PATIENT/FAMILY-CENTERE CARE STUDY ON

A PATIENT WITH RIGHT NECK FEMUR FRACTURE

COMPILED BY

PRAISE IYANU EMMANUEL

A FINAL YEAR STUDENT OF WISCONSIN INTERNATIONAL UNIVERSITY

COLLEGE, GHANA

SUBMITTED TO NURSING AND MIDWIFERY COUNCIL OF GHANA IN PARTIAL

FULFILLMENT OF THE AWARD OF REGISTERED GENERAL NURSING LICENSE

37 MILITARY HOSPITAL, ACCRA

JANUARY, 2023
 PREFACE

The patient and family care study gives a thorough and in-depth written report of all the nursing activities

(care) that a student nurse provided to a specific patient and family while keeping their anonymity. The

patient and family care study thoroughly examines the nursing process' phases. The five interrelated steps

of the nursing process—assessment, diagnosis, planning, action, and evaluation—are explored to help

nurses recognize patients' problems and make plans to address them. It takes into account every element

influencing a person's health. It entails communication between the patient and the patient's family from

the moment of contact at admission until the patient is discharged, as well as follow-up visits. The student

nurse is in charge of overseeing, observing, and managing patients while using the nursing procedure

under the direction of senior nurses and in charge, the patient until he or she is discharged. Data

collection, information analysis, and nursing care evaluation all take into account the idea of holistic care.

The patient and family care study provides the student nurse with the chance to put their newly gained

nursing knowledge to use by caring for, observing, monitoring, and managing the patient's condition.

Additionally, it enables nurses to provide patients, families, and communities with goal-directed, client-

centered, and evidence-based care. The care study is completed in part to meet the criteria for the granting

of professional license by the nurses and midwives’ council of Ghana at the end of the 4 years training

program for the Registered General Nurses Certificate to be awarded to him/ her by the Nursing and

Midwifery Council of Ghana (NMC).

 ACKNOWLEDGEMENT

I would also like to thank Madam A. S and her family for her compliance and willingness to help me in

care study.

Secondly I would like to thank the ward officers of Easmon ward namely WO Joseph APPENTENG, Sir

Otchere for their advices, corrections, and assistance in my course of study.

Lastly, I would like to thank my lovely mother, very Rev Awe, siblings, Aunties and Uncles for their

support materially, emotionally, spiritually and encouraging me in times of need and help.
 INTRODUCTION

In January 2023, during the morning shift at 37 Military Hospital, Madam A.S. was wheeled from the

TSEU Ward into the Easmon ward at 1300 hours with a diagnosis of Right neck of femur fracture. I was

given the duty of admitting her to the ward. When I first spoke to Madam A.S. and her family, I identified

myself as a nursing student. As part of building my care study, which is a prerequisite of the course

requirement for the licencing examination as a student nurse, I guided them through the admissions

process and then informed them of my desire to care for them. I requested their consent to work by

describing the purpose of the care study with them I also gave them an explanation of how anonymity is

ensured and told them that, in order to protect their privacy, just initials of names will be used in place of

complete names. Madam A.S. accepted my suggestions, therefore the nursing procedure continued up

until the point at which care was terminated.

There are five chapters in this study on patient and family care.

The evaluation of the patient and family is the main topic of the first chapter. The analysis of data is

covered in the second chapter. Planning for family or patient care is the main topic of the third chapter.

The implementation of family or patient care is the subject of the following chapter, and the evaluation of

the patient's care is the subject of chapter five.

:
 CHAPTER ONE

1.0 Assessment of patient and family

The first of the nursing process's five phases is assessment. It is a methodical way of gathering

information about a patient's family, community, and client in order to determine what issues the

patient has. The information in this chapter was gathered during discussions with Madam A.S.

and her family throughout the nursing procedure' evaluation phase. It includes the patient's

personal information, the medical history of the patient's family, socioeconomic history,

developmental history, lifestyle, and interests, past medical and surgical history, current medical

history, patient admission, patient concept of illness, literature review on the patient's condition,

and data validation.

1.1 Patient's Particulars

Mrs. A.S. was born on January 10, 1958, in Boko, Ashanti Region. She is a nice and helpful 65-year-old

woman. Mrs. A.S. is 167 cm tall, has black eyes, a light complexion, and no physical disabilities. She

weighs 80 kg. Mrs. A.S is a widow and the mother of two kids. The parents of Mrs. A.S, Mr. M.S and

Mrs. H. M, were Muslims. Mrs. A. S. used to trade, but she stopped once her husband passed away. She

practises Islam and takes her kids and grandkids to the mosque every Friday. She resides at Sowutuom-

Lomnava Junction and speaks both Hausa and Twi fluently. Her children take care of her. Her closest kin

are her eldest daughter F.S .Madam A.S has no educational background .
1.2 Patient's Family Medical History

According to Madam A.S., she is unaware of any chronic diseases such as Sickle Cell Disease, Diabetes

Mellitus, Hypertension, Mental Illness, Heart Disease, Cancer, Hyperlipidaemia (high cholesterol),

Obesity, Allergies, Arthritis, and bleeding in either the nuclear or extended families. Madam A.S is

unaware of any communicable diseases such as tuberculosis or leprosy in either her nuclear or extended

family. She also mentioned that she and her family were rarely ill.

1.3 Patient's Socio - Economic History

Madam A.S. lives in a rented flat with other tenants with her second daughter, who is married
with three children. Madam A.S was a merchant who ceased working immediately after her
husband died. As a result, her children look after her. Madam A.S enjoys attending parties,
funerals, and naming ceremonies.

1.4 Patient's Developmental History

According to Madam A.S, her mother went through nine months of pregnancy before giving birth by

Spontaneous Vaginal Delivery with the aid of a Traditional Birth Attendant in the region of Boko. There

were no difficulties during or after the delivery. My client was immunised against paediatric killer

illnesses at birth and was vaccinated through periodic vaccination programmes. Madam A.S recalls her

mother informing her that she had been solely nursed for six months before being introduced to

supplemental feeding alongside nursing for two years. Madam A.S's mother informed her that she was

sitting at four months, crawling at six months, and walking at a year and a half. Madam A.S. recalls her

mother saying she had a smooth sail through the developmental stages without any serious complications.

However, Madam A.S has no educational background due to financial constraints. Hence, she learned

how to trade and sell by following her mother to the market. Thus, Madam A.S grew up to be a trader.

Madam A.S married in her early twenties and gave birth to two girls with three years age difference.
Madam A.S and her husband trained their children, one becoming a Nurse and the other a Teacher.

Madam A. S’s husband died five years ago. After, the death of Madam A. S’s husband, she stopped

trading and has since been cared for by her children.

1.5 Patient's Lifestyle And Hobbies

Madam A.S wakes up around 5am to perform ablution, prays and goes back to sleep then wakes up again
by 8am. She takes her breakfast prepared by her daughter and takes her bath around 9am and makes her
bed. She takes lunch around 12:30pm. Her daughter however, does the cooking herself and does not like
buying food from local vendors. closes from work around 2:00pm and starts preparing supper. Madam
A.S takes supper with her family around 5:30pm. She spends sometime watching television with her
grandchildren and children. She prays her five Islamic prayers daily, brushes her teeth with pepsodent
toothpaste, takes a warm bath with Geisha soap and goes to bed at 10:00pm.

On Fridays, she goes to Mosque with the family with public transport to pray in the afternoon and teaches

her grandchildren Qur’an and Islamic quotes during her leisure time. She reads the Qur’an and listens to

Islamic sermons by ALFA'S during the day. Though she does not discriminate against food, her favourite

food is Tuozafi and Ayoyo soup with Wagashi. She does not exercise often but stretches her body twice

daily. Madam A.S prefers to eat rice porridge and beans cake for breakfast, Ampesi and kontomire soup

for lunch and Tuozafi , Ayoyo and stew for dinner. Madam A.S empties her bowels twice daily ( morning

and evening) and urinates on an average of five times a day.

1.6 Patient's Past Medical / Surgical History

According to patient, she used to have minor ailments such as headache and Malaria when she was young

and was treated with over-the-counter medications, such as Paracetamol, and also used herbal leaves such

as Neem tree and bitter leaves to treat it. According to her, she underwent a first Caesarean Section when
she was about to deliver her first child. She also mentioned that, she underwent a second Caesarean

Section when she was about to deliver her second daughter. She has no cardiac or renal conditions.

Patient has no known allergies to food and any medications.

1.7 Patient's Present Medical History

According to Madam A.S, she slipped and fell on the floor on the 3rd of January, 2023 after taking her

bath while no one was home. She started feeling pains in her waist and hip side ever since. She informed

her daughter about the injury and her daughter started helping her mom by buying ointments to rub and

massage her thigh and waist to ease the pain. Her daughter also bought some pain killers with the intent

of helping with the pain. However, she still complained of having pains around her waist and hips, and

she started finding it difficult to walk and stand. On the 14th of January, Madam A. S’s daughter brought

Madam A.S to the 37 Military Hospital; Trauma Surgical Emergency Unit (TSEU) to be reviewed by Dr

B.A. Doctor B.A after examining Madam A.S requested for an X-ray for her pelvis and after viewing the

X-ray was diagnosed of Fracture of the Right Neck of femur and was then transed out to Easmon Ward

for further treatment and management.

1.8 Admission Of Patient

Madam A.S. was admitted to the Easmon ward of the 37 Military Hospital on 14 th January 2022 at

11:30am on the account of Right Neck of Femur Fracture. She was wheeled into the ward by a student

nurse accompanied by her daughter in a conscious and alert state. She was then admitted under the care of

Dr. B.A. They were received calmly into the ward, and I introduced myself and some other staff on duty

to them. She was admitted into an already made simple bed with the head of bed raised at 45-degree

Celsius. I called her name from her folder to confirm her identity which she responded in affirmation. I

then introduced myself as a nursing student from Wisconsin International University College, Accra-
Ghana, and asked for her consent in using her for my case study. I provided her with the details of the

case study and assured her that confidentiality of all information will be kept at its highest standard and

she consented to it. Her valuables were taken and arranged on the side locker by the bed side. I explained

clearly the ward protocols and visiting hours to her and her daughter. On admission, her vital signs were

recorded as Temperature: 36.6ºC, Pulse: 88bpm, Respiration: 20cpm, Blood pressure: 110/75mmHg,

Random bloodsugar:5.4mmol/L and oxygen saturation:100%. I oriented her to the ward , its environs and

informed her of the visiting days been 6:00am to 7:00am in the morning and 3:00pm to 4:00pm in the

afternoon. I made her comfortable in bed and reassured her that she is in competent hands and all will be

well. Madam A. S’s history was collected and documented in the nurses note and the Admission and

Discharge book as well as the Daily Ward State. All items required for admission such cups, cloth, brush,

sponge and others were provided. Vital signs sheet, Medication chart, Fluid Intake and Output charts

were also prepared for patient’s admission. Patient and family were briefed on the condition, risk factors,

signs and symptoms, complications and prevention. Madam A.S ’s condition on the ward is fairly ill. She

had difficulty in walking, general body weakness, waist and hip pain. Madam A.S is registered on

National Health Insurance Scheme(NHIS). On admission Madam A.S was prescribed the following

medications:

IV Paracetamol 1g 6hourly for 24 hours

IM Pethidine 50mg 6hrly 24hrs

IV Cefuroxime 750mg 8hrly 48hrs

IV Clindamycin 300mg 8hrly 5/7

IV Ciprofloxacin 400mg 12hry 5/7

IVF 0.9% Normal saline 2 liters 24 hours

Tab Diclofenac 75mg BD hours 26/7

Tab Zincovite 1 daily

Cap Feroglobin 1 12hourly 6/7

Tab Rivaroxaban 10mg daily 14

The following laboratory investigations were done before admitting into surgical ward;

Full Blood Count

X-Ray of the pelvis

Blood Urea Electrolyte and Creatinine

Chest x-ray

1.9 Patient's Concept Of Illness

Madam A.S believes that the illness is because of her fall and her old age which makes her weak and slow

when walking nowadays. With her hope in God and the trust she had in the healthcare team, she was very

optimistic that she would regain her health.

