CHAPTER ONE

ASSESSMENT OF CLIENT

Assessment as the first step in nursing process involves collection of information through

interviewing, observing and investigation from client’s relatives and other sources from

which analysis can be made in order to identify the problems of the client so as to plan

and implement care. The component includes:

CLIENT’S PARTICULARS

Mr. Thomas Gyamfi a 42 year old gentleman is the subject for this care study. He is a

Ghanaian and was born on the 4th of April 1968, to Madam Rose Opoku and the late Mr.

Owusu Gyamfi at Mampong Atonsu in the Ashanti region where he hails from. He

communicates only in Twi language.

Mr. Thomas Gyamfi has a height of 1.60 meters and weighs 60 kilograms. He is fair in

complexion and looks younger than his age. He is the only child of his parent but has

three step siblings. He is married with six children, of which five are girls and a boy. The

mother of his children is Madam Esi Gyamfi. He is a Christian by religion and worships

with the Methodist church by denomination.

1
FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY

Client stated that his late grandfather had diabetes mellitus and a distant aunte of his had

a minor mental illness. He also said that the family occasionally suffers from headache,

stomach ache and malaria which they sometimes ignore; however, if symptoms persist

for long, they buy drugs from the pharmacy shop, take herbal preparations and sometimes

report to the nearest clinic or hospital for treatment.

Mr. Thomas Gyamfi works as a cleaner at the ADB bank at Mampong.

According the client, his monthly salary is GH¢ 200.00, but this puts him into a low class

income earner because looking at the number of children he caters for with each having

education associated with school fees he has nothing to save for each month and

sometime he goes for an overdraft before they can survive in the month.

His wife is a trader and lives at Tafo with the children. He spends most of his time at

work and occasionally, with friends.

CLIENT’S DEVELOPMENTAL HISTORY

According to client, his mother said he was born at 9 months through spontaneous vagina

delivery at Mampong Atonsu without any complications or congenital abnormalities.

Client was not exclusively breastfed but rather had a supplementary feeding. He sat

earlier but he confirmed that mother said she cannot recall the exact time he crawled and

took the first step. He walked without assistance at age 12 months. Client said that he was

not immunized against the six childhood killer diseases. He experienced a complete

development of sexual characteristics at the age of 15years. He got married at age

2
21years. He had started having gray hair as a sign of maturity which is seen in most

members in his family.

CLIENT’S LIFESTYLE AND HOBBIES

According to client, he routinely wakes up from bed as early as 5:30am almost everyday

except on weekends which he confirms that he either relaxes for a long period since he

lives alone or spends it with his wife and children at Tafo and sometimes with friends. He

mostly retires to bed around 9:00pm each day. According to him, as soon as he is up, he

goes straight to work without brushing his teeth or taking his bath. I took the opportunity

to educate him on the need for personal hygiene and the effect it has on his health if it is

neglected before the start of the day. He comes back home after the morning cleaning to

care for his personal hygiene. He then goes back to work where he usually have his

breakfast and lunch, which is mostly kenkey with fish or fufu with soup.

After work, he takes his supper, takes his bath and then goes to bed. He empties his

bowel once in a day and his bladder whenever he feels like it. His favourite food is fufu

with any soup. He has no special hobbies. He is an introvert in nature and does not smoke

but occasionally, takes in alcoholic beverages with friends especially when he is

bereaved.

CLIENT’S PAST MEDICAL HISTORY

Client did not suffer any major illness whiles growing up, and according to him he has

not been hospitalized before. He has also not undergone any surgery or has been

3
transfused before. The major ailment he suffered was an abdominal pain about three

years ago which is related to the present condition.

CLIENT’S PRESENT MEDICAL HISTORY

Client was well after experiencing the same episode of illness three (3) years before his

admission. Until 2 weeks before his admission he started having the abdominal pain. The

pain was stabbing in nature and was associated with sensation of a mass in the abdomen,

palpitation, dizziness, easy fatigability, paleness, weight loss and anorexia. The above

complaint was becoming progressively worse so he decided to visit a clinic at

Sepebuokrom on the 5th of December, 2009, where he was referred to KATH for further

management.

4
ADMISSION OF CLIENT

Mr. Thomas Gyamfi was admitted to medical ward D3 on the 6th of January, 2010 at

6:00am in the company of one admission team member, wife and stepmother.

He was brought in a wheel chair from the Accidents and Emergency unit as a referral

from a clinic at Sepebuokrom. He came with a diagnosis of spleenomegaly on account

with a history of abdominal pain which was stabbing in nature and was associated with

sensation of mass in the abdomen, palpitation, dizziness, easily fatigueability , weight

loss and anorexia. He was under the care of Team C group of doctors headed by Dr Issac

Owusu. They were welcomed to the ward and client’s folder was collected from the

admission team member to verify particulars. He was quickly made comfortable in an

admission bed.

His relatives were hosted at the nurses’ station where they provided information on his

particulars such as name, age, address and others which were recorded in the admission

and discharge book as well as the daily ward state.

His vital signs were checked and recorded as follows:

Temperature 37.1ºC (degree Celsius)

Pulse 110 beats per minute

Respiration 24 cycles per minute

Blood pressure 130/70mmHg (millimeters of mercury)

5
Since the pulse and respiration was above the normal range, it confirmed an increased

level of anxiety. Therefore client was encouraged to rest for sometime, after he and the

family members were reassured that necessary measures will be put in place by the

competent staff to help him return to his usual state of health that is the pre illness state

with his cooperation. Blood sample were taken for an urgent full blood count, malaria

parasite, sickling and grouping and cross matching. Other investigations included Blood

Urea Electrolyte, Blood Urea Nitrogen and creatinin. Result of investigations done

included:

White blood cell count - 3.89 10ˆ3/ul

Red blood cell count - 1.57 10ˆ6/ul

Hemoglobin level - 4.5 g/dl

Malaria Parasite - Negative

Sickling - Negative

Grouping and cross matching - group O Rhesus positive

Since there was an extreme reduction of blood count, donation of blood was discussed

with client’s family. He was transfused with 1 unit of packed cells with blood group O

with rhesus factor negative with a batch number of K0054 from the blood bank but client

reacted by itching on completion, therefore a stat dose of IV hydrocortisone 200mg was

administered as prescribed. An abdominal ultrasonography revealed that there was an

enlargement of the spleen (spleenomegaly).

