CHAPTER THREE

PLANNING FOR PATIENT AND FAMILY CARE

The nursing care plan is the sum total of all the care rendered to the patient to help the

patient attain and regain strength as soon as possible. It is also a systematic method of

which both nurse and patient work together to plan and implement effective nursing care.

It gives the opportunity to assess, plan, analyze and implement patient’s problems and

offer solutions to those problems.

OBJECTIVE OUTCOME CRITERIA

 Altered thermoregulation (pyrexia of 39.1oC) related to parasitic infection.

Client’s body temperature will be restored to normal within 24 hours as evidenced

by:

1) Client verbalizing she no more feels hot.

2) Nurse observing that client’s temperature is within normal range from 36.2oC

to 37.2oC with the use of a thermometer

 Altered glucose level (hyperglycemia of 32.2mmol/L) related to scanty insulin

production. Client’s glucose level will be restored to normal (7-11.1mmol/L)

within 48 hours as evidenced by nurse observing that blood sugar is within

normal range of 7-11.1mmol/L

 Anxiety (family) related to uncertain admission. Client’s family will be relieved

of anxiety within 24 hours as evidenced by:

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 1) Client’s family verbalizing that, they are relieved of anxiety.

2) Nurses observing that client’s family members are relaxed and cheerful.

 Activity intolerance (could not walk well) related to general body weakness.

Client’s activity level will be enhanced within 48 hours as evidenced by:

1) Client verbalizing that, she has been able to walk alone with no assistance.

2) Nurses visualizing patient has been able to walk alone with no assistance.

 Self care deficit (bathing, grooming and overgrown nails) related to weakness.

Client will be able to have her bath alone and shorten her finger and toe nails

within 72 hours as evidenced by:

Client verbalizing that, she has been able to have her bath and trim her finger and

toe nails alone. Therefore nurses visualizing that, patient has been able to have her

bath and trim finger and toe nails without assistance.

 Alteration in nutritional status (less than body requirement) related to anorexia.

Client will regain her appetite and eat enough within 24 hours as evidenced by:

1) Client verbalizing an improvement in her appetite

2) Nurse visualizing client has eaten enough amount of food served her (a ball

of fufu with vegetable soup and dried herrings)

 Potential for impaired tissue integrity related to glycoceamia. Client will

maintain normal tissue integrity within period of hospitalization as evidenced by:

1) Nurses visualizing no skin breakdown

2) Patient verbalizing no sign of skin lesion.

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 TABLE FIVE

NURSING CARE PLAN

DATE AND NURSING OBJECTIVE NURSING NURSING EVALUATION SIGN

TIME DAIGNOSIS OUTCOME ORDERS INTERVENTION
CRITERIA
30/12/09 Altered Client’s body  Reassure  Client and  Goal fully
2:00PM thermoregulation temperature will be client and family met. As
( Pyrexia of restored to normal family members were client said
39.1oC) related to within 24 hours as members. reassured that she no more
parasitic infection evidenced by; 1) everything will felt hot
client verbalizing be done to  Nurse
she is no more hot. bring client’s observed
2) Nurse observing temperature that, client’s
that, client’s within its temperature
temperature is normal range. was within
within normal normal range
range; 36.2oC to of(36.2oC-
37.2oC with a  Explain the  It was 37.2oC with
thermometer. cause and explained to a
effect of the patient and thermometer
condition to relatives that, .
patient and the cause of the
relatives. pyrexia was as
a result of
parasitic
infection and
that, if patient is
not tepid
sponged,
patient will
have rigor

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 Explain  Procedure for
procedure. tepid sponging
was explained
to client.
 Set trolley.  Trolley for
tepid sponging
containing
warm and cold
water in basins
and towels was
set and brought
to patient’s
bedside.
 Provide  Patient was
privacy screened to
provide
privacy.

 Tepid  Patient was

sponge tepid sponged
patient. and left for 15-
20minutes to
take off heat
from patient’s
body

 Serve cold  Cold low sugar

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 low sugar drink was
drinks served client to
hydrate her and
take away heat
as well

 Open nearby  Nearby

windows windows were
and turn on opened and fans
fan. Loosen turned on as
patient’s well as patient’s
clothing. clothes loosen
to allow fresh
air into the
ward and
prevent
restriction in
patients body.

 Administer  Prescribed
prescribed antipyretic
antipyretic (tablet
paracetamol
1000mg) was
administrated to
patient to
decrease
temperature to
normal.

