CHAPTER FOUR

IMPLEMENTATION OF PATIENT/FAMILY CARE PLAN

Implementation refers to carrying out the proposed plan of care. The nurse assumes
responsibility for the implementation but includes the client, his family and other members of the
health care team. While implementing nursing care, the nurse continually assesses the patient
and his response to the care rendered and makes amendments when necessary.

SUMMARY OF ACTUAL NURSING CARE

The nursing care in the management of my client started on the day of admission 4 th January,
2016, throughout to the time of discharge on 8 th January, 2016.The aim of the management was
to meet the client and family’s physiological, emotional, psychological and spiritual needs.

DAY OF ADMISSION (4th JANUARY, 2016)

Client was admitted into Holy Family Hospital male medical ward on 4 th January, 2016 at
3:45PM from the Out-Patient Department, accompanied by his mother and a nurse. He walked to
the ward with assistance by his mother. They were warmly welcomed and offered seats to seat
down.

Client was immediately received into an already prepared bed and the upper end raised to prop
him up in other to ensure airway patency and proper breathing after he was observed to be
having difficulty in breathing. Client was also encouraged to take in more fluid at frequent
interval to help loosen pulmonary secretions to ensure airway patency and proper breathing and
to also replace fluid loose.

All admission procedures involving taking of client’s particulars which included his name, age
address occupation, marital status, religion, nationality, and next of kin were recorded in the
admission and discharge book and the ward daily state.

His vital signs were checked and charted as follows:

Temperature : 38.2ºc (Degree Celsius)

Pulse : 90 Beats per minute
Respiration : 25 Cycles per minute
Blood pressure : 110/60 milliliters of mercury
The following investigations were ordered:

 Chest X-ray
 CDC
 Sputum for Acid Fast Bacillus (AFB)
 Polymerase Chain Reaction (PCR) on sputum for Mycobacterium Tuberculosis (MTB)

Client was put on the following treatment:

 Intravenous Amoksiclav 1.2g tds x 5days

 Tab Ibuprofen 400mg tds x 5days
 Tab Azithromycin 500mg tds x 5days
 Syrup Carbocisteine 15mls tds x 5days

Prescribed mucolytic was administered to reduce purulent secretions associated with

inflammation in addition to tablet ibuprofen to reduce pain from interfering with deep breathing
and coughing. Client was observed to be pyretic (38.2 oC) using the clinical thermometer. Client
was reassured that measures are available for him to regain and maintain a normal body
temperature with good nursing care to relieve him of anxiety whiles all procedures to be taken
explained to him. All drugs were administered as prescribed and charted in the drug
administration chat and recorded in the nurses notes.

At 9pm, patient’s vital signs were checked and recorded

Temperature : 38.1ºc (Degree Celsius)

Pulse : 88 Beats per minute
Respiration : 24 Cycles per minute
Blood pressure : 110/60 milliliters of mercury
SECOND DAY OF ADMISSION (5TH JANUARY, 2016)

Master A. K. M. woke up around 5:30am, according to the night nurse, patient did not have a
sound sleep. Patient also complained to me that he had been coughing the entire night. I
explained to him that the he will be fine, since it is a gradual process in recovery. His vital signs
assessed in the morning were:

Temperature : 37.2oC

Pulse : 90 beats per minute

Respiration : 24 cycles per minute

Blood pressure : 120/70mmHg

SPO2 : 96%

His personal hygiene was maintained. He took tea with little bread as breakfast which was
brought in the morning by his mother and elder sister. Afterwards, he had his morning
medication served. Patient was put in a comfortable position and also his bed was propped up to
improve respiration. At 9: 30am, the ward doctor came around and after assessing him, he
ordered that results for AFB be retrieved from the lab. The doctor again asked that treatment
should be continued.