Prescribed drugs for client included,

6
  Intravenous hydrocortisone 200mg stat

 Tab coartem 4 tablet bd x 3

They paid a deposit of GH¢52.00 as client was not a beneficiary of the NHIS. The

opportunity was used to discuss the essence of the NHIS and they were encouraged to

register. Client’s relatives were oriented to the ward since client was weak and was

having episodes of fainting attacks. They were reassured again and were told the visiting

time which is from 6:00 – 7:00am and 3:30 – 5:30pm in the mornings and evenings

respectively. All other information was documented in the progressive sheets, daily ward

state and admission and discharge book.

CLIENT’S CONCEPT OF ILLNESS

Though he was scared about the outcome of the disease, he was hopeful that with medical

care and prayers, he will be in his normal state of health again. He did not attribute it to

superstitial beliefs but believed that it was change in body condition.

7
LITERATURE REVIEW

The spleen maintains healthy red and white blood cells and platelets. Because of its wide

variety of functions, the spleen may be affected by many conditions involving the blood

or lymph system, by infection, malignancies, liver disease, and parasites.

DEFINITION

Spleenomegaly is an enlargement of the spleen beyond its normal size. Thus spleen size

> 12cm.

INCIDENCE

Sex

 Tropical spleenomegaly syndrome (or hyperactive malarial syndrome) has a

female-to-male incidence ratio of 2:1. Otherwise, no sex predilection is

documented for spleenomegaly.

Age

 No age predilection is recognized for spleenomegaly. Nonetheless, the capsules of

older spleens are much thinner than their younger counterparts. The combination

of capsular thinning with increased spleen weight and size makes spleenic injury

more common in elderly persons. These factors account for the increased

likelihood of spleenectomy for trauma in this subgroup.

8
Race

 No race predilection is recognized for spleenomegaly. However, note that blacks

may have hemoglobin SC disease, a disorder related to sickle cell disease. Unlike

sickle cell disease that results in a small, autoinfarcted spleen, patients with

hemoglobin SC disease may have spleenomegaly that accompanies their pigment

gallstones.

CAUSES

 Infections

o Bacterial infections

o Cat scratch disease

o Infectious mononucleosis

o Other viral infections

o Parasitic infections

 Diseases involving the liver

o Biliary Artesia

o Cirrhosis (alcoholic cirrhosis, portal vein obstruction, portal hypertension)

o Cystic fibrosis

o Sclerosing cholangitis

 Hemolytic anemia’s

o Hemoglobinopathies

o Hemolytic anemia due to G6PD deficiency

o Idiopathic autoimmune hemolytic anemia

9
 o Immune hemolytic anemia

o Thalassemia

 Cancer

o Hodgkin's disease

o Leukemia

o Lymphoma

 Other causes

o Felty syndrome

o Sarcoidosis

o Sickle cell spleenic crisis

PATHOPHYSIOLOGY

Many of the mechanisms leading to an enlarged spleen are exaggerated forms of normal

spleen function. Although a wide variety of diseases are associated with enlargement of

the spleen, 6 etiologies of spleenomegaly are considered primary, including: (1) immune

response work hypertrophy, such as in subacute bacterial endocarditis or infectious

mononucleosis; (2) RBC destruction work hypertrophy, such as in hereditary

spherocytosis or thalassemia major; (3) congestive such as in splenic vein thrombosis or

portal hypertension; (4) myeloproliferative, such as in chronicmyeloid metaplasia; (5)

infiltrative, such as in sarcoidosis and some neoplasms; and (6) neoplastic, such as in

chronic lymphocytic leukemia and the lymphomas.

Miscellaneous causes of spleenomegaly include trauma, cysts, hemangiomas, metastasis,

giant abscess, and certain drugs.

10
SIGN AND SYMPTOMS

 Abdominal pain

 Back pain,

 Early satiety due to spleenic encroachment

 Symptoms of anemia due to accompanying cytopenia.

 Palpable left upper quadrant abdominal mass.

 Febrile illness (infectious)

 Pallor

 Weight loss

 Hiccups

DIGNOSTIC INVESTIGATION

 CT scan

 Full blood count and tests of your liver function

 Tests for suspected causes

 Physical examination

 Ultrasound

11
NURSING MANAGEMENT

Reassure patient and family

 Reassurance – addressing client’s misconceptions.

 Introduce client to successfully recovered clients

 Explain the condition, causes, treatments modalities, and possible complications

to client

 Assure client of the competency of the surgical/ medical team

 Provide supportive care

 Allow client to verbalise feelings and concerns

 Clarify all misconceptions

 Provide diversional therapy

Rest and sleep

 Ensure calm conducive atmosphere to promote rest

 Provide comfortable bed

 Turn on dim light to ensure sleep

 Serve warm drinks if not contraindicated to the clients condition to help

increase the blood supply to the superficial tissues and reduce blood to the

brain

 Restrict visitors during hours of sleep

 Ensure quiet environment

12
Maintain personal hygiene

 Bathing (bed bath or assisted bath) to refresh client, remove dirt’s and to

promote circulation

 Treat pressure areas to improve circulation

 Wash, dry and comb hair to prevent infestations such as pediculosis

 Care for the hands and feet at least once a week

 Change linens when soiled

 Wash clients hands before and after visiting the toilet and before and after

meals

 Provide oral care to prevent oral infections

Observations

 TPR and BP quarterly, half hourly, hourly, 2 hourly and 4 hourly and increase the

time duration as the condition improves

 Monitor fluid and electrolyte balance and document

 Monitor fluid intake and output chart and intervene appropriately

 Observe the client for the clinical manifestations of the condition

 Assess for any possible complications of the condition and document

 Assess the therapeutic and side effects of all medications and intervene

appropriately

 Assess the clients level of orientation/ consciousness and document

 Assess the clients weight

 Elimination including colour, amount, odour and clarity and document

13
  Observe site for infusions for any swelling and the drop rate

 Assess for signs of dehydration including poor skin turgor, increased capillary

refill time

 Assess signs of increasing intracranial pressure

 Assess for signs of over hydration

 Take measures to avoid infection

 Measurement of abdominal girth

NUTRITION

 Collaborate with the nutritional therapist to provide clients meal

 Involve client and relatives in decisions regarding the meals planning

 Consider the clients culture in relation to the meals and intervene

appropriately

 Assess for any nutritional restrictions and why

 Provide parenteral nutrition in severe cases of the condition

 Maintain fluid intake and output chart

 Assess fluid and electrolyte balance

 Serve food in bits and attractively.

 Ensure that easily digestible nourishing meals are always provided

 Encourage exclusive breastfeeding for the first six months

 Encourage frequent feeding of the client or child if client cannot take

enough at a go.

