with conditions unknown to her. According to her, apart from
visiting the hospital with conditions such as malaria and fever, she and her family sometimes use
over the counter (OTC) medications to treat minor ailment. There are no known allergies in her
family. There is also no record of mental illness in patient’s family.

1.3: Family’s Socio - Economic History

According to Madam. D.B, there is a strong family bond in her
family whereby they support each other all the time. Her family
members engage in occupational activities such as farming,
trading, vocational works and few are into government
employees. Patient is an entrepreneur who deals in decor and
hampers at Teshie. Her father is a Reverend minister, and her
mother was also a trader before she passed on. Patient is a strong
Christian who fellowships with Christ Apostolic Church at the
Spintex branch. She and her nuclear family members are
covered by the national health insurance scheme (NHIS) which
helps them finance most of their medical bills. Patient’s husband
is a middle level income earner. Patient said that her family is
2
not bounded by any taboos, norms, customs or cultural practices
that could have an effect on their health and living.

1.4: Patient’s Developmental History

Sterdman (2020) defined growth as the increase in size of a
living being or any of its parts occurring in the process of
development; as measured in increments of weight, volume and
linear dimensions. Development is a progressive acquisition of
various skills (abilities) such as head support, speaking,
learning, expressing feelings and relating with other people
(Llewellyn, 2019).

Weber (2019) defined maturation as a part of development that

refers to the acquisition of new characteristics or competencies
that are transmitted genetically. This implies that growth;
development and maturation begin from conception through
infancy, childhood, adolescence, adulthood till death and
involves physical, psychosocial, intellectual, emotional, moral
and spiritual aspects.

Madam. D.B was born through a spontaneous vaginal delivery

at Okomfo Anokye hospital at term with a normal birth weight

3
of 2.5kg without any complications or defects. She had neither
physical defects nor cognitive impairments when she was
delivered according to her mother. She does not recall either
being exclusively breastfed or not. According to her, she
stopped breastfeeding at the age of 2 years. She had not suffered
any severe illness that might have retarded her growth.
According to Madam D.B. She has no idea whether she was
immunized during her childhood. But upon physical assessment,
it was noted that patient received the Bacille Calmette Guerin
(BCG) vaccine for tuberculosis since she has the scar on her
right shoulder. Patient also said that according to her mother, she
started sitting up without support at the age of 8 months, crawled
at the age of 11 months, started walking at the age of 15 months
and started talking clearly at the age of 2 years. She started
kindergarten education at the age of 3 years through to junior
secondary school at age 15 years. According to her, she started
developing secondary sexual characteristics at the age of 11
years.

She had her formal education up to the junior high level where
she completed at Latebioquashie LB3 School. She then

4
continued to saciado sectarian school. She then decided to
engage herself in the sales of hampers as well as decor and has
been doing well at it. Her goal now is to open more branches of
her business. Patient got married at the age of 28 years to Mr.
Mr. D. D and they are blessed with four children (two males and
two females).

Madam D. B is at the seventh stage of Erik Erikson’s

psychosocial theory of personality development (26-64 years).
During this stage according to Erikson, the individual aims at
establishing and guiding the next generation. This is shown in
raising and taking care of children, engaging in forms of
productivity like farming, teaching and nursing. The individual
at this stage is interested in the welfare of society. Looking at
Madam D. B., she is married with children, she also has an
occupation that enables her to take care of her family, and she
takes church activities seriously and also partakes in communal
labor in her community. It can therefore be concluded that she
has achieved the goal of this stage successfully.

5
1.5: Patient’s Lifestyle/ Hobbies
Madam D.B usually wakes up at 5 o’clock am almost every day
to perform her activities of daily living such as brushing teeth,
bathing and grooming. She on most occasions engages in
morning devotion with her family as part of her spiritual routine.

Normally on weekdays, she makes sure she prepares all orders

of hampers as well as prepare for the decor if booked at home to
avoid disappointment to her customers. She sometimes, as part
of her work routine, has to travel a few distances to deliver
goods to people upon request. She mostly has to take her
breakfast around 7am, and lunch at 2pm. She occasionally has to
buy food from vendors. She usually takes her supper after 7pm
when she returns home from work. After taking her supper, she
maintains her personal hygiene, watches some television
programs before retiring to bed at about 10:00pm.

On Saturdays, she uses her leisure times to attend funerals,

outdooring, weddings and other occasions whenever the need
be.

6
Her Sundays are for church activities. She fellowships with the
Apostolic Church of Ghana at Spintex-Accra. She is the women
ministry leader in the church. Her other Sunday routines are for
attending prayer meetings and visiting other church members
and relatives. She spends time with her family on Sunday
evenings.

According to her, unless she is unwell, she does not have

difficulty eating any food and takes her three-square meals every
day along with snacks. She consumes alcohol in moderation
however, does not take coffee or tobacco. She has a normal
bowel and bladder elimination patterns. she is not allergic to any
food or medications and strictly adheres to prescriptions. Her
hobbies are playing ludo, watching movies and other television
programs. She also enjoys reading the bible. She does not
readily engage in any forms of specific exercises. Patient is
psychologically stable and exhibits emotions appropriately. She
is an extrovert and likes to communicate with others freely.
Some of her favorite foods include rice with stew, ripe plantain
and fufu with light soup.

7
1.6: Past Medical History
Patient did not give any account of suffering any childhood
diseases. She was admitted to the hospital in 2019 when she
visited her parents at Kumasi. She was treated and discharged
after three days on account of malaria. Patient has never been
involved in any road traffic accident. She added that she
occasionally suffers minor sicknesses and aches in her body but
goes to the pharmacy or drugstore to get treated. She sometimes
boils herbs to drink at home which makes her strong and
healthy. The patient undergone cesarian session during the
delivery of her last born. Patient has no known allergies to food
or medications. Patient has no physical impairments or
disabilities.

1.7: Present Medical History

Patient has no known chronic illness and was well until about a
week ago when she started experiencing severe pain and
swelling at her umbilical region. she noticed a mass in her
umbilical region which moved back when she assumed some
positions. With time patient also started to vomit and was unable
to perform any activities. She went to the drug store to purchase

8
some pain medications but to no avail. She was rushed to the
hospital by her sister for further treatment as the signs and
symptoms were persisting and never improved. She was seen
and assessed by Dr. Mensah Emmanuel at the emergency
department and admitted on account of strangulated Para
umbilical hernia.

1.8: Admission of the Patient

Madam D.B was received into the Female surgical ward of the
LEKMA hospital at 1:00pm on the 17th December, 2024. She
walked into the ward accompanied by her sister and a nurse
from the emergency department with the diagnosis of
strangulated umbilical hernia.

She was warmly received and made comfortable in bed. Initial

vital signs were taken and recorded as Temperature 36.9℃,
Pulse 86bpm, Respiration 22cpm, Blood pressure 124/80 mmHg
Pain = severe (10) SPO2 98% on room air. Vein was entered
and prescribed medications were collected served. She was to be
managed on Intravenous paracetamol 1g tds x 48 hours

IM morphine 10mg QID x 48 hours

1L Ringers lactate daily for 24 hours

9
2L dextrose 5% daily x 24 hours

The following laboratory investigations were requested for patient; and blood samples were
taken at the emergency before patient came to the ward. Hence follow ups were made on the
laboratory investigations.

Full blood count (FBC)

Blood urea nitrogen and creatinine

Grouping and cross matching

Sickling status

Introduction was made and patient information were collected

from both the accompanying nurse and her sister and were
entered on the computer.

Her name was identified and confirmed, and reassured of

competent and comprehensive nursing care. She was now
orientered to the ward and its environment. She was also
introduced to the staff on duty and was made aware of the
various activities on the ward such as ward rounds and visiting
hours. She was also introduced to the patients who were in bed
next to her to establish rapport. Her sister was also informed of

10
the visiting hours and other items that would be needed on
admission

Patient’s initial vital signs on arrival indicated that she had

hyperthermia (37.9℃) and further assessment on observation
showed no respiratory distress, hydration was fair, patient was
admitted into the admission and discharge book including the
daily ward state. She was also assisted later to change into her
night wear and her items kept in her bedside locker. Patient was
asked if she had anything she would want to keep safe with the
nurses, but her response was negative.

Patient is a subscriber of the National Health insurance Scheme

(NHIS) but it was made known to her that NHIS does not cover
all drugs and treatments so, provision should be made for any
additional cost.

Patient’s problems were identified as hyperthermia, severe pain

in the umbilical region, nausea and vomiting, little knowledge
on condition and anxiety. These problems were used to establish
a nursing care plan to help in her care and management. All
procedures carried out during the admission process of patient
were documented on both the computer and in the nurse’s noted.
11
my intentions were made to patient about wanting to use her for
my care-study. They were glad and consented to it.

1.9: Patient family’s concept of illness

Patient did not relate her condition to any spiritual forces but
was optimistic that the condition was something normal and will
get well with treatment. Her expectation was to receive the best
of treatment at the hospital, get better and return home within
the shortest possible time.

1.9.1: Literature Review on Umbilical Hernia

What is Hernia

It refers to the escape or protrusion of hollow viscous organ

through a weakened area or cavity in which it is contained. It
can also be defined as a protrusion of an organ through the wall
of the cavity which normally contains (Suzanne, Brenda, Hinkle
& Kerry, 2020).