 Recheck  Patient’s

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 temperature temperature
and record was rechecked
and recorded as
37.8oC
 Report  Patient’s
temperature temperature
afterwards was reported to
and restart the nurse-in-
tepid charge and
sponging tepid sponging
restarted for
temperature to
drop to 36.8o C.
30/12/09 Altered glucose Patients glucose  Reassure  Client was  Goal fully
03:00PM level level will be client reassured that, met as nurse
(hyperglycemia of restored to normal measures will observed
32.2mmol/L) (7-11.1mmol/L)wit be taken to that ,client’s
related to scanty hin 48 hours as make her random
insulin evidenced by nurse random blood blood sugar
production. observing that sugar return to is within
random blood its normal range normal range
sugar is within (7-11.1mmol/L) (9.8mmol/L)
normal range (7-
11.1mmol/L)  Explain the  It was
cause and explained to
effect of client that ,the
condition to increase in
client. glucose level in
the body has
come about as a
result of the
pancreas not
producing

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 enough insulin
for tissue
absorption of
glucose
therefore
making glucose
accumulate in
the blood, and if
not checked can
result in
complications
such as brain
damage.
 Check
random  Random blood
blood sugar sugar was
for hourly checked at
and record. 3:15pm with
result of
32.2mmol /L

 Administer
diabetic  Prescribed
prescribed insulin injection
insulin of 20 units was
injection administered to
according to patient in
the result divided doses of
10im, 10iv.
 Observe
client for  Client did not
any exhibit any
deviation reaction to drug

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 and report administered.
for
correction

 Educate
client on low  Client was
sugar and educated to take
carbohydrate in foods which
meals and contain low
protection. sugar and
carbohydrate to
prevent glucose
from
accumulating
the blood and to
protect her self
from injuries
such as cuts.
30/12/09 Anxiety (family) Client’s family will  Reassure  Client’s family Goal fully met:
04:30PM related to be relieved of client’s was reassured 1) Client’s
uncertain anxiety within 24 family that all efforts family
admission of hours as evidenced are being put in verbalized
client. by: place to bring that they
their relative’s were
condition under relieved of
control. anxiety.
2) Nurses
 Explain the  It was observed
cause and explained to that,
effect of client’s family client’s
condition to that, her family
client’s condition is as a members
family. result of the were

39
 pancreas not relaxed
producing and
enough insulin cheerful.
1) Client’s for tissue
family absorption of
verbalizing glucose and if
that, they not checked can
are relieved lead to brain
of anxiety. damage.
2) Nurses
observing
that client’s
family
members
are relaxed
and
cheerful.

 Educate  Client’s family

client’s were educated
family on that,
the need for hospitalization
the will help
hospitalizati prevent further
on complication
and to enable
adequate
monitoring and
treatment to
cure their
relative.

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 Explain all  All procedures
procedures carried out on
that are to be client, example
performed checking of
on the client vital signs,
to the changing of
family. positions,
taking of
samples were
explained to the
family. This
enabled them
understand the
reasons and
complied with
the procedures.

 Allow  Client’s family

family were allowed to
members to ask questions
ask which were
questions answered in
and answer simple terms to
client’s their
family understanding.
member’s
questions.

 Orient  Client’s family

client’s was introduced
family to the nurses
and doctors

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 who would be
working on
their relative
and how
competent we
are. They were
also oriented to
the ward and
other places
like the
bathroom, toilet
and pantry to
help them
familiarize with
the new
environment

 Give  Client’s family

diversional was engaged in
therapy to conversation on
distract to distract their
family attention. They
attention were allowed to
from watch
anxiety. television
programs to
divert their
attention from
their anxiety.

31/12/09 Activity Client will be able  Reassure  Client was Goal fully met
8:00AM intolerance (could to walk alone client. reassured that, as :

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not walk well) within 48 hours as she will be 1) Client
related to general evidenced by: assisted to walk verbalized
body weakness 1) Client until she is able that, she had
verbalizing to do it her self. been able to
that, she is able walk with no
to walk alone assistance.
with no 2) Nurse
assistance. visualized
patient had
been able to
2) Nurses  Educate  Client was walk with no
visualizing client on the educated that, assistance.
patient being cause and her pancreas is
able to walk effect of her not able to
with no condition. produce enough
assistance. insulin for the
tissue to take it
up to generate
energy needed
for the body.
That is why she
feels weak and
not able to do
most activities
by herself.

 Educate  Client was

patient to educated to
avoid over avoid activities
activity and such as walking
over alone and call
exhaustion for assistance

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 and to call whenever
for needed.
assistance
when there
is the need.
 Support  Client was
client to assisted in
carry out carrying out
daily her daily
activities activities
and use involving
ambulatory mouth care,
gadgets. bathing,
walking in the
ward and
feeding

 Carry out  Patient was

passive helped to carry
exercise. out passive
exercise to
improve joint
movement.

