CHAPTER FOUR

IMPLEMENTATION OF PATIENT AND FAMILY CARE PLAN

Implementation is the act of the client and the nurse carrying out the plan of care. The

primary focus of implementation is the provision of individualized self care with

maximum concentration. Client and relatives are encouraged to participate by playing

their part for the client’s speedy recovery. The nurse must not forget the individuality of

man. The culture, religious and socio-economic status of the client must be respected.

SUMMARY OF ACTUAL NURSING CARE

The nursing management of Madam Cecelia Donkor started on the day of admission

which was the 30th of December, 2009 at 2:00pm to the time of discharge on the 5th of

January, 2010 until the care was terminated.

The nursing care rendered throughout her stay at the female medical ward C6 was aimed

at meeting psychological, physiological and spiritual needs.

FIRST DAY ON ADMISSION (30/12/2009)

Madam Cecelia Donkor was admitted to the female medical ward C6 at 2:00pm. She was

immediately put on admission bed and doctor on duty called to examine client. It was

confirmed that, she was suffering from diabetes mellitus type II with hyperglycemia.

54
A tray was set for the doctor, which I assisted to take sample for haematological

examination. The samples were labeled and sent to the laboratory together with the

request form.

The vital signs, that is temperature, pulse, respiration and blood pressure were checked

and recorded as well as the random blood sugar (RBS). The client was put on treatment

and her drugs were served accordingly and documented. However, during the checking of

vital signs and RBS, client was noticed to have pyrexia (39.1oC) and high glucose level

(32.2mmol/L). Client and relatives were reassured that, all efforts will be put in place to

bring client’s temperature and blood sugar to normal.

Because of that, cause and effect of the condition was explained to patient as parasitic

infection and if patient was not tepid sponged, she will have rigor. Procedure for tepid

sponging was explained to client as well as trolley containing items for tepid sponging

was also set. Screen was provided to provide privacy for client. Tepid sponging was done

and left for 15-20minutes to take off heat from patient’s body. Cold low sugar drink was

served client to hydrate her and take away heat.

Nearby windows were also opened and fans turned on as well as patients clothes

loosened to allow fresh air into the ward and prevent restriction in patient’s body.

Prescribed antipyretic (paracetamol tablets 1000mg) was administrated to patient to bring

temperature to normal. Patient’s temperature was checked and recorded afterwards as

55
37.8oC. Patient’s temperature was reported to nurse –in-charge and tepid sponging

restarted for temperature to drop to 36.8o C.

Moreover, client was reassured that, measures will be taken for her blood glucose to

return to its normal range.

Also explanation was given to the effect that, the increase in glucose level was as a result

of the pancreas not producing enough insulin for tissue absorption of glucose, hence the

accumulation of glucose and if not checked can lead to complications such as brain

damage

Random blood sugar was then checked and recorded as 32.2mmol/L, prescribed insulin

of 20 units was administered in divided doses of 10im, 10iv. Client was observed for any

reaction to drug after which blood glucose was rechecked and recorded as 9.8mmol/L.

Client was educated on low sugar and carbohydrate meals to prevent the accumulation of

glucose in blood and to prevent her self from injuries.

During admission of patient, client’s family was noticed to be anxious so they were

reassured that all efforts are being put in place to bring their relatives condition under

control. They were allowed to ask questions which were answered in simple terms to

their understanding to allay their fears. The cause and effect of the condition was

explained to them to make them understand the condition.

56
Procedures carried out on the client such as checking vital signs, taking of samples,

changing of positions were all explained to the family. This helped them to understand

the reasons and complied with the procedures.

The client and relatives were introduced to the nurses and doctors on duty who would be

working on the client. They were oriented to the ward and other patients too were

introduced. This helped them familiarized with the new environment.

Client’s family was educated on the need for hospitalization to prevent further

complication and enable adequate monitoring and treatment.

Television set was switched on for family members to divert their attention and also

distract them from their anxiety.

SECOND DAY ON ADMISSION (31/12/09)

It was observed that, due to general body weakness, client could not walk well.

The following nursing measures were put in place to solve the problem.

Reassurance was given to client to allay her fears and also to assist her undertake her

activities of daily living until she is well to do them by herself. She was educated on the

cause and effect of her condition as the inability of the pancreas to produce enough

insulin for the body which causes her weakness.