Definition of Umbilical Hernia

According to Suzanne, Brenda, Hinkle & Kerry (2020), an

umbilical hernia usually happens in the groin, when one of your
organs pushes through the muscle or tissue that contains it. This
12
occurs when the abdominal muscles do not close completely
after birth, leaving a weak spot in the abdominal wall. It may or
may not cause symptoms such as discomfort or pain. However,
most hernias eventually will need surgery.

Incidence Of Umbilical hernias

The incidence of umbilical hernia varies by age and sex. In
children, umbilical hernias are common, affecting 10-20% of
children. They are common in African-American, low birth
weight infants and premature infants. In adults, umbilical
hernias are the second most common type of hernia, accounting
for 6-14% of all abdominal wall hernias. They are three times
more common in women due to pregnancy and childbirth.
Etiology of Hernias
The causes of hernia can be grouped into two according to
Basavanthappa (2019);
Congenital or anatomical defect. This is due to congenital
weakness probably as a result of defect in the fusion of tissue
around the opening.
Acquired. The weakening nature of any part of the abdominal
muscle due to;

13
Aging: as the individual ages, the body cells atrophies and lead
to possible muscle weakness. This weakness prone the
individual to have hernia.
Severe infection affecting the peritoneal and muscular structure
reduces it resistance to any little extensive pressure.
Past-surgical incision with poor closing leaves behind possible
weakened site which may follow any form of herniation.
Obesity. This is associated with more deposit of fat in the body.
The greater deposit and presence of fat increase in the body
reduces the interlacing nature of the muscles. This loosens the
musculature resistance capacity of the viscera wall especially.
Parts of Hernia
Content: This includes organ that is forced through the
weakened area of the musculature. This is found in the sac and it
usually the intestines or omentum.
Sac: This describes the immediate covering of the content which
could be the peritoneum.
Coverings: The covering refers to the weakened muscle or skin
overlying the hernia. Example is the abdominal muscle.
Ring Neck: This is the entrance of the sac where strangulation
usually takes place (Basavanthappa, 2019).
14
Precipitating Factors of umbilical Hernia
These factors basically contribute to increased intra-abdominal
pressure. People with the under listed as well as increased intra-
abdominal pressure are at a higher risk in the development of
hernia (Sharon, Shannon, Heitkemper & Bucher, 2022);
Persistent intense coughing
Straining on defecation
Lifting or pushing heavy objects
Constant blowing of wind instrument e.g., trumpet
Pregnancy
Obesity.
Repeated increased intra-abdominal pressure which precipitate
the protrusion of the viscous.
Pathophysiology of Umbilical Hernia
An umbilical hernia forms when part of the intestine or fatty
tissue protrudes through an opening in the abdominal muscles
near to the navel, causing the belly button to swell. This type of
hernia may develop in babies if the opening that the umbilical
cord passes through does not close properly after birth. This
hernia can also affect adults, possibly due to repeated abdominal
strain. In children, umbilical hernia rarely causes complications,
15
although complications can occur if protruding abdominal tissue
becomes trapped and is not possible to push back into the
abdominal cavity. This incarcerated tissue receives a reduced
supply of blood which can lead to tissue damage and umbilical
pain. If the trapped tissue receives no blood supply at all
(strangulation) gangrene may occur and infection may spread
throughout the abdomen, which can be life threatening.
Incarceration or obstruction of the intestine is more likely to
occur in adults and these individuals must receive emergency
surgical intervention immediately. (Suzanne, Brenda, Hinkle &
Kerry, 2020).
Classification of Umbilical Hernia
Umbilical hernias can be classified by their size, morphology
and type.
By size it is grouped into two that is European Hernia Society
and Chang – Seok et al.’s classification
By morphology, it is grouped into three
Sessile: the largest diameter of the hernia is at the base and the
hernia is conic in shape.
Pedunculate: the base diameter is smaller than the middle part
of the hernia.
16
Hornlike: the summit of the hernia is sharp and pushed down,
giving the hernia comma or horn shape.
By type it is grouped into three that is, reducible, incarcerated
and strangulated
Reducible; where hernia can be manipulated back into its place
with ease.
Incarcerated; when hernia cannot be moved because of
adhesions found in the hernia
sac.
Strangulated; if part of the herniated intestines becomes twisted
or edematous, causing
serious complications.
Clinical Features of umbilical Hernia
Mass above or below umbilicus (paraumbilical)
Discomfort, painless or dragging pain due to tissue
tension/obstruction.
Protruding mass at the umbilicus (umbilical)
Crescent shape appearance of umbilicus
Firm and dull on percussion(omentum)
Nausea and vomiting
Basavanthappa (2019), Marieb (2021)
17
Diagnostic Investigations of Hernia
According to (Sharon, Shannon, Heitkemper & Bucher, 2022)
the following measures can help in effective diagnosing of
umbilical hernias;
Physical examination like inspection and palpation of the site for
swelling and a feel of the hernia content.
History of the patient such as loading heavy goods, fishing
lifting or pushing objects.
Pain on coughing
X-ray of the abdomen
Scan of the abdomen
Medical /Conservative Treatment Management of Umbilical
Hernias
Suzanne, Brenda, Hinkle & Kerry (2020), Basavanthappa (2019)
suggested the following treatment measures for umbilical
hernias;
Mechanical Reduction: Very often patient can reduce their own
hernias to keep the mass from protruding when in a standing up
position is assumed, a truss (a pad made from firm material is
18
placed externally over the hernia and held in place with a belt)
may be worn.
A truss may be recommended in infant when there is the need
for weight gain before surgery. For adults or those who have an
underlying problem that needs to be resolved first. When a
patient has worn a truss, Valsalva maneuver can be used to
check the effectiveness of the truss. Drugs: morphine, Pethidine,
phenobarbitone ``can be administered to allay anxiety and
nervous tension or Diazepam (valium) may be ordered.
Phenobarbitone 30mg tds and Pethidine, morphine to relief
abdominal pain. Warm compresses to the abdomen may also be
useful.
Diet: Give full diet but should be of low residue so that there
will be no irritation of the colon residue. Adequate protein and
vitamins given to correct anemia, correct electrolyte losses
especially potassium. Maintain input and output and record.
Specific surgical management
According to Paul-Martin (2023), umbilical hernias that enlarge,
cause symptoms, or become strangulated are treated surgically.
In infants and children, umbilical hernias are always operated on
to prevent incarceration from occurring. Surgery is usually done
19
on an outpatient basis. Recovery time varies depending on the
size of the hernias, the technique used, and the age and health
status of the patient. The types of surgery for the hernia are as
follows:
Herniorrhaphy: is done to reposition protruding intestines into
the abdominal cavity and the defect in the abdominal wall is
repaired; in Herniorrhaphy, also called “Open hernia repair”, a
person is given local anesthesia in the abdomen or spine to the
area or general anesthesia. Then the surgeon makes an incision
below the umbilicus, pushes the hernia back into abdomen, and
reinforces the muscle wall with stitches. It accounts for about
95% of all hernia repairs.
Hernioplasty: it involves re-enforcing the weakened area with
wire, fascia or mesh and is normally done in obese patient are
advised to lose weight.
Herniotomy: this involves incision into the hernia and the
contents returned back into the abdomen and the removal of the
sac. This is the most common type done in pediatric hernia.
Laparoscopy: laparoscopy is done under general anesthesia and
involves three small incisions (1/2 inch or less) in the abdomen
which is then inflated with carbon dioxide. A laparoscope (a
20
fiber-optic narrow tube with a light on the end) and other
instruments are inserted through the incision. Using a monitor,
the surgeon pushes the herniated tissue back into place and
staples a patch over the opening. Full recovery takes a week or
less.
General Nursing Management
Pre-Operative Management
Paul-Martin (2023) suggested the following pre-operative
nursing management of umbilical hernias;
Establish rapport with patient to build some level of trust. Apply
covered ice packs and administer analgesics to relieve pain e.g.
injection pethidine 100mg. Explain the need of the surgery
(Herniorrhaphy) to the patient and reassure them of the
competency of the surgical staff and introduce patient to
someone who has undergone herniorrhaphy and is recovery
successfully to reduce anxiety. Identify and address any
concerns or explore patient fears and provide desired
information explaining to the patient what to expect after
surgery. Methods of pain relief after surgery must be discussed
with patient. Give spiritual support involving significant others
like a spouse whenever necessary. Set tray and take blood
21
sample for laboratory tests, respiratory and other infection must
be treated adequately before surgery. Teach patient methods of
coughing and sneezing after surgery and create conducive
environment for patient to sleep well the night before surgery.
Assist patient to maintain personal hygiene (bathing, shaving,
mouth care removing all jewels, beads that may interfere with
surgery and monitor vital signs and record.

