CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment involves gathering of information and it is the first phase of the

nursing process. The gathering of information about the patient includes his

developmental history, his family’s past and present medical history and the family’s

socio-economic history. The data can be collected from the patient, his or her family, the

healthcare team and the records of the patient.

PATIENT’S PARTICULARS

Mr. B.K.33 year old man was born on Saturday, 10th June, 1978 at Suntreso

Government Hospital in Kumasi. He was born to Mr. E. A and Madam D.A. He is the

first amongst their five children. He hails from Manso-Abore, but he stays at

Atimatim(closure to Akwasi Oppong area,a suburb of Kumasi in the Ashanti region). He

is married to Mrs. K.A and they were blessed with 2 children.

Mr. B.K is a trader who deals with buying and selling of hardware(body parts) of

vehicles and cars.

Mr. B.K started his basic education at the age of three years at State Boys Primary

School at Suame Roundabout in Kumasi and also continued with the Junior High School

at the same school. He had his Senior High School at Prempeh College the age of fifteen

years for three years. According to Mr. B.K, he could not continue his tertiary education

1
due to financial problems of his parents. He speaks English and Twi but he is more fluent

in speaking Twi. His next of kin is his brother, Mr D.A. he is a Christian and fellowship

with a Penticostal Church at Atimatim. He is 130 cm tall and he weighed 50kg on

admission.

FAMILY’S MEDICAL AND SOCIO-ECONOMIC HISTORY

According to Mr. B.K, there is no hereditary disease like hypertension, diabetes,

pancreatitis, mental illness or asthma in their family. However minor ailment like

headache, diarrhoea, coughing and body pains are treated with drugs bought from the

nearest drug store. In severe cases, they are sent to the nearest clinic where they are

usually treated on out-patient basis

The house consists of six rooms of which not more than five people live in a

room. There are two bathrooms and toilets, each for male and female and two kitchens.

There is a well in the middle of the compound, which has been cemented to prevent dust

from getting into their source of water. The family’s main source of income is the profits

he earns and the profits from his wife’s provision shop.

PATIENT’S DEVELOPMENTAL HISTORY

Mr. B.K said he was delivered spontaneously per-vaginum at Suntreso

Government Hospital with the help of a midwife wife at the hospital. He was immunized

2
against all the preventable childhood diseases according to his mother, he was also

breastfed for 14 months. On my observation, at his right shoulder, there was a scar

indicating the Bacille Calmette Guerin (BCG) vaccination.

He started crawling when he was eight month and at one year he started walking

as been told by his mother.

Mr. B.K started developing secondary sexual characteristics at the age of thirteen.

He started growing pubic hair, broadening of the chest and development of deep voice.

PATIENT’S LIFESTYLE AND HOBBIES

According to Mr. B.K, he usually sleeps around 9:00 pm and wakes up around

5:00am. He always observed his quite time in bed for about 30 minutes before he gets out

of bed to wash his face and brush his teeth. He mostly spends time with his daughter and

helps to feed her with breakfast whiles Mary his wife is mostly engage in arranging items

in order in the shop.

He empty’s his bowel twice daily and after which he takes his bath. He sometimes

takes his breakfast at home but most often at his working place at around 7:[Link] likes

oats and bread for breakfast. Between 7:00am and 7:45am, he would be at his work place

at Suame, with his workers and friends.

On Saturdays, he likes to play draft with his friends in front of his house and during

the evenings and watch television with his family. On Sundays, they all go to church on

3
occasions and closes by 12:[Link] then spends time with his friends and loved ones

mostly at drinking spots where they really enjoy themselves after church. He takes his

supper at 6:00pm and sleeps around 9:00pm after watching television.

PATIENT’S PAST MEDICAL HISTORY

Mr. Ansah said that because of the Asthma, he visits the hospital every month for

his check-ups. The condition which was previously been treated with Salbutamol is now

being treated with Ventolin inhaler as he stop responding to the Salbutamol. Apart from

this, he occasionally suffers from fever, headaches which are treated at the out patient

department basis. He said the Asthmatic attack sometimes gets worse caused him to be

detained at the hospital, he had never been seriously sick to warrant an admission at the

hospital.

PATIENT’S PRESENT MEDICAL HISTORY

Mr. Ansah said on the 18th November 2009, he started experiencing fever and

stomach ache and during the night at around 11:30pm he started passing watery stools for

six times till the next morning. He took 1 gram of Trisilicate.

4
 The next day, the diarrhea did not subside, it got worsen. He vomited about three

times, feeling dizzy and has loss of appetite. This alarmed his wife and urged him to

come to the hospital. He came to the hospital with his wife and was seen by Medical

Assistant. [Link] at the Out-patients Department. Based on the signs and

symptoms exhibited by Mr. Owusu Ansah, he was diagnosed Gastroenteritis. He was

admitted to the Medical Ward for further observations and treatment since the condition

has really taking its toll.

ADMISSION OF THE PATIENT

Mr. Ansah was admitted to the Male Medical Ward of Presbyterian Hospital

Agogo through the Out Patient Department on 20 th November, 2009 at around 10:40am.

On admission he complained of diarrhea, vomiting, loss of appetite and headache. He

came in as an ambulant patient accompanied by his wife Mrs. Mary Owusu Ansah and a

nurse from the Out-patient Department.

They were welcomed to the nurses’ station and seats were offered to them. The

accompanying nurse handed the patient and his folder over to me. The name on the folder

was mention to confirm that he was the right patient. I reassured him and his wife by

creating their awareness of the availability of competent nurses and doctors. I further

made them aware of their readiness to provide every needed care for his speedy

successful recovery. I asked Mr. Ansah if I could use him as my patient for my patient

and family case study. He answered in the affirmative.