 Give mouth care to prevent halitosis and promote appetite.

14
MEDICAL MANAGEMENT

When possible, a doctor treats the underlying disease that caused the enlarged spleen.

Surgical removal of the spleen may be necessary but can cause problems, including an

increased susceptibility to infections. However, the risks are worth taking in certain

critical situations: when the spleen destroys red blood cells so rapidly that severe anemia

develops; when it so depletes stores of white blood cells and platelets that infection and

bleeding are likely; when it is so large that it causes pain or puts pressure on other organs;

or when it is so large that parts of it bleed or die. As an alternative to surgery, radiation

therapy can sometimes be used to shrink the spleen.

COMPLICATION

 Abdominal distention

 Hemolytic anemia

 Spleenic infarction

 Spleenic rapture

 Hypersplenism

VALIDATION OF DATA

15
Validation of data is done to render the work piece free of biases and misinterpretations.

The data gathered from relatives and literature review, were compared to those obtained

from client and found to be genuine. Majority of the signs and symptoms manifested by

client were in accordance with those of the literature review and results from the

abdominal ultrasonography thus confirmed that client’s condition was Spleenomegaly.

CHAPTER TWO

16
 ANALYSIS OF DATA

Analysis of data involves a critical look into the information gathered in order to draw

final conclusion on client’s condition and plan to solve problems identified.

DIAGNOSTIC INVESTIGATIONS

The following diagnostic investigations were requested and done for client, it included:

 Blood for full blood count

 Presence of malaria parasites

 Sickling test

 Grouping and cross matching

 Blood urea nitrogen

 Blood urea nitrogen and creatinine

 Abdominal ultrasonography

17
 TABLE ONE DIGNOSTIC INVESTIGATION REQUESTED AND DONE FOR CLIENT

Date Specimen Investigatio Result Normal Interpretation Remarks

ns Range

6/01/2010 Blood White blood 3.89 10ˆ3/ul 2.60-8.50 Within normal Show no sign of

cell count 10ˆ3/ul range infection

6/1/2010 Blood Red blood cell 1.57 10ˆ6/ul 4.50-5.50 Result is below Client was

count 10ˆ6/ul normal range which haemotransfused with 1

indicate anemia (one) pint of blood with

a batch number of

K0054

6/1/2010 Blood Haemoglobin 4.5 g/dl 14.5-18.0 Level is below Client was

Level g/dl normal range haemotransfused with 1

indicating anemia (one) units of blood

and haematinics were

18
 administered as

prescribed

6/1/2010 Blood Sickling Negative Circular Normal Client has no sickle cell

biconcave

RBC

6/1/2010 Blood Malaria No malaria There Normal No treatment given

parasite seen should be

no malaria

parasite

6/1/2010 Blood Grouping and Group O A, B, AB,O Client can receive This helped the health

cross Rhesus with Rhesus blood from group team to detect the

matching positive (+ or - ) O+ blood group of client to

help in the transfusion

because client had a

reduction in

haemoglobin level and

19
 red blood cell count

8/1/2010 Blood Renal 623mmol/l 250-830 Within normal No treatment given

Function Test: mmol/l range

urea

8/1/2010 Blood Creatinine 94 umol/l 62-106 Within normal No treatment given

umol/l range

8/1/2010 Blood Blood urea 6.6mmol/l 5.0- Within normal No treatment given

nitrogen/creati 36.0mmol/l range

nine ratio

8/1/2010 Blood Sodium 136 mmol/l 135-145 Within normal No treatment given

mmol/l range

8/1/2010 Blood Potassium 3.6 mmol/l 3.5-55 Within normal No treatment given

mmol/l range

8/1/2010 Blood Chloride 108 mmol/l 90-110 Within normal No treatment given

20
 mmol/l range

10/1/2010 Blood White blood 3.25 10ˆ3/ul 2.60-8.50 Within normal Tablet Cefuroxime

cell count 10ˆ3/ul range 250mg tds ×7 was

given to rule out

possible infectious

agent.

10/1/2010 Blood Red Blood 1.87 10ˆ6ul 4.50-5.50 below normal range Tablet Folate 1daily

cell 10ˆ6/ul which indicate ×15

anemia

10/1/2010 Blood Haemoglobin 5.0 g/dl 14.5-18.0 below normal range Tablet Fersolate 200mg

g/dl which indicate tds ×15

anemia

14/1/2010 Blood White blood 3.35 10ˆ3/ul 2.60-8.50 Within normal Tablet Amoksiclav

21
 cell 10ˆ3/ul range 1.2g bd×3

14/1/2010 Blood Red blood cell 2,32 10ˆ6/ul 4.50-5.50 Below normal Tablet Fersolate

10ˆ6/ul range 1daily×15

14/1/2010 Blood Haemoglobin 6.4 g/dl 14.5-18.01 Below normal Tablet Fersolate 200mg

g/dl range tds×15

CAUSES

With reference to the causes in the literature review, the causes of spleenomegaly are; Infections, Diseases involving the liver,

Hemolytic anemia’s, Cancer and other causes. From investigations, client’s condition was caused by Hemolytic anemia

22
TABLE 2 COMPARISON OF CLINICAL FEATURES IN THE

LITERATURE REVIEW TO THE CLINICAL

FEATURES EXHIBITED BY CLIENT

CLINICAL FEATURES IN CLINICAL FEATURES SHOWN

LITERATURE REVIEW BY CLIENT

There is abdominal pain Client complained of an abdominal pain

which he described as stabbing in nature

There is back pain Back pain was not experienced by client

There is early satiety Early satiety was present on observation

and was confirmed by client

There is symptoms of anemia Severe anemia was present since the

haemoglobin level dropped drastically to

4.5g/dl which lead to easy fatigability of

client

There is palpable left upper quadrant There was an abdominal mass at the upper

abdominal mass left quadrant

There is febrile condition Fever was present (37.8) on the 4th day of

admission

There is pallor Client was pale on observation

There is weight loss Client had weight loss

There is hiccups There was no sign of hiccups

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TREATMENTS

Medical treatments

 Tablet Cefuroxime 1.5g stat then 750mg × 7

 Tablet Fersolate 200mg tds ×15

 Tablet Paracetamol 500mg tds × 5

 Tablet Fersolate 1daily × 15

 IV Hydrocortisone 200mg stat

 Tablet Coatem 4 tablet bd × 3

 IV Phenegan 25mg stat

 IV Amoksiclav 1.2g bd × 3

Other treatment

Blood transfusions

 1 unit of blood was set up on the 6th of January, 2010 with batch number K0054 at

