CHAPTER FIVE

EVALUATION OF CARE RENDERED TO MRS.D.Y AND THE FAMILY

The evaluation of care is the last step in the nursing process. It determines the extent of

progress in patient and family care and the effectiveness of nursing orders implemented towards

the achievement of objectives set for the care of the patient and family.

This chapter involves:

1. Statement of evaluation.
2. Amendment of the nursing care plan for partially met or unmet outcome criteria.

3. Termination of care.

Statement of Evaluation

Mrs. J. N., a 34-year-old woman, was admitted to the female medical ward of Kumasi South

Hospital through the Accident and Emergency Unit on August 24, 2023, with the diagnosis of

intestinal obstruction. Based on interaction, observation, and formulated nursing diagnoses,

patient problems were prioritized and solved accordingly. She was given comprehensive and

individual care throughout her hospitalization and after her discharge into her own environment.

This was made possible because of her cooperation, compliance, and the necessary support given

by the [Link] nursing process was used as a guide for Mrs. J. N’s individualized and

comprehensive nursing care. Various problems were identified. Nursing objectives were set and

interventions carried out to solve the problems, but one of the interventions was not achieved.

The patient’s abdominal and incisional pain was relieved as the patient verbalized the relief of

pain, and the nurse observed a cheerful patient's facial expression and her cooperation in the

care. Mrs. J. N. and her relatives gained adequate knowledge of her condition by answering

questions put to them correctly. Her wound healed completely by her first intention and she had a

normal body image. There was no complication due to the effective nursing, medical, and

surgical care rendered to her throughout the period of [Link]. J. N. was discharged on August
31, 2023, with much improvement in her condition. She honored her reviewed date of September

7, 2023. She was advised to avoid lifting heavy objects and take in more fluids, about 3–4 liters

per day.

Three home visits were made to assess the environment of the patient and to give education to

the patient on the health problems identified. The first home visit was made when the patient was

still on the ward and ensured that the patient’s environment was safe for her when she was

discharged, to verify the data collected and to give health education on some of the health

problems identified. The second visit was made to find out how well they are coping with Mrs. J.
N’s management and to ensure that her family has honored her review date. A third home visit

was made to terminate the care given and to hand her over to a registered community nurse in

their area for continuity of care.

Amendment of the Nursing Care Plan for Partially Met Goals

All the objectives set for Mrs. J. N’s problems were met except for acute pain related to the

surgical incision, which was partially met as the patient complained of mild pain. The care plan

was amended by increasing the duration set for outcome criteria, and new orders were given and

implemented. These were achieved before the patient was discharged.

Table 5: Amendment of the Nursing Care Plan Mrs. J. N.

Date N Nursing Objective Nursing Nirsing Date/ Evaluatio sign

/ Diagnosis s / orders Interventi Time n

Tim outcome ons

e criteria

28/08/202 Acute pain Patient [Link] Patient 31/08/202 Goal fully A.N

3 related to will be patient was 3 met as

2:00pm incision pain level pain that pain 2:00pm verbalized

within using the will that there

48hours as scale of 0- subside. is no more

evidenced 10. 2. Patient pain

by 3. Put pain was

1. Patient patient in asses

verbalizin comfortab using the

subside. position. 10.

2. Nurse 4. Use 3. Patient

observing diversiona was put in

that l therapy. dorsal

patient 5. Ensure position.

looks adequate 4. Patient

cheerful. bed rest. was asked

6. Serve to watch

prescribed television.

analgesics 5. Patient

for pain. was

served

with 1g

8hourly ×

48hours.

6.

Adequate
 bed rest

was

ensure as

the

environme

nt was

made

conducive
for

relaxing

by

ensuring

good

ventilation

Termination of Care

This is the last stage of the nurse-patient relationship. Mrs. J. N. and her relatives were told on

the day of admission that Mrs. J. N. would be discharged to go home after she had recovered.