5
 Mr. Ansah was orientated to the ward unit. He was shown the bathroom, toilet,

the nurses’ office and where he can get water from polytank outside the ward. He was

then put in a simple admission bed after assisting him to change into the ward gown. He

was introduced to other patients in the room

I explained to him that if he has any valuables that he cannot keep in his locker, it

can be kept for him and that he can have them after discharge but he said he had nothing

so valuable. The consent form was signed by him and witnessed by his wife,Mary.

I explain to Mrs. Owusu Ansah that she can pay her husband visits at 5:30am to

6:30am in the morning, 12:30pm to 1:30pm in the afternoon and 5:30pm to 6:30pm in the

evening. Mr. Ansah’s vital signs were checked and recorded as follows:

Temperature - 38.5 Degree Celsius (0C).

Respiration - 20 beats per minute (bpm).

Pulse - 78 cycles per minute (cpm).

Blood Pressure - 110/80 millimeters of Mercury (mmHg).

Weight - 60 kilograms (kgs).

Height - 150.4centimeters (cm).

Drugs and Infusions for treatment or Mr. Ansah were collected from the

pharmacy department. He was made comfortable in bed and the nursing process was used

to plan for his care.

6
 PATIENT’S CONCEPT ABOUT HIS ILLNESS

Mr. Ansah did not attribute his illness to any spiritual force. He said his illness

could have been something he might have eaten. However, he expressed his confidence

in the doctors and nurses at the hospital and was ready to co-operate with them for the

management of his condition.

LITERATURE REVIEW ON GASTROENTERITIS

Definition:

Gastroenteritis is an inflammation of the stomach and intestines. It is

characterized by diarrhea, nausea and vomiting and abdominal cramps. Brunner and

Suddarth (1988).

INCIDENCE

7
 It occurs in persons of all ages and it is a major cause of mortality and morbidity

in under developed nations. It can be life-threatening in the elderly and debilitated

people.

CAUSES

Gastroenteritis is caused by the following:

a) Bacteria - Escherichia Coli, salmonella groups, shigella groups,

Staphylococcus.

b) Virus - Rotavirus, Enterovirus.

c) Protozoa - Entamoeba histolyliea, Giaelia intestinalis.

d) Helminthes - Strongyloids, Ascaris.

e) Toxins - Plants, Toad stools.

The bowel reacts to any of these enterotoxins with hyper motility producing severe

diarrhea and secretion of water and electrolyte.

PATHOPHYSIOLOGY

8
 Bacterial and viral agents that cause gastroenteritis produce pathologic conditions

in one of these three (3) ways.

a) Toxigenic agent such as shigella strains and enterotoxigenic [Link] release

enterotoxins that acts in the small intestines to produce a local inflammation and

secretary diarrhoea with rapid loss of electrolytes.

b) Invasion pathogens such as shigella, campytobacter and invasion strain of [Link]

penetrate the small or large intestines producing cellular destruction necrosis and

potential ulceration. The diarrhoeal stools in these conditions sometimes contain

leucocytes and erythrocytes.

c) Some pathogenic such as the rotavirus attaches itself to the mucosal epithelium

without invasion. They destroy intestinal villi, resulting in mal absorption of

electrolyte and the potential for electrolyte imbalance.

The general effect of all the above pathologic condition is to increase

gastrointestinal motility and to increase the secreting rate of fluid and electrolyte

into the intestines. The outcome may be rapid dehydration, electrolyte imbalance,

circulatory failure and death. Fluid and electrolyte loss in other forms of

gastroenteritis may develop more gradually or may not occur at all.

Infants, children, and debilitated people are at greater risk for severe dehydration.

The attachment of the pathogens to the mucosa may be altered by non specific resistance

factors in the host such as:

9
 a) The PH of the gastrointestinal tract acts to impede the growth of some

microbes altering the PH through the ingestion of antacids reduces the

effectiveness of this defense.

b) The normal bacterial flora of the intestinal tract acts to inhibit attachment by a

production of volatile organic acids. If the normal flora is diminished as a

result of antibiotic therapy or malnutrition this host defense becomes

ineffective.

c) Normal gastroenteritis motility purges the intestinal tract of many pathogens

and interference with this function increases the risk for invasion of

pathogens.

Specific immune responds of varying duration occur in the host following infection with

shigella, parovirus like agents, rotavirus and [Link].

CLINICAL FEATURES

The clinical features of gastroenteritis vary in severity and duration according

to the type of infection or causative organism. The clinical features are classified into

mild and severe:

MILD:

a) Loose stools from 2-4 to 10-12 per day.

b) Irritability and loss of appetite.

c) Minimal dehydration.
10
 d) Normal and slight sunken eyes and fontanelles.

SEVERE:

a) Diarrhoea with vomiting.

b) Dehydration.

c) Dry skin and loss of turgor.

d) Sunken eyes and fontanelles.

e) Weak but rapid pulse.

f) Greenish and probably, bloody tinged stools(mucoid stool)

g) Colicky abdominal pain and distension

h) Mild pyrexia

i) Drowsiness

j) Oliguria

k) Cold extremities

l) Oedematous legs

DIAGNOSTIC INVESTIGATIONS

a) Patient’s history

b) Stool culture for both bacterial and viral pathogens

c) Blood Examination to rule out malaria (septicemia)

d) Electrolyte level estimation – B U N, creatine

11
 SPECIFIC MEDICAL TREATMENT

The treatment of gastroenteritis is mainly medical

AIM:

a) To primarily establish a normal fluid and electrolyte balance

b) Patient is isolated till the causative organism is detected

c) Oral rehydration therapy to restore and maintain fluid and electrolyte balance

d) Intravenous fluid therapy e.g. Dextrose Saline

e) Anti malarial and anti microbial drugs

f) Gradual addition of non-irritating diets. Milo products are not given at rest

because they can irritate the gastric mucosa and induce diarrhoea. Also salty

foods should be avoided.