1.10 Literature Review

1.10 Introduction To Fractures

A Fracture is a break in the continuity of a bone. A signifant percentage of bone fractures occur because

of high force impact or stress. ( Lauren et.al 2021)

Types Of Fracture

 Avulsion fracture : A muscle or ligament pulls on the bone fracturing it .

 Communited fracture : An impact shatters the bone into many pieces.

 Fracture dislocation : This occurs whne a joint dislocates, and one of the bones of the

joint fractures.

 Greenstick fracture: The bone partly fractures on one side but does not break completely ,

becuase the rest of the bone can bend .

 Pathological fracture : This occurs when an underlying condition weakens the bone and

causes a fracture.

 Spiral fracture: Here, at least one part of the bone twists during a break .

 Longitudinal Fracture : This is when the fracture extends into the surface of a joint .

 Intra-articular fracture: This occurss when a fracture extends into the surface of a joint.

 Compression , or crush, fracture : This generally occurs in the spongy bone in the spine.

( Lauren Catiello, Ms AGNP-C-By yvette Brazier August 2021

Femure Fracture

Defintions

Femoral neck fractures are a commonly encountered injury in orthopedic practice and result in

significant morbidity and mortality. It is essential that surgeons. (references) Femoral neck fractures are a

specific type of intrascapular hip fracture. The femoral neck connects the femoral shaft with the femoral

head. The hip joint is the articulation of the femoral head with the acetabulum. The junctional locations

make the femoral neck prone to fracture. The blood supply of the femoral head is an essential

consideration in displaced fractures as it runs along the femoral neck. (Kazley & Bagchi, 2022)

Classification Of Femur Fracture

Fracture of the hip can generally be subdivided into intracapsular and extracapsular.

Where extracapsular, the blood supply to the femoral head usually remains intact. This provides

an opportunity to preserve the femoral head using a surgical procedure to fix the fracture,

commonly using a dynamic hip screw, intramedullary device, or cannulated screws.

Where a fracture is intracapsular, the blood supply to the femoral head may be damaged. In the

event of an intracapsular displaced fragility fracture, the native femoral head is likely to progress

to malunion or avascular necrosis, necessitating a procedure. For those who meet these criteria,

the recommended procedure of choice is misanthropy of the hip. (Roberts et al., 2015)
Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral

neck fracture characterization that help dictate appropriate treatment.

The Garden Classification

 Type I : Incomplete fracture - valgus impacted - non displaced.

 Type II: Complete fracture - nondisplaced

 Type III: Complete fracture - partial displaced

 Type IV - Complete fracture -fully displaced

 The Garden classification is the most used system used II: to communicate the type of

fracture. For treatment, it is often simplified into nondisplaced (Type 1 and Type 2)

versus displaced (Type 3 and Type 4)

Pauwel Classification

The Pauwel classification also includes the inclination angle of the fracture line relative to the horizontal.

Higher angles and more vertical fractures exhibit greater instability due to higher shear force. These

fractures also have a higher risk of osteonecrosis postoperatively.

 Type I: less than 30 degrees

 Types II: 30 to 50 degrees

 Type III: greater than 50 degrees.

Incidence

Hip fractures in the elderly represents a major public concern. These accounts for a quarter of all fractures

in patients aged 75 years and over. The majority of proximal femur fractures ( PFFs) affects the elderly as
more than three quaters of PFFs occur in patients over the age of 75 in Germany. ( Fischer et al, 2021) .

With a global incidence of 1.7 million hip fractures in 1990, this is targeted to reach 6.3 million in 2050.

(Holroyd et al., 2008) Seventy percent of all hip fractures occur in women. Hip fracture risk increases

exponentially with age and is more common in white females. (Kazley & Bagchi, 2022)

Etiology

Femoral neck fractures are associated with low energy falls in the elderly. In younger patients sustaining a

femoral neck fracture, the cause is usually secondary to high -energy trauma such as a substantial height

or motor vehicle accidents. (Kazley & Bagchi, 2022)

Predisposing Factors

1.Age (elderly population)

2.Pathological factors

3. Female gender

4. BMI (Body mass index)

5. Thigh diameter

6.Average thigh circumference

7. BMD (low Bone mineral density)

8. Decreased mobility

Pathophysiology
The chief source of vascular supply to the femoral head is the medial femoral circumflex artery, which

runs under the quadratus femoris. Displaced fractures of the femoral neck put the blood supply at risk,
usually tearing the ascending cervical branches that stem off the arterial ring supply formed by the

circumflex arteries. This, comprise the healing ability of the fracture, inevitably causing non-union or

osteonecrosis. This is most important when considering the younger population that sustains this fracture,

for which arthroplasty would be inappropriate. In patients treated via open reduction internal fixation,

avascular necrosis is the most common complication. (Kazley & Bagchi, 2022)

Clinical Manifestation

1. Hip pain

2. Swelling

3. Bruising

4. Discolored skin around the affected area

5. Inability to move the affected area

6. Protusion of affected area at an unusual angle.

7. Constipation

8. Inabilty to put weight on the injured area.

9. A grating sensation in the affected bone or joint.

 Diagnostic Investigations

1.Physical examination of the leg

2.Pelvic and leg x-ray is done to assess the anatomical structure of the leg by showing a

dense shadow at the affected part.

3.Laboratory investigations ( Blood urea electrolyte and creatinine, full blood count)
 4. Ultrasound scan

5. Computed tomography scan helps better classify the fracture pattern or delineate a

subtle fracture line.

6. Magnetic Resonance Imaging is used to evaluate for femoral neck stress fractures.

7. Past medical and surgical history of patient.

Specific Medical and Surgical management.

Medical Management

Medically, Right neck of the femur fracture is managed with; antibiotics such as Cefuroxime,

Clindamycin, Analgesics such as Paracetamol, Non-steroidal Anti-inflammatory Drugs (NSAIDs) ,

intravenous fluids like Normal Saline and Anticoagulants .

Surgical Management

Femoral fractures can be treated using the principles of biological osteosynthesis or by anatomic

reduction and stabilization. The surgical approach will vary, depending on the technique selected.

1. Pin and wire - Pins and wire fixation is effective for stabilization of long oblique and

spiral fractures of the femoral shaft. Intramedullary pins can be placed either retrograde

or nemograde.

2. Situ fixation

3. Closed or open reduction

 4. Internal fixation

5. Hemiarthroplasty

6. Total hip arthroplasty

7. Bipolar prosthetics

Nursing Management

The nursing management involves three phases. They are the preoperative phase, intraoperative phase,
and postoperative phase.

Preoperative Phase

This involves psychological, physical, physiological, socio-economic and spiritual preparation of the
patient before the surgery. This is done to ensure a safe surgery, promote speedy recovery, and to prevent
any postoperative complication.

Psychological Care

1. Inform patient about the consent form and its importance and ensure that patient signs it.

2. Establish rapport with patient and family. This is done by introducing yourself and
giving patient a warm reception followed by exchanges of greetings and preliminary
conversations.

3. Explain the procedure to the patient and her daughter, this helps to allay fear and
anxiety. This also enables the patient to sign the consent form to enable the surgery to
be performed.

4. Allow patient and family to ask questions and answer them clearly
 Introduce patient and family to other patients who have successfully undergone similar operation
and are doing well if available.

5. If possible, make sure patient sees the doctor who will perform the surgery on the patient to
relieve any feeling of incompetence in the staff

6. If possible, take patient to the theatre room where the surgery will be done and
explain the functions of the gadgets and equipment there to assure the patient that,
his/her life sustenance is the topmost priority.

7. Patients per their religious affiliations may require that they see their pastor, imam,
family head before surgery is performed. The nurse ensures that this is done.

Physiological Care

1.Ensure all necessary laboratory investigations like blood test, grouping and cross
matching are done and results have been received.

2. Ensure patient restricts oral fluids and food intake at least 6 to 8 hours before
surgery.

3. Check baseline vital signs including temperature, pulse, respiration, blood pressure
and oxygen saturation level.

4. Assist the doctor to pass urethral catheter and monitor fluid intake and output.

The patient must be well hydrated with intravenous fluids requested to be administered.

5. Serve prescribed preoperative medications as ordered.

Physical Care

1. Bath the patient

2.Shave the Patient's thigh and hip area and clean with antiseptic solution.
 3.Any artificial dentures, jewellery, prosthesis, wigs and hairpins should be removed
to prevent any infections and interference during surgery.

4. A name tag is placed on patient wrist bearing the name, age, diagnosis, sex and
ward.

5. All items needed for surgery such as medication and intravenous fluids, dressing
materials must be ready

6. Remove patient's clothing and assist patient to put on theatre gown and send patient
to theatre in either a stretcher or bed.

Intraoperative Phase

1. Maintain a normal temperature of the environment of patient.

2. Every theatre team should apply universal precautions before and in the theatre
room.
3. Prescribed blood transfusion was administered.
4. Close monitoring and observation of patient and her vital signs.

Immediate Postoperative Care

1. A postoperative bed is prepared to receive patient with bed accessories such as drip
stand and post-anaesthetic tray.

2. Patient is received and made comfortable in bed in the supine position with no
pillow.

3. Patient's affected leg was placed flat on the bed.

4. Level of consciousness is assessed.

5. Incisional site is observed for possible bleeding and discharge. If present, reinforce
dressing and report to surgeon.
 6. Monitor patient’s vital signs including temperature, pulse, respiration, blood
pressure and oxygen saturation level every 15minutes for the first hour, 30minutes for
the next hour and then hourly until condition is stable.

7. Administer prescribed analgesics and postoperative medications as ordered that is

IV Paracetamol, IM Pethidine

8. Administer prescribed fluids as ordered to prevent dehydration or over hydration.

9. Administer prescribed antibiotics as prophylaxis to prevent the wound from getting

infected.

10. Maintain fluid intake and output chart to monitor fluid volumes.

Subsequent Postoperative Phase

Observation

1. Assess patient’s level of consciousness using the Glascow Coma Scale.

2. Observe the incision site for bleeding or discharges. Reinforce dressing if there is
bleeding from the incision site. Inform surgeon if bleeding persist.
3. Ensure all intravenous infusions are flowing freely and prescribed medications
have been served.
4. Check vital signs for every 15 minutes for the first 30 minutes, 30 minutes for the
next 1 hour then, hourly for the next 4 hours and 4 hourlies until patient is fully
recovered.
5. Observe for signs of dehydration while monitoring fluid intake and output 4
hourly.

Wound Care

1. Check the dressing regularly for bleeding and discharges every 2 to 4 hours during
the first 24 hours after surgery and report immediately.

2. Dress wound using aseptic techniques and use sterile instruments. Decontaminate
all used instruments to be sent for sterilization.
 3. Clean the incisional area with methylated spirit with sterile gauze from inside out
to prevent infection and pad it with a sterile gauze dipped in povidone iodine solution
and secure together with an adhesive tape.

4. Prescribed antibiotics should be administered to prevent infection.

Pain Relief

1. Patient should be position in a supine position with head tilted to one side after the
surgery.

2. When patient becomes fully conscious, encourage patient to restrict movements as

much as possible to ease with pain.

3. Patient should be reminded of deep breathing exercises to relive her of pain.

4. Administer prescribed analgesics to relief patient of pain such as IM Pethidine and

IV Paracetamol

Elimination

1. Ensure that patient voids 24 hours after surgery. If patient is on catheter, monitor
the volume of urine output and record appropriately.
2. Strictly monitor the intravenous fluids and drainage from the incisional site.

Exercise

1.Encourage deep breathing and coughing exercises to promote optimal lung

function.

2. Encourage patient's relative to listen to physiotherapists instructions on when

movement should and how to start moving.