 Assist client  Client was

to walk assisted to walk
around the in the ward for
ward, let her some time and
try walking left to walk
and report alone, it was
any noticed that,
deviation on client was

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 walking walking
sideways and
was corrected.
01/01/10 Self care deficit Client will be able  Reassure  Client was Goal fully
6:00AM (bathing, to have her bath client. reassured that, achieved as :
grooming and alone and shorten she will be 1) Client
overgrown nails) her finger and toe given assisted verbalized
related to nails within 72 bed bath as well that, she had
weakness hours as evidenced as trimming her been able to
by: finger and toe have her
1) Client nails until she is bath and trim
verbalizing well to do them her finger
that, she has herself. and toe nails
been able to alone.
have her bath  Explain  It was 2) Nurses
and trim her cause and explained to visualized
finger and toe effect of client that, her that, patient
nails alone. condition to pancreas is not had been
patient able to produce able to have
2) Nurses enough insulin her bath and
visualizing that, for the tissue to trimmed her
patient has been take it up to finger and
able to bath and generate energy toe nails
trim her nails needed for the without any
without assistance. body. That is assistance.
why she feels
weak

 Explain  Measures to put

procedures in place and
to patient procedures such
as screening,
setting of

45
 trolley were
made clear to
patient to gain
her co-
operation.

 Give  Patient was

assisted bed given bed-bath
bath to with mild soap
patient twice and water set to
daily. patient’s
preference. The
perineum was
cared for to
prevent
infection.
Pressure areas
were also
treated with
mild soap
applied in the
palm to prevent
decubitus ulcer.

 Observe  Client’s skin

client’s skin was observed
for any for lesions,
deviation rashes, cuts but
and report none was
noticed.

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  Groom  Patient was
patient to groomed with
her pomade and
satisfaction. talcum powder.
Clean gown
was put on
patient and hair
nicely combed.

 Trim finger  Finger and toe

and toe nails nails were
with care soaked in water
and trimmed to
desired level to
prevent
harboring of
micro
organisms
02/01.10 Alteration in Client will regain  Reassure  Client was Goal fully met
10:00AM nutritional status her appetite and eat client. reassured that as :
(less that body enough within 24 measures would 1) Client
requirement) hours as evidenced be taken to verbalized
related to by: improve her an
anorexia 1) Client appetite. improvement
verbalizing an  Educate  Client was in her
improvement in client on the educated on the appetite.
her appetite. importance importance of 2) Nurse
2) Nurse of essential essential visualized
visualizing nutrients in nutrients to the client had

47
client eating food and the body and the eaten
enough amount essence of need to restrict enough of
of food served diet herself from food served
her. restriction. taking certain her
foods such as
simple sugars
which include
honey, sugar,
sweets and
others instead, a
sweetening
agent may be
used.

 Plan diet  Client was

with client involved in the
and serve planning of her
her meal of meals to enable
low sugar her have meals
and which she
carbohydrate preferred and
diet. can eat. Foods
that can be
taken in
moderation
include starchy
foods like yam,
cassava,
plantain and
others, bread,
some cereals

48
 such as wheat.
Foods that can
also be taken
are fish, egg,
and vegetable.

 Ensure that,  The ward

the ward environment
environment was cleaned
is clean and and made free
free from from unpleasant
any odour before
unpleasant meals were
odour before served to help
meals meals improve
are served. client’s appetite
and to prevent
nausea and
vomiting.

 Give mouth  Client was

care before assisted to
and after brush with a
each meal. fluoride tooth
paste and brush
before meal
time to keep the
mouth fresh and
to stimulate
appetite.

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  Serve meals  Client was
attractively, encouraged to
small eat her food in
quantities at bits to prevent
regular her from
intervals. vomiting and
with scheduled
times.

 Serve and  Client was

encourage served and
client to take encouraged to
moderate take fruits
amount of (pineapple and
fruits or low oranges) to
sugar fruit improve her
drinks after appetite and to
each meal. prevent
constipation.
03/01/10 Potential for Client will  Reassure  Client was Goal fully met
8:00AM impaired tissue maintain normal client. reassured that, as:
integrity related to tissue integrity proper skin care 1) Nurse
hyperglycemia within period of will be carried visualized no
hospitalization as out to enable skin
evidenced by: her have no breakdown.
1) Nurses skin 2) Patient
visualizing no breakdown. verbalized
skin breakdown  Educate  .Client was no sign of
2) Patient client on the educated on the skin lesion.
verbalizing no need to need to

50
sign of skin maintain maintain intact
lesion. skin intact. skin such as not
cutting herself
with any sharp
items like blade
because
diabetic
wounds are
slow to heal.

 Help and ask  Client was

client to helped and
check feet asked to check
everyday. feet everyday
for irritation,
redness and
blisters and to
wriggle feet to
enable blood
flow.

 Keep  Client’s skin

client’s skin was kept clean
clean. using mild soap
and soft sponge
to bed-bath
patient to
prevent itching.

 Caution  Client was

client to cautioned to

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wear low wear low heels
heel slippers when
slippers. ambulating to
prevent
stepping on
sharp objects,
hitting foot
against items
and slipping.

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Sample of a pancreas

53
Pancreas

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