Post- Operative Management

Paul-Martin (2023) suggested the following post-operative
nursing management of patients diagnosed with umbilical
hernias;
Assess patient’s level of consciousness positioning patient in left
or right lateral position to reduce risk of aspiration. Assess skin
color, nail beds, lips and oral mucosa for pallor ensuring
dressing or suture line for obvious bleeding or drainage and
apply extra dressing if needed. Check the patency of IV line and
monitor the flow rate and monitor post operative vitals
accordingly as the condition requires. Position patient in a semi-
fowler position when consciousness is regained. Maintain nil per
os then begin with sips, if well tolerated then to fluid diet, then
22
liquid, if well taken then light and finally normal diet as patient
can tolerate. Dress wounds aseptically as per physician’s order
and ensure urethral catheter care if any to prevent any infection.
Serve food rich in Vitamins C and K, administer all prescribed
post-operative medications. Update and educate patient and
relatives on the condition and progress of treatment.
Specific Nursing Management
Paul-Martin (2023) suggested the following specific nursing
management of patients with umbilical hernias;
Observe canula site for infiltration and monitor the flow rate of
the fluids. Check the incision site for bleeding and re-enforce
dressing, observe and record the amount, color, consistency of
drains if any. Remind patient to splint incision site when
coughing and encourage them to change position in bed using
the side rails. Encourage proper hand washing, oral toileting,
and perineal care and educate patient on the need to keep the
incision site clean and dry. Assess for return of the gag reflex
and bowel sound returns and resume feeding by serving sips of
water, plain tea, soft diet and patient can tolerate. Encourage
intake of fluids at least 2litres daily. Serve diet high in calorie,

23
protein, vitamin A and C, Zinc and cellular fiber for protection
and to enhance healing process.
Health Education
Educate patient on the causes of the condition, signs and
symptoms, complications, available treatment and signs of
infection such as headache, fever and discharge from the
incisional site. Ask patient to resume normal activities after 6
weeks. Encourage patient to comply with treatment regimen, all
restrictions and behavior modification and the need for
continuity of care.

Complications of Umbilical Hernia

Hematoma: is a large bruise or accumulation of blood caused
by infiltration of blood into the subcutaneous or muscle tissue
tissues due to coagulation defect. It is evidenced by swelling,
discoloration of skin and deformity of tissues. If slight, it is
reabsorbed and if big or considerable may require evacuation.
Recurrence: The longer the duration, the bigger the hernia, the
weaker the fascia. Muscles of the inguinal canal have the greater
risk of recurrence.

24
Surgical site infection: the invasion and multiplication of
micro-organisms in body tissues.
Complication related to mesh placement include seroma,
adhesion and bowel injury. (Coste AH, Bamarni. S et al, 2024)
Prevention of umbilical Hernia
Paul-Martin (2023) listed the following measures to the
prevention of umbilical hernias;
Use of proper lifting techniques when lifting heavy objects, if
you have to lift something that is heavy, bend from your knees,
not at your waist, or don’t lift it at all. Eating of fruits,
vegetables, and whole grains regularly and also drinking at least
eight (8) glasses of water daily not only are these practices good
for the body, they are also packed with lots of fibre that will
prevent constipation and straining. Excessive blowing of wind
instruments such as trumpet and pulling of fishing nets should
be avoided. Persistent coughing and sneezing should be treated
as it increases intra-abdominal pressure. Straining on defecation
or urination should be avoided.
Validation of Data
According to Wharton (2017), Validation of data means
checking the accuracy and quality of source of data before
25
using, importing or otherwise processing data. After a careful
cross check, the data collected from client and family through
observation, repeated interviews and investigations and
compared to the data gathered from textbook, the healthcare
team and diagnostic investigations confirmed that Madam D.B
was suffering from strangulated umbilical hernia which is
attributed to straining on defecation, pregnancy and heavy lifting
and pushing.

CHAPTER TWO
ANALYSIS OF DATA
2.0 Introduction
Data analysis is a method in which data is collected and
organized so that one can derive helpful information from it
(Forbes, 2019). It is the second step of the nursing process and
deals with careful study of the data collected during assessment
in order to identify patient’s capabilities, actual and potential

26
problems to enable one direct his nursing care plan accordingly.
This chapter comprises:

Comparison of patient’s data with standard.

Identification of patient and family strength.

Identification of patient and family problems.

Formulation of nursing diagnosis.

2.1: Comparison of Diagnostic investigation

According to Walter (2018), Diagnostic investigations and tests
are procedures carried out to identify an individual’s specific
areas of weakness and strength in order to determine a
condition, disease or illness. With reference to the reviewed
literature, the following diagnostic measures were carried out on
Madam D.B; Complete history and physical examination, full
blood count (FBC), blood urea nitrogen and creatinine, grouping
and cross matching and sickling status.

27
Table 2.1 Laboratory Investigations Carried out on patient.

Date Specimen Investigation Result Normal Value Interpretation Remarks

17/12/2024 Blood White blood cell (WBC) 4.83×109 /L 4.00-10.00×109 /L WBC count were within No treatment was
count normal range indicating given
absence of infection
17/12/2024 Blood Complete blood count 12.4g/dL 12-18g/dL Hemoglobin was within No treatment was
Hemoglobin level normal range indicating given
absence of anemia
17/12/2024 Blood Red blood cell (RBC) 5.8x1012/L 3.8-5.4×1012/L RBC count was within No treatment
count normal range given
17/12/2024 Blood Grouping and Group O Group A, B, AB and Client belongs to blood No
crossmatching Rhesus O group O with negative heamotransfusion
negative (-) Rhesus Factor. given
17/12/2024 Blood Sodium 139mmol/L 135-145mmol/L All fall within normal No treatment was
Potassium 3.9mmol/L 3.5-5.5mmol/L range. The patient’s given to patient
Chloride 107mmol/L 90-110mmol/L kidneys are functioning
Creatinine 71mmol/L 62-106mmol/L well
Blood Urea Nitrogen 17mmol/L 8.0-36mmol/L
17/12/2024 Blood Sickling Test Negative Positive/Negative Patient’s red blood cells No treatment was
had normal shape given to patient

According to literature, complete physical examination is the main diagnostic tool for umbilical hernia together with other adjunct
investigations. About 70% of the diagnostic measures were carried out on client and confirmed the condition.

28
Comparison of Cause of Patient’s Condition

According to the literature review, the predisposing factors to umbilical hernia includes;
Persistent intense coughing, straining on defecation, Lifting or pushing heavy objects, Constant
blowing of wind instrument, pregnancy, Obesity, repeated increased intraabdominal pressure
which precipitate the protrusion of the viscous. From all the assessment and history taken on
patient, the predisposing factor to her condition was due to straining on defecation, pregnancy
and heavy lifting and pushing which led to increased intra-abdominal pressure.

Comparison Of Clinical Manifestation

This is where the signs and symptoms manifested by the patient is compared to the general
clinical manifestations from the literature review.

Table 2.2 Clinical Features Manifested by Patient as Compared to the Literature Review

Clinical Features in Literature Review Clinical Features Manifested by Patient

There may be paraumbilical swelling Patient had protruding paraumbilical mass

Paraumbilical pain maybe experienced There was pain around patient umbilicus

Constipation maybe experienced Patient had constipation

Crescent shape appearance of umbilicus Patient’s abdomen had crescent shape.

Discomfort, painless or dragging pain Dragging pain was not present in patient

Nausea and vomiting There was nausea and vomiting

29
Comparing clinical features from literature, patient showed about 95% signs and symptoms from
literature.

Comparison of Treatment Administered

According to literature review the most effective management of strangulated hernia is prompt
surgical intervention. Patient underwent herniorrhaphy with the support of other medical
interventions.

Medical treatment include;

Intravenous paracetamol 1g tds x 48 hours

Intramuscular morphine 10mg QID x 48 hours

Intravenous ciprofloxacin 400mg bd x 72 hours

Intravenous metronidazole 500mg tds x 72 hours

Tablet metronidazole 500mg tds for 7/7

Suppository Diclofenac 100mg bd x 72 hours

Tablet paracetamol 1g tds x 7/7

Tablet vitamin C 200mg daily for 15 days

Tablet amoxiclav 625mg bd for 7 days

1L ringers lactate daily for 24 hours

2L dextrose 5% daily x 24 hours

30
 Table 2.3: Pharmacology of Drugs Administered to Madam B.D

Date Drug Standard Dosage/route Dosage/route of Classification Desired Actual action Side effects &
of administration in administration effect/mechanism observed Remedies
literature for patient of action
17/12/2024 I.V/Tab 325mg– 1000 mg 1g tds x 2 Analgesic and It produces anti- Patient’s pain Headache, nausea,
Paracetamol antipyretic inflammatory, and dizziness, vomiting.
Routes: Intravenous Routes: analgesic and hyperthermia None was observed
Orally, Intravenous antipyretic effects was reduced in patient.
Orally, by inhibiting
prostaglandin
synthesis.
17/12/2024 I.M Morphine 10mg-30mg 10mg qid x 2 Opioid Relief of moderate Patient’s pain Respiratory
Route : Analgesic to severe, acute, or was relieved. depression, skeletal
Route: Intramuscular intramuscular chronic pain. muscle flaccidity,
cold/ clammy skin.
None was observed
in patient.
17/12/2024 I.V 200mg-750mg 400mg tds x 3 Fluoroquinolon Inhibits enzyme, Prevented Headache, Diarrhea,
Ciprofloxacin e DNA gyrase, in infections in Nausea, Abdominal
Route: Intravenous Route: susceptible preoperative pain. Not observed
Intravenous bacteria, interfering and in patient.
with bacterial cell postoperative
replication
17/12/2024 I.V 500mg-750mg 500mg tds x 3 Antibacterial, Treatment of Patient was Anorexia, nausea,
Metronidazol Route : antiprotozoal, anaerobic bacterial free from dry mouth, metallic
e Route: Intravenous intravenous amebicide. infections and also bacterial taste. Not observed
for surgical infections in patient
prophylaxis throughout her
hospitalization.