10:30am and completed at 12:50pm

 1 unit of blood was set up on the 9th of January, 2010 with batch number MB0026

at 2:45pm and completed at 6:15pm

 1 unit of blood was set up on the 12th of January, 2010 with batch number K0211

at 11:35am and completed at 12:15pm

24
 TABLE 3 PHARMACOLOGY OF DRUGS

Date Drug Dosage/ Classification Action Of Actual Side Effect Remark

Route Of Drug Drug Action

Observed

On Client

6/1/10 Intravenous 1.5g stat then Antibiotic It inhibits cell Prevented Nausea, None of

Cefuroxime 750mg tds×7 (Bacteriociadal) wall synthesis, occurrence anorexia, these

Intravenously promoting of infection vomiting, were

then Orally osmotic diarrhea, observed

instability; temperature with

usually elevation client

bactericidal

25
6/1/10 Tablet Fersolate 200mg tds × 15 Hematinics Provides Helped to Nausea, None of

Orally elemental iron, boost epigastic pain, these

an essential hemoglobin vomiting, were

component in level constipation, observed

the formation diarrhea, black with

of hemoglobin stools client

6/1/2010 Tablet 500mg tds×5 Analgesics non- To a lesser Client pain Hemolytic None of

Paracetamol Orally salicylate extend blocks was relieved anemia, these

antipyretic non- pain impulse as client had neutropenia, occurred

nacortic through a relaxed leucopenia,

peripheral facial liver damage,

action expression hypoglycemia

6/1/2010 Tablet Folate 1daily ×15 Protein binding Stimulates Helped to Rash, pruritus, None of

orally and vitamin normal boost red erythema these

supplement erethropoeisis blood cell occurred

and

26
 nucleoprotein level

synthesis

6/1/2010 Intraveneous 200mg stat Anti- Decrease Allergic Euphoria, None of

Hydrocortisone Intravenously inflammatory inflammation, reaction was insomnia, these

drug mainly by treated hypertension, were

stabilizing edema, peptic observed

leukocyte ulcer with

lysosomal client

membranes;

suppresses

immune

response

6/1/2010 Tablet Coartem 4 tablets bd×3 Antimalaria Unknown. May Prevented Nausea, None was

27
 orally bind to and the vomiting, observed

alter the occurrence diarrhea

properties of of malaria

DNA in

susceptible

organisms

9/1/2010 Intravenous 25mg stat Antiemetic and Competes with It prevented Sedation, None was

Phenegan Intravenously antihistamin histamine for allergic confusion, observed

H1-receptor reactions hypertension,

sites on effector blurred vision,

cells. Prevents urine retention,

but does not nausea,

reverse, vomiting, dry

histamine mouth

mediated

28
 responses

9/1/2010 Intravenous 200mg stat Anti- Decrease Allergic Euphoria, None of

Hydrocortisone Intravenously inflammatory and inflammation, reaction was insomnia, these

antiallregic drug mainly by treated hypertension, were

stablilizing oedema, peptic observed

leucocyte ulcer

11/1/2010 Intravenous 1.2g bd×3 Bacteriostatic Prevent Help combat Agitation, None of

Amoksiclav Intravenously antibiotics bacteria cell infection anxiety, these

wall synthesis bacterium confusion, occurred

during and dizziness,

replication prevented glossitis,

infection stomatitis

29
OTHER TREATMENT

Date Treatment Dosage/ Classification Action Of Actual Side Effect Remark

Route Of Other Drug Action

Treatment Observed

On Client

6/01/2010 Blood 1 unit of Blood group A, Replaces Client Urticaria rash, Pruritus was

(Parked cells) blood O with B, AB, O. blood loss, received pruritus, observed and

rhesus factor increases blood and it shock, and was combated

positive blood cell and corrected the vomiting. with

intravenously improve severe intravenous

haemoglobin anaemia on a hydrocortisol

level. check after 3 200mg to stop

days the reaction.

9/01/2010 Blood 1 unit of Blood group A, Replaces Client Urticaria rash, No reaction

30
 (Parked cells) blood O with B, AB, O. blood loss, received pruritus, was observed

rhesus factor increases blood and it shock, and with client.

positive blood cell and corrected the vomiting

intravenously improve severe

haemoglobin anaemia on a

level. check after 3

days

12/01/2010 Blood 1 unit of Blood group A, Replaces Client Urticaria rash, No reaction

(Parked cells) blood O with B, AB,O. blood loss, received pruritus, was observed

rhesus factor increases blood and it shock, and with client.

positive blood cell and corrected the vomiting

intravenously. improve severe

haemoglobin anaemia on a

level. check after 3

days

31
COMPLICATIONS DEVELOPED BY CLIENT

With reference to the complications stated in the literature reviewed, my client developed

that of haemolytic anemia, abdominal distention and hypersplenism.

CLIENT AND FAMILY STRENGTHS

 Client could walk on the third day of admission, although was weak on arrival for

admission all nursing care was done with little assistance.

 He was well oriented to place, time and person.

 Client could communicate well with relative and health team in the Twi language.

 Client could maintain his personal hygiene on the fourth day of admission.

 Client relative gave their support by being with him always on visiting hours.

 Client had financial support from the relatives and they were able to pay all his

hospital bills.

32
HEALTH PROBLEMS

 Abdominal pain which was stabbing in nature on admission.

 Client had high temperature after four days of admission.

 Client had general body weakness.

 Client was anxious towards hospitalization and unknown outcome of disease

condition.

 Anorexia.

 Insomnia.

 Client had no knowledge about his condition.

 Client could not maintain personal hygiene because of weakness and

dizziness resulting in fainting attacks.

NURSING DIGNOSIS

 Alteration in comfort related to abdominal pain which was stabbing in nature

resulting from an enlargement of the spleen and gastrointestinal disturbances.

 Ineffective thermoregulation (Pyrexia 37.8ºc) related to inflammatory process to

the spleen and possible infections.

 Activity intolerance (body weakness) related to inadequate food intake and

reduction of blood and its components in the system.

 Ineffective coping (anxiety) related to hospitalization and unknown outcome of

disease condition.

33
 Altered nutrition (less than body requirement) related to anatomical changes of

the body system.

 Sleep pattern disturbance (Insomnia) related to hospitalization, pain and fear of

death.

 Knowledge deficit related to lack of information on spleenomegaly.

 Self care deficit (partial) related to weakness resulting from decreased blood

volume and oxygen supply to the vital organs.