Rest And Sleep

1. Provide a well laid and clean bed, free from creases, to promote good sleep.

2. Provide a quiet and well-ventilated environment for patient

3. The patient should be given complete bed rest and made comfortable in bed.
 4. Activities should be organized in order not to interfere with sleeping time.

5. Limit the number of visitations from nurses and relatives when patient is sleeping
to promote sleep.

Nutrition

1. Ensure that patient maintains nil per os but is placed on IV fluids after surgery until
bowel sounds return.

2. Patient may begin with taking sips, then to light diets, then to normal diets when
bowel sound returns

3. When the patient begins normal diets, encourage intake of fruits and vegetables,
and foods rich in fibre to prevent constipation and straining.

4. Encourage patient to take in copious fluids and emphasize restriction on dry foods
such as bread in order to prevent constipation and straining.

5. Encourage patient to avoid spicy and oily foods.

Personal Hygiene

1. Assist patient with personal hygiene when necessary, such as bathing, mouth care
and care of hair and nails and serve a bed pan when necessary.

2. Ensure the patient washes her hands beofre and after eating every meal.

3. Ensure patient washes her hands before and after using the wash room.

4. Frequently remove the patient's dirty linen , wash and sterilize before laying clean
linen on the patient's bed to ease comfort and promote personal hygiene.

5. Encourage patient to maintain oral hygiene twice daily using toothpaste and tooth
brush.

6. Encourage patient to eat meals in clean utensils and cover utensils when they are
not in use.
 7.Teach patient proper hamd washing technique.

8. Assist or bath patient twice daily with soap and water and change dirty linens
frequently .

Patient Education

1.Assess patient’s knowledge on the present condition and the just ended surgical
operation.

2. Add up to what patient knows and teach patient about causes, signs and symptoms,
treatment and managements, prevention and complications.

3. Educate the patient on the need for early ambulation from bed to prevent deep vein
thrombosis. However, patient was informed by the doctor to maintain complete bed
rest until three days after review with the physiotherapists who will help her starting
moving little by little.

3. Encourage patient to take in more fluids and foods rich in fibre to enhance
immunity bowel movement.

4. Encourage patient to report possible post-operative complications or drug reactions

if noticed.

5. Advice patient to report to any health professional around when she notices signs
like bleeding, discharge or pain at the incision site.

6. Emphasize the need for good personal hygiene and caution against vigorous wiping
and scratching of the incisional site to prevent infection to the patient and patient's
relative. Patient was

7. Advice patient to reduce too much physical activity and avoid lifting heavy objects
to prevent gaping of the incision site.
 8. Advice patient to take all her due medications to improve quick recovery. Teach
patient how to administer each medication after discharge. Encourage patient on the
benefits of taking drugs.

9. Encourage patient and family to adhere to treatment and follow up visit to nearby
hospital.

Complications Of Femur Fracture

Complications include pin migration, sciatic nerve entrapment, infection, nonunion, delayed union,

dislocation increased with total hip arthroplasty surgery, implant failure, quadriceps tie- down, and

premature physeal closure leading to limb shortening or angualr deformity. Most of these complications

can be avoided by good surgical surgical planning, appropriate implant selection, good surgical technique

and proper postoperative management.

1.11 Validation Of Data

The data collected from Madam A.S, and her family the signs and symptoms she exhibited as well as

those gathered by the doctors, nurses, laboratory investigations and physical assessment were in

accordance with known clinical features as indicated in most textbooks. All these were done to ensure

that information collected was free from errors and misinterpretations.


 CHAPTER TWO

ANALYSIS OF DATA

2.0 INTRODUCTION

This phase of the patient/family care study entails comparison of data with standard to

confirm or identify actual or potential health problems. The client and family strengths

are also identified to lead the nurse to a specific nursing diagnosis which provides the

nurse with the opportunity to identify relevant information on the treatment of patient and

helps to render appropriate nursing care and helps to render appropriate nursing care and

interventions. This chapter will consider the following heading.

 Comparison of patient’s data with standards

 Identification of patient and family’s strengths

 Patient’s health problems

 Nursing diagnosis

2.1 Comparison Of Patient's Data With Standards

Data collected from the various diagnostic investigations, causes, clinical manifestations, treatment and

complications of the condition will be compared to standards in literature and observed for similarities or

differences.

2.1 Diagnostic Investigations

These are tests and investigations that are carried out in order to give accurate diagnosis to the presenting
signs and symptoms of the patient. The following are the investigations carried out on the patient:

1. Physical examination
2. Full blood count
3. Blood urea Electrolyte and Creatinine
4. CHest X-ray
5. X-ray of the pelvis.
 Table 2.1

DATE SPECIMEN INVESTIGATION RESULTS OF NORMAL INTERPRETATIONS TREATMENT

INVESTIGATIO
VALUE
N

14/01/2023 Blood Hemoglobin level HB: 12.2 g/dl Female: 12.0-16g/dL It was normal No treatment was given.

Male; 13.5-18g/dL indicating the absence of anemia.

14 Blood White blood cell 8.7 x 10g/dl 4.5-10x10g/dl It was within the normal range No treatment was given.
/01/2023 indicating the absence of an
count
infection.

14/01/2023 Blood Malaria parasites Negative There should be no Patient was not having malaria No treatment was given.
malaria parasite in
the blood.

14/01/2023 blood Hematocrit 39 36-44 It was in normal range meaning No treatment was given.
there is the abscence of anaemia .
14/01/2023 Blood Blood urea and Sodium - 135-145 mmol/L It was within the normal range No treatment was given
electrolyte 137mmol/L indicating that the patient had a
normal level of sodium in her
blood.

Continuation of Table 2:1

DATE SPECIMEN INVESTIGATION RESULTS OF NORMAL VALUE INTERPRETATIONS TREATMENT

INVESTIGATIONS

14/01/2023 Blood Blood Urea Chloride 95-110 Chloride level was within the normal No treatment was

Electrolyte 99mmol/L range. given

14/01/2023 Blood Blood Urea Urea- 2.1-7.1mmolL Creatinine level was within the normal No treatment was

Electrolyte 4.89 mmol/L range. given

14/01/2023 Blood Potassium 3.5-5.5 Potassium level was within the normal No treatment was

3.8 mmol/L range. given

14/01/2023 Blood RBC 3.26 3.8- 6.5 It was below the normal level hence No treatment was

multi vitamin and minerals were given

prescribed for the patient.

Body (leg) X-RAY AN X-ray of the leg A normal X-ray of The X-ray of the neck displaced a Patient underwent
14/01/2023 displaced a fracture the leg should not fracture of the neck of the femur which a surgical

of the neck of the show break in the is not normal. procedure called

right femur. continuity in th bone. Bipolar

DATE SPECIMEN INVESTIGATION RESULTS OF NORMAL VALUE INTERPRETATIONS REMARKS

INVESTIGATIONS

14/01/2023 Body(chest) X-ray X-ray of the chest In a normal chest x- The result of the X-ray of the chest was No treatment was

showed that the chest ray , the chest cavity is normal. given .

cavity is outlined on outlined on each side

each side by the white by the white bony

bony structures that structures that represent

represent the ribs of the the ribs of the chest

chest wall. wall.

14/01/2023 Body( Pelvis) CT-Scan CT-Scan of the pelvis A normal CT Scan of The result of the CT -Scan should fracture Patient underwent a

displaced a fractue of the pelvis should not of the neck of femur. bipolar prothetis

the right neck of femur show breaks, tumours, surgery.

fracture. and appendicitis.

Statement Of comparison
Table 2.1 shows that most of the diagnostic investigations which should be carried out according to literature review was carried out on Madam A.S ,
to be precise, about 90% of the diagnostic investigations were requested which helps diagnose the patient of the condition.
Table 2.2 Comparison of Madam A.S.’s Diagnostic investigations to Literature Review

Diagnostic investigations according to Literature Diagnosis Investigations ordered for the patient by
Review the doctor
X- Ray of the pelvis and femur It was requested for the patient

Computed Tomography Scan it was requested for the patient

Magnetic Resonance Investigations It was not requested for the patient

Blood urea electrolyte It was requested for the patient

Full blood count it was requestd for the patient

Creatinine It was requested for the patient.

Ultrasound It was not requested for the patient.

B. Causes Of Patient's condition

With reference to the causes of femoral fracture in Madam A.S's literature review, Madam A.S 'S condition was caused by low energy falls .

.
C. Clinical Features

Table 2.3 Comparison of Clinical Manifestations.

NO. CLINICAL FEATURES IN THE FEATURES EXHIBITED

BY CLIENT
LITERATURE

1. Hip pain Patient compained of pain at the right hip.

2. Swelling Patient had a swell at her right hip region.

3. Bruising Patient had a bruise at her right hip region.

4. Discolored skin around the affected area Patient had a discoured skin around her right hip

region

5. Protusion of the affected area Patient did not have a protusion of the right hip

region

6. Inability to put weight on the affected area Patient was not able to put weight at the right hip

region.

7. Inability to move the affected area Patient found it difficult to move her her right hip

and thigh

8. A grating sensation in the affected bone or Patient did not have a grating sensation in the

joint. affected bone or joint.

9. Constipation Patient had constipation.

Statement Of Comparison

Table 2.3 shows that patient exhibited about 78% of the clinical manifestations that was used in diagnosing Madam of the fracture, to be precise,

Madam A.S , exhibited about of the clinical featutres.

d. Specific Medical Treatment

The following drugs were prescribed and administered to Madam A.S to provide relief to her condition.

1.IV Paracetamol 1g 6hourly ×24hrs

2. IM Pethidine 50mg 6hrly × 24hrs

3. IV Cefuroxime 750mg 8hrly × 48hrs

4. IV Clindamycin 300mg 8hrly × 5/7

5. IV Ciprofloxacin 400mg 12hrly ×5/7

6. IVF 0.9% Normal saline 2 liters × 24 hours

7. Tab Diclofenac 75mg BD hours ×6/7

8. Tab Zincovite 1 ×daily

9. Cap Feroglobin 1 12hourly ×6/7

10. Tab Rivaroxaban 10mg daily ×14

Table 2.5: Comparison of Madam A.S's treatment to literature

Treatment of Fracture according to Literature Madam A.S's treatment in the hospital

Analgestics Analgestics was prescribed for the patient i.e IV

Paracetamol

Antibiotics Antibiotics was prescribed for the patient i.e

Clindamycin and Cefuroxime.

Intravenous fluids Intravenous Infusion was prescribed for the

patient to be precise IV Nomal Saline.

Anti-Coagulant medication Anti -coagualant was prescribed for the patien to

be precise, Tab Rivaroxa

Multi-vitamins and Supplements Multi-Vitamins was prescribed for the patient to

be precise Tab Zincovit, Vitamin C

NSAIDS NSAIDS was prescribed for the patient to be

precise Tab Diclofenac

TABLE 2.6 PHARMACOLOGY OF DRUGS

DATE DRUGS STANDARD PRESCRIBED CLASSIFI DESIRED ACTUAL SIDE EFFECTS /
DOSAGE/ ROUTE DOSAGE CATION EFFECTS / ACTION REMEDIES
OF /ROUTE OF MECHANISM OF OBSERVED
ADMINISTRATIO ADMINISTRATI ACTION
N ON
14th IV 1g Non-opoid Blocks pain generation Patient"s pain Hepato-toxicity, nauseas,
Paracetam 500mg-1g bd for 24 hours Analgesics impulse to relieve pain was relieved Anorexia, diarhoea,
January, ol Route : Intravenous intravenously by inhibiting vomiting, constipation, rash,
prostaglandin anaemia. None was
2023 synthesis. observed.

