EVALUATION OF CARE RENDERED TO PATIENT/FAMILY
The chapter gives information about the statement of evaluation, amendment of nursing goals, and the termination of the care rendered to my patient and family.
5.1 Statement of Evaluation
Evaluation is used to determine the patient’s response to the nursing interventions and the extent to which the objectives have been achieved. Madam A. A. was admitted to the Female Surgical ward through the Theatre after a total abdominal hysterectomy had been done under spinal anesthesia, at the operating theatre, with the diagnosis of bleeding uterine fibroid. During my interaction with her, her elder sister, and eldest son, five (5) problems were identified post-operatively.
1: Madam A. A. and their family were relieved of anxiety within the period of hospitalization.
On 14th November 2011, at 11:00 am Madam A. A. and their family was anxious related to deficient knowledge about the condition and the related treatment plan. A goal was set to allay their anxiety within the period of hospitalization. The patient and family were reassured that the disease was manageable and that the staff was ready to help in her care. Their knowledge of the condition and its treatment (post-operative management), fears, and concerns were assessed. They were informed about the availability of modern equipment and expertise, condition, and its treatment (post-operative management); misinformation/misconceptions were clarified and they were helped to cope with stress. All procedures were explained to them and they were encouraged to ask questions and tactful answers were given. The patient was introduced to other patients in the ward who were suffering from the same disease and were doing well. On the day of discharge (18/11/11) at 11:00 am the goal set was fully met as Madam A. A. and family had a relaxed facial expression and participated in the care of Madam A. A.
On the day of admission (14/11/11) at 11:30 am, an objective was set to relieve Madam A. A. of acute pain related to surgical incision. Patient and family were educated that pain would minimize as healing of wound occurs. The reasons for pain and available management were explained to the patient/family. Diversional therapy such as watching television and engaging the patient in conversation was done. Prescribed analgesics such as morphine were served. The objective was met fully on 16th November 2011, at 11:30 am as Madam A. A. reported relief of abdominal and incisional pains and ambulated without pain.
3: Madam A. A.’s wound was protected from infection within the period of hospitalization.
A goal was set to protect Madam A. A.’s wound from infection on 14th November 2011 (day of admission) at 11:45 am because her wound (incisional site) was likely to get infected. A goal was therefore set to protect her wound from infection within the period of hospitalization. Madam A. A. and their family were educated on the need to prevent wound infection. They were educated on the signs and symptoms of wound infection such as purulent wound discharge, increased persistent pain, and increase in body temperature. The wound was dressed aseptically. Signs and symptoms of wound infection were monitored for prompt management. The patient was encouraged and assisted to meet her personal hygiene needs. They were encouraged to avoid touching the wound or wetting it. Prescribed antibiotics such as gentamycin were administered. On the discharge day (18/11/11) at 11:45 am, the objective was fully met as Madam A. A.’s wound was healing by the first intention and there was no sign or symptom of wound infection observed or reported.
Madam A. A. complained of difficulty in sleeping on 15th November 2011, at 7:00 am because of the painful incisional wound. A goal was set A.’s sleep pattern and the education of Madam A. A. and family on the need for her to sleep were done. Sleep/rest and activity periods were planned with her family and her. Madam A. A. and family were taught pre-sleep routines such as voiding, toileting, and bathing. She was encouraged to take a warm bath and a warm comfortable bed was provided for her. Adequate ventilation, dim light, and a noise-free environment were provided for her to induce sleep. She was encouraged to sleep at the same time each day and night and visitors were only allowed to visit her during visiting hours. On 17th November 2011, at 7:00 am, the goal was fully met as Madam A. A. slept uninterrupted for more than 6 hours (61/2 hours) at night and 2 hours during the day and reported that she slept well.