Fourth Day of Admission/Third Day Post-Operative (17/11/11)
Madam A. A. woke up around 5:00 am. She emptied her bowels and later brushed her teeth and had her bath.
At 7:00 am, the objective that was set on the 15th of November, 2011, to help the patient regain her normal sleep pattern within 48 hours was evaluated. The goal was fully met as the patient slept uninterrupted for more than 6 hours (61/2 hours) at night and 2 hours during the day and she also reported that she slept well the night before.
Also evaluated at 8:00 am the same day was the objective that was on 15th November 2011, to enable patient care for her self-care needs within 48 hours. This goal was also fully met as the patient performed her self-care practices unaided and the patient/family participated in self-care activities and verbalized rationale for self-care practices.
She took porridge (“kooko”) and about 300mls of fruit juice as breakfast. On inspection, her wound was clean and dry.
The medical officer ordered that she could take a normal diet and continuity of treatment and he said that Madam A. A. was to be observed for possible discharge the following day. Her vital signs were monitored and recorded as indicated in the appendix.
Her wound was aseptically dressed and she was made comfortable in bed.
I embarked on my first home visit to Madam A. A.’s house with her eldest son. When we returned I briefed her about my observations and recommendations and also congratulated her on the cleanliness of her house and veranda.
In the afternoon, she ate “fufu” and light soup with tilapia and smoked herrings.
Nursing interventions for objectives/outcome criteria that were not due for evaluation that is nursing interventions to allay anxiety inpatient/family and prevents patient’s wound from infection were implemented as aforementioned. They were assessed on their knowledge of the condition and were reassured that sooner than later Madam A. A. would be discharged home as soon as there is improvement in her condition and that patient would have to come for follow-ups when discharged.
In the evening, however, she took rice and stew and 400mls of fruit juice 15minutes later. She was able to tolerate all the meals served her and did not show any sign of gastrointestinal disturbances like diarrhea, vomiting, or constipation.
She later brushed her teeth, emptied both her bowels and bladder, before engaging herself in a dialogue with her elder sister. She had a warm bath and slept around 10:00 pm. The interventions carried out were entered into the appropriate documents to ensure continuity of care.