34
 CHAPTER THREE

PLANNING FOR CLIENT/FAMILY CARE

Planning is the third phase of nursing process. It involves identification

of the client’s problems, formulation of nursing diagnosis and setting of goals and

objectives to meet the health needs of the client and family.

OBJECTIVES/OUTCOME CRITERIA

 Client will be relieved of pain within three day as evidenced by:

a) Nurses observing that client have a relaxed facial expression and abdominal

girth on check decreased.

b) Client verbalizing that the pain has subsided.

 Client will have a normal thermoregulation status within five hours as evidenced

by nurses observing that there is a thermometer reading of a reduced temperature

to a normal range of (36.2-37.2) ºC.

 Client will be able to perform activities within four days as evidenced by client

resuming normal self care activity (bathing and grooming and walking around).

 Client will be less anxious towards hospitalization and disease outcome within

twenty-four hours as evidenced by:

a) Nurses observation that client have a relaxed facial expression.

35
 b) Client verbalizing and giving feedback information on ward routine and also

involving passively in self care activities in bed.

 Client nutritional pattern will be restored within a week as evidenced by:

a) Nurses observing that client is able to eat or tolerate at least half of each meal

served.

b) Nurses observation that client’s weight increasing by 1kg within the week.

 Client will have a normal sleeping within seventy- two hours as evidenced by:

a) Nurses observing that client slept well at least two hours in the day and six

hours at night uninterrupted.

b) Client confirming that he slept well and feels refresh after each sleep.

 Client will be abreast with the disease condition within two hours as evidenced by

nurse’s observation that client is able to answer questions about the condition and

giving feedback information on the knowledge acquired.

 Client will be able to maintain his personal hygiene within five days as

evidenced by:

a) Nurses observation that client maintains his personal hygiene with little

assistance after two days in bed.

b) Nurses observation that client looked neat well groomed in bed each day.

36
TABLE 4 NURSING CARE PLAN

DAT NURSING OBJECTIVE NURSING NURSING DAT EVALUATIO SIGNATUR

E DIAGNOSI / OUTCOME ORDERS INTERVENTIO E N E

AND S CRITERIA N AND

TIME TIME

6/1/10 Ineffective Client will be 1. Give 1. Client and relatives 7/1/10 Goal fully met a

8:10am coping less anxious psychological were reassured that 8:00am nurses observed

(anxiety) towards care. they are in the hands that client and

related to hospitalization of competent staffs family have

hospitalization and disease and that they will be cheerful facial

and unknown outcome within well taken care of. expression and

outcome of twenty-four verbalized that

disease hours as 2. Assess 2. Client and family they are not

condition. evidenced by: client and member’s level of anxious but rather

a) Nurses family anxiety was assessed gave feedback

37
observation that member’s by observing their information on

client have a level of facial expression and hospital routines

relaxed facial anxiety. their responds and and assisted in

expression. behavior towards care activities in

b) Client staffs and ward bed.

verbalizing and procedures.

giving feedback

information on 3. Encourage 3. Client and family

ward routine and client and were allowed to

also involving family to express their feelings

passively in self express their of fear to help relieve

care activities in feelings of them of anxiety.

bed. fear verbally.

4. Allow 4. Client and family

client and were allowed to ask

38
family to ask questions and they

questions that were answered in

bothers them simple and clear

and answer language that they

them in understand.

simple and

clear language

to clear

misconception

5. Client’s calls were

promptly attended to

5. Promptly and sometimes, spend

attend to time with him to relax

client’s calls and relieve him of his

and spend anxiety.

39
time chatting

with him. 6. Client was

involved in self care

6. Involve activities in bed.

client in self

care activities

in bed. 7. Client and family

members were

7. Allow them allowed to give

to give feedback information

feedback on what they think

information disease outcome will

on what they be.

think disease

outcome will

be.

40
DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS / OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA TIME

6/1/10 Alteration in Client’s pain [Link] the 1. Client was 9/1/10 Goal fully met as

9:15am comfort related will be client reassured that the pain 8:00am nurses observed

to abdominal relieved he was feeling was that client have a

pain which is within three due to his condition relaxed facial

stabbing in days as and that as treatment expression and

nature resulting evidenced by: continuous the pain is client verbalized

from a) Nurses going to subside. that the pain had

enlargement of observing that subsided.

the spleen and client have a 2. Help client to 2. Client was helped

gastrointestinal relaxed facial assume a to assume a position

41
disturbances. expression and comfortable that will reduce the

abdominal position pain a little

girth on check 3. Assess clients 3. Pain assessment

decreased. level of pain was done with the

b) Client pain scale to note the

verbalizing severity, intensity and

that the pain aggravating factors to

has subsided. help combat pain.

4. Engage client in 4. Client was given a

diversional therapy. diversional therapy by

allowing patient to

watch television

programme under

lowered volume.

42
5. Observe for 5. Client’s abdominal

abdominal girth. girth was observed

daily and recorded in

the abdominal girth.

6. Administer 6. Prescribed
analgesics that is
prescribed
Tablet Paracetamol
analgesics.
500mg was
administered and
desired effect of drug
was observed. It was
detected that client
looked cheerful
without complain of
pain but none of the
side effect of drug
were detected with
him.

43
DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS / OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA TIME

6/1/10 Activity Client will be 1. Reassure client. 1. Client was 10/1/10 Goal fully met as

intolerance able to reassured that he is client resumed his

11:00am 10:00am
(body perform going to be strong normal activities

weakness) activities once again. (bathing and

related to within four grooming,

2. Perform all 2. All nursing
inadequate food days as walking around).
nursing procedures procedures were
intake and evidenced by
at a time performed at a time to
reduction of client
give client more time
blood and its resuming
to rest in order to
component. normal self
regain back his
care activities

44
(bathing and strength
grooming,

walking 3. Encourage client

3. Client was
around). to eat a balanced
encouraged to eat well
diet.
balanced diet such as

leafy vegetables and

fruits.

4. Encourage client
4. Client was
to do moderate
encouraged to do
exercises.
moderate exercises to

strengthen him and to

make him more

active.

5. Transfuse client
5. Client was
with blood.

45
transfused with one
pint of blood with a
batch number of
K0054. Pruritis as the
side effect of blood
transfusion was
noticed after the
transfusion. The ward
in charge and the
group of doctors in
charge of the client
were prompted.
Quickly, an
intravenous
hydrocotisol of 200mg
was administered to
stop the reaction and
documentation was
done in the nurses’
note.