57
Client was also educated to avoid activities which results in fatigue such as walking and

bathing alone and to call for assistance whenever needed. She was assisted to use

ambulatory gadgets in walking and was helped in carrying out her daily activities

involving mouth care, bathing, walking in the ward and feeding. She was then helped to

carryout passive exercise to improve joint movement.

Client was left to walk alone in the ward noting any deviation from normal.

THIRD DAY ON ADMISSION (01/01/10)

On this day, client looked a little better than the previous days. Her face looked so

cheerful. The routine nursing cares were given such as checking of vital signs, serving of

medications, meals and so on. However, client was not able to go to the bathroom to have

her bath alone and also had overgrown nails. The following nursing cares were carried

out to ensure her personal hygiene.

Client was reassured that, she will be given assisted bed bath as well as trimming her

finger and toe nails to make her feel clean. Measures were put in place and procedures

such as screening, setting of trolley were made clear to patient to gain her co-operation.

58
Patient was helped to bed-bath with mild soap and water set to patient’s preference. The

perineum was also cared for to prevent infection. Pressure areas were also treated with

mild soap applied in the palm to prevent decubitus ulcer.

Patient was groomed to her satisfaction with pomade and talcum powder. Clean gown

was put on patient and her hair nicely combed. Finger and toe nails were soaked in water

and trimmed to desired level to prevent harboring microorganisms.

FOURTH DAY ON ADMISSION (02/01/10)

On this day, the general nursing cares were rendered to client. On observation, it was

noticed that, client had alteration in nutritional status (less than body requirement) due to

anorexia. Reassurance was given to client that measures will be taken to improve her

appetite.

Education was given to client on the importance of essential nutrients to the body and the

need to restrict herself from taking certain foods such as simple sugars which include

honey and sweets.

Client was involved in the planning of her meals to enable her have meals which she

preferred and can eat. She was told of foods that can be taken in moderation which

include starchy foods like yam, cocoyam, bread, cereals and so on. Foods that can also be

taken are fish, egg and vegetables.

The ward environment was cleaned and made free from unpleasant odor before meals

were served to help improve client’s appetite and prevent nausea and vomiting.

59
Client’s mouth was cleaned before meal time with fluoride toothpaste and toothbrush to

keep the mouth fresh and stimulate appetite.

She was also encouraged to eat her food in bits to prevent her from vomiting and with

scheduled times.

Client was served and encouraged to take fruits such as pineapple and orange to improve

her appetite and prevent constipation.

FIFTH DAY ON ADMISSION (03/01/10)

On this day, it was noticed that, client had potential for impaired tissue integrity due to

hyperglycemia. The nursing measures carried out to solve client’s problems were as

follows;

 Client was reassured that, proper skin care will be carried out to enable her

have no skin breakdown. She was educated on the need to maintain intact skin

such as not cutting herself with any sharp item like blade because diabetic wounds

are slow to heal.

 She was helped and asked to check feet everyday for irritation, redness

and blisters and also to wriggle feet to enable blood flow.

 Client’s skin was then kept clean using mild soap and soft sponge to give

assisted bed-bath to patient to prevent pruitus.

 Client was cautioned to wear low heel slippers when ambulating to

prevent stepping on sharp objects, hitting foot against items and slipping. Caution

was also taken to make the floor in the ward as dry as possible to prevent fall.

60
SIXTH DAY ON ADMISSION (04/01/10)

Client’s condition had improved tremendously. Client and relatives were happy and

were psychologically prepared that, very soon she will fully recover and be

discharged home. On the 4th of January 2010, during doctors ward rounds, the doctor

declared his intention to discharge client on the 5th of January, 2010. Client was asked

to continue with her drugs. The drugs were served and charted accordingly.

On the 5th of January 2010, during doctors ward rounds, client was thoroughly

examined and discharged.

PREPARATION OF CLIENT/FAMILY FOR DISCHARGE AND

REHABILITATION

Preparation towards discharge of the client and family started on the day of

admission. Although family members were anxious and perplexed about the outcome

of client’s condition, they were reassured that everything possible would be done so

that, client would recover and be discharged home. This preparation is aimed at

giving the client and family insight into the client’s condition since diabetes mellitus

can generate into serious complications.