Her family was informed that the therapeutic relationship with them would last for a specific

period of [Link] interaction with Mrs. J. N. and her family began on August 24, 2023, and

ended on September 10, 10/09/[Link] were given health education on intestinal obstruction
and other health problems identified during the home visit. Mrs. J. N. and her family were

reminded during my second home visit of the review date, and she was to report any adverse

effects of the medication given on discharge to the [Link] the third home visit, I handed

over Mrs. J. N. and her family to the community health nurse, and she promised to visit them for

continuity of care.

I thanked Mrs. J. N. and the family for their family cooperation in making my nursing care

a success. The family also expressed their gratitude for the care I rendered to Mrs. J. N. during

the visit, the health education, and the advice given to them. They promised to visit me one day.
Summary

The patient and family care study was written on Mrs. J. N, a 34-year-old woman who was

admitted to the female ward of the Kumasi South Hospital on August 24, 2023, with the

diagnosis of intestinal obstruction secondary to adhesions. Mrs. J. N. was discharged home on

August 31, 2023, with much improvement in her condition. She came for review on September

7, [Link] health problems were found, objectives were set, and the nursing care plan was

used as a guide in meeting the set objectives. Exploratory laparotomy and adhesiolysis were

done on August 25, 2023. Medical treatment was given, and her wound was healed by first

[Link] home visits were made: the first was done before the patient was discharged, and

the second was done once after she was discharged. This was to ensure continuity of care. Mrs. J.

N. and the family were informed of the termination of the care right from the day of admission.

My last home visit, which ended the therapeutic relationship, was on September 10, 2023, during

which I handed over Mrs. D.Y. and the family to a community health nurse to continue care.

Conclusion

The writing of this care study has been quite tough but interesting. It has been a challenge to me

and has taught me that one will never achieve in life unless they are committed. My commitment

to the writing of this care study has helped to enrich my knowledge as far as intestinal

obstruction is concerned. The care has broadened my knowledge of the care given to an

individual client. It has also taught me how to relate to a patient and his or her family to gain
their cooperation and [Link] has also broadened my scope of knowledge on the use of

the nursing care plan to deliver quality nursing care to a patient, and it has also given me the best

opportunity to care for a patient to full recovery and to practically manage such conditions in the

near future.

Appendix

Table 6: Observation Chart for Mrs. D.Y.

Time Temperature Pulse (bpm) Rhythm Respiration Blood

(mmHg)

12:00pm 36.2 80 Regular 18 130/80

12:15pm 36.0 81 Regular 18 130/80

12:30pm 36.5 81 Regular 19 120/80

12:45pm 36.7 87 Regular 18 120/80

1:00pm 36.9 87 Regular 18 120/80

1:30pm 36.9 88 Regular 18 130/80

2:00pm 36.7 88 Regular 19 120/80

3:00pm 36.8 91 Regular 18 120/80

4:00pm 36.9 91 Regular 18 130/80

8:00pm 36.9 89 Regular 18 120/80

BIBLIOGRAPHY
Beveridge, T.J., (2001). Use of the Gram Stain in Microbiology, Biotech

Histochema 76(3). 1118. PMID 11475313

Hinkle, J. L., & Cheever K.H., (July, 2014). Brunner and Suddarth’s Textbook of medical-

surgical nursing (13th Ed.). New York: J.B Lippinocott Company Juall, C.L.J., (2009). Nursing

Care Plan & Documentation: Nursing Diagnosis and Collaborative Problems. (5th Ed.).

Philadelphia: EdditonLippinocott Company.

Royal Pharmaceutical Society of Greatb Britain. (September, 2014). British National Formulary

(BNF). (67TH Ed.).London: British Medical Association.

Publish Limted

Patient’s Folder Number 002616/16

SIGNATORIES

NAME OF STUDENT ……………………………………………………………….

SIGNATURE……………………………………………………………………………

DATE…………………………………………………………………………………….

NAME OF CLINICAL SUPERVISOR……………………………………………….

SIGNATURE………………………………………………………………………

RANK………………………………………………………………………………..

DATE …………………………………………………………………………………

NAME OF SUPERVISING TUTOR……………………………………………….....

SIGNATURE…………………………………………………………………………

RANK…………………………………………………………………………………...

DATE………………………………………………………………………………
SIGNATURE OF PRINCIPAL………………………………………………………

DATE………………………………………………………………………