In the afternoon, his was served with mashed kenkey with milk and bread. The food was served
in bits and frequently in an attractive manner. Afternoon medication was served and his vital
signs checked in afternoon were;

Temperature : 37.5oC

Pulse : 86 beats per minute

Respiration : 24 cycles per minute

Blood pressure : 110/60mmHg

At 5:00pm, his mother visited him and brought his evening meal. A friend of his accompanied
his mother. He was served with fufu ad light soup. He could not eat much. I encouraged him to
drink more of the soup and also do well to chew the fishes in the soup. At around 7:30pm, client
went to bed. Client was served with his evening medication around 10:00p. Vital signs checked
and recorded as

Temperature : 37.3oC

Pulse : 87 beats per minute

Respiration : 23 cycles per minute

Blood pressure : 110/60mmHg

THIRD DAY OF ADMISSION (6TH DECEMBER, 2016)

Master A. K. M. woke up around 5:00am. He had his bath and brushed his teeth. His mother
brought his breakfast at around 5:40am and I reassured his mother that his son was responding to
treatment. Patient looked stronger than previous days. His cough had subsided and was less
productive. Patient verbalized that he was getting better and was able to sleep at night. His bed
linen was changed and new one was prepared for him. His vital signs checked and recorded as

Temperature : 36.8oc

Pulse : 84 beats per minute

Respiration : 22 cycles per minute

Blood pressure : 110/70mmHg

He took his breakfast at 6:15am which was rice porridge and milk. At 8am, his medications were
served and recorded. On Doctor’s rounds, she assessed him and ordered for continuation of
treatment. Also the Doctor ordered that syrup Carbocisteine should be stopped. The result of the
urine AFB ordered the previous day was shown to the doctor. The result was negative.

He then took his lunch; his vital signs in the afternoon were;

Temperature : 37.0oc

Pulse : 86 beats per minute

 Respiration : 22 cycles per minute

Blood pressure : 110/70mmHg

Client and his mother were given education on the causes, signs and symptoms, mode of
transmission, treatment and prevention of the disease condition. Patient returned to bed at
3:00pm and rose at around 5:30pm. His personal hygiene was maintained. He ate banku with
groundnut soup as supper. Later in the evening at around 9:55pm, medications were served and
vital signs checked and recorded as;

Temperature : 36.7oc

Pulse : 84 beats per minute

Respiration : 24 cycles per minute

Blood pressure : 110/70mmHg

Patient returned to bed at 10:15pm.

FOURTH DAY OF ADMISSION (7TH JANUARY, 2016)

Client’s condition had improved this day. He woke up cheerfully because he was able to sleep
well the previous night and looking so refreshing. He maintained his personal hygiene with little
assistance while all other routine activities such as administering prescribed medications, bed
making, and were carried out. Client’s vital signs were checked and recorded as follows:

Temperature : 36.7oc

Pulse : 80 beats per minute

Respiration : 22 cycles per minute

Blood pressure : 110/70mmHg

During the ward routine rounds, treatment was to be continued and discharge to be considered
two days later should client condition improves further. The doctor ordered that if his mother
could afford Polymerase Chain Reaction (PCR) test on sputum for mycobacterium tuberculosis
(MTB). Doctor ordered that if patient does well on antibiotics, he will be discharged the
following day and they should follow up with the results when they report for review. Mother
was able to raise funds for the test. She paid for the test at MDS Lancets laboratory in Techiman.
She was given a sterile specimen bottle which my client is supposed to produce sputum into it
the following day. I explained to my client how to handle the specimen bottle to avoid
contaminating the sputum.

Client took his lunch at around 1:15pm. Afternoon medication was served and vital signs
checked and recorded as follows:

Temperature : 36.8oc

Pulse : 84 beats per minute

Respiration : 22 cycles per minute

Blood pressure : 110/70mmHg

Patient went to bed at around 2:00pm and woke up at around 4:00pm. My client and I took a
walk in the hospital premises to serve a form of exercise. We walked for about twenty minutes
and we later returned to the ward. In the evening, he took fufu with groundnut soup. He took his
bath after eating Evening medication was served.

At around 9:50pm, medication was served. Vital signs were checked and recorded as:

Temperature : 37.2oc

Pulse : 82 beats per minute

Respiration : 21 cycles per minute

Blood pressure : 110/70mmHg

He slept around 10:30pm.