31
 Table 2.4: Pharmacology of Drugs Administered to Madam B.D cont’d

Date Drug Standard Dosage/route of Classification Desired effect/mechanism Actual action Side effects &
Dosage/route of administration for of action observed Remedies
administration in patient
literature
17/12/2024 Ringer’s Dosage is 1 Litre for 24 hours Electrolyte To replace fluid and Patient was Fluid overload,
Lactate individualized Route : Intravenous solution and electrolyte lost in rehydrated and osmotic diuresis
an isotonic dehydration. electrolyte and
Route: Intravenous replacement. balance hyperglycemia.
maintained. None was seen in
patient.
17 12/2024 Dextrose 5% Dosage is 2 litres for 24 hours Parenteral Minimize glycogenesis, Patient was Fluid overload,
individualized Route : Intravenous fluids and prevents anabolism in rehydrated and osmotic dieresis
caloric patient’s whose oral caloric energy was and
Route: Intravenous replacement intake is limited. restored hyperglycemia.
None was seen in
patient.
18/12/2024 Suppository 50mg-100mg 100mg bd x 3 NSAID, Reversibly inhibits cyclo- Patient’s pain Headache,
Diclofenac Analgesic oxygenase-1 and -2 level was abdominal
Route: Rectal Route: Rectal enzymes, resulting in reduced. cramps,
decreased formation of constipation,
prostaglandin. Produces diarrhea, nausea,
analgesic, antipyretic, anti- dyspepsia.
inflammatory effects. Not observed in
patient.

32
 Table 2.3: Pharmacology of Drugs Administered to Madam B.D cont’d

Date Drug Standard Dosage/route of Classification Desired effect/mechanism Actual action Side effects &
Dosage/route of administration for of action observed Remedies
administration in patient
literature
18/12/2024 Tablet Dosage is dependent 200mg daily x 15 Vitamin Cofactor in various Patient’s May cause
Vitamin C physiologic reactions, wound healing calcium oxalate
Route: Orally Route: Orally necessary for collagen process was crystalluria,
formation, acts as enhanced. esophagitis,
antioxidant. Used in poor diarrhea. None
wound healing, bleeding observed in
gums, scurvy. patient.
21/12/2024 Tablet 500mg-850mg 625mg bd x 7 Penicillin Amoxicillin inhibits Patient’s Mild diarrhea,
Amoxiclav bacterial cell wall synthesis wound was nausea, vomiting,
Route: Orally Route: Orally by binding to PCN-binding free from headache, oral/
proteins. Clavulanate infection vaginal
inhibits bacterial beta- during my candidiasis. None
lactamase protecting home visits. observed in
amoxicillin from patient.
degradation and prevents
bacterial infections.

33
Comparison of complications

According to literature reviewed, some likely complications of umbilical hernia are recurrence,
surgical site infection, hematoma, adhesion, bowel injury, etc. Madam D. B suffered
strangulation as a complication of umbilical hernia due to failure to report to the hospital early
for treatment. Madam D.B did not experience any of the complications stated in the literature
review due to competent and quality healthcare delivery.

2.2 Patient and Family Problems

According to Wayne, (2022), patient problems are limitations or situations that the patient and
his family experience which the nurse and the other health team members help to solve. It could
be actual, potential or physiological. From the data collected and observations made on Madam
D. B and the family, the following problems were identified;

Pre – Operative Problems

Patient had a high body temperature (37.9℃) (17/12/2024).

Patient complained of severe umbilical pain (17/12/2024).

Patient was anxious about unknown outcome of surgery (17/12/2024)

Patient is prone to nutritional deficiency (17/12/2024)

Patient had little knowledge on the causes, treatment and prevention of umbilical hernia
(17/12/2024).

Post- operative problems

Patient complained of pain at the incision site (18/12/2024)

Patient could not move due to incisional pain (18/12/2024).

Patient could not sleep well due to incisional pain (18/12/2024).

Patient was at risk for constipation (18/12/2024)

Patient was at risk of surgical site infection (18/12/2024)

34
2.3 Patient and Family Strength

Walter (2021) defines Strength as a quality that someone or something has that helps them
succeed or make progress. Patient and family strengths are therefore resources and capabilities
that help the individual to cope with his condition and to ensure a rapid recovery. This involves
communication skills, cognitive abilities, physiological functioning as well as financial support.
This enhances effective nursing care to both the patient and family. In assessing madam D. B and
the family, the following strengths were identified;

Pre – Operative Strengths

Patient has good hydration habit which helps in managing body temperature.

Patient has good pain tolerance and could verbalize its characteristics.

Patient was able to verbalize the source of her anxiety.

Patient has positive attitude to adhere to dietary advice to enhance recovery

Patient was willing to be educated and actively ask questions about surgery

Post – operative Strengths

Patient and family were able to purchase his analgesic medications

Patient was willing to adhere to physical activity recommendations.

Patient was willing to comply to prescribed pain management strategies

Patient was willing to adhere to dietary modifications and hydration to improve bowel
movement.

Patient was aware of the importance of wound care to promote healing.

35
2.4 Nursing Diagnosis

According to Heather (2022), a nursing diagnosis is a clinical judgement concerning a human

response to health conditions/life processes, or vulnerability for that response, by an individual,
family, groups and communities. The following are the formulated nursing diagnosis made from
the problems identified on Madam D B;

Pre-Operative

Hyperthermia (37.9 degrees Celsius) related to inflammatory process (strangulation of the

intestine).

Acute pain (umbilical) related to strangulated hernia.

Anxiety (patient and family) related to unknown outcome of surgery.

Risk for nutrition imbalance (less than body requirement) related to temporary restriction of oral
intake.

Deficient knowledge related to inadequate information on umbilical hernia.

Post – Operative

Acute pain (incisional site) related to surgical intervention.

Impaired mobility related to post operative restrictions

Disturbed sleep pattern related to pain

Risk for constipation related to decreased gastrointestinal mobility secondary to reduced physical
activity

Risk for infection related to presence of incisional wound.

36
 CHAPTER THREE
PLANNING OF PATIENT/FAMILY CARE
3.0 Introduction

The nursing care plan contains relevant information about a patient’s diagnosis, the goals of
treatment, the specific nursing orders (including what observations are needed and what actions
must be performed) and an evaluation plan (Kathleen, 2022).

3.1 Objective/Outcome Criteria

The goals set on the pre-operative and post-operative problems identified and diagnosed on
madam D. B include;

Pre-operative

1. Patient will attain normal body temperature (36.2-37.2℃) within 2 hours of nursing care as
evidenced by;
a. patient’s skin feeling cool to touch and patient verbalizing absence of warmness.
b. nurse record’s patient’s axillary temperature within the normal range of 36.2 – 37.2℃.
2. Patient’s pain level will reduced within 4 hours as evidenced by;
a. Patient verbalizing reduction in pain level.
b. nurse observes patient with cheerful facial expression
3. Patient and family will demonstrate reduced anxiety within 8 hours as evidence by;
a. patient verbalizing decreased in anxiety.
b. nurse observes demonstrates the use of coping strategies within care period.
4. Patient will maintain good nutritional status during period of NPO restrictions as evidence
by;
a. patient verbalizes absence of hunger
b. nurse observes patient with her normal weight
5. Patient and family will attain adequate knowledge about hernia and its management within 2
hours as evidence by;

37
 a. patient mentioning at least three causes, signs and symptoms, treatment and prevention of
his condition.
b. nurse observes that patient is able to answer his review questions accurately
6. Patient will attain reduction in pain within 4 hours as evidence by;
a. patient verbalizes reduction in pain
b. nurse observes patient rate pain at 4 on 0-10 pain rating scale
7. Patient will attain improved mobility and increased physical activity within the limit of post
operative restrictions as evidence by;
a. patient safely moving from bed to chair
b. nurse observes patient perform basic range of motion (ROM) exercises.
8. Patient will regain improved sleep quality and duration with reduced pain within 48 hours as
evidence by;
a. patient verbalizing improved sleep quality and duration
b. nurse observes patient sleep for 6-8 hours uninterrupted
9. Patient will maintain regular bowel movement and prevent constipation during period of
hospitalization as evidence by;
a. Patient verbalizing no signs of constipation such bloating
b. Nurse observes patient have regular bowel movement without straining
10. Patient will maintain clean and intact wound with no signs of infection during period of
hospitalization as evidence by;
a. Patient maintains clean, intact and dry wound.
b. Nurse observes no signs of infections such as redness at incisional site.