SUPPORTIVE TREATMENT

a) Bed rest

b) Nutritional support

c) Increase fluid intake/medication

d) Personal hygiene

e) Observation

f) Emotional support

g) Health education and prevention

12
 COMPLICATIONS

a) Dehydration

b) Fluid and electrolyte imbalance

c) Nutritional Anaemia

d) Circulatory failure

e) Intussusceptions

f) Death

VALIDATION OF DATA

This is the process to confirm or verifying that data collected is correct. The

purpose of data collected is to keep it free from any errors, bias and misinterpretations.

The data collected on Mr. Samuel Owusu Ansah and his family was cross checked by

nurses and doctors. All investigations, clinical features and pathophysiology of

[Link]’s condition were compared with other textbooks and found to be valid.

The purpose of the data collected was achieved since the data was free from

bias ,errors and misinterpretation

13
 CHAPTER TWO

ANALYSIS OF DATA

This is the act of comparing data collected on my client with standard. It is the

second stage of the nursing process and includes patient/family strength, health problem

and diagnosis.

COMPARISON OF DATA WITH STANDARDS

This involves comparing the causes, clinical features and diagnostic

investigations on patient’s condition with the standard on the literature review.

DIAGNOSTIC INVESTIGATIONS

The laboratory investigations ordered and carried out on Mr. Ansah during his

stay at the hospital were as follows

a) Blood for malaria parasites

b) Blood for white blood cell count

c) Stool for routine examination

14
TABLE 1: DIAGNOSTIC INVESTIGATIONS

DATE SPECIMEN INVESTIGATION RESULTS NORMAL INTERPRETATION REMARKS

20/11/09 Blood Malaria parasite Negative Negative Patient has no malaria He was not sick of
malaria

20/11/09 Blood WBC Count 4.2x109/L 4.5×109/L Within normal range No treatment given

20/11/09 Stool Parasite and Ova No Parasite Negative There was no parasite or No treatment given
seen ova in stool

15
 CAUSES OF PATIENT CONDITION

In reference to the causes in the literature review Mr. Ansah’s condition might have been

caused by ingestion of contaminated food and water.

CLINICAL MANIFESTATION :

Clinical manifestations presented by Mr. Ansah as compared to those in the literature

review are presented in table two

16
 TABLE 2: COMPARISMS OF CLINICAL FEATURES IN LITERATURE REVIEW

WITH THAT EXHIBITEDBY MR. SAMUEL OWUSU ANSAH.

CLINICAL SIGNS IN THE MR. ANSAH’S CLINICAL FEATURES

LITERATURE REVIEW EXHIBITED.

Frequent loose stool 2-4 to 10-12 per day Frequent loose stools 4 per day to 5-6 per

day present.

Irritability and anorexia Irritability and anorexia were present

Normal or slightly sunken eyes and fontanelles Slightly sunken eyes were present

Mild dehydration Mild dehydration present

Vomiting 3-6 per day Vomiting three times present

Greenish and probably bloody tinged Greenish-yellow mucoid stool but no blood

mucoid stools stained

Oliguria Oliguria present

Weak and rapid pulse Slightly weak and rapid pulse

Colicky abdominal pain and distension Absent

Drowziness Mild drowsiness present

Pyrexia Pyrexia present

Cold extremities Absent

17
Oedematous legs Absent

TREATMENT

Mr. Ansah’s treatment was purely medical. It includes;

I. Paracetamol 1000mg 8hourly × 7 days

II. Tablet Aludrox 1000mg 8hourly ×7 days

III. Infusion Dextrose saline 500mls ( 8 hourly) × 48 hours intravenously

IV. Oral Rehydrated salt (ORS) ,500mls prepared for patient to be taken liberally

after each loose stool .

18
 TABLE3: PHARMACOLOGY OF DRUGS FOR MASTER ANSAH.

DATE DRUGS DOSAGE/ROUTE CLASSIFICATION ACTION/DESIRED ACTUAL SIDE

OF EFFECT ACTION EFFECTS/REMARKS
ADMINISTRATION OBSERVED

20/11/09 Tablet 1000mg 8hourlyx7 Non-opioid  Blocks pain impulses Patient’s fever Drowsiness, nausea,
Paracetamol days orally analgesic(Antipyretic) peripherally that was reduced to vomiting,
occurs in response to normal hepatotoxicity, hepatic
inhibition of seizures(overdose),
prostaglandin renal failure. None
synthesis observed

 Antipyretic action
from inhibition of
prostaglandin in the
CNS(hypothalamic
heat regulationg
center)

20/11/09 Tablet aludrox 1000mg 8hourlyx7 Antacid Neutralizes gastric Patient Constipation, anorexia,
hydroxide days orally hypophosphatemic. acidity, binds verbalized fecal impact,
(Anti ulcer) phosphates in gastro relieved of hypophosphatemia,
intestinal tract nausea and hypercalciuria. Non
vomiting observed

19
20/11/09 Oral When every Fluid and electrolyte To correct fluid and Patient was Constipation, nausea,
rehydrating necessary(PRN) replacement agent electrolyte imbalance relieved of vomiting, abdominal
salt(ORS) orally diarrhea. pain. Non observed

20/11/09 Infusion 500mls 8 hourly x 48 Carbohydrates Adequate utilization Fluid and Confusion, glucosuria,
dextrose saline hours intravenously of amino acids electrolyte flushing rash, warm
Total parental nutrition decrease protein, balance were feeling,
component nitrogen and prevent maintained as hyperglycaemia, fluid
Caloric agent ketosis evidenced by overload, pulmonary
normal skin edema. None observed.
Electrolyte solution Provide supplemental turgor .
calorie and electrolyte
replacement Absence of
sunken eyes

20
 COMPLICATIONS

With reference to the complications listed in the literature review, Mr. Ansah did

not develop any of them.