46
DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS / OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA TIME

6/1/10 Altered Client 1. Reassure client 1. Client was 10/1/10 Goal fully met as

nutrition (less nutritional reassured that he that nurse observed

2:00pm 11:00am
than body pattern will be he will be able to eat that client was

requirement restored well very soon. able to eat well

related to within a week and client’s

anatomical as evidenced weight increased

2. Weigh client 2. Client’s weight
changed of the by: by 1.2kg at the
daily on the same increases by 0.2kg
body system. a) Nurses end of the week.
scale each day after each
observation
check from the same
that client is
scale on an electronic
able to eat

47
well or scale.
tolerate at

least half of
3. Client’s diet was
each meal 3. Plan meal with
discussed with him in
served. client.
order to come out with
b) Nurses
the food he preferred.
observation

that client’s
4. A pleasant
4. Ensure a
weight has
environment was
pleasant
increased by
ensured by putting
environment
at least 1kg in
away all nauseating
the week.
items and ensuring

good ventilation in

order to stimulate

client’s appetite.

48
 5. Meal rich in
5. Serve meal in
proteins, vitamins and
bits and
carbohydrate was
attractively.
served in bits and

attractively in order to

boost client’s appetite

considering mostly on

palava source and

green vegetable food

to increase

haemoglobin levels.

6. Snacks such as
6. Serve snacks in
juice with bread were
between meals.
served in between

meals to improve

client nutritional

49
 status.

DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS / OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA TIME

7/1/10 Self care deficit Client will be 1. Give 1. Client was 11/1/10 Goal fully met as

8:20am (partial) related able to psychological care. reassured that he will nurses observed
8:00am
to weakness maintain his be assisted to take his that client had an

resulting from personal bath until he regains assisted bed bath

decrease in hygiene within full strength. for the first two

blood volume five days as days and client

and oxygen 2. Assess skin and 2. Client’s skin and looked neat and
evidenced by:
supply to the oral mucus mucus membrane well groomed in
a) Nurses
vital organs. membrane for were assessed for any bed each day after
observation
abnormalities abnormalities but no maintaining
that client
abnormalities were personal hygiene.
maintains his

50
personal observed.

hygiene with

little 3. Bed bath client 3. Client was bath in

assistance for the first two bed for the first two

after two days days and assist days and was

in bed. client to bath and subsequently assisted

groom in bed after the third day to

b) Nurses
subsequently after bath and groom in bed
observation
the third (3rd) day. by providing him the
that client
required items such as
looked neat
sponge, pomade, tooth
and well
brush and pressure
groomed in
areas treated.
bed each day.

4. Encourage
4. Client was
early ambulation
encouraged to do few

51
and make client activities passively in

comfortable in bed bed and his bed was

after passive made comfortable by

activities. making sure it was

free from all creases

and crumps.

5. One unit of
5. Transfuse client
prescribed blood of
with prescribed
group O with rhesus
blood to reduce
factor positive and
weakness,
batch number
dizziness and
MB0026 was
fainting attacks as
transfused on the 9th of
signs of anaemia
January, 2010 and no
when necessary.
side effect was

52
 detected.

DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS / OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA TIME

7/1/10 Sleep pattern Client will 1. Reassure client. 1. Client was 9/1/10 Goal fully met as

4:00pm disturbance have a normal reassured that 8:00am nurse observed

(insomnia) sleep pattern measures will be put that client slept

related to within in place to ensure well uninterrupted

hospitalization, seventy-two sound sleep. at least two hours

pain and fear of hours as in the day and

death. evidenced by: 2. Make bed 2. A well prepared client’s report

a) Nurse comfortable for bed free from creases proved that he

observing that client. and cramps was made slept eight hours

client slept for client in order to continuous for

well at least enhance relaxation. each night.

53
two hours in

the day and

six hours at 3. Put off bright 3. Bright lights on the

night lights. ward were switched

uninterrupted. off leaving the dim

b) Client lights to enhance sleep

confirming especially before bed

that he slept time.

well and feel

refresh after 4. Minimize noise 4. Noise on the ward

each sleep. on the ward. was minimized by

lowering the volumes

of the television and

radio sets to promote

sleeping especially in

the day.

54
5. Restrict visitors 5. Visitors were

and encourage restricted from

warm shower bath entering the ward in

and intake of warm order to prevent them

beverage from disturbing client

considering fluid and warm bath was

restriction. encouraged also warm

and administer milo drink was served

prescribed as a bed ritual to aid in

analgesic to relieve inducing sleep.

pain.

6. Administer 6. Analgesics of

prescribed paracetamol 500mg

55
analgesic to relieve was administered each

pain. day as prescribed

before bed until pain

was not felt. No side

effect of drug was

seen but rather desired

effect was achieved

and documentation

was done in the drug

administration and

nurse’s note.

56
DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS / OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA TIME

8/1/10 Knowledge Client will be 1. Reassure client. 1. Client was 8/1/10 Goal fully met as

10:30am deficit related to abreast with reassured that he will 12:30pm nurses observed

lack of the disease be given required that client was

information on condition education on able to answer

spleenomegaly. within two Spleenomegaly. questions about

hours as the condition.

evidenced by 2. Allow client to 2. Client was allowed

nurse’s say what he knows to share his views on

observation about the disease. the condition in order

that client is to know his

able to answer knowledge about the

57
questions disease by building

about the from the known to the

condition and unknown.

giving

feedback 3. Educate client on 3. Client was educated

information on the disease on disease condition

knowledge condition. by defining it and

acquired. telling him some of its

causes, signs,

symptoms and

treatment in order to

enhance client

understanding about

it.

4. Encourage client 4. Client was given

58
to ask questions time to ask questions

and give feedback in order to know

information on where he did not

what has been understand properly

taught. and gave feedback

information on what

was taught.

5. Assess client on 5. Client was assessed

the education on the education given

given. in order to know

client’s level of

understanding on the

condition.

59
DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS / OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA TIME

10/1/10 Ineffective Client’s body 1. Reassure client. 1. Client was 10/1/10 Goals fully met as

thermoregulatio temperature reassured that nurses observed

8:00am 1:00pm
n (pyrexia will reduce to measures are put in that thermometer

37.8oC) related normal within place to bring the reading of 37.2 oC

to inflammatory five hours as body temperature to which is within a

process to the evidenced by normal and all normal range.

spleen and nurses procedures were

possible observations explained to him.
infections. that there is a

thermometer
2. Tepid sponge 2. Client was tepid
reading of a

60
reduced client. sponged to bring body
temperature to temperature to
a normal normal.
3. Serve cold
range of (36.2-
drinks 3. Cold drinks were
37.2) ºC.
served to reduce body

temperature.