38
 Table 3.1: Pre-Operative Nursing Care Plan for madam D. B

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria

17/12/2024 Hyperthermia Patient will attain normal 1. Reassure patient of 1. Patient was reassured 17/12/2024 Goal fully met as;
A. N. A
1:45pm (37.9℃) related to body temperature (36.2- competent nursing of competent nursing care 3:45pm a. patient
inflammatory process 37.2℃) within 2 hours of care. to attain normal verbalized
(strangulation of the nursing care as evidenced 2. Check patient’s temperature absence of
intestine). by; temperature every 2. Patient’s temperature warmness
a. patient’s skin feeling 30minutes using was checked and recorded b. nurse record
cool to touch and patient axillar thermometer as 36.8℃. axillary
verbalizing absence of 3. Serve prescribed IV 3. Prescribe IV Ringers’ temperature of
warmness. fluids lactate was infused to 36.8℃.
b. |nurse record’s patient’s 4. Remove excess maintain hydration and
axillary temperature within clothing and switch on electrolytes balance
the normal range of 36.2 – fan 4. Excess clothing was
37.2℃. 5. Administer removed to promote heat
prescribed antipyretics loss
5. Prescribed 1g IV
paracetamol was
administered to reduce

39
 fever

Table 3.2: Pre-Operative Nursing Care Plan for madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
17/12/2024 Acute pain Patient’s pain level 1. Reassure patient of 1. Patient was reassured that 17/12/2024 Goal fully met as; A. N. A
1:45pm (umbilical) related to will reduced within 4 measures taking place measures are being put in place 5:45pm a. patient
strangulated hernia. hours as evidenced to alleviate pain. to alleviate her pain verbalized
by; 2. Assess pain level 2. Patient’s pain level was reduction in pain
a. patient verbalizing and characteristics assessed and rated 10 on the intensity
reduction in pain 3. Place patient in a scale 0-10 and described as b. nurse observed
level. position for comfort sharp piercing. patient with
b. nurse observes 4. Teach patient 3. Patient was placed in supine cheerful facial
patient with cheerful relaxation techniques position with slightly elevated expression
facial expression such as deep breathing head and knee to reduce
exercise. tension on abdominal muscles
5. Encourage to avoid 4. Patient was taught deep
strenuous activities. breathing exercise to help
manage pain.
5. Patient was counselled to
avoid strenuous activities
which aggravates pain

40
 Table 3.3: Pre-Operative Nursing Care Plan for madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
17/12/2024 Anxiety (patient and Patient and family 1. Reassure patient and 1. Patient and family reassured 17/12/2024 Goal fully met as; A. N. A
1:45pm family) related to will demonstrate family about of the competency of the 7:45pm a. patient
unknown outcome of reduced anxiety competent surgical surgical team regarding her verbalized
surgery. within 8 hours as team. safety. reduced level of
evidence by; 2. Assess patient’s 2. Patient’s anxiety level was anxiety
a. patient verbalizing anxiety level assessed using verbal cues and b. nurse observed
decreased in anxiety. 3. Provide clear and nonverbal behaviors like patient
b. nurse observes accurate information restlessness, sweating, etc. demonstrated
demonstrates the use concerning the 3. All information about the coping strategies
of coping strategies surgery. surgery was explained to within care
within care period. 4. Encourage patient to patient and family clearly and period.
express feelings and accurately.
ask questions. 4. Patient was encouraged to
5. Involve family and express her feelings and the
other support system source of her anxiety.
5. Patient family and
significant others were
involved to provide emotional

41
 support before surgery.

Table 3.4: Pre-Operative Nursing Care Plan for madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
17/12/2024 Risk for nutrition Patient will maintain 1. Assess patient’s 1.Patient’s nutritional status 19/12/2024 Goal fully met as; A. N. A
4:30pm imbalance (less than good nutritional nutritional status by was assessed to rule out signs 10:30am a. patient
body requirement) status during period monitoring weight and of nutritional imbalance verbalized
related to temporary of NPO restrictions wasting. 2. IV 5% dextrose 2 liters and absence of
restriction of oral as evidence by; 2. Ensure adequate 1 liter Ringers’ lactate was hunger
intake. a. patient verbalizes fluid and electrolyte administered to maintain b. nurse observed
absence of hunger balance hydration and balance. weighed patient
b. nurse observes 3. Explain the 3. The reason for NPO was normal weight.
patient with her rationale for NPO to explained to patient and family
normal weight patient and family. as to prevent potential
4. Maintain fluid aspiration.
intake and output chart 4. An intake and output chart
5. Provide frequent ensured to maintain fluid
mouth care to maintain balance.
oral hygiene. 5. Patient was assisted in
frequent oral care to avoid dry
mouth and discomfort.

42
 Table 3.5: Pre-Operative Nursing Care Plan for madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
17/12/2024 Deficient knowledge Patient and family 1. Assess patient and 1. Patient and family’s 17/12/2024 Goal fully met as; A. N. A
1:45pm related to inadequate will attain adequate family’s current knowledge was assessed on 3:45pm a. patient and
information on knowledge about knowledge. umbilical hernia to identify family mention
umbilical hernia. hernia and its 2. Educate patient and gap. some causes,
management within 2 family in simple 2. Patient and family educated prevention and
hours as evidence by; language on the causes, treatment, complications of
a. patient mentioning 3. Encourage patient prevention and complications umbilical hernia.
at least three causes, and family time to ask of hernia. b. nurse observed
signs and symptoms, questions. 3. Patient and family were patient and
treatment and 4. Reinforce teaching allowed time to ask questions family answer
prevention of his with follow-up and were addressed review question
condition. 5. Promote active accordingly. accurately.
b. nurse observes that participation 4. Key points in teaching were
patient is able to reviewed during subsequent
answer his review interaction.
questions accurately 5. Patient and family were
involved in planning care by
discussing lifestyle

43
 modifications.

Table 3.6: Post Operative Nursing Care Plan for Madam D. B

Date/Time Nursing Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Diagnosis Criteria
18/12/2024 Acute pain Patient will attain 1. Assess patient’s 1. The intensity of patient’s pain 18/12/2024 Goal fully met as; A. N. A
11:35am (incisional site) reduction in pain level of pain regularly. was assessed and recorded as 7 on 3:35pm a. patient
related to within 4 hours as 2. Position the patient the scale 0-10 verbalized
surgical evidence by; for comfort. 2. Patient was encouraged to reduction in pain
intervention. a. patient verbalizes 3. Teach patient to assume safe position that reduces b. patient rated
reduction in pain support incisional site pain level pain at 4 on 0-10
b. nurse observes during movement. 3. Patient was taught to splint pain rating scale.
patient rate pain at 4 4. Promote rest and incision site with hand or pillow
on 0-10 pain rating sleep. when coughing, sneezing or
scale 5. Assess the changing position to minimize pain.
incisional site for signs 4. A quiet and serene environment
of infection. was ensured to enhance rest and
6. Administer sleep.
prescribed pain 5. Patient’s incisional site was
medications. assessed for signs of infection such
redness, swelling and warmth that
could exacerbate pain.
6. Prescribe pain medication was

44
 administered.

Table 3.7: Post Operative Nursing Care Plan for Madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
18/12/2024 Impaired mobility Patient will attain 1. Assess patient’s 1. Patient’s baseline level of 19/12/2024 Goal fully met as; A. N. A
11:35am related to post improved mobility baseline level of mobility was assessed to know 8:30am a. patient was
operative restrictions. and increased mobility. her range of motion and able to move
physical activity 2. Regularly assess strength. from bed to chair
within the limit of patient’s ability to 2. Patient was assessed b. nurse observed
post operative move, walk or perform regularly to test her function of patient performed
restrictions as activities of daily movement and to know any basic exercises.
evidence by; living. setbacks.
a. patient safely 3. Encourage gradual 3. Patient was supported to
moving from bed to ambulation. slowly resume activities to
chair 4. Ensure safe promote circulation and
b. nurse observes positioning. prevent deep vein thrombosis..
patient perform basic 5. Administer 4. Patient was assisted in
range of motion prescribed pain maintaining proper body
(ROM) exercises. medications. alignment to prevent strain on
the incision site.
5. Prescribed medications
were administered before

45
 physical activity to reduce
discomfort and encourage
mobility.

Table 3.8: Post Operative Nursing Care Plan for Madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
18/12/2024 Disturbed sleep Patient will regain 1. Reassure patient of 1. Patient was reassured that 20/12/2024 Goal fully met as; A. N. A
12:05pm pattern related to pain improved sleep measures to manage measures are put in place to 8:30am a. patient
quality and duration her pain manage her pain. verbalized
with reduced pain 2. Assess patient level 2. The intensity and quality of improved sleep
within 48 hours as of pain. patient’s pain was assessed. quality and
evidence by; 3. Position patient well 3. Patient’s position was duration.
a. patient verbalizing for comfort adjusted frequently to reduce b. nurse observed
that she was able to 4. Provide conducive pressure on incisional site. patient sleep for
sleep well. environment for sleep. 4. Environmental noise was 6-8 hours
b. nurse observes 5 Administer minimized and lighting system uninterrupted.
patient sleep for 6- prescribed pain was adjusted to promote sleep.
8hours uninterrupted. medications. 5. Prescribed medications were
administered to reduce pain.