PATIENT AND FAMILY STRENGTHS

Patient’s strengths are the assets or resources and abilities that can help him/her to

recover quickly or cope with the disease condition. These includes healthy physiological

functioning, emotional, social and spiritual support of the person and adequate financial

support in a healthy environment

During interaction with Mr. Samuel Owusu Ansah on admission, the following

strengths were noted.

1. He had no known allergies

2. He had a supportive family

3. He was co-operative and friendly to the hospital staff

4. He was registered under the National Health Insurance Scheme

5. His drugs were taking willingly

6. He could walk without difficulties

21
 PATIENTS HEALTH PROBLEMS

A health problem is any stress be it physical, social or psychological that can

cause an overt reaction to patient’s health which needs nursing care or medical attention.

Based on the data collected on Mr. Ansah, the following problems were identified

during admission.

a) Diarrhoea

b) Vomiting(3×)

c) High body temperature(38.50C)

d) Loss of appetite

e) Mild dehydration

f) Anxiety

g) Infection

NURSING DIAGNOSIS

Nursing diagnosis is a clear concise and definite statement of the patient health

status that can be influenced by nursing interventions. It makes it possible to give a

patient comprehensive health care. This is by identifying, validating and responding to

specific health problems.

The following nursing diagnosis was made on Mr. Samuel Owusu Ansah:

22
a) Alteration in body temperature related to inflammatory process associated

with disease condition

b) Altered elimination pattern(diarrhea) related to irritated gastric

mucosa(hyperactive bowel)

c) Fluid volume deficit(dehydration) related to vomiting and diarrhoea

d) Anxiety related to unknown outcome of disease condition

e) Alteration in nutrition (less than body requirement) related to anorexia and

malabsorption

f) Risk for infection related to cannula insitu

23
 CHAPTER THREE

PLANNING FOR PATIENT/FAMILY CARE

This involves writing of the nursing care plan and it is the third phase of the

nursing process. Nursing diagnosis is used to formulate a plan on how the patient will be

cared for. Planning includes setting of priorities, goals, objectives/outcome criteria and

outlining the care strategies in the nursing care plan.

In writing the plan of care, objectives/outcome criteria must tally with nursing

diagnosis and must be arranged in order of importance.

SETTING PRIORITIES:

This is the process of establishing nursing diagnosis and problems and arranging

them in a preferential order. It is facilitated by using a frame work such as nursing theory.

Consideration is given to the urgency of the problem with the most critical problem

receiving priorities.

PATIENTS OBJECTIVES/OUTCOME CRITERIA:

After priorities of the nursing diagnosis have been established, goals and nursing

action appropriate for attaining the goals are identified. The patient and his/her family is

included in the establishment of goals for the nursing actions.

The goal is the desired outcome of the nursing intervention and the outcome is the

expected change in the patient status. Outcome criteria and statements that describe
24
specific, observable and measurable responses of the patient. They determine whether the

goals have been achieved and they are essential tools in evaluation.

PLANNING NURSING STRTEGIES/INTERVENTIONS

Nursing strategies are nursing plans used to achieve the already established goals

for the total well-being of the patient. It involves decision making and choosing one more

nursing strategies regarded as the best and the greatest probability of success.

WRITING NURSING CARE PLAN:

The nursing care plan is a writing guide used by the nursing staff to meet the

needs of the patient at a given time. It is individualized and aids in the provision of

continuity of care.

The nursing care plan is made up of the following;

a) Date and time

b) Objectives/outcome criteria

c) Nursing others/interventions

d) Evaluation

25
 THE NURSING CARE PLAN FOR MR. SAMUEL OWUSU ANSAH IS TABULATED IN TABLE 4 BELOW.

DATE/ NURSING OBJECTIVES/ NURSING DATE/ EVALUATION SIGNATURE

TIME DIAGNOSIS OUTCOME CRITERIA ORDERS/INTERV TIME

ENTION

20/11/09 Alteration in Patient’s body -monitor body 20/11/09 Goal fully met as

body temperature would temperature his temperature

temperature gradually reduce to 4hourly reduced and was

(pyrexia) normal within 30 -Tepid sponge if maintained

related to the minutes and be maintain temperature throughout his

inflammatory throughout his exceeds 37.2 hospitalization

process hospitalization as -Dress patient in

associated with evidenced by absence of light clothes

gastroenteritis. high body temperature -Give fluids

-Patient comfortable in

26
 bed frequently

-Stable vital signs -Provide adequate

-Temperature reduced ventilation

by 10C -Serve cold drinks

-Serve prescribed

anti pyretic e.g

Paracetamol.