15th IV 750mg 8hrly *48hrs It acts as a bactericidal Patient was Back, leg or stomach pains,
Cefuroxim Intravenously Cephalospo agent by inhibiting the free from bladder pains , Vomiting,
January e 750mg-1.5g rin bacterial cell wall infection abdominal pain and hepatic
(Antibiotic) synthesis. through out dysfunction. None was
,2023 Route: Intravenous hospitalization. observed.,

15th IM 50 mg /ml in 1ml Opoid It acts as a weak Patient was Dizziness , Sweating,
Pethidine 50mg-100mg Intravenously agonist of opoid sedated and Hallucianations,
January, Route : Intravenous 6hourly for 24 receptors, which relieved from Constipation, Nauseas and
hours. creates sedation and pain. vomiting. None of these
2023 analgesia. were observed.

15 th IV It acts by slowing or Patient was Nausea, Vomiting, joint

January, Clindamyc 300mg 8hrly *5/7 Lincomyci stopping the growth of free from pain, heartburn , white
2023 in 300mg-600mg Intravenously n bacteria. infection patches in the mouth. None
Route: Intravenous (Antibiotic) throughout of these were observed in
hospitalization. the patient.
15th IV 200mg-400mg 400mg 12hrly *5/7 Quinolone It works by killing Patient was Diarrhoea, bad taste ,
January, Ciprofloxa Route:Intravenous Intravenously (Antibiotic) bacteria or preventing free free from Nausea, redness or
2023 cin their growth. infection. discomfort in the eye. None
of these were observed in
the patient.

DATE: DRUGS STANDARD PRESCRIBED CLASSIFI DESIRED EFFECTS ACTUAL SIDE EFFECTS /
DOSAGE / DOSAGE / CATION / MECHANISM OF ACTION REMEDIES
 ROUTE OF ROUTE OF ACTION OBSERVED
ADMINISTRATIO ADMINISTRATI
N ON
15th Vitamin C 75mg for women Water It provides protection Patient's Nausea,vomiting,
January, Route : Oral soluble against oxidative immune system headaches,. None of these
2023 Orally vitamin stress-induced cellular was were observed in the
damage. strengthened patient.
15th 0.9 Nomal Crystalloid It replaces lost fluid Patient's lost Swelliing of hands, ankles
January, Saline 0.4% -0.9% 2 liters for 24 hours fluid and electrolyte in the fluids and and feet, extreme
2023 Route: Intravenous body. electrolytes drowsiness, seizures, mood
Intravenously were restored. changes. none of these were
observed in the patient.
16th Tab 75mg-150mg Nonsteroid It inhibits prostagladin Patient's pain Headaches, Nausea.
January, Diclofenac 125mg 75mg *6/7 al anti- synthesis by inhibitio and Stomach ache, Mild rash,
2023 Route: Orally inflammato of inflammatio n Anorexia. None of these
Orally ry drug cyclooxygenase(COX) was treated. were observed in the
(NSAID). patient.
16th Tab Anticoagua It binds directly to Patient was Back pain, muscle
January, Rivaroxab 10mgDaily * 14 lnt: Factor factor Xa , effectively free from clots weakness, tiredness,
2023 an Orally Xa blocks the amplication in the blood. shortness of breath, feeling
Orally Inhibitors. of the coagulation dizzy. None of these were
cascade, preventing the observed in the patient.
formation of thrombus.
16th Tab 1 daily *3/7 Multivitam It is used to treat and Patient was Allergic reaction,
January, Zincovite -200mg after meals ins with prevent vitamin and supplied with sleeplessness,bitter taste in
2023 minerals. mineral deficiency by essential the mouth. None of these
Orally Orally supporting the body micronutrients side effects were observed
with essential and minerals. in the patient.
micronutrients.
DATE DRUGS STANDARD PRESCRIBED CLASSIFI DESIRED ACTUAL SIDE EFFECTS/
DOSAGE / DOSAGE / CATION EFFECTS ACTION REMEDIES
ROUTE OF ROUTE OF /MECHANISM OF OBSERVE
ADMINISTRAT ADMINISTRATIO ACTION D
ION N
16th Cap Multi- It is designed with a Patient was Headache , Nausea,
January Feroglobin 1 tab twice daily vitamins special slow release free from Vomoting, Metallic taste,
,2023 *6/7 with delivery system to excess iron Upset stomach, Loss of
Orally minerals. prevent excess iron in in the appetite. None of these
Orally the stomach. stomach. side effects were observed
in the patient.
2. Specific surgical treatment

Madam A.S had a bipolar prosthetic surgery performed on her.

e. Complications.

With reference to the complications of the Fracture of femur stated in Madam A.S 's literature
review, which includes pin migration, sciatic nerve entrapment, infection, nonunion, delayed
union, dislocation increased with total hip arthroplasty surgery, implant failure, quadriceps tie-
down, and premature physeal closure leading to limb shortening or angular deformity and many
more. Madam A.S showed no signs and symptoms of such complications before, during and
after medical and surgical treatment. This is due to the holistic treatment and management
offered to Madam A.S during and a and after medical and surgical treatment. This is due to the
holistic treatment and management offered to Madam A.S during and after her hospital.

2. Patient's Health Problems

Patient’s health problems are the challenges that put the patient's health in jeopardy and delay her

recovery which demands effective nursing interventions to manage it. Upon thorough assessment

and observation of my patient, the following health problems were discovered and intervened.

The health problems identified were :

Preoperative problems

1. Patient complained of pain at the hip and thigh area. ( 14th January,2023 at 12:00pm )

2. Patient found it difficult to walk. ( 14th January, 2023 at 1:00pm )

3. Patient was worried about whether she will be able to walk again. ( 14th January,2023

1:30pm)

4. Patient complained of dificulty to pass stool ( 14th January, 2023 ,4:00pm)

5. Patient had swollen hip ( 14th January ,2023 6:00pm )

6. Patient has no knowledge about the health condition.( 14th January, 2023 6:00 pm)

Post operative problems

1. Patient experienced pain at the surgical site. ( 15th January, 2023 4:00pm)

2. Patient has a wound at the surgical site ( 15th January, 2023 4:30 pm)

3. Patient could not bath herself (16th January, 2023 6:30 am)

4. Patient complained of interrupted sleep. (16th January, 2023 6:30 am)

5 Patient could not move out of the bed after the surgery. ( 16th January, 2023 2:00pm)

6. Patient was worried about how she will be able to pay her bills. (20th January, 2023 1:00pm )

add problem 1,2 and 5 preoperative to chap4 and 6 preoperatively . Add time to 3 and 4.

Add time to 6 in chap 4.

2. Patient /Family Strengths

Patient strengths are the patient’s abilities that can help her cope with the stress and help in

patient’s recovery. These include healthy physiological functioning, emotional stability, and

cognitive coping skills, presence of supportive family, adequate financial support and healthy

environment. During the analysis, the following strengths were identified on Madam A.S .

Preoperative Strengths

1. Patient could verbalise the location and severity of the pain using the numerical pain scale (0-

10, where 0 means no pain, 1-3 means mild pain, 4-7 means moderate pain and 8- 10 meaning

severe pain.) Patient's pain when assessed was 8 over ten.

2. Patient could move with the assistance of the nurse.

3. Patient is willing to talk to the doctor about the possibility of her walking again.

4. Patient could tolerate intravenous fluids.

5. Patient was willing and ready to engage in passive exercise.

6. Patient is willing to be educated about the disease condition.

Post operative Strengths

1. Patient has prescribed analgestics and Opoid to help her with the pain.

2.Patient could tolerate wound dressing to prevent infection.

3. Patient could be given assisted bed bath.

4. Patient was willing to learn more about the condition

5. Patient could move with assistance.

6. Patient was happy about the support system from the hospital about payment of bills.

2. Nursing Diagnosis

Nursing diagnosis is a standardized statement about the health of a patient (who can be an

individual , family or a community) for the purpose of providing nursing care. Nursing diagnosis

is a clinical judgement concerning a human response to health conditions, life processes,

vulnerability for that response to health conditions by an individual ,family, group, or

community( NANDA International, 2013).From the health problems identified during analysis

on Madam A.S, the following nursing diagnosis were made.

Pre operative Nursing Diagnosis

1. Acute pain related to pressure on the femoral nerve.

2. Impaired walking related to break in the bone continuity ( fracture of the neck of the right

femur.)

3. Anxiety related concerns about ability to walk again

4. Constipation related to Opoid use .

5.Risk for peripheral neurovascular dysfunction related to interruption of blood flow.

6. Deficient knowledge related to lack of information on disease condition( Fracture of the neck

of femur)

Post operative Nursing Diagnosis

1. Chronic pain related to tension from the suture line in the patient's wound.

2. Risk for surgical site infection related to incisional wound on the right leg.

3. Bathing self-care deficit related to inability of patient to move after the surgical procedure.

4. Disturbed sleep pattern related to prolonged position in bed.

5. Anxiety related to inability to pay her bills.

6. Impaired physical mobidity related to bed confinement.

 CHAPTER THREE

3.0 PLANNING FOR PATIENT AND FAMILY CARE

INTRODUCTION

Planning is the third phase of the nursing process. It initiates nursing management by

formulating specific goals and interventions to meet patient's problems. The patient's care plan is

written based on the data collected which is translated into nursing diagnosis. It is where goals

and objectives are set with outcome criteria . The nursing care plan facilitates achievemnts of the

client goal. It communicates clearly the nature of the client's problems and specifies the nursing

and medical intervention necessary for the client.

3.1 OBJECTIVES AND OUTCOME CRITERIA

Short term goals

Short term goals are goals which are met or set within 72 hours i.e 3 days . The following are

short term goals.

1. Patient will experience relief of pain within 40 minutes of hospitalization evidenced by:

a. Patient verbalising that she is not feeling pains any more.

b. Nurse observing that the patient is relaxed in bed.

2. Patient will be able to have a normal bowel movement within 24 hours as evidenced:
a. Patient verbalising understanding of methods to maintain normal bowel elimination.

b. Nurse observing and assessing the patient's stool to be soft and no longer hard.

3. Patient will maintain tissue perfusion within 24 hours as evidenced by:

a. Patient having palpable pulses.

b. Nurse observing the patient having stable vital signs.

4. Patient's incisional site pain will subside within 24 hours as evidenced by :

a. Patient verbalizing relief of the pain

b. Nurse observing the patient's facial expressions and noting no signs of pain.

5. Patient will have a normal sleeping pattern by the end of 48 hours as evidenced by:

a. Patient verbalising uninterrupted sleep for 6 hours to 8 hours in the evening.

b. Nurse observing patient's sleep pattern and noticing a normal sleep pattern.

6. Patient will attain adequate knowledge about her condition within 24 hours evidenced by :

a. The nurse observing the patient's ability to answer questions and make contributions

concerning her condition.

b. The patient verbalising that she now understands her disease condition.

Long-term goals
7. Patient will regain strength to walk within 3 days of hospitalization as evidenced by:

a. Patient verbalising been able to walk around the bed side with the help of Zimmer Frame.

b. Nurse observing patient walking out of bed with the help of Zimmer Frame .

8. Patient will be relieved from her anxiety state within 5 days evidenced by :

a. Patient verbalising been able to interact with other patients in the ward.

b.Nurse observing patient watching Tv, smiling and happy.

9. Patient will be free from infections throughout hospitalization as evidenced by :

a.. Patient observing no discharge from the incisional site.

b. Nurse observing that , incisional site is clean and free from pus.

10. Patient will perform bathing self -care activities within 3 days with little assistace as

evidenced by:

a. Patient's willingness to participate in activites of daily living.

b. Nurse observes client take part in self- care

11. Patient will regain mobility at the highest possible level within 3 days as evidenced by

a. Patient demonstrating techniques that enable resumption of activities.

b. Nurse observing patient showing increase strength or function of affected body part.
12 . Patient will be relieved from her anxiety state throughout hospitalization evidenced by:

a. Patient verbalising feeling better about herself and her situation

b. Nurse observing a change in the behaivour of the patient.