FIFTH DAY OF ADMISSION (8TH JANUARY, 2016)

This was the client’s day of discharge. He woke up quite early in the morning in good condition
and with a healthy and cheerful facial expression. His personal hygiene was maintained quickly
as compared to the previous days without any assistance. All other routine cares were carried out
and documented. His medication was served and vital signs checked and recorded with values as
follows:

Temperature : 36.8oc

Pulse : 80 beats per minute

Respiration : 22 cycles per minute

Blood pressure : 110/70mmHg

At 10:45am, my client was reviewed during general ward rounds. The doctor discharged client
after thorough assessment of his health status which he found to be stable. Tablet azithromycin
500mg daily x 3 and Tab Augmentin 625mg bd x 7 days was prescribed for client while at
home .He was informed of his discharge and review date which was on the 15 th of January, 2016.
All other necessary information transferred to the admission and discharge book as well as the
daily ward state for record keeping. Client’s folder was taken to the revenue department for
assessment of his bills which were catered for by the national health insurance.

Client and family were educated on issues such as the need to continue with his medications and
how to take them whiles in the house and the need to eat nutritious diet that would keep them
healthy. He was also made to know the importance of coming back for review when the date is
due and to also bring the results of the PCR on sputum for MTB test when coming for review.

After helping client and family in packing their belongings, they expressed their appreciations to
the entire staff on the ward for the care rendered to them. They ceased that opportunity to bid
other patients in the ward as well as the entire staff on duty goodbye. They were escorted from
the ward at 1:30pm. The bed linen was discarded and the mattress disinfected with bleach 1:10
part of water and later cleaned with savlon.
PREPARATION OF CLIENT/FAMILY FOR DISCHARGE AND REHABILITATION

The preparation of client and family towards discharge started on the day of admission till the
day he was discharged where measures were put in place to relieve client of his anxiety through
reassurance that he would recover and be discharge home. A pre-discharge home visit was made
to client’s house on 7th January, 2016 whiles client was still on admission to assess the facilities
and condition of the house and community as a whole.
Series of health education on the condition was given to client and family right from admission
till discharge. Education was given based on client and family’s knowledge by telling them the
predisposing factors, signs and symptoms, treatment and preventive measures. Education of
preventive measures was focused on the avoidance of risk factors such as overcrowding; opening
of his chest especially during could seasons, excessive alcohol intake, smoking and too much
exposure to dust and fumes.
On the 7st of January, 2016, client was informed about his possible discharge on the next day if
his condition improves further after the doctor had said during ward rounds. Client and family
were again educated on the need to ensure good health through good personal and environmental
hygienic needs. Client and family were encouraged to bath at least twice daily. However,
emphasis was laid on oral hygiene which reduces the number of microbes in the oesophagus
which can spread easily to the lung. Besides that, they were educated to have enough rest and
sleep in a highly ventilated room to prevent the possibility of inhaling particles which can cause
lung inflammation. Proper hand washing techniques before meals and after visiting the toilet
were not left out. They were also educated on the need to wear heavy cloth especially during
cold seasons. Proper waste disposal, weeding to ensure adequate ventilation and prevention of air
pollution were also not left out in their education.

The doctor discharged client after thorough assessment of his health status which he found to be
stable on the 8th of January, 2016. He was informed of his discharge and review date which was
on the 15th of January, 2016 after all his discharge papers were signed by the doctor. All other
necessary information was transferred to the admission and discharge book as well as the daily
ward state for record keeping. Client’s folder was taken to the revenue department for
assessment of his bills which were catered for by the national health insurance.
Client and family were educated on the need to stick to his drug regimen and the essence of
monitoring his condition by reporting to the nearest health facility in case he encounters any
problem.

Furthermore, education on the need to take in a well-balanced diet which builds up the body’s
immune system to fight against any infection was stressed. Client and family were informed to
prevent constipation by taking in adequate fluids, roughage diet and also understanding exercise
in order to ensure good health. They were again reminded of the review date.