20/11/09 Alteration in Patient will attain an -Assess for and Goal fully met as

nutrition(less adequate nutritional report signs and patient could

than body status as evidenced by symptoms of mal perform activities

requirement)rel -Weight within normal nutrition(eg weight of daily living

ated to range for patient loss) within his range

anorexia and -Usual strength and -Serve non irritant and a healthy oral

mal absorption activity tolerance food mucous membrane

-Healthy oral mucous -Serve easily was maintained.

membrane
27
digestible foods

-Serve food in bit

but frequently

-Eliminate

nauseous smell and

sight from patient.

-Assist client in

planning menu

28
DATE/TIME NURSING OBJECTIVES/ NURSING DATE/TIME EVALUATION SIGNATU

DIAGNOSIS OUTCOME ORDERS/INTERVENTION RE

CRITERIA

20/11/09 Anxiety Patient will experience -Assess client for signs and Goal fully met as client

Related to a reduction in anxiety symptoms of anxiety(e.g. could understand and

unknown within 45 minutes as restlessness, tenseness) interpretate cause, signs

outcome of evidenced by -Educate client and family and symptoms and

disease verbalization of feeling about disease condition prevention of his

condition(gastr less anxious -Encourage client and family condition.

o enteritis) -Relaxed facial to ask questions.

expression -Monitor client’s blood

-Participating in pressure 4 hourly-Orientate

activities patient on the environment

-Introduce patient to other

patients on the ward

-Explain drug regimen to

29
 patient

20/11/09 Risk for Patient will remain free -Reassure patient Goal fully met as patient

infection from infection as -Avoid bleeding from the was free from infection

related to evidenced by cannula site

cannula insitu -Absence of fever and -Ensure patency of cannula

chills -Monitor rate of flow

-White blood cell and -Attend to cannula site

differential count aseptically

within normal range

-Negative results of

cultured specimen

30
DATE/ NURSING OBJECTIVES/ NURSING ORDERS DATE/TIME EVALUATION SIGNATURE

TIME DIAGNOSIS OUTCOME

CRITERIA

20/11/09 Altered Patient’s elimination -Assess pattern and 22/11/09 Goal fully met as

09:00am elimination pattern will be frequency of patient could pass

pattern(diarrhea) restored to normal defecation daily. well formed stool.

Related to within 48 hours as -Assess for factors

irritated gastric evidenced by that may be causing

mucosa passage of well diarrhoea.

(hyperactive formed stools. -Identify and

bowel) -Reduction in eliminate foods the

urgency and cause’s bowel

consistency of stool

31
 irritations.

-Serve prescribed

drug e.g. Aludrox

20/11/09 Fluid volume Patient’s hydrational -Assess the severity 22/11/09 Goal fully met as

deficit status would be of dehydration. hydrational status

(dehydration) restored to normal -Monitor intake and were restored to

related to within 48 hours as output. normal as

vomiting and evidenced by normal -Assess the capillary evidenced by

diarrhoea. skin turgor. refill time. normal skin turgor.

-Serve required fluid -absence of sunken

and electrolyte to eyes

restore lost fluid and

electrolyte.

Administer

prescribed fluid and

electrolyte
32
replacement e.g.

Dextrose saline

500mls

-Monitor the flow

-Observe the site to

prevent swelling

33
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT/FAMILY CARE PLAN

Implementation is the fourth stage of the nursing process. It deals with the

performance or putting into action the nursing interventions described in the nursing care

plan. This stage deals with the actual care that was rendered to the patient and family

from admission to the time of discharge.

SUMMARY OF THE ACTUAL CARE RENDERED TO MR. SAMUEL OWUSU

ANSAH AND FAMILY.

DAY OF ADMISSION(20/11/2009)

[Link] Ansah was admitted on 20th November, 2009 at 10:45am to the

medical ward. He was diagnosed of gastroenteritis through the out –patient department.

The process of admission was carried out and all vital signs were taken including other

assessment. They were recorded as follows.

Temperature--- 38.5 degree Celsius

Respiration-----20 beat per minute

Pulse rate---- 78 cycles per minute

Blood pressure--- 110/80 millimeters of mercury

34
Weight------60 kilograms

Height-----150.4 centimeters.

On admission , Mr. Ansah looked quite and depicted a high level of anxiety. He

was oriented through the ward environment and all procedures that were to be carried out

on him were explained to him. He was also reassured of the readiness of nurses to consist

him in any way to facilitate his speedy recovery. The importance of the written consent

form was all explained to him later, he verbalized a reduction in his anxiety level to the

minimum.

All prescribed drugs and infusion were purchased and set with the National health

insurance. He was made comfortable in bed. An education of gastroenteritis was given

and the importance of personal hygiene and proper hand washing could play a vital role

in his recovery as how organisms are being taking in through improper hand washing.

His ORS was made and advice to drink any time he was thirsty and after visiting the

toilet.

At 6 ; 00pm he took vegetable soup as his supper and took a warm bath. At 7; 00pm, he

slept as his condition had stabilized.

35
 SECOND DAY OF ADMISSION (21-11-2009)

Mr. Ansah woke up at about 6; [Link] had a warm bath. He looked more related and

refreshed after his bath. He had his breakfast which was Lipton tea with three slice of

bread.

On doctor’s rounds I was asked to continue with his prescribed treatment.

Bro. Sammy’s vital signs and fluid replacement still continued with the intake and

output being monitored closely and recorded.

Celsius, pulse of 76 beats per minute and blood pressure of110/70millimeters of mercury.

These and the care rendered to him were recorded and reported to the sister in-charge

Gastroenteritis is a communicable disease so I informed the public health unit about Bro.

Sammy’s condition. He was advised in thorough hand washing with soap and running

water anytime he visited the washroom and to practice it at home.