 Pre-operative Problems Table 3.1
Nursing Outcome Nursing Orders Nursing Intervention Date/Tim
Date / Time Diagnosis objectives/
criteria
14th Acute pain Patient will 1. Assess the level of pain 1. Client was reassured and 14th
January,2023 related to experience using appropriate pain client's pain was assessed for January,
12: 00 pm pressure relief of assessment tool based on the severity and according to her it 2023
on the pain within level of litercy of the patient. was 6 on a scale of 0-10. 12: 45pm
right 45 minutes 2. Position patient into a supine 2. Patient was assisted into a
femoral evidenced position . supine position and the use of
nerve. by: 3.. Ensure patient is not bed accessories was ensured.
1. Patient wearing tight or excess 3. Patient was encouraged not
verbalizing clothing. to wear tight clothing and
that she is 4. Assist patient with activities excess clothing.
not feeling of daily living. 4. Patient was asisted with
pains any 5. Provide diversionational activities of daily living .
more. therapy to the patient. 5. Diversional therapy was
2. Nurse 6. Reassure patient of proper provided by allowing the and
observing pain management watch television or engaged in
that client is 7. Assess baseline vital signs . a healthy conversion with the
relaxed in 8. A comfortable bed was patient.
bed . made for the patient. 6. Patient was reassured of
9.Administer prescribed proper pain management.
Analgestics i.e iv paracetamol 7. Baseine vital signs was
24 hours. assesed.
8. Make a comfortable bed for
the patient.
9 Prescribed analgestics was
administered i.e IV
Paracetamol.

Table 3.2
Date/Time Nursing Outcome / Nursing Orders Nursing Intervention
Diagnosis Objective
Criteria
14th Impaired Patient will 1. Assess patient's impaired 1. Patient's ability to perform
January, walking regain strength to walking. activities was assessed.
2023 related to walk within 3 2.Assist patient with Range of 2. Patient was assisted with range of
break in the days evidenced motion exercises. motion exercises.
1:00pm continuity by: 3. Provide items close to the 3. Patient's items was provided
 of the 1. Patient patient's bed for easy reach. close to the patient's bed for esy
bone. verbalising been 4. Allow patient to ambulate with reach.
able to walk as can be tolerated with the help 4. patient was encouraged to
around the bed of the zimmer frame after ambulate with the help of the
side with the surgery. Zimmer Frame after surgery.
help of the 5. Assist the patient to sit 5. Patient was assisted to sit
Zimmer Frame . comfortable in bed comfortable in bed when performing
2. Nurse when performing activities activities such as brushing her teeth
observing patient 6. Assist patient in bed when and eating.
walking out of performing activities of daily 6. Patient was assisted in bed
the bed with the living. 7. Physiotherapists instructions were
help of Zimmer 7. Follow the physiotherapists followed after surgery to enable
Frame. instructions after surgery to patient to walk.
enable patient to walk. 8. Patient's tolerance was monitored
8. Monitor the patient's tolerance during walking and recorded.
during walking and record. 9. Patient's vital signs was monitored
9. Monitor patient's vital signs before and after each activity to
before and after each activity to ensure that the patient is fit to
ensure that the patient is fit to perform these activities.
perform these activities..

Table 3.3
Date/ Nursing Objectives / Nursing Orders Nursing Interventions Date/T
Time Diagnosis Outcome
Criteria
14th Anxiety related Patient will 1. Asses patient's anxiety 1. Patient's anxiety level was 19th
January, to concerns attain maximum level. assessed. January
2023 about ability to diversional 2. Educate patient on the 2. Patient was educated on the 2023
1:30pm walk again. activity need to engage in need to engage in interaction 4:30pm
engagement interaction with other with other patients on the
within 5 days patients on the ward. ward.
evidenced by : 3. Encourage patient to ask 3. Patient was encouraged to
1. Patient questions . ask questions.
verbalising been 4. Orient patient to the 4. Patient was oriented to the
able to interact ward ward.
with other 5. Introduce other fracture 5. Patient was introduced to
patients on the patients or the pictures of other fracture and the pictures
ward. other patients who have of other patients who have
2. Nurse had fractures and are still had fractures of the femur and
observing able to walk. are still able to walk.
patient 6. Encourage patient to 6. Patient was encouraged to
watching Tv , speak to her doctor and associate herself with her
smiling and surgeon about her fears. family and explain her
happy. 7. Refer patient to the grievances to them also.
clinical psycologist. 7. Patient was refered to the
 8. Reassure patient to allay clinical psychologists.
fear and allay anxiety. 8. Patient was reassured to
allay fear and anxiety.

Table 3.4
Date/ Nursing Objectives / Nursing Orders Nursing Interventions Date/TI
Time Diagnosis Outcome
Criteria
14th 1. Asses patient's usual 1. Patient's usual bowel pattern 15th
January,2 Constipatio Patient will bowel pattern and and habit was assessed January
023 n related to be able to habits. 2. Patient's dietary intake was 2023
4:00pm Opiod use. have a 2. Assess patient's assessed and amendments was 4:30pm
normal bowel dietary intake and made as tolerated.
movement make amendments as 3. Patient was encouraged to
within 24 tolerated. drink more fluids.
hours 3. Encourage patient 4. Patient was sered with diet rich
evidenced to take in fluids . in roughages after the surgical
a. Patient 4. Serve patient with procedure.
verbalising diet rich in roughage 5. Patient was served with bed
understandin after the surgical proc pan promptly on request and stool
g of methods edure. was observed for abnormalities.
to maintain 5. Serve bedpan 6. Patient was sevred with
normal bowel promptly on request prescribed Intravenous Infusions
elimination. and observe stool for i.e. IVF 0.9% Normal Saline 2L
b. Nurse any abnormalities . 24 hours.
observing 6. Serve patient 7. Patient was educated on the
and assessing prescribed causes of constiaption and
the patient's INtravenous Infusion remedies .
stool to be i.e. IVF 0.9% Normal 8. Patient was encouraged to
soft and no Saline 2L 24 hours. enage in passive exercises to the
longer hard. 7. Educate patient on limit of the prescribed activity.
the causes of
constipationand
remedies.
8. Encourage passive
exercises to the limit
of the prescribed
activity.

Table 3.5
 Date/ Nursing Objectives/ Nursing Orders Nursing Interventions
Time Diagnosi Outcome
s Criteria
14th Risk for Patient will 1. Assess capillary return, skin colour, 1. Patient's capillary return, skin
Januar periphera maintain warmth distal to the fracture. colour, warmth distal to the fractu
y,2023 l tissue 2. Remove jewlry from the affected 2. Jewlry from the affeted limb w
6:00p Neurova perfusion limb. removed..
m scular within 24 3. Maintain elevation of injured 4. Patient was encouraged to exer
dysfuncti hours as extremities unless contraindicated by digits and joints distal to the
on evidenced the conformed presence of injury(right leg).
related to by: compartmental syndrome. 5. Ice bags was applied around th
interrupti 1. Patient 4. Encourage the patient to exercise fracture site for short peroids on a
on of having digits and joints distal to the injury intermittent basis for 24-72hours.
blood palpable routinely. 6. Prescribed intravenous fluids w
flow pulses. 5. Apply ice bags around the fracture administered i.e Nomal Saline.
2. Nurse site for short periods on an 7. Patient was prepared for surgic
observing intermittent basis for 24-72 hours. intervention by bathing for her an
the patient 6. Administer prescribed IV fluids i.e making sure she fasts for at least
having stable Normal Saline. hours prior her surgery.
vital signs. 7. Prepare for surgical intervention as 8. Patient was assisted with
indicated. intrcompartmental presuresas
8. Assist with intra-compartmental appropraite.
pressures as appropraite.

Table 3.6
Date/ Nursing Objective/ Nursing Orders Nursing Interventions Da
Time Diagnosis Outcome Tim
Criteria
14th Deficient The patient will 1.Assess the patient‟s 1. The patient‟s knowledge was 15
Januar knowlege attain adequate knowledge on assessed by Jan
y,2023 related to knowledge goitre, thyroidectomy and verbal communication, and ,20
6:00pm inadequate about thyroid questioning. 6:0
informatio her condition hormone replacement 2. The nurse explain what goitre
n within 24 hours therapy. is, its causes,
as evidenced by: 2. Provide information signs and symptoms, available
a. The nurse about goitre. treatment, and
observing 3. Educate the patient and complications, using simple
the family terms.
patient‟s ability regarding thyroid 3. The nurse has educated
to answer hormones such as patient and family on
questions and levothyroxine sodium. levothyroxine sodium, its uses,
make 4. Educate the patient and side effects, and
contributions family on its dosage forms.
concerning her the rationale of 4. The nurse educated patient
condition. thyroidectomy and and family on why
b. The patient thyroid hormone the thyroid gland will have to be
verbalizing that replacement. removed, and
she now 5. Describe signs and the importance of replacing the
understands her symptoms of function of the
disease over and under-dosage of thyroid gland with medications.
condition. medications. 5. Shakiness, difficulty breathing
6. Encourage the patient to were described
have as signs of over dosage, and
medical identification weight loss, muscle
about hormone weakness were described as
therapy and to inform all some signs of under
healthcare dosage .
provider about it. 6. The nurse encouraged patient
7.Explain the importance to have medical
of identification about hormone
long-term follow up to therapy and to
patient and inform all healthcare provider
family. about it.
8.Explain contraindications 7. The importance of long-term
to follow up was
levothyroxine such as iron emphasized to patient and
supplements and family.
ciprofloxacin. 8. The nurse has explained the
contraindications
to levothyroxine such as iron
supplements and
ciprofloxacin.
Table:3.7Postoperative careplan
Date/ Nursing Objectives/ Nursing Orders Nursing Interventions Dat
Time Diagnosis Outcome Tim
Critera

15 th Impaired Patient's 1. Reassure patient that comfort 1. Patient was reassured that 16th
January, comfort incisional will b e restored. comfort wiil be restored. Janu
2023 related to site pain 2. Assess the level of pain by 2. The location and severity of y,20
4:00pm tension will subside asking the patient parts of the the pain was assessed. 4:00
from the within 24 body involved , intensity, and 3. Adequate bed rest was m
sutures in hours as frequency of pain. ensured to ease the pain
the patient's evidenced 3. Ensure adequate bed rest to sensation.
wound. by : reduce the pain and 4. Prescribed analgesics and
1. Patient 4. Serve prescribed analgesics opoid was administered i.e IV
verbalizing and opoids .eg. IM Pethidine Pethidine .
relieve of 5. Provide comfortable bed for 5. Patient was provided a
the pain at the patient to be precise a comfortable bed .
the simple bed . 6. Patient's right leg was
2. Nurse 6. Immobilise patient's limb to immobolised to reduce the pain
observing reduce the pain sensation. sensation.
 the patient's 7. Monitor patient's vital signs 7. Patient's vital signs was
facial and record. monitored and recorded.
expressions 8.Ensure bed rest by reducing 8. Bed rest was ensured by
and noting visitors and relatives. reducing visitors and relatives.
no signs of 9. Encourage patient to assume 9. Patient was encouraged to
pain. a comfortable position. assume a comfortable position
that wil ease pressure and
weight on the incisional site.