46
 Table 3.9: Post Operative Nursing Care Plan for Madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
18/12/2024 Risk for constipation Patient will be able to 1. Assess for signs of 1. Signs of constipation such as 21/12/2024 Goal fully met as; A. N. A
4:40pm related to decreased maintain regular constipation. abdominal distention, bloating 3:30pm a. patient verbalized
gastrointestinal bowel movement 2. Promote early and discomfort assessed. no signs of
mobility secondary to during period of ambulation. 2. Patient was encouraged to constipation.
reduced physical hospitalization as 3. encourage adequate walk as tolerated to stimulate b. nurse observed
activity evidence by; intake of fluids to peristalsis. patient have regular
a. patient verbalizing enhance hydration. 3.patient was served with bowel movement.
free bowel movement 4. promote the intake enough oral fluid and was
b. nurse observes of a high fiber diet. encouraged to take.
patient have regular 5. Teach patient and 4. Whole grain, fruits,
bowel movement family the importance vegetables and legumes were
without straining of movement. included in patient daily meal
5. Patient and family were
educated on the importance of
high fiber diet.

47
 Table 3.9.1: Post Operative Nursing Care Plan for Madam D. B cont’d

Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing interventions Date/Time Evaluation Sign
Criteria
18/12/2024 Risk for infection Patient will maintain 1. Assess the 1. Patient wound was inspected 21/12/2024 Goal fully met as; A. N. A
5:35pm related to incisional clean and intact incisional site regularly for signs of infection such as 10:35am a. patient
wound. wound with no signs regularly redness, swelling and fever, maintained cleaned,
of infection during 2. Monitor vital signs. 2. Patient’s vital signs were checked intact and dry
period of 3. Dress wound every 4 hours to rule out systemic wound.
hospitalization as aseptically infections. b. nurse observed
evidence by; 4. Encourage high 3. Wound was dressed every alternate no signs of
a. patient maintaining protein diet. day to prevent infection. infection such as
clean, intact and dry 5. Educate patient on 4. Patient encouraged to consume high redness at
wound. proper wound care. protein diet to promote fast wound incisional site.
b. nurse observing no 6. Administer healing.
signs of infections prescribed antibiotics 5. Patient was educated to keep
such redness at incisional site clean.
incisional site. 6. Prescribed antibiotics were
administered to prevent infection.

48
 CHAPTER FOUR
IMPLEMENTATION OF PATIENT AND FAMILY CARE PLAN
4.0: Introduction

Implementation in nursing is the step which involves action or doing and the actual carrying
out of nursing interventions outlined in the plan of care (Adraro, 2020). It is the fourth phase
of nursing process which involves the performance of nursing orders.

This chapter covers the following;

Summary of actual nursing care rendered to patient and family during admission.

Preparation of patient and family for discharge and rehabilitation.

Home visit and continuity of care.

4.1: Summary of Actual Nursing Care Rendered

The nursing management of Madam D. B started on the 17th of December, 2024, the day of
admission till she was discharged on the 21st of December, 2024. The aim of her admission
was to undergo surgery (herniorrhaphy) on account of right strangulated umbilical hernia in
order to prevent potential complications. The actual nursing care rendered to patient
according to the nursing care plan were as follows;

Day of Admission (17th December, 2024)

Madam D.B was received into the Female surgical ward of

the LEKMA hospital at 1:00pm on the 17th December, 2024.
She walked into the ward accompanied by her sister and a
nurse from the emergency department with the diagnosis of
strangulated umbilical hernia.

49
She was warmly received and made comfortable in bed. Initial
vital signs were taken and recorded as Temperature 36.9℃,
Pulse 86bpm, Respiration 22cpm, Blood pressure 124/80
mmHg Pain = severe (10) SPO2 98% on room air. Vein was
entered and prescribed medications were collected served. She
was to be managed on Intravenous paracetamol 1g tds x 48 hours

IM morphine 10mg QID x 48 hours

1L Ringers lactate daily for 24 hours

2L dextrose 5% daily x 24 hours

The following laboratory investigations were requested for patient; and blood samples were
taken at the emergency before patient came to the ward. Hence follow ups were made on the
laboratory investigations.

Full blood count (FBC)

Blood urea nitrogen and creatinine

Grouping and cross matching

Sickling status

Introduction was made and patient information were

collected from both the accompanying nurse and her sister
and were entered on the computer.

50
Her name was identified and confirmed, and reassured of
competent and comprehensive nursing care. She was now
orientered to the ward and its environment. She was also
introduced to the staff on duty and was made aware of the
various activities on the ward such as ward rounds and
visiting hours. She was also introduced to the patients who
were in bed next to her to establish rapport. Her sister was
also informed of the visiting hours and other items that would
be needed on admission

Patient’s initial vital signs on arrival indicated that she had

hyperthermia (37.9℃) and further assessment on observation
showed no respiratory distress, hydration was fair, patient was
admitted into the admission and discharge book including the
daily ward state. She was also assisted later to change into her
night wear and her items kept in her bedside locker. Patient
was asked if she had anything she would want to keep safe
with the nurses, but her response was negative.

Patient is a subscriber of the National Health insurance

Scheme (NHIS) but it was made known to her that NHIS does
not cover all drugs and treatments so, provision should be
made for any additional cost.

51
Patient’s problems were identified as hyperthermia, severe
pain in the umbilical region, nausea and vomiting, little
knowledge on condition and anxiety. These problems were
used to establish a nursing care plan to help in her care and
management. All procedures carried out during the admission
process of patient were documented on both the computer and
in the nurse’s noted. my intentions were made to patient
about wanting to use her for my care-study. They were glad
and consented to it.

preparation of patient towards discharge started on the day of admission as patient was
informed that admission was temporal and that she would be discharged home few days after
surgery.

Because patient was to undergo surgery the following day, her items and medications for
surgery were collected from the hospital’s pharmacy. Preparation for her surgery started on
the day of admission as patient was informed of the need for surgery and also to keep Nil per
ox (NPO) from 10pm that day. She was encouraged to express her fears and any source of
anxiety. Patient and family’s knowledge on umbilical hernia were assessed to identify gap
and educated on the causes, treatment, prevention and complications of hernia and key points
in teaching were reviewed during subsequent interaction to ensure they understood what was
taught. Patient was also educated on what to expect before, during and after the surgery to
help allay fears and anxiety. Patient and family were reassured of the competency of the
surgical team. Procedure was explained to patient and family and patient was made to sign
the consent form. The anesthetist reviewed her and did the necessary assessment. IV 5%
dextrose 2 liters and 1 liter Ringers’ lactate were administered to maintain hydration and
electrolyte balance, patient retired to bed at 10:00 pm.

Range of vital signs on the day of admission;

Temperature = 36.9 - 37.9 ℃

52
Pulse= 99 - 106bpm

Respiration= 18 - 24cpm

Blood pressure= 110/70 - 124/80mmHg

SPO2= 98 – 100%

Pain = 4 - 10

First Day on Admission, Day of Operation (18th December, 2024)

On this day, patient couldn’t sleep very well as a result of intermittent pain. She woke up at
5am and was assisted to maintain her personal hygiene such as oral care, bathing and
toileting. Patient was prepared physically and psychologically for surgery. Site for surgery,
umbilical region, was shaved and cleaned with an antiseptic lotion. Patient was also inspected
for dentures, ring and other ornaments. Urethral catheter was passed for patient and she was
change into a disposable gown. Patient was reassured again competency. Her vital signs in
the morning recorded Temperature-36.8℃, Pulse-94 bpm, Respiration-19cpm, Blood
pressure-115/70 mmHg, Oxygen saturation- 99% and pain-6 (moderate). At 6:00am, patient
was sent to the theatre and handed over to the team.

Post-Operative Management

Patient was sent back to the theatre recovery unit in a conscious state at 8:50am. Her
incisional site was intact, clean and not soaked with blood or any discharges. She had about
750ml of ringers’ lactate on her which was infusing normally at a drop rate of 15 drops per
minute. Throughout her monitoring, patient’s vital signs were stable. Her post-op instructions
were to monitor her at recovery unit until she recovers from anesthesia before sent back to the
ward. She was also to be administered with IM morphine 10mg and IV paracetamol 1g (To
be alternated 3hourly for 24 hours). Intravenous antibiotics also included Ciprofloxacin
400mg bd for 24 hours and metronidazole 500mg tds for 24 hours. Patient’s catheter was to
be removed when she returns to the ward. She was to stat with sips of water 6 hours post-op
and monitored strictly on intake and output chart. Intravenous fluids such as normal saline,

Dextrose 5% and ringers’ lactate were to be continued. Patient was to avoid exerting pressure
on the abdomen.

53
She was tranced-out from the recovery unit and received back to the ward at 11:30am in a
fully conscious state. Her vital signs checked on arrival recorded; Temperature-37.1 ℃,
Pulse-98 bpm, Respiration-20cpm, Blood pressure-128/90 mmHg, Oxygen saturation- 97%
and pain score of-7. Patient was educated not to be touching wound site to prevent wound
infection as well as the need to apply pressure to the incisional site in case of coughing and
sneezing to avoid wound dehiscence.