On the 4th of January, 2010, during ward rounds, the doctor declared his intention to

discharge client on the 5th of January, 2010. Madam Cecelia Donkor and her relatives

were informed. Pre-assessment was carried out by taking patient folder to the revenue

61
office staff so that, the patient’s relatives will have knowledge of the amount they will

pay as their bill. Client and relatives were advised to report immediately to the

hospital anytime they fall sick. They were also educated on the need for daily self

care skills to prevent fluctuations in the glucose level in the blood and to avoid cuts

and wounds which maybe difficult to heal. Client was also educated not to skip meals

to prevent hypoglycemia.

On the day of discharge, during doctor’s rounds, the patient was declared fit for

discharge after thorough examination. She was therefore discharged and asked to

come for review on the 12th of January, 2010. Client was discharged home on

Metformin 1gbd×30, gliclazide 80mg dly ×30, tab zinnat 250mg bd ×7.

The date of discharge and diagnosis were entered into the admission and discharge

book as well as the daily ward state. The folder was taken to the revenue department

where it was assessed but patient had no bill to pay because the National Health

Insurance covered all payment. On the ward, client was assisted to pack her items into

a bag, relatives were reminded of review date and they were educated on how to take

the drugs (Metformin, gliclazide, zinnat) at home. That is the dosage and time and to

observe for side effects of drugs and report immediately if any of them occurs. They

bade goodbye to the ward staff and other patients.

Patient’s bed linen was taken to the laundry, the mattress and pillows were taken

outside to be aired. Bedstead was cleaned with Para zone 1:10 and soap and water.

62
FOLLOW UP/HOME VISITS/CONTINUITY OF CARE

Follow up/home visit is a purposeful visit to the home of the client with the aim of

finding out their actual and potential health problems. It is also to assess the use of

available resources at home as well as in the community that can be used to solve

health problems. It is also to follow the progress of the client after discharge.

FIRST HOME VISIT (02/01/10)

The first home visit was carried out while patient was on admission. It was on the 2nd

of January 2010. The visit was made to the house with Mr. Charles Dua (Son of

client) and other relatives to assess for the first time patient’s home environment so

that, health education could capture findings in the visit.

A critical observation revealed the environment in the house as clean. The house is a

self contained apartment with four (4) bedrooms with a common big hall. There are

two (2) bathrooms, two toilet facilities, a kitchen and a storage room. All doors and

windows had a mosquito proof net. The house is painted yellow. The nearest health

facility in the area is St. Theresa’s Clinic. The family members were happy on my

arrival and issues concerning Madam Cecelia Donkor’s condition were discussed.

They were advised to take Madame Cecelia Donkor to the diabetic centre on regular

basis after her discharge. Their questions were answered in clear terms for them to

understand. After being with them for a while, I promised to pay them another visit

soon. It is about forty-five (45) minutes drive from the school to the house.

63
SECOND HOME VISIT (05/01/10)

The second home visit took place on the 5th of January, 2010. Madam Cecelia

Donkor and her son were accompanied home. All her drugs were collected from the

pharmacy department and given to her. Thus the drugs which were prescribed by the

physician. On reaching the house, we were welcomed by the family members.

I was offered a seat and had a little chat together with them. Her youngest daughter

who had already prepared food brought it to her mother. It was “fufu with light soup”

and dry fishes which was served in a clean bowl. After patient had finished eating,

education was given to the family members about the need to administer the drugs

according to the prescription. That is the right time and dose.

Also, they were reminded of the review date which was the 12th of January, 2010 and

its importance. They were advised to continue keeping their environment clean and

take in balanced diet. It was made known to the patient and family members that,

arrangement had been made with a public health nurse who would be available during

the third home visit for the client to be handed over to her for continuity of care.

THIRD HOME VISIT (15/01/10)

After client had come on review on the 12th of January 2010, a third home visit was

made with a public health nurse from Tafo government hospital on the 15th January,

64
2010. We met client at home together with her eldest son and youngest daughter. I

asked of client’s health and she told me she has been doing better ever since she was

discharged out of the hospital which was confirmed by the eldest son. Client and

family members were advised to continue medication and a well balanced diet

avoiding simple sugar.

Client assured me that, she will adhere strictly to all diet and medication, the public

health nurse was then introduced to them for continuity of care to enable me continue

with other academic issues in school.

I then bade them goodbye after asking permission to leave.

65