Second Day of Admission/First Day Post-Operative (15/11/11)
Madam A. A. woke up around 4:00am.
At 7:00am, she reported that she had difficulty sleeping last night due to her incisional pains. A nursing diagnosis of sleep pattern disturbance (insomnia) related to painful incisional wound was made and an objective set to help patient regain her normal sleep pattern within 48 hours. The interventions that were undertaken included assessment of patient’s sleep pattern and education of patient/family on the need for patient to sleep, planning sleep/rest and activity periods with patient/family, teaching patient/family pre-sleep routine such as voiding, toileting and bathing and the encouragement of patient to take a warm bath and provision of a warm comfortable bed for patient to sleep. Provision of adequate ventilation, dim light and a noise free environment for her to induce sleep, encouragement of patient to sleep at the same time each day and night and the allowance of visitors only during visiting hours were among the interventions carried out.
At 8:00am, she complained of incisional pains which had made her incapable of caring for herself unaided. A nursing diagnosis of hygiene self care deficit related to incisional pains was made. An objective to enable patient care for her self-care needs within 48 hours was set. Some of the nursing interventions implemented included planning self care activities such as bathing and oral hygiene with patient/family, assisting patient in bathing, oral hygiene, toileting and dressing twice daily (including care of her clothes), encouraging patient’s active participation in postoperative care, involving patient/family in patient care and commending patient in her effort to gain independence in her care.
Afterwards she was assisted to brush her teeth and she was bathed in bed and vulva toileting was done because of her incisional pains. Pressure areas were also cared for and she was reassured that soon she would be able to care for herself and that incisional pains would subside. She was encouraged to move her limbs in bed to promote early ambulation and prevent deep vein thrombosis, prevent bladder dysfunction and promote blood circulation.
The incisional site was inspected and it was dried and clean. Site of IV fluids was checked and the infusion was dripping well. She was asked to support the incisional site with the hand when she was coughing or moving to prevent excessive pain and gaping of the wound.
Other nursing interventions such as interventions to allay patient/family’s anxiety, minimize patient’s abdominal and incisional pain and to protect patient from infection which were started the day before were continued. Patient and family were reassured that immediately patient’s gets better she would be discharged home.
The vital signs were checked and recorded as indicated in the appendix. Intake and output of fluids were monitored as shown in the appendix. The urine was still bloody.
During the ward rounds, the medical officer ordered that IV fluids to be continued with IV Ringer Lactate 1 litre and IV 5% Dextrose Water 1/2 litre and patient to start taking sips of clear fluids. He also ordered the continuation of urinary catheter. She took sips of water and lipton and she was able to tolerate it as she did not vomit or complain of any abdominal discomfort. All her medications were served as prescribed.
At 5:30pm, the medical officer came to review Madam A. A. and ordered discontinuation of urinary catheter and free fluids. Urine was clear and the total output read 2000mls. Urinary catheter was discontinued (removed) and discarded. She was encouraged to void to prevent bladder dysfunction and to continue taking copious amount of fluids. The IV line and cannula were removed and discarded.
She was made comfortable in bed, watched television, brushed her teeth, had her bath and slept around 11:00pm. All interventions carried out were documented.