He passed a semi-solid stool at 10; 00am and 300mls of ORS was served and recorded

with the temperature at 37.0 degree Celsius there were no complains.

At 1; 00pm he had his lunch which was plantain with kontonmire stew. He topped it up

with 350mls of O.R.S. At about 1: 45pm he had his medication which were served and

recorded and his infusion was to be removed as ordered.

Mr. Ansah’s vital signs were checked and recorded at 6; [Link] doctors’ rounds at

6; 15pm tablet Paracetamol 1gram was prescribed on account of a temperature of 38.4

degree Celsius. Medication was served and recorded. He had soup for supper as he

36
complained that he was still heavy from the lunch he took. He listened to the news and

drifted to sleep.

I asked Mr. Ansah earlier in the day to seek his consent to pay a visit to his home

which he agreed.

THIRD DAY ON ADMISSION ( 23-11-2009)

Mr. Ansah woke up at about 6; [Link] brushed his teeth and had his bath.

He was weighed with a weight of [Link] was followed by his breakfast of maize

porridge with three slice of bread. Afterward his vital signs were checked and encourage

to take his ORS of 300mls.

During the doctor’s rounds he ordered to continue treatment, his vital signs were;

temperature 37 degree Celsius, pulse 76 cycles per minute and his blood pressure 110/70

millimeters of mercury.

I left for his residence at Agogo near Collin’s secondary school in Ashanti Akim

district. I administered his drugs and recorded his fluid intake at around 2:15 on my

return from his house. As at that time he had passed only one stool which was semi-solid.

At 6; 20pm Bro. Sammy had a warm bath, this was followed by his supper of rice balls

with palm nut soup. He read some news papers and listened to sports news and called it

day.

37
 FOURTH DAY ON ADMISSION (24-11-2009)

Bro. Sammy woke at 6; 10am and had his bath and brushed his teeth. This was

followed by a breakfast of torn-brown with skimmed milk, two slice of bread. Later his

drugs were given as ordered. We chartered for a while, this was after the doctor’s rounds

where he was declared better.

At 6; 30pm he passed a stool and had his bath. This was followed by his supper of

banku and groundnut soup. He enjoyed the meal as he was no longer anorexic. He played

with his daughter and about 8:00pm he drifted to sleep. These were his vital signs;

temperature of 36.9 degree rge of the ward.

FIFTH DAY ON ADMISSION (DISCHARGE DAY)

Bro. Sammy had his bath and was well groomed. He has his breakfast of Lipton

tea and five sliced of bread.I inquired about his knowledge about gastroenteritis .He

demonstrated this by answering some questions I asked correctly. I continued my health

education and told him he should be cautious about food and drink he takes.

I told him to eat his food warm in a clean bowl and drink from clean water. Mrs. Owusu

Ansah had her share of the education on her environment. That day the doctor declared

Bro. Sammy fit and discharged him. He was asked to come for review on 10th December

2009,no new drugs were ordered for him.

38
 I informed him about his discharge and review day. I helped him pack his things. His

bills were settled with the National health insurance scheme.

The take home drugs were as follows;

-Tablet Paracetamol 1gram three times daily for 3days.

-Oral Rehydrated Salt 5 sachet.

I saw them off to a taxi park in front of the hospital. From there, I documented his

discharge in the admission and discharge book and in the ward bed state. I

decontaminated patient’s bed and locker thoroughly with 1:10 bleach for ten minutes.

PREPARATION OF MR. ANSAH/FAMILY FOR DISCHARGEAND

REHABILITATION.

Preparation of Mr. Samuel Owusu Ansah and family towards discharge began on

the day of his admission. Preparation towards discharge is vital as it promote

understanding of basic principle of health such as hand washing thereby promoting and

maintaining health and the prompt seeking of healthcare when deviation arises in health.

Mr. Ansah was prepared for discharged during the process, Mr. Ansah and his

families were educated on gastroenteritis, its possible causes, clinical manifestations,

possible complications, and prevention. The family was also educated on the take-home

drugs, their effects, their possible side effects, and the importance of completing the drug

39
therapy, they were reminded on the need to report for review on the review date, that was

on the 10th December, 2009.

They were both happy as they left the hospital after the completion of all the

necessary discharge procedure.

FOLLOW UP / HOME VISIT FOR CONTINUITY OF CARE

Home visit gives the nurse the opportunity to visit the patient and family in their

home to identify health problems that may be in the home or anything in the environment

or community that might have caused the disease condition and evaluate the care

rendered to them.

The home visit of Mr. Ansah and family was a selective one. This was done three

times during and after his hospitalization.

FIRST HOME VISIT (12 – 11- 09)

The first home visit was made on the 21st November, 2009 around 2:00pm when

Mr. Ansah was still on admission and arrived at 2:15pm at his residence at Agogo town

opposite the Collins School Secondary School to be precise. I was welcomed by Mrs.

Owusu Ansah and her daughter. She offered me a seat and water. She called another

woman whom I got to know as sister Abena, her younger sister and I interacted with

them about their health and how they were fairing.

During my period of interaction with the family, I made a quick assessment of the

compound. The compound was well swept and a portion of the compound was not

40
cemented. There was a taken - up of dust when the wind blows. I advised the family to

sprinkle water on the ground regularly to reduce the uptake of dust which could be a

source of contamination to their food and water.

Moreover, the importance of hand washing, and keeping their environment clean

was stressed on so that they could maintain good health and reduce the growth and spread

of micro organisms from the environment. They were also advised to cover their water

since it has been discovered that mosquitoes breed best in clean water. They should sleep

under insecticide net to avoid mosquitoes from biting them prevent malaria.