Patient’s problems were identified post-operatively as pain, inability to move, insomnia,

constipation and surgical site infection. These problems were used to draw a post-operative
nursing care plan to help in her management. Her pain was assessed and rated at 7 on 0-10
rating scale. She was helped to assume safe position to reduce pain. She was taught to splint
wound when coughing or sneezing and prescribed pain medications administered duly.
Patient was encouraged to have enough rest and sleep and wound site was inspected for signs
of infections. Madam D. B’s mobility status was assessed to know her range of motion and
strength and was assisted to resume tolerable activities to improve circulation and prevent
deep vein thrombosis.

At 2:00pm, patient complained of not being able to sleep due to pain . . Pain was assessed on
the pain scale and patient rated her pain at 7. Her position was readjusted, due postop pain
medications were served and patient was reassured that pain will reduce with time.
Conducive environment was ensured to promote sleep. Patient’s vital signs were assessed and
recorded.

At 4:40pm patient was assessed for bowel movement and she verbalized she has passed out
air. she was encouraged to ambulate early to stimulate peristalsis as well as to enhance early
recovery. Her wound was inspected for signs of bleeding, vitals sins were checked and
recorded every 4 hours and was encouraged to keep incisional site clean and dry.

Patient’s catheter was removed and she was able to pass urine freely without pain or
difficulty. At 5pm, patient was made to start sips of water per doctor’s instruction. Patient
was assisted in maintaining her personal hygiene in the evening. All due medications were
served and vital signs checked and recorded. Patient was also encouraged to eat more fruits
and foods containing fiber from the following day so as to improve bowel activity. She was
to avoid straining herself. She was also encouraged on the need to maintain her personal
hygiene at all times and perform range of motion exercises in bed. At 9:00pm patient took

54
about 20 spoons of light soup before finally retiring to bed. She was handed over to the night
staffs for continuity of care. Summary of vital signs for the day were as follows:

Temperature = 36.5 - 36.8 ℃, Pulse= 78 - 88bpm, Respiration= 17 - 25cpm, Blood

pressure= 125/765 - 135/70mmHg, SpO2= 96– 100% and Pain = 5 – 7.

Second Day on Admission, Post Operative Day One (19th December, 2024)

According to night nurse , patient woke up at 6am and verbalized she was able to sleep well
due to reduction in pain. She was able to perform her personal hygiene with little assistance.
She was served with oats as requested. After taking up from the night nurse at 8am, the need
to take in more protein and vitamins was reenforced to facilitate wound healing. The need to
avoid lifting heavy objects and abstain from strenuous activities until further notice was
emphasized. She was encouraged to ambulate as soon as possible to enhance circulation and
to prevent deep vein thrombosis. Patient’s vital signs were checked, recorded and due
medications served. She was reviewed at 10:30 am by Doctor Emmanuel Nii Noi and team
and seen to be doing well. She was to continue current medications, monitored closely, to do
post-op HB, resume normal diets rich in vitamins, fiber and proteins. Incisional site was to be
inspected for any abnormalities. She was now placed on the following medications.

Tab flagyl 500mg tds for 7/7

Suppository Diclofenac 100mg two times daily x 72 hours

Tab paracetamol 1g tds x 7/7

Tab vitamin C 200mg daily for 15 days

Tab amoxiclav 625mg bd for 7 days

Later in the afternoon, patient and relative were informed about my intention to visit their
home the following day. The aim was to identify resources in their environment that will help
in her recovery process after discharge and also identify any health problems that might
impede her recovery. Patient ate fufu with light soup at lunch and plantain with kontommire
stew as supper. She also took some fruits ( apple and banana ) before retiring to bed at
10:10pm. All due medications were served within the day as well as vital signs monitored.

55
Patient’s incisional site was kept dry and intact. Her vital signs within the day ranged;
Temperature = 36.2 - 36.8℃,

Pulse= 83 - 88bpm,

Respiration=18 - 20cpm,

Blood pressure= 110/70 - 125/80mmHg,

SpO2= 98 – 100%

Pain (incisional site) = 2 – 4 (mild)

Third Day on Admission, Post Operative Day Two (20th December, 2024)

On this day, patient verbalized she slept well throughout the night. She was able to maintain
personal hygiene by herself in the morning. She verbalized relieve of pain at the incisional
site. She was served with rice porridge and biscuits. Morning vital signs were checked and
recorded as well as due medications administered. Patient was reviewed at 9:00 am by doctor
Emmanuel Mensah Bonsu and team. Plan was to complete intravenous medications and
switch to orals and prepare for possible discharge the following day. Patient’s post operative
Hb level was 12.9g/dl. In the afternoon, I accompanied patient’s husband, Mr. D. D to their
home at Teshie camp 2 near 31st school to assess their home environment in order to help
improve upon her care. Education given earlier on the management of wound were
reenforced.

Patient ate kafa with light soup and fish as lunch and then akpele with spinach soup as
supper. She maintained her personal hygiene in the evening during visiting hours and retired
to bed at 10pm after taking her medications. All objectives set in her care-plan were
evaluated and all goals fully met. Her vital signs within the day ranged;

Temperature = 36.2 - 36.8℃,

Pulse= 83 - 88bpm,

Respiration= 18 - 20cpm,

Blood pressure= 110/70 - 120/80mmHg,

56
SpO2= 98 – 100%,

Pain (incisional site) = 0 – 2.

Day of Discharge, Post Operative Day Three (21st December, 2024)

On this last day on admission, Patient woke up at 5aml in a healthy state without any new
complains. She verbalized relieve of pain and was able to free her bowel as well. All signs
and symptoms present during admission were now absent. She was able to maintain her
personal hygiene and took her breakfast. Her post-operative care-plan was reviewed and
goals were fully met. Patient’s incision site was cleaned aseptically with gauze and spirit.
Her wound was free from infection and was healing very well by first intention. She was
encouraged to always keep incisional site clean and dry and splint wound when coughing.
Patient was reviewed by Dr. Emmanuel Mensah and team at 10am and was to be discharge
home on current oral medications. Her review date was scheduled on 2nd January, 2025 which
was two weeks from the day of discharge

patient and husband were informed about the discharge and were lead them through the
discharge process. It was ensured that all her hospital bills were settled . I handed over her
oral medications to them and educated them on the indications, dosage, the right time to take
the medications and the side effects.

They were also encouraged on the need to ensure personal hygiene all the time and to avoid
lifting heavy objects. They were also educated on the importance of adhering to the education
given them on the preventive measures of her condition. They were reminded of the review
date (2nd January,2025) and stressed on its importance. They were also informed that, should
there be any health problem before the review date, they should report to the hospital. They
were also informed about my next visit to them. I thanked them for their cooperation and the
review date was emphasized once more. I escorted them to the roadside at 1:45pm and bid
them good bye. After the departure, she was discharged from the admission and discharge
book and the daily ward state. Her bed linen was removed and decontaminated. Her vital
signs within the day prior to discharge ranged; Temperature = 36.5 - 36.6℃,

Pulse= 76 - 85bpm,

57
Respiration= 18 - 20cpm,

Blood pressure= 120/70 - 120/80mmHg,

SpO2= 98 – 100%

Pain = Nil

4.2: Preparation of Patient / Family for Discharge and Rehabilitation

The preparation of the patient/family towards discharge started on the day of admission till
the day they were discharged from the hospital. It is very important in the management of a
patient as soon she is admitted so that, she will return to her home and community healthy
and enjoy normal independent life. Patient/family were made to understand on the day of
admission that, the hospital was not a place where people come to stay forever and admission
was temporal and necessary for managing her condition. A nursing care plan was drawn pre
and post-operatively to guide effectively in her care. Objectives set were properly evaluated
and all goals fully met.

Patient/family were encouraged to adhere strictly to the education given them to prevent
complications. They were also educated on the disease process, causes, risk factors, signs and
symptoms, treatment and complications, the need to complete treatment regimen, desired and
undesired effects of the medications. Finally on the day of discharge, the importance of
keeping to the review date and the need for follow-up visits after discharge were all
communicated to them. The patient was discharged on the following medications;

Tab Metronidazole 500mg tds for 7/7,

Suppository Diclofenac 100mg bd x 3,

Tab paracetamol 1g tds x 7/7,

Tab vitamin C 200mg daily for 15 days

Tab amoxiclav 625mg bd for 7 days.

The necessary recordings were made in the admission and discharge book and in the daily
ward state. The bedside locker together with the mattress were disinfected with 0.5% chlorine
solution.

58
4.3: Summary of follow up/home visits/continuity of care

Home visit is a family-nurse contact which allows the health worker to assess the home and
family situations in order to provide the necessary nursing care and health related activities
(Matt, 2019). Three home visits were made to patient/family.

First Home Visit (20th December, 2024)

When client was on admission, a visit was paid to her house with her husband (Mr. K. B) on
20th December, 2024 at 4:20pm. It was a planned visit with the aim of locating client’s house
to identify anything that could contribute to her health and wellbeing positively or negatively
and intervene. This visit was also done to locate any health facility near patient’s house for
referral when care is terminated. Patient lives in a chamber and hall self-contain with her
husband and children.