4. Open nearby
4. Nearby windows
windows.
were opened to

promote proper

ventilation.

5. Recheck vital

signs and record. 5. Vital signs was

rechecked and

recorded as 37.2ºC

which is within the

61
 normal range.

6. Prescribed

6. Administer antibiotics were

prescribed administered and

antibiotics and recorded in the drug

record. administration chart

and nurses note.

62
 CHAPTER FOUR

IMPLEMENTATION OF CLIENT/ FAMILY CARE

This is an essential part of the nursing process which starts from the day of admission till

discharge. It involves the routine nursing care given to client to promote client’s early

recovery and to limit complication.

SUMMARY OF ACTUAL NURSING CARE

This involves the summary of the nursing care rendered to client from the day of

admission to the day of discharge.

FIRST DAY OF ADMISSION (6TH January, 2010)

Mr. Thomas Gyamfi was admitted to medical ward D3 on the 6th of January, 2010 in a

wheel chair and in the company of one admission team member, wife and stepmother.

They were all welcomed and client was made comfortable in an admission bed. He was

diagnosed of spleenomegaly. His vital signs which was checked and recorded throughout

the day ranged as listed in the table below:

63
TABLE 5 VITAL SIGNS CHART.

Time Temperature Pulse (beats Respiration Blood

(ºC) per minute) (cycles per pressure

minute) (mmHg)

6:00am 37.1 110 24 130/70

10:00am 37.0 112 28 110/60

2:00pm 37.1 110 26 110/60

6:00pm 37.3 100 24 110/70

10:00pm 37.0 80 25 110/70

The increase in the level of pulse and respiration above normal confirmed an increase in

anxiety level therefore client was encouraged to rest for some time.

Client and relatives were reassured that they are in the hands of competent staffs

and that they will be well taken care of. Client and family member’s level of anxiety was

assessed by observing their facial expression and their responds and behaviour towards

staffs and ward procedures. Client and family were allowed to express their feelings of

fear to help relieve them of anxiety. Client and family were allowed to ask questions and

they were answered in simple and clear language that they understand. Client’s calls were

promptly attended to and sometimes, spend time with him to relax and relieve him of his

anxiety. Client was involved in self care activities in bed. Client and family members

were allowed to give feedback information on what they think disease outcome will be.

At 9:15am client had an abdominal pain which was stabbing in nature. An

objective was set and the interventions which were made included the following; Client

64
was reassured that the pain he was feeling was due to his condition and that as treatment

continuous the pain is going to subside. Client was helped to assume a position that will

reduce the pain a little. Pain assessment was done with the pain scale to note the severity,

intensity and aggravating factors to help combat pain. Client was given a diversional

therapy by allowing him to watch television programme under lowered volume. Client’s

abdominal girth was observed daily and recorded. Prescribed analgesics that is Tablet

Paracetamol 500mg was administered and desired effect of drug was observed. It was

detected that client looked cheerful without complain of pain but none of the side effect

of drug were detected with him.

At 11:00am, client was weak. The following interventions were made: the Doctor

was assisted to take blood sample for an urgent full blood count and grouping and cross

matching. Client had a hemoglobin level of 4.5 g/dl therefore, Client was reassured that

he is going to be strong once again. All nursing procedures were performed at a time to

give client more time to rest in order to regain back his strength. Client was encouraged

to eat well balanced diet such as leafy vegetables and fruits. Client was encouraged to do

moderate exercises to strengthen him and to make him more active. Client was transfused

with one pint of blood with a batch number of K0054. Pruritis as the side effect of blood

transfusion was noticed after the transfusion. The ward in charge and the group of doctors

in charge of the client were prompted. Quickly, an intravenous hydrocotisol of 200mg

was administered to stop the reaction and documentation was done in the nurses’ note.

At 2:00pm, client had anorexia therefore client was reassured that he will be able

to eat well very soon. Client’s weight increased by 0.2kg each day after each check from

the same electronic scale. Client’s diet was discussed with him in order to come out with

65
the food he preferred. A pleasant environment was ensured by putting away all

nauseating items and ensuring good ventilation in order to stimulate client’s appetite.

Meal rich in proteins, vitamins and carbohydrate was served in bits and attractively in

order to boost client’s appetite considering mostly on palava source and green vegetable

food to increase haemoglobin levels. Snacks such as juice with bread were served in

between meals to improve client nutritional status.

Routines of the ward such as checking of vital signs, visiting time, ward rounds

and drug administration was explained to him so as to gain his trust and co-operation. All

drugs for the day was administered as prescribed.

66
SECOND DAY OF ADMISSION (7TH JANUARY, 2010)

Client’s general condition was fair; the other routine nursing cares such as oral hygiene

and feeding were also carried out. His vital signs were checked and recorded as follows:

Temperature ranges from 36.9 to 37.0 degree Celsius

Pulse ranges from 92 to 100 beats per minute

Respiration ranges from 24 to 26 cycles per minute

Blood pressure ranges from 120 / 80 to 120/70 millimetre of mercury.

Because client was weak, there was the need for him to observe personal hygiene.

Client was reassured that he will be assisted to take his bath until he regains full strength.

Client’s skin and mucus membrane were assessed for any abnormalities but no

abnormalities were observed. Client was bath in bed for the first two days and was

subsequently assisted after the third day to bath and groom in bed by providing him the

required items such as sponge, pomade, tooth brush and pressure areas treated.

Client was encouraged to do few activities passively in bed and his bed was made

comfortable by making sure it was free from all creases and crumps.

According to client and the night nurse, client could not sleep well during the

night therefore, Client was reassured that measures will be put in place to ensure sound

sleep. A well prepared bed free from creases and cramps was made for client in order to

enhance relaxation. Bright lights on the ward were switched off leaving the dim lights to

enhance sleep especially before bed time. Noise on the ward was minimized by lowering

the volumes of the television and radio sets to promote sleeping especially in the day.

67
Visitors were restricted from entering the ward in order to prevent them from disturbing

client and warm bath was encouraged, also warm Milo drink was served as a bed ritual to

aid in inducing sleep. An analgesic of paracetamol 500mg was administered each day as

prescribed before bed until pain was not felt. No side effect of drug was seen but rather

desired effect was achieved and documentation was done in the drug administration and

nurse’s note.