They asked questions which I answered and reassured them that Mr. Ansah would

be discharged soon to join them. I informed them of my next visit which will be after his

discharge. I thanked them and was escorted to the exit of the house where I went back to

the campus at around 3:40pm.

SECOND HOME VISIT (30 – 11- 09)

My second home visit was made on 30th November, 2009. The aim of the visit

was to ensure continuity of care and assess the home situation.

I got to the house around 11:00am. I greeted them on arrival and asked of their

health which they said they were doing well. I asked Mr. Ansah how he was doing and

coping at home. I educated him on infection prevention and maintenance of good

personal hygiene and asked him to wash fruits and buy food from hygienic environment.

I answered some few questions he asked. I reminded him of the review date,

that’s 10th December, 2009.

41
 I informed the family about my next visit, thanked them for their co-operation and

asked permission to leave. They expressed their appreciation and escorted me to the exit

of the house.

REVIEW DAY (10TH DECEMBER, 2009)

10th December, 2009 was the date scheduled for Mr. Owusu Ansah to come for

review. He arrived at the Out-Patients Department of Agogo Presbyterian Hospital at

about 7:30am, where he retrieved his folder. I met him and he looked stronger and

healthier, His vital signs were checked and recorded as follows

Temperature - 36.4 Degree Celsius

Pulse - 76 Cycles per minute

Respiration - 20 Beats per minute

Blood Pressure – 110/70Milimetres of Mercury

Weight - 62Kilograms

Dr. Boateng after physical examination, declared his health status satisfactory. No

laboratory investigations were requested and no medications were also prescribed for

him. He was advice to eat well and protect himself from injury,I discussed with him that I

will pay him another visit in his home on the 28th December 2009 to terminate the

nursing care. I saw him off after everything.

42
 THIRD HOME VISIT

The third and final home visit was done on the 28th December 2009. The actual

purpose of this visit was to terminate the care which commenced on 20th November 2009.

Because the visit was a scheduled with them, Mr. Ansah and his family had

prepare food for me. The family was happy to see me again. I realized that the compound

has been cemented and the environment cleaned. I advised them on the need to seek early

treatment at the hospital since The National Health Insurance Scheme gives them access

to the hospital.

At 2:20pm this day, I terminated the patient and family care of Mr. Owusu Ansah

and his family. I thanked them for their co-operation and accepting me to care for Mr.

Ansah.

I finally asked permission to leave and they saw me off.

43
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO MR. SAMUEL OWUSU ANSAH

Evaluation is the appraisal of the set goals of the nursing care plan. It is the last

stage of the nursing process. Here, a critical look at the level of achievement of the set

objective is made.

A goal may be fully, partially or not met at all. The aim of evaluation is to

determine whether the nursing care plan implemented has been successful, especially in

terms of being beneficial to the patient and determine if care provided has met pre-

established standards.

Mr. Owusu Ansah was admitted to the medical ward through the Out-Patient

Department on 20th November, [Link] admission, at around 10:40am, looked weak,

moderately dehydrated, feverish, anxious and complained of loose stools and vomiting

and loss appetite .He was diagnosed of gastroenteritis based on signs and symptoms of

patient and physical examination. Later laboratory investigations of stool and full blood

count to rule out malaria. He was treated with the following drugs

-Tablet Paracetamol 1000 mg 8hourly x 7days orally.

-Tablet Aludrox 1000mg 8 hourly x 7days orally.

-Oral Rehydration Salt whenever necessary orally.

Infusion Dextrose Saline 500mls× 48hours.

44
 Mr. Ansah was orientated to the ward and its annexes. Treatment regimen was

also explained to alley his fears and anxieties and to gain his consent for treatment. I

reassured him of quality nursing care and competent nurses’ and doctors at the hospital.

He readily complied with treatment and this facilitated to his speedy recovery.

He was discharged on the 25th of November, 2009.

AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET AND

UNMET OUTCOME CRITERIA .

This involves any changes made in the nursing care plan. It is done if some goals

were partially or not met .With reference to the evaluation of the nursing care plan, all the

set goals form Mr Owusu Ansah were fully met within the stipulated time and so on

amendment was made.

TERMINATION OF CARE.

This is the period in which the student nurse ends his/her therapeutic relationship

with the patient and [Link] care of Mr. Samuel Owusu Ansah and family was

terminated during my third home visit on the 28th December 2009. This was a week after

he had been declared fit by Dr. Boateng during his review. Mr. Ansah and family were

appreciative as they thanked me for the care rendered to them.

45
 CHAPTER SIX

SUMMARY AND CONCLUSION

SUMMARY

The patient and family care study gives detailed account of the care which was given to

Mr. Samuel Owusu Ansah a 33 year old man who lives with his wife and daughter at Agogo in

the Asante Akim North District.

He was admitted on 20th November 2009 at the Agogo Presbyterian Hospital, with

diagnosis of gastroenteritis. The nursing process approach was used to identify his problems;

diagnosis and appropriate intervention were carried out to ensure his full recovery. Goals set to

render competent care were fully met. No complications were encountered. Mr. Ansah was

discharged by Dr. Boateng on 25th November 2009.

Home visits were carried out to ensure continuity of care. He came for review on the 10th

December 2009, after thorough physical examination he was declared fit by Dr Boateng .He

recovered from his condition so no treatment was given by Doctor Boateng

CONCLUSION

I have obtained great insight on what gastroenteritis is , causes, Pathophysiology, clinical

manifestations, treatment modalities and prevention.