Table 3.8
Nursing Objectives/ Nursing Orders Nursing Interventions
Date/ Diagnos Outcome
Time is Criteria
15th Risk for Patient will 1. Assess the incisional site for signs 1. Patient's risk for infection was assess
Januar surgial be free from and symptoms of infection. 2. Wound dressing procedure was
y,2023 site infections 2. Explain wound dressing procedure explained to the patient.
infectio throughout to the patient. 3. All used instruments was
4:30p n hospitalizati 3. All used instruments should be decontaminated and sterilized after use
m related on as decontaminated and steriized before 4. Patient was educated not to touch the
to evidenced and after use. incisional site.
incision by : 4. Educate patient to not touch the 5. Patient was encouraged to eat
al 1. Patient incisional site. nutritional diet rich in protein and vitam
wound observing no 5. Encourage patient to eat . eg. jollof rice, fruits and vegetables.
on the discharge nutritoonal diet. 6. Prescribed antibitotics was administe
thigh. from the 6. Administer prescribed antibiotics ( IV Clindamycin and iV Cefuroxime
incisional and intravenous fluids. 7. Patient was assisted in performing he
site. 7. Assist patient when performing self -care duties and aseptic methods w
2. Nurse self care and use aseptic method used while water and soap was avoided
observing while cleaning the patient and avoid the incisional site.
that , pouring water or soap at the 8. A septic technique was carried out w
incisional incisional wound.. performing procedures on client.
site is clean 8. Observe a septic technique when
and free carrying out procedures on client.
from pus.
Table 3.9
Date/Time Nursing Objectives/Outcome Nursing Orders Nursing Interventions Date/Time
Diagnosis Criteria
16th Bathing Patient will perform 1. Patient was assisted 20th
January, self-care self care activities 1. Assist patient to to bath. January,202
2023 deficit within 3 days with bath twice daily 2. Patient was assisted 6:30am
related to little assistance as 2. Assisst client to to cleanher mouth.
6:30am inabilty of evidenced by ; clean her mouth. 3. Patient was assisted
patient to a. Nurse observes 3. Assist her to cut to cut her nails.
move after client take part in slef- her nails. 4. Relatives were
the surgical care. 4. Teach the taught on assisting
procedure. b. Patient' willingness relatives assisting skills.
to participate in skills. 5. Patient was assisted
activities of daily 5. Assist patient to to walk around her
living. walk around her bed.
bed. 6. patient was
6. Encourage bed encouraged to bed
rest. rest.
7. Protect and 7.Patient's bed linen
change bed linen was protected and
when performing changed .
bed bath 8. 1. Patient and
8. Reassure patient family were reassured
and familly of been in competent
hands .
 Table 3.10
Date/ Nursing Objectives/ Nursing Orders Nursing Interventions Date/
Time Diagnosis Outcome Time
Criteria

16th Disturbed Patient will 1. Asssess patient's sleep 1. Patient's sleep 19th
January, sleeping pattern have a normal pattern. waspattern assessed. Janua
2023 related to sleeping 2. Provide a quiet 2. Patient was provided a ,2023
6:30am prolonged pattern by the environment for the quiet environment . 7:00a
position in bed. end of 48 patient. 3. Nearby doors and
hours as 3. Nearby doors and windows were opened.
evidenced by: windows should be 4. Patient's bed was made
1. Patient opened to ensure comfortable devoid of
having ventilation creases and crumbs.
uninterrupted 4. Make bed comfortable 5. Dim light was provided
sleep for 6 to 8 devoid of creases and on the ward during
hours in the crumbs. bedtime.
evening. 5. Provide dim light on 6. Prescribed medications
2. Nurse the ward during bed time. were served such as the
observing 6. Serve prescribed analgesics, supplements
patient's sleep medications and monitor and anticoagulant.
pattern and for side effects. 7. Nursing acticities were
noting a 7. Schedule nursing sceduled such that it did
normal sleep activities such that it does not interfere with the
pattern not interfere with patient's patient's sleep.
sleep. 8. The number of visitors
8. Limit the number of in the ward was limited.
visitors in the ward.

Table 3.11
DATE/ NURSING OBJECTIVES/ NURSING ORDERS NURSING
TIME DIAGNO OUTCOME CRITERIA INTERVENTIONS
SIS
16th 1. The degree of mobility w
January,2 Impaired Patient will regain 1. Assess the degree of assessed .
023 physical mobility at the highest immobility produced by 2. Patient was taught and
2:00pm mobility possible level within 3 injury. assisted with passive range o
related to days as evidenced by 2. Teach patient or assist with motion exercises of affected
bed active and passive range of and unaffected extremeties.
confineme a. Patient demonstrating motion exercises of affected 3. The use of isometric
nt techniques that enable and unaffected extremeties. exercises starting with the
 3. Encourage the use of unaffected leg was encourge
resumption of activities. isometric exercises starting i.e. leg leg then the right leg
with the unaffected limb i.e 4. Patient was encouraged to
b. Nurse observing leg leg then to the right leg listen to the physiotherapist
patient showing which is thre affected leg. instructions.
increase strength or 4. Encourage patient to listen to 5. A footboard was provided
function of affected the physiotherapist immobilize the leg and prov
body part instructions. support.
5. Provide footboard to 6. Patient was assisted with
immobilize the leg and self-care activities( bathing,
provide support. shaving, and brushing of
6. Assist with self-care teeth).
activities ( bathing , shaving 7. Patient was provided with
and brushing of teeth) mobility aidessuch as Zimm
7. Provide the patient with frame.
mobility aides 8. Patient was reassured on
8. Reassure patient on the possibility of her been able t
posssibility on her walking walk again soon .
again.

Table 3.12
Date/ Nursing Objectives/ Nursing Orders Nursing Interventions Date/
Time Diagnsis Outcome Time
Criteria
20th Anxiety Patient will not 1. Assessing the patient's 1. Patient's risk for 21 st
January, related to have situational risk for situational low situational low self-esteem January,
2023 inability low self esteem self-esteem. was assessed. 2023
1:00am to pay within 24 hours 2. Encourage dicussion of 2. Patient ewas encouraged 10:
her as evidenced concerns about the to discuss concerns about 00am
hospital by : hospital billls the hospital bills.
bills. 1. Patient 3. Acknowledge the 3. The difficulties the patient
verbalisng difficulties the patient was experiencing was
feeling feeling may be experiencing acknowledged.
better about 4. Provide emotional 4. Emotional support was
himslef and his support for the patient. provided for the patient.
situation. 5 Refer patient to see the 5. Patient was refered to the
2. Nurse clinical psychologist. clinical psychologist.
observing a 6. Encourage patient to 6. Patient was encouraged to
change in the talk to the hospital social talk to the hospital social
behaivour of the welfare for assistance. welfare for support.
patient. 7.Encourage patient to 7.Patient was encouraged to
talk to her relatives for talk to her relatives for
assistance. assistance.
8. Institute diversional 8.Diversional therapy was
therapy to the patient to instituted for the patient.
help relieve her of her
 CHAPTER FOUR

4.0 IMPLEMENTING PATIENT/ FAMILY CARE PLAN

The fourth step of the nursing process is the implementation stage. Implementation is a change-

oriented process of endorsing an action plan ( Koichu et al, 2019.) This is where the nurse tends

to be responsible for all care rendered to patient and family based on the nursing diagnosis and

collaborative problems of patient which is geared towards fast recovery of patient. It entails a

summary of the actual nursing rendered to Madam A.S and her family from the first day of

admission till discharge and the preparation towards discharge, rehabilitation and home visits.

The main duty here is responsibility for the implementation and coordination of activities of all

those involved in the intervention , including the patient , family and other members of the

healthcare team, so that the scheduled activities facilitate speedy recovery or peaceful death.

4.1 SUMMARY OF THE CARE RENDERED TO PATIENT AND FAMILY

Day Of Admission ( 14th January, 2023)

Madam A.S , a 65-year-old woman was admitted into the Easmond Ward through the Trauma

Surgical Emergency Unit at the 37 Military Hospital on the 14th January, 2023 at 11: 30 am on

account of Right Neck of Femur fracture. She was wheeled into the ward by a student nurse

accompanied by her daughter in a conscious and alert state. Madam A.S 's necessary documents,

admission notes and other information from the accompanying nurse. She was then admitted

under the care of Dr. B.A. They were received calmly into the ward, and I introduced myself and

some other staff on duty to them. I called her name from her folder to confirm her name,

particulars which she responded in affirmation. She was sent to her already laid admission bed,

introduced to other patients near her and made comfortable in her bed. She was then changed
into her nightgown and pajamas and asked to declare valuables if any and was informed to the

nurse in charge. I then introduced myself as a nursing student from Wisconsin International

University College, Accra-Ghana, and asked for her consent in using her for my case study. I

provided her with the details of the case study and assured her that confidentiality of all

information will be kept at its highest standard and she consented to it. Her valuables were taken

and arranged on the side locker by the bedside. I explained clearly the ward protocols and

visiting hours to her and her daughter The National health Insurance System was explained to the

patient and family. On admission, her vital signs were checked and recorded as Blood Pressure -

mmhg, Temperature-36.6 °C), Pulse - 88 bpm Respiration- 20 cpm and Oxygen Saturation-

100%.Her name was then entered into the admission , discharges book and daily ward state.

The nurse on duty consulted with the specialist. According to the patient’s folder, the following

investigations were to be carried out; MRI, CT Scan,, leg X-ray, full blood count which were

done. At 12:00pm, Madam complained of pain at her hip and thigh area. A comprehensive Care

plan was written for Madam's A.S pain. Her pain was treated by first of assessing the type of

pain she was in. She was then positioned into a supine position to ease her of the pain. Patient

was assisted with activities of daily living and administered prescribed IV Paracetamol 1g

6hourly for 24 hours. Around 1:00pm the same day, It was observed that Madam A.S , found it

difficult to walk. Madam A.S's difficulty to walk was addressed by writing a comprehensive

Care plan for her and encouraging Madam A.S to ambulant as often as tolerated. Madam A.S's

items were provided close to her bed for easy reach, and she was assisted in bed when

performing daily activities. Lastly, Madam A.S was encouraged to follow the physiotherapist

instructions after her surgery tomorrow at 11:00 am. Madam A.S was then encouraged to neither

eat nor drink anything till her surgery scheduled for the next day (15/04/2023) At 1:30pm,
Madam A.S expressed her worry of not been able to walk again even after the surgery. Madam

A.S was then educated on her medical condition, on the need to talk to her doctor about the

possibility of her walking again. Madam A.S was also introduced to other people both visually

and in person who have experienced fracture of their femur and have been able to walk again.

Madam A.S complained of difficulty to pass stool at 4:00pm. Madam A.S was assessed and her

intravenous infusions was administered i.e Normal Saline. She was also encouraged to drink a lot

of fluids and take fruits after hours of her surgery the next day to ease her of the constipation.

Madam A.S around 6:00pm complained of having a swollen hip. Her swollen hip was treated by

applying ice packs around her the fracture site for short periods on an intermittent basis for 24-72

hours. She was also encouraged to exercise her digits and joints distal to the injury routinely.

Madam A.S's leg was also elevated on a pillow.

She was served the prescribed analgesic tab paracetamol 1g, Prescribed Intravenous Infusions i.e

RIngers Lactate which was then documented in medication chart and the nurses’ note. Patient

was made comfortable in bed as she prepared to sleep, I bid her goodnight as he finally slept

around 19 30 hours. Her general condition was improving, and she was responding to treatment.

First Day Of Admission ( 15th January, 2023- Day of Surgery)

According to night nurses, Madam A.S , woke up early in the morning 5:30am, prayed, brushed

her teeth and took her bath with the help of her daughter . The signed consent form was retrieved

from Madam A.S's daughter after the procedure was explained to her. Immediate pre-operative

care was given to patient; the site for the surgery was shaved, nicely washed with antiseptic soap

and clean water, kept dry and nicely covered with operating towel and secured in position with

adhesive strapping. She had no dentures, necklace or bracelets. Patient's clothing was removed,
and was then gowned with a clean theatre gown. Patient was asked to empty her bladder and

remove dentures if any. Vital signs were checked and recorded immediately before she was sent

to the theatre and were recorded as follows: Blood pressure - 120/70 mmHg, Temperature -

36.1°C ,Pulse – 84 bpm, Respiration – 22 cpm and Oxygen Saturation -99% . Madam A.S 's

items for surgery included ,Crepe bandage 6'-2 , Cefuroxime,

Patient was accompanied to the theatre with two nurses with the following drugs: IV

Paracetamol, IV Normal Saline and IV Ringers lactate. All laboratory results of patient were

attached to her folder and sent to theatre.

IMMEDIATE POST-OPERATIVE CARE

Madam A.S was brought back from recovery ward after bipolar surgery done under general

anaesthesia to the ward at 3:15pm in a Semi-conscious state with about 250mls of dextrose saline

in situ. Incisional site was dry and clean.