Upon request, I was taken round the house and allowed to inspect it. The house had a kitchen,
bathroom and a toilet facility (water closet) which were all clean. The house is fenced with
blocks and painted with cream color and has a brown metal gate at the entrance. It is a
compound house and other tenants occupied other rooms. They have a good lighting system
and a proper refuse disposal site (dust bin). However, I realized that there was a choked gutter
in front of the house, so they were encouraged to work on it to prevent mosquitoes from
breeding there. At 5:00pm, I thanked them for their warm reception and departed back to the
hospital.

Second Home Visit (30th December, 2024)

My second home visit was made on 30th December, 2024 at 3:30pm. The aim was to assess
patient’s state of health after discharge, remind her of the review date and its importance as
well as inform her and family about possible termination of care on my next visit. On arrival,
I was warmly welcomed and offered a seat. Client and family were doing well with no
complications and complain. The wound was almost healed. The family and client were
encouraged to maintain their personal and environmental hygiene. It was also emphasized
that client should not lift heavy objects. Client and family were reminded that should any
health problem1 arise, they should not hesitate to come to the hospital for early treatment.
Regular medical checkups were also encouraged. She was also reminded of her review date,
which was 5th January, 2025. I thanked them and informed them of my next home visit when

59
care would be terminated. The family members and the patient expressed their gratitude for
the care given and wished me all the best in life. I left the house around 4:10 pm.

Day Of Review (5th January, 2025)

On the day of review, client was assisted to collect her folder and accompanied to the
consulting room. The doctor examined and encouraged her to continue taking her prescribed
drugs. Client had no complains on examination. She was encouraged not to lift heavy objects
and also practice good lifting techniques. Again, she was encouraged to report to the hospital
whenever she was not feeling well.

Third Home Visit (7th January, 2025)

My final official visit to patient’s home was aimed at terminating the of patient as previously
discussed. On my arrival to patient’s home at about 4:00pm, patient was watching television
and was very glad to see me. She was doing very well and lodged no complains. Her
incisional wound was completely healed. All education given to patient and family from the
beginning of our interaction until the second home visit were emphasized. The family was
also reminded of the need for early medical treatment if they encounter or experience any
health problem. They were informed that this visit marked the end of the care. I thanked
them very much for all their support and co-operation during their care and our interaction.

60
 CHAPTER FIVE
EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY
5.0: Introduction

Craven (2020) defined evaluation in nursing as the judgement of the effectiveness of nursing
care to meet client goals. In this phase, the nurse compares the client behavioral responses
with predetermined client goals and outcome criteria. It is the fifth step in the nursing
process. It is not only a part of the nursing process, but it is also an integral process in
determining the quality of health care delivered to the patient.

This chapter comprises of the following;

Statement of evaluation

Amendment of nursing care plan for partially met/unmet outcome criteria

Termination of care with patient/family

Summary

Conclusion

5.1: Statement of Evaluation

Madam D. B was admitted to the female surgical ward of the LEKMA hospital on an account
of strangulated umbilical hernia after she presented with high body temperature, severe
umbilical pain, anxiety and other potential problems. She was admitted on the 17th December,
2024 and was managed medically and surgically. Problems were identified on patient before

61
and after surgery and a nursing care plan designed to help in her management. Goals set for
patient’s health problems in nursing care plan were all met.

Goal set for “Hyperthermia (37.9℃) related to inflammatory process” at 1:30pm on 17th
December, 2024 were fully met as patient verbalized absence of warmness and nurse record
axillary temperature of 36.8℃ the same day 3:30pm. In achieving this objective patient was
reassured, temperature checked every 30 minutes, excess clothing removed and Paracetamol
administered.

Goal set for “Acute pain (umbilical) related to inflammatory process” at 1:30pm on 17 th
December, 2024. Pain was assessed, patient positioned for comfort and pain medications
served to manage pain. This goal was fully met on the same day at 5:30pm as patient
verbalized reduction in pain level and the nurse observed patient with cheerful facial
expression.

Goal set for “Anxiety (Patient and family) related to unknown outcome of surgery” on 17th
December, 2024. Patient and family reassured, anxiety level assessed and the surgery was
explained to them. This objective was fully met as patient verbalized reduced level of
anxiety and nurse observed patient demonstrated coping strategies within care period.

An objective set to maintain balanced nutritional status during period of admission on 17th
December, 2024 was met as patient was able to maintain a balanced nutritional status
throughout the period of admission.

An objective set later same day that patient and family will attain adequate knowledge about
hernia and its management in two hours was met as patient and family were able to answer
review question accurately after education was given.

On 18th December, 2024 at 11:35am, a goal was set to reduce patient’s pain in 4hours. Goal
fully met at 3:35pm as patient verbalized reduction in pain and nurse observed patient rate
pain at 4 on 0-10 rating scale.

62
On 19th December, 2024, a goal was set to improve patient mobility and increased physical
activity during period of post op restriction. Goal fully met as patient moved from bed to
chair and nurse observed patient perform range of motion exercises.

19th December, 2024 at 12:05pm, a goal was set to help patient regained sleep quality and
duration within 24 hours. Goal fully met at 8:30am on 20th December, 2024 as patient
verbalized improved sleep quality and nurse observed patient sleep for 6-8 hours
uninterrupted.

At 4:40pm same day, another goal was set to maintain patient’s regular bowel movement and
prevent constipation within 24hours. Goal fully met as patient verbalized no sign of
constipation and nurse observed patient have regular bowel movement without straining.

A goal was set at 5:35pm the same day to maintain clean and dry wound with no signs of
infection during period of hospitalization. Goal fully met as patient maintained cleaned and
intact wound and nurse observed no signs of infections.
5.2: Amendment of Nursing Care Plan for Partially Met or Unmet Outcome Criteria

Amendment of care plan requires a reassessment of patient’s current condition, to identify

current human responses that require nursing interventions and that means reviewing those
that were previously identified (NANDA, 2018). It involves resetting of goals and objectives
and adjusting them accordingly for goals that were not met during the care given. All set
goals and objectives made on all the problems identified on patient were fully met hence no
amendments were made.

5.3: Termination of Care

Termination of care is the last phase of the nurse-patient relationship. Preparation for
termination of care began on the day of admission when Madam D. B and family were
reassured and informed that hospitalization was just a temporal means of monitoring and
managing her condition so that she could be discharged home as soon as possible. Three
home visits were made to patient.

The first home visit was made on 20th December, 2024 while she was still on admission. The
aim was to assess her home environment, prepare her family towards receiving her after
discharge, identify issues of health concern and give required health education. During the

63
second home visit on 30th December, 2024, her general condition was assessed after which
her relatives were notified that care would be terminated on the next visit. During the last
home visit on 7th January, 2025, patient and family were encouraged to put all that was
discussed during our interaction into practice to help her maintain good health. Termination
of care therefore did not have any effect on the patient and family since they were educated
from the beginning. Client was educated on current issues in health and on health promotion
and primary health prevention.

5.4: Summary

Madam D. B, a 35-year-old woman, was admitted to the female surgical ward of the LEKMA
hospital on an account of strangulated umbilical hernia after she presented with high body
temperature, severe paraumbilical pain, anxiety among others. She was admitted on the 17 th
December, 2024 and was given medical, surgical and nursing management.

Patient had herniorrhaphy done the following morning (18th December, 2024). A nursing care
plan was designed pre and post operatively to guide in the effective management of her
condition. Her condition became very stable and she was discharged home on the 21st
December, 2024 and reviewed on 5th January, 2025. Three home visits were made to patient
and care was terminated officially upon the third visit (7th January, 2025).

Diagnostic investigations carried out on patient included;

Full blood count (FBC)

Blood urea nitrogen and creatinine

Grouping and cross matching

Sickling status

Post-operative full blood count

All medications used in the management of patient included;

Intravenous paracetamol 1g tds x 2/7

IM morphine 10mg qid x 48 hours

64
Intravenous ciprofloxacin 400mg bd x 72 hours

Intravenous metronidazole 500mg tds x 72 hours

Tab flagyl 500mg tds for 7/7

Suppository Diclofenac 100mg bd x 72 hours

Tab paracetamol 1g tds x 7/7

Tab vitamin C 200mg daily for 15 days

Tab amoxiclav 625mg bd for 7 days

1L ringers lactate daily for 24 hours

2l dextrose 5% daily x 24 hours

5.5: Conclusion

The total nursing care rendered to Madam D.B and family together with the compilation of
this report has equipped me with additional knowledge and practical experience. This is my
first experience of providing a total holistic individualized nursing care to a patient and
family. The study has given me the chance to put into practice all the skills and knowledge
acquired during the course of my training in school. The patient and family care study has
broadened my knowledge and scope especially as it has enabled me to research thoroughly on
hernia, it’s medical and surgical management and patient education involved. Indeed, I must
admit that this has really prepared and given me a lot insight for greater tasks ahead in the
nursing profession.

65
 BIBLIOGRAPHY

1. Adraro Z., Mengistu D., (2020). Implementation and factors affecting the nursing
process among nurses working in selected government hospitals in southwest
Ethiopia. BMC
2. Nurs 19, 105. Retrieved from; https: doi.org/10.1186/s12912
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