I am happy to have gained this depth of knowledge which has helped me to care for Bro

Sammy and family from his admission till discharge. It has also helped me to gain more

experience in my relationship with people from diverse socio-economic background.

46
 The patient and family care study is a good assessment tool of final year nursing student

as it help in upgrading the skills and resolving their weakness.

I look forward to care for as many patients I would come in contact with especially those

with gastroenteritis by the use of the nursing process.

47
 APPENDIX I

FLUID INTAKEAND OUTPUT CHART FOR MR. OWUSU ANSAH

DATE TIME FLUID FLUID BALANCE

INTAKE(MLS) OUTPUT

20/11/09 11:00am Dextrose saline Input – 1800

500mls

2:00pm O.R.S 200mls Output – 700

3:05pm O.R.S 200mls Urine 300mls Balance = 1100

5:30pm Dextrose saline

500mls

6:00pm Soup 400mls

7:30pm O.R.S 200mls

7:35pm

21/11/09 3:00am Dextrose saline

500mls

6:00am Urine 400mls Input – 2700

6:10am Lipton 400mls Output – 1300

10:00am Urine 350mls Balance = 1400

10:30am O.R.S 300mls

1:00pm Dextrose saline

500mls

48
 6:30pm Soup 500mls Urine 300mls

7:00pm Dextrose saline

500mls

7:05pm Urine 250mls

22/11/09 3:00am Dextrose saline Input – 3050

500mls

7:05am Milo 350mls Output – 1800

8:05am O.R.S 150mls Urine 400mls Balance = 1250

12:00pm O.R.S 300mls

DATE TIME FLUID FLUID BALANCE

INTAKE(MLS) OUTPUT

22/11/09 12:10pm Urine 200mls

1:30pm O.R.S 400mls

4:00pm O.R.S 200mls

4:30pm Urine 300mls

6:30pm O.R.S 400mls

7:05pm O.R.S 250mls Urine 300mls

7:30pm O.R.S 200mls

10:00pm Urine 300mls

12:45am O.R.S 300mls Urine 250mls

23/11/09 6:20am Porridge 400mls Urine 300mls Input – 2100

49
 7:30am O.R.S 350mls Output -1100

1:00pm O.R.S 400mls Balance = 1000

2:00pm O.R.S 350mls

2:15pm Urine250mls

6:20pm Soup 400mls

6:30pm Urine 300mls

7:30pm O.R.S 300mls

24/11/09 12:30am O.R.S 300mls

Tom brown Input – 2200

6:50am 400mls

8:00am O.R.S 300mls Output – 1210

12:15pm Urine 350mls Balance = 2200

1:00pm O.R.S 450mls

6:30pm Soup 400mls

DATE TIME FLUID FLUID BALANCE

INTAKE(MLS) OUTPUT

50
 24/11/09 7:00pm O.R.S 350mls Urine 300mls

APPENDIX II

VITAL SIGNS OF MR. OWUSU ANSAH FROM DAY OF ADMISSION TO DISCHARGE

IN A TABLE

DATE TIME TEMPERATURE PULSE(Beats RESPIRATORY BLOOD

(Degree Celsius) per minute) (Cycles per minute) PRESSURE(Millimeters

of Mercury)

20/11/09 11:00am 38.5 78 c/m 20 b/m 110/80mmHg

12:00pm 76 c/m 20 b/m 110/80mmHg

21/11/09 5:30am 36.0 78 c/m 18 b/m 110/70mmHg

2:00pm 37.0 74 c/m 18 b/m 110/70mmHg

6:00pm 38.4 74 c/m 18 b/m 110/80mmHg

22/11/09 6:00am 36.0 76 c/m 20 b/m 110/70mmHg

2:00pm 36.0 76 c/m 20 b/m 110/70mmHg

6:00pm 37.5 74 c/m 18 b/m 110/70mmHg

23/11/09 6:05am 36.0 76 c/m 20 b/m 110/70mmHg

2:15pm 36.0 76 c/m 20 b/m 110/70mmHg

51
 6:30pm 36.2 76 c/m 20 b/m 110/70mmHg

24/11/09 5:45am 36.2 74 c/m 20 b/m 110/70mmHg

2:15pm S36.0 76 c/m 18 b/m 110/70mmHg

6:20pm 36.2 76 c/m 18 b/m 110/70mmHg

25/11/09 6:00am 36.0 76 c/m 20 b/m 110/70mmHg

BIBLIOGRAPHY

52
 Ackley B.J, Ladwig G.B(2006)

Nursing Diagnosis Handbook

7th edition, Mosby Elsevier.

Cholar, N (1993) Nursing Intravenous Drug Hand Book

(6th edition) Pennsylvania, springhouse.

O’shea, J.J (1996), Hand book of diseases, (6th edition), Pennsylvania,

Springhouse Co-operation.

Skidmore, L’(2006), Drug Guide For Nurses,(6th edition), Elsevier Mosby

Company, Philadelphia, U.S.A.

Smetter S.C base B.G Brunner and Saddarth’s Textbook andMedical-Surgical

Nursing 7th edition.

Ulrich, S.P & Canale S.W (2005), Nursing Care Planning Guide 6th edition.

SIGNATORIES
53
NAME OF DOCTOR:

RANK:

SIGNATURE:

DATE:

NAME OF NURSE-IN-CHARGE:

RANK:

SIGNATURE:

DATE:

NAME OF SUPERVISOR:

RANK:

SIGNATURE:

DATE:

NAME OF HEAD OF INSTITUTION:

RANK:

SIGNATURE:

DATE:

NAME OF STUDENT:

54
RANK:

SIGNATURE:

DATE:

55