Madam A.S. was welcomed and was put on an already prepared operation bed in a supine

position. Bed rails was provided for safety and the level of consciousness by the use of stimulus

was observed. Madam A.S was semi-conscious on arrival to the ward from the Theatre.

Post-operative notes were quickly read. Patient was assessed and other observations done. Vital

signs were checked and recorded as follows; Blood pressure - 125/80 mmHg, Temperature - 36.6

°C, Pulse – 55 bpm, Respiration – 17 cpm and Oxygen Saturation: 98%.. Vital signs was

monitored for 15 minutes for the first one hour , 30 minutes for the next hour , 1 hour for the

next 4 hours and 4 hourly intervals as condition stabilizes. Patient was observed for bleeding

from the operational site . Patient was assessed for pain and prescribed analgesics and opoids

was served. Her cannula was ensured to be in situ , the flow rate of the intravenous fluid was
checked and regulated .She was being managed post operatively on, IV Paracetamol 6hourly, IM

Pethidine 100mg 6hourly. Condition on arrival was fairly ill. 1 gram of paracetamol was

administered intravenously. There was no abnormality in the patient's condition and findings and

nursing interventions was documented. Patient and relatives were reassured.

Second Day Of Admission ( First Day post-operative - 16th January,2023 - self care

Madam A.S. woke up around 6:30am but was weak, and complained of interrupted sleep

according the night to the night nurse. She was given assisted bed bath and also assisted to brush

her teeth while sitting up in bed with tooth brush as paste. She was then made comfortable in

bed. Vital signs were checked and recorded as follows: Blood pressure 120/80 millitres of

mercury (mmhg), Temperature -37.00C, Pulse -80 beats per minute(bpm), Respiration -20 cpm

and Oxygen Saturation : 98%.

She had a problem of bathing self-care deficit related to inability of patient to move after the

surgical procedure. A nursing diagnosis was formulated to help patient address the problem of

bathing self-care within 24hours. Nursing interventions included reassuring patient that she will

be able to move freely within 24hours, encouraging her to lie on her unaffected side before

getting out of bed, supporting her to sit up in bed or on a chair and helping patient to do passive

exercises and encouraging her to perform active exercises. Assisting her to perform self-care

activities and helping patient to perform passive exercise and encouraging her to do active

exercise. A nursing diagnosis of disturbance in sleeping pattern related to prolonged position in

bed was formulated to help patient solve the problem. Patient was reassured that she will be

relieved of insomnia and therefore will be able to sleep, a comfortable bed was prepared with

clean linen and free from creases and cramps to ensure her comfort and to promote sleep, the

number of visitors were limited on the ward to prevent disturbance to patient’s sleep, a quiet
environment was provided to promote sleep and nearby windows were opened to allow adequate

ventilation to induce sleep. Prescribed medication was served.

Third Day Of Admission (Second Day Postoperative - 17th January,2023 ) couldn’t sleep

Madam A.S's condition was improving as compared to the previous days and slept better

according to the night nurses. According to the night nurses, madam A.S woke up around 5:30

am . She prayed her morning prayers, was assisted to brush her teeth and take her bath. She was

then made comfortable in bed. She later drank Millet koko and Beans cake for breakfast and then

was served her prescribed medication. Vital Signs was checked and recorded as: Blood Pressure:

129/82 mmhg, Temperature: 37.0 , Pulse- 80 bpm, Respiration -24 cpm and Oxygen

Saturation -97% . Madam A.S's wound was dressed aseptically. The wound was healing well.

Madam A.S was reviewed by the doctors on ward rounds and was later seen by physiotherapist.

The physiotherapist helped the patient to stand with the help of a Zimmer Frame. The

physiotherapists helped her stand on her feet for about 5 minutes allow her sit for a while and

encourage her stand again. Patient was able to do this for about 30 minutes till she got tired and

even complained of pain. The physiotherapist also encouraged Madam A.S to be moving her toes

often to promote blood circulation. Her prescribed analgesics was served to be precise IV

Paracetamol

Her daughter visited her with Waakye and shito with fruits during visiting hours. Madam A.S ate

well and lodged no complains.

Fourth Day Of Admission (Third Day Postoperative - 18th January,2023)

In the morning, Madam A.S , woke up early around 5:30 am prayed and was assisted to maintain

her personal hygiene. Her bed was made and her dirty linen was changed. She was fed breakfast
in the morning, and morning medications were served. Vital Signs was checked and recorded as :

Blood Pressure : 128/80 mmhg, Temperature: 36.8 C, Pulse: 110 bpm , Respiration: 26 cpm and

Oxygen Saturation -98%. The doctor asked about her and she said she feeling well now. Madam

A.S's wound was dressed using aseptic technique. The wound was healing i.e dry and not

offensive. A picture of the wound was shown to Madam's A.S's doctor who commended her and

the nurses of the good progress of the wound and reassured Madam A.S and her family.

At 12:00pm , the Physiotherapist came around and this time helped Madam A.S stand longer on

her feet with the aid of the zimmer frame. She was able to endure standing longer and didn't

lodge any complaints after her session with the physiotherapists. Madam A.S's daughter visited

her during the visiting hours at 3:00pm till 5: 00 pm. Prescribed medications were served to

Madam A.S .

Fifth Day Of Admission (Fourth Day Postoperative - 19th January)

According to the night nurse, Madam A.S lodged no complaints over the night. She slept well

and woke up her normal time of 5:30 am to say her prayers, was assisted to brush her teeth and

bath. Madam A.S then took Milo and Pie for her breakfast and her due medications were served.

Madam A.S 's wound was dressed and after it was shown to the doctor, she was scheduled for

the removal of stitches the next day. At 12:00pm, Physiotherapists during their routine check-ups

helped Madam A.S walk around her room with the help of her Zimmer frame . She was able to

walk around her room but was rather slow in her pace. The physiotherapist encouraged her to try

to move around more with the assistance of either a nurse or her relative by standing behind her

per venture she falls. So, during visiting hours when Madam A.S's daughter brought her lunch,

her daughter assisted her mother to walk around the room. Madam A.S looked more joyful and

eager to walk around her room and bed and ate well.
Sixth Day Of Admission ( Fifth Day Postoperative -20th January, 2023)

According to the night nurse, Madam A.S woke up around 5:30am , Madam A.S was able to

brush her teeth herself and move to the bathroom with the help of the Zimmer frame . However,

the nurse was in the room per venture the patient needed help while bathing. Vital Signs was

checked and recorded as : Blood Pressure: 127/69 mmhg, Temperature-36.8, Pulse- 64bpm,

Respiration- 18cpm and Oxygen Saturation -99%.

Her stitches were removed, and surgical site was observed by her doctor. Madam A.S's doctor

reassured Madam A.S and her family that since the wound was healing well and the stitches

removed yet no complications were observed from the surgical site, she will be discharged the

following day . At 12:00pm, ,Madam A.S's physiotherapist came for routine checkups and

helped Madam A.S this time to walk around the whole Easmond Ward with the aid of the

Zimmer frame . Madam A.S was a bit faster than she was the previous day during her

physiotherapist session. Madam A.S was provided a chair to sit in between the walks whenever

she was too tired to move on. So far, Madam A.S sat about thrice during her walks around the

ward and rested for about 5 minutes during those times. Madam A.S expressed worry of not

been able to pay her hospital bills when the doctor said she was due to discharge the following.

A nursing diagnosis was formulated for this problem been Anxiety related to inability to pay her

fees. Madam A. S was As the student nurse in charge of Madam A.S 's care because of the care

study, I spoke to Madam A.S's family on the fact that i would have to visit house to see how

things are at home and if the condition of the home will either cause more harm or rather relive

Madam A.S of her condition. Madam A.S 's daughter gave me her consent and i went home with

her to look at her house.

Seventh Day Of Admission (Sixth Day Postoperative - 21st January,2023- Discharge date )

In the morning, Madam A.S woke up early and maintained her personal hygiene. I made her

bed and she laid in bed for a while. She looked very happy and had no complain. Routine vital

signs were checked and recorded which were in the normal ranges and due medications were

administered. Madam A.S was reviewed by doctors on ward rounds. The doctor asked about her

health and she said she was fine. Patient was discharged later in the day and to be reviewed on

the in order to remove the stitches. I educated Madam A.S on how to clean the incisional area

and keep it dry to avoid infections. I restated the doctor’s instructions for her to come for review

on the stated date above. I also educated her on how to administer the medications she was

discharged and to report to the hospital immediately for any signs like bleeding, discharge from

the site of incision for immediate interventions to be taken. Vital Signs was checked and

recorded as: Blood Pressure: 130/78 millimeters per mercury, Temperature: 36.5 C, Pulse -75

beats per minute( bpm), Respiration- 21 cpm

4.2 PREPARATION OF PATIENT AND FAMILY FOR DISCHARGE AND

REHABILITATION

The preparation of patient and family for discharge started as soon as Madam A.S was admitted.

This was done throughout hospitalization period to ensure patient and family needs were well

catered for. They were reassured that their cooperation with the medical team and and nurses,

Madam A.S will get well soon and go home. This preparation was carried out with the aim of

helping Madam A.S and her family to understand the condition, its causes, signs and symptoms,

management, complication as well as the need for review and follow up care so that they can
stay healthy and prevent reoccurrence of the disease and also for patient to be able to fit back

into society and resume her routine activities without any hindrances (for instance, resulting from

the complications of the disease condition). Madam A.S and her family were educated on each of

the drug dosages, their side effect when and how they will be administered, keeping the

incisional site always clean and dry, ensuring proper hand washing before and after visiting the

toilet, proper eating of balanced diets, and proper maintenance of personal hygiene. The need for

review and follow-ups after discharge was also explained to Madam A.S and her family. Patient

was also encouraged to ambulate more often with the aid of the Zimmer Frame. The family was

also heartened to support her physically and psychologically. Preparation towards discharge

began on the first day of admission and throughout her hospitalization to the final day of

discharge. Patients name was entered into the admission and discharge book and daily ward state

and other necessary documents. Madam A.S was assisted in packing her belongings. I assured

Madam A.S and her family of my second visit to their home and bade them goodbye.

4.3 HOME VISIT/FOLLOW-UP CARE

Home visit is effective in reducing the frequency of hospitalization in the older Adults, and

improving physical and psychosocial health.(doi.org /1018502/ijph.v51i4.9234). Home visit is

normally carried out by a health professional i.e a nurse to ensure the patient follows the protocol

and advices of the doctor has given the patient . Home visit is also done to make sure there are

no situations at home that can worsen the patient's condition.

FIRST HOME VISIT ( 20th January, 2023)

This visit was scheduled and arranged with ultimate concern and assistance of the patient on

January, whiles she was on admission.

The purpose of this visit was to familiarize myself with the home and the environment of my

patient in order to identify health problems which are contributing factors to patient’s condition.

This visit was scheduled on the January , 2023 while Madam A.S was still on admission

I went with Madam A.S 's daughter to the house in her car after my moring shift . The house is

self- contained bungalow with four rooms=, a fenced wall around and a black metallic gate in

front located at Sowutuom -Lomnava street. The house had good lightening system and two cats

roamed the compound.There was a mosque not too far from Madam A.S's house which

according to her daughter was where she worshipped on Fridays. I met Madam A.S's inlaw and

grandchildren watching Television in the hall.

I was warmly welcomed and I quickly observed and inspected the house which was clean before

I took my seat. We exchanged greetings as custom demands and i was served a glass of water.