Client and family were assisted to pack his belongings and the rest of his drugs handed over to
them. They expressed their appreciations to the entire staff on the ward for the care rendered to
them. They ceased that opportunity to bid other patients in the ward as well as the entire staffs on
duty goodbye. They were escorted to the car park to pick a car home.

FOLLOW UP/HOME VISIT/CONTINUITY OF CARE

Follow up care or home visit is a friendly but an important role in the car e of the client after
discharge. It helps to observe the health and environmental conditions of the client. It also helps
to know the predisposing factors and other hazards which could be dangerous to the health of the
client and family.

FIRST HOME VISIT (7TH JANUARY, 2016)

The first home visit was made on 27 th December, 2009 whiles client was still on admission. This
was done in order to know the home and assess the facilities and condition of the house and
community as a whole and situations he is exposed to and the type of health education to be
given while still on admission and to correct any abnormality in his environment before he is
discharged. The visit was a scheduled one that was planned with client to go with his mother on
their return home after they had come to visit him. It was not difficult locating the house since
his mother was available and took me there straight away. The house is located at Techiman
New-Site off the Sunyani-Techiman road.
On arrival, I was received nicely by the rest of the family. A thorough observation was made on
the environment which was found to be quite clean and healthy. The house was a self-contain
house with a hall and three bedrooms built with cement blocks and plastered, roofed with
aluminium sheets.

The surrounding was very neat. I congratulation them for their cleanliness and reassured them
that client will recover soon and join them soon. They were encouraged to keep the environment
always neat to prevent the outbreak of communicable diseases like cholera, malaria and typhoid
fever. Client’s relatives were reassured of the possibility of his discharge within few days. With
permission from the family, I left the house and promised them of another visit.

SECOND HOME VISIT (11ND JANUARY, 2016)

Three days following client discharge, the second have visit was made to assess health status and
offer the necessary health education. Client verbalized a great improvement in his condition and
how well he has been sticking to the drug regimen. I was very impressed when client and family
marvellously gave the correct feedback of the education that was given during the admission
period.

Emphasis was placed on ensuring good and adequate ventilation by opening windows.

However they were discourage from sleeping with fan which blow away particles in the room
and when inhaled can bring inflammation of the lungs parenchyma cells. They were also urged
to wear protective cloths especially in humid weathers. Client was reminded of the review date
(15th January, 2016). Client and family were also prepared psychologically towards the intended
handing over to the public health nurse whom was to be held in client home or house.

REVIEW (15TH JANUARY, 2016)

Client came alone to the hospital at around 6:30am. I met my patient at the hospital and
welcomed him. He was looking very healthy and I asked him if he had brought the results for the
PCR on sputum and his response was yes. My client’s vital signs were checked and the values
were:

Temperature : 36.4oc

Pulse : 74 cycles per minute

Respiration : 22 cycles per minute

Blood pressure : 110/70mmHg.

Doctors started consulting at around 8:30am. He was examined by the medical officer but no
complaint was made. he medical officer opened the result of the test and it turned out to be
negative. My client was not given any medication. I encourage him to continue eating nutritious
meals and to add fruits to his meals. I advised him to reduce alcohol intake and to avoid drinking
alcohol at all if possible and to alcohol. I also asked to desist from smoking though he had
already told me that he doesn’t smoke. I eventually escorted my client to the gate of the hospital
where he boarded a taxi home.

THIRD HOME VISIT (20TH JANUARY, 2016)

Five days following my client’s, I went for my third and final home visit. The purpose of this
visit was to terminate the care which commenced on 4 th January, 2016. Client verbalized a great
improvement in his condition and how well he was faring after he had been taken of
medications. I was very impressed when client and family marvellously gave the correct
feedback of the education that was given during the admission period.

Finally, client’s family and neighbours around were grateful and expressed their appreciation for
the care given to the client. I terminated my care for my client on 20th January, 2016 at 2:00pm.
They were thanked for their trust and co-operation. I bade them farewell and departed.