I then explained the reasons for my visit to her family. I explained that a good sanitary

environment is vital to the health of every individual and as such if the environment is not kept

clean always, it will predispose the family to contract diseases. The entire family was then

educated on the need to keep the environment clean always. I also noticed that their floors were

tiled and slippery which could have been the reason for Madam A.S's fall hence, fracture. I

encouraged the family to buy carpets and use it to cover the slippery floors Madam A.S was most

likely to pass on . I also encouraged the family to make sure Madam A.S has a lot of space as
possible to pass when shes either going to her room or bathroom. This is because i noticed alot of

things were blocking Madam A.S's path to her bedroom. Madam A.S 's daughter listened to me

and immediately started clearing the place. I also went to Madam A.S's bathroom to see how it

will affect Madam A.S and noticed that her bathroom had no shower curtain. Hence, water could

easily pour out of the bathroom while Madam A.S bathed making the place wet and increasing

the risk of falls for Madam A.S. Her daughter promised to get shower curtain for the bathroom

and more carpets to keep the bathroom dry.

Another thing observed in Madam A.S's house was that her bed was too high for her reach hence

she had to climb a stool or step in order to reach her bed. I disagreed firmly against this

arrangement and encouraged her daughter to find a way and call carpenters to reduce the bed a

bit shorter to reach Madam A.S or better still she should just change the bed all together for her

mother to a shorter one. Her daughter agreed on changing the bed for her mother. Most of the

houses around Madam A.S' daughter's house were compound and apparently, the house belonged

to her husband.

I informed Madam A.S 's daughter of my departure and promised to visit again.

Second Home Visit ( 29th January,2023)

On the 29th January,2023, I visited Madam A.S and her family after discharge to ensure that the

instructions i gave the family concerning Madam A.S was followed. I was warmly received by

the family of Madam A.S and they thanked me for the time and care i had rendered to their

Mother. I went into the house to ensure check if the changes i suggested earlier was followed to

the letter. Fortunately, Madam A.S 's daughter made all the changes I encouraged her to make on

my previous home visit that is ,

I asked her if she has been taking her medications as prescribed and she said she does but

sometimes when her daughter is not around, she forgets to take the medicine. I then educated

Madam A.S and her daughter on taking her medications as prescribed at the right time, right

dosage, and to eat fruits and balanced diet. I observed Madam A.S's wound and observed that her

wound was clean and dry. I commended Madam A.S and her daughter on keeping the wound

clean. I reminded Madam A.S and her family about her review date and wound dressing date on

the 1st of February, 2023. Her daughter agreed to come for the review date with her mother. I

observed Madam A.S walk and noted that she was able to move with her ZInner Frame. I

encouraged Madam A.S to engage in passive exercises, eat fruits and balanced diets to speed up

the healing process of the wound. I also encouraged to have adequate rest and to reduce

psychological stress as much as possible. I bid farewell to the family and promised another visit

to the family.

Third Home Visit (5th February,2023)

My third home visit to Madam A.S's home was on the 5th of February, 2023, in the afternoon.

On reaching the house, i was warmly received by Madam A.S's Son -In -Law, who ushered me

into the home and informed me that his wife had gone to the market and will be back in about

twenty minutes time. Madam A.S when I met her was eating lunch to be precise Ampesi and

Palava Sauce. Her Son-in-law gave me a seat and offered water for me to drink while I waited

for Madam A.S to finish her lunch. I then asked Madam A.S 's Son -In-law for privacy once

Madam A.S was done eating . I then asked her about her health and how she has faring so far.

She claimed she is feeling better and the doctor even suggested that there is the possibility of her

dropping the ZImmer Frame if her next review goes well as planned. I asked Madam A.S if she
has been taken her medications which she answered positively. I also ask Fortunately, by the

time I was done talking to Madam A.S her daughter was back from the market.

I also informed Madam A.S and the family that this is my last visit to her since school had

resumed by then and promised to visit once I am chanced. I thanked Madam A.S and her familY

for their cooperation and willingness to allow me use their mother for my patient and family care

study especially her daughter.

Madam A.S and the family wished me well in all my endeavours and prayed for me to excel in

my academics. Finally, I bid Madam A.S and her family goodbye and i was seen off at the

nearest bus stop to board a car back home.

 CHAPTER FIVE
5.0 Introduction
This is the fifth and final phase of the nursing process. This is where the nurse assesses the
effectiveness of the care, whether the care rendered in comparison to previously determined
goals had been achieved . The nursing care plan is repeated until goals set are achieved .
Evaluation is
It is written under the following headings :
 Statement of evaluation
 Amendment of care given
 Termination of care given

5.1 Statement of Evaluation

This phase indicates whether the nurse was able to help client meet her needs or not . Madam
A.S was admitted on the 14th of January, 2023 to the Easmond Ward of the 37 Millitary Hospital
with the diagnosis of Fracture of the right neck of femur. After identifying problems of the
patient and family, the needed nursing interventions were ensured , and the following objectives
were met:
On 14th January, 2023 at 12:00 pm , Madam A.S complained of pain in her hip and thigh . The
objective criteria that was formulated for Madam A. S was that she will be relieved of pain
within 45 minutes evidenced by Patient verbalising that she is not feeling pains anymore and
Nurse observing that patient is relaxed in bed at 12:45 pm. Goal was partially met as
At 1:00pm the same day, Madam found it difficult to walk and an objective criteriw formulated
was that Patient will regain strength to walk within 3 days as evidenced by Patient verbalising
been able to walk around the bed side with minimal help and nurse observing patient walking out
of bed with the help of assistive devices to be precise Zimmer Frame . Goal was fully met as
patient verbalised bee able to walk around the bed with minimal help with Zimmer Frame in 3
days.
At 1:30pm ,Madam A.S was anxious about whether she will be able to walk again and an
objective was set to relieve Madam A.S of her anxiety throughout hospitalization evidenced by
patient verbalising been able to interact with other patients. Goal was fully met as patient by the
time she was discharge no longer expressed signs of been anxious.
At 4:00 pm Madam A.S complained of difficulty to pass stool and an objective was set to help
Madam A.S empty her bowels normally within 24 hours evidenced by nurse observing Madam
A.S
At 6:00pm , Madam A.S had a swollen hip and thigh region and an objective was set to enable
Madam A.S maintain tissue perfusion within 24 hours evidenced by Madam A.S having palpable
pulses in her leg and nurse observing Madam A.S having stable vital signs. . Goal was fully met
on 15th January, 2023 6:00pm as Madam A.S had palpable pulses.
On 6:00 pm the same day , Madam A.S also had no knowledge about her health condition and
an objective was set to enable Madam A.S attain adequate knowledge about her condition within
24 hours . Goal was fully met as Madam A.S verbalised her understanding of her disease
condition i.e.fracture after 24 hours.
On 15th January,2023, 4: 00pm Madam A.S complained of chronic pain after the surgery and an
objective was set to relieve Madam A.S of her incisional pain within an hour evidenced by
patient verbalizing relief of the pain at the incisional site. Goal was fully met as Madam A.S
At 4:30pm, on 15th January,,2023 8: 00 am Madam A.S had a wound on the right hip region and
an objective was set to enable Madam A.S be free from infections throughout hospitalization . .
Goal was fully met as Madam A.S showed no signs of infection throughout hospitalization.
On 16th of January,2023 6: 30 am in the morning , Madam A.S could not not bath for herself
and an objective was set for Madam A.S to enable her perform bath self-care activities within 3
days evidenced by Patient's willingness to participate in activities of daily living. Goal was fully
met as Madam A.S by the third day was willing and able to participate in activities of daily
living.
On the of 16th January,2023 at 6:30 am in the morning , Madam A.S complained of interrupted
sleep and an objective was set for Madam A.S that she will have a normal sleeping pattern by 24
hours evidenced by Madam having uninterrupted sleep for 6-8hours. Goal was fully met as
Madam A.S had an uninterrupted sleep for 6 hours.
On th January,2023 at 2:00pm , Madam A.S could not move out of her bed after the surgery and
an objective was set to enable Madam A.S regain mobility at the highest possible level within 3
days.. Goal was fully met as Madam A.S was demonstrated techniques thata enabled resumption
of activities.
On the 20th of January,2023 at 1:00pm , Madam A.S was anxious of been unable to pay her
hospital bils and an objective was set for Madam A.S to relieve Madam A.S of her anxiety
throughout hospitalization . Goal was fully met as Madam A,S verbalised feeling better about
herslef and her situation.
5.2 Amendment of Nursing Care for Partially met or Unmet Outcome Criteria
Amendment of care involves the resetting of goals ad objectives , adjusting them accordingly for
problems that were not met or partially met during the period care was given . Most goals and
objectives were met except for the objective set for the pain at her hip and thigh region.
The care plan was amended the same day 14/01/2023 at 3:00 pm with the outcome criteria
Patient will be relieved of pain within 40 minutes evidenced by
a. Patient verbalizing that she is not feeling pains any more.
b. Nurse observing that client is relaxed in bed.
Goal was fully met evidenced by patient verbalizing that she was no longer feeling pains any
more.
 Nursing Outcome Nursing Orders Nursing Intervention Date/Tim
Diagnosis objectives/
Date / Time criteria
14th Acute pain Patient will 1. Assess the level of pain 1. Client was reassured and 15th
January,2023 related to experience using appropriate pain client's pain was assessed for January,
pressure relief of assessment tool based on the severity and according to her it 2023
3:00pm
on the pain within level of litercy of the patient. was 6 on a scale of 0-10.
12: 00pm
right 45 minutes
2. Position patient into a supine 2. Patient was assisted into a
femoral evidenced
position . supine position and the use of
nerve. by:
bed accessories was ensured.
3.. Ensure patient is not
1. Patient
wearing tight or excess 3. Patient was encouraged not
verbalizing
clothing. to wear tight clothing and
that she is
excess clothing.
not feeling 4. Assist patient with activities
pains any of daily living. 4. Patient was asisted with
more. activities of daily living .
5. Provide diversionational
2. Nurse therapy to the patient. 5. Diversional therapy was
observing provided by allowing the and
that client is 6. Reassure patient of proper
watch television or engaged in
relaxed in pain management
a healthy conversion with the
bed . 7. Assess baseline vital signs . patient.

8. A comfortable bed was 6. Patient was reassured of

made for the patient. proper pain management.

9.Administer prescribed 7. Baseine vital signs was

Analgestics i.e iv paracetamol assesed.
24 hours.
8. Make a comfortable bed for
the patient.
9 Prescribed analgestics was
administered i.e IV
Paracetamol.
5.3 Termination Of Care
This is the final stage of the patient/family care study. Termination is the This is where the
nurse-patient relationship comes to an end . The nursing care of Madam A.S started from the day
of admission ( 14th January, 2023) , through to the day she wa discharged 21st January, 2023.
She was informed that hospitalization was a temporal procedure to treat her condition . In the
course of treatmet , the patient and family were prepared psychologically, physiologically and
physically towards discharge. The patient was informed to return to the health facility for review
on 1st February, 2023.
6.0 SUMMARY AND CONCLUSIONS
This script is an account of comprehensive care given to Madam A.S , a 65 year old woman . She
was admitted to the Easmond Ward on the 14th of January,2023 with the diagnosis fracture of
the neck of the femur. Diagnostic investigations were carried on Madam A.S after which
treatment commenced on her.
On admission, she was conscious , wheeled in by a student nurse and accompanied with her
daughter. She came to the ward with pain at her hip region, difficulty in walking , a swollen hp
region , anxiety, difficulty to pass stool and inadequate knowledge on her condition.
Comprehensive care plans were written for Madam A.S's problems and treated.
Madam A.S was nursed for 8 days on the ward . The duration for my interaction with Madam
A.S was from 14th January, 2023 to 5th February, 2023. Madam A.S responded well to
treatment and was discharged on 21st January,2023. Three home visits were done ; the first one
was done to while the patient was still on the ward , the second and third home visit was done
when Madam A.S was discharged.These home visits were to help assess the health status of the
patient and family, how the patient was coping after discharge and give recommendations.

Conclusion
Writing of this care study has been an educative experience for me because it has broadened my
knowledge about Fractures and how to render complete and effective care to the patient. It has
also given me an insight into what holitic care means and with this I am convinced that I can
give nursing care to any patient using the nursing process.