68
THIRD DAY OF ADMISSION (8TH JANUARY, 2010)

Client verbalized that, although he had an intermittent sleep, it was better than the

previous nights. His personal hygiene such as bed bath, mouth care and grooming was

maintained. His vital signs were checked and recorded as follows:

Temperature ranges from 37.0 to 37.5 degree Celsius

Pulse ranges from 94 to 104 beats per minute

Respiration ranges from 20 to 24 cycles per minute

Blood pressure ranges from 120 / 80 to 120/70 millimetre of mercury.

It came to our notice that client lack knowledge about disease condition. Client

was reassured that he will be given required education on Spleenomegaly.

Client was allowed to share his views on the condition in order to know his knowledge

about the disease by building from the known to the unknown. Client was educated on

disease condition by defining it and telling him some of its causes, signs, symptoms and

treatment in order to enhance client understanding about it.

Client was given time to ask questions in order to know where he did not understand

properly and gave feedback information on what was taught. Client was assessed on the

education given in order to know client’s level of understanding on the condition.

69
FOURTH DAY OF ADMISSION (9TH JANUARY, 2010)

Client had a sound sleep, but woke up early in the morning. Morning routine nursing care

such as assisted bed bath and grooming, mouth care and bed making were done and

documented.

His vital signs were checked and recorded as follows:

Temperature ranges from 36.9 to 37.2 degree Celsius

Pulse ranges from 80 to 106 beats per minute

Respiration ranges from 24 to 28 cycles per minute

Blood pressure ranges from 100/80 to 110/70 millimeter of mercury.

He was served with porridge and bread for breakfast and client ate well as he was

encouraged to do. Client and family were reassured that he is going to be strong once

again. All procedures were performed at a time to give client more time to rest in order to

regain back his strength. Client was also transfused with one pint of blood to help him

regain his strength, no reaction was observed.

70
FIFTH DAY OF ADMISSION (10TH JANUARY, 2010)

Routine nursing care was ensured thus: Client was assisted to maintain his personal

hygiene, all prescribed medications were administered, and His vital signs were checked

and recorded as follows:

Temperature ranges from 37.0 to 37.8 degree Celsius

Pulse ranges from 94 to 104 beats per minute

Respiration ranges from 20 to 24 cycles per minute

Blood pressure ranges from 120 / 80 to 120/70 millimetre of mercury.

Client’s temperature was high (37.8ºC) therefore client was reassured that

measures are put in place to bring the body temperature to normal and all procedures

were explained to him. Client was tepid sponged to bring body temperature to normal.

Cold drinks were served to reduce body temperature. Nearby windows were opened to

promote proper ventilation. Vital signs was rechecked and recorded as 37.2ºC which is

within the normal range. Prescribed antibiotics were administered and recorded in the

drug administration chart and nurses note.

71
SIXTH TO THE NINTH DAY OF ADMISSION (11TH – 15TH

JANUARY, 2010)

Client’s general condition was good; the other routine nursing cares such as oral hygiene

and feeding were also carried out. His vital signs were checked and recorded as follows:

Temperature ranges from 36.1 to 37.2 degree Celsius

Pulse ranges from 76 to 104 beats per minute

Respiration ranges from 20 to 29 cycles per minute

Blood pressure ranges from 110 / 70 to 120/80 millimetre of mercury.

Client’s general condition had improved and he was able to perform most activities on his

own. Client’s drug was changed from Cefroxime to Amoskiclav to help improve his

health on the (11th). On the (12th), client was haemotransfused with one pint of blood with

batch number MB0026; it was set up at 2:45pm and completed at 6:15pm. Client was

monitored throughout and no reaction was observed. On the 14th, client blood was taken

for complete blood count. Result for the test shows haemoglobin level of 6.4g/dl. Client

abdominal distension had also reduced a little as shown by an abdominal

Ultrasonography. Client was booked for discharge and asked to come for review on the

18th of January, 2010.

72
PREPARATION OF CLIENT/ FAMILY FOR DISCHARGE

The preparation of client and family for discharge began on the day of admission. The

aim was to make the family understand that client’s hospitalization was necessary to

ensure proper monitoring and care of his condition and that he will be discharged home

when his condition improves.

Client and family were reassured of competent nursing staff that will be there to care for

him since it was observed that they were anxious and disturbed about client condition and

his long stay at the hospital. They were also given series of education on the condition

(spleenomegaly).

Client was advice to take in well balanced diet rich in protein, carbohydrate, iron,

vitamins and roughage. Education was also given on how to take his drugs.

During doctors’ rounds on the 15th of January, 2010, client was discharged and

asked to come for review on the 18th of January, 2010.

The date and time of discharge were entered into the admission and discharge book and

into the daily ward state. Client hospitalization bill of GH¢450.00 was paid by client’s

brother. Client was reminded of the date for review, he was also reminded on the time

and dose of drug to be taken and the need to complete it. Client was assisted to pack his

belongings. They then thanked the health workers in the ward and bid them good bye.

73
FOLLOW UP/ HOME VISITS/ CONTINUITY OF CARE

Home visit or follow up is a friendly and purposeful visit to a client’s home to assess the

environment and health conditions of the home to assist in the education given and to

guide in the general care.

FIRST HOME VISIT (11TH JANUARY, 2010)

My first home visit to my client’s house was on the 11th, January, 2010, with the

company of his younger brother. Client lived in a compound house built with blocks and

plastered but the house was not painted. There were about 12 rooms and my client was

occupying one, which was a single room. The room was not that spacious but was well

managed.

The house had no kitchen therefore they cook in the corridor in front of their rooms.

There were two bathrooms and no toilet therefore uses that of the community toilet

facility. They have electricity and good water supply. Their household refuse is kept in a

plastic waste bin and disposed off at the main refuse dump.

74
SECOND HOME VISIT (17TH JANUARY, 2010)

This was an informed visit to assess how client was doing. Client was happy to see me

and his condition was satisfactory. However he complained of a slight abdominal pain

and I assured him that he is going to be fine soon and that he should continue with his

medication. I advised him to report to the hospital if he had any symptoms and reminded

him of his next review schedule which was on the 18th of January, 2010. Client was also

encouraged to keep his environment and personal hygiene neat and to register with the

national health insurance scheme (NHIS). I made them aware that in my next visit there

will be an introduction of a community health nurse to continue the care. After some time

of interaction, I asked permission to leave. He thanked me for the visit and escorted me

out.

THIRD HOME VISIT (10 TH FEBRUARY, 2010)

On my visit to the client, the wife had come to visit him and they were so glad and happy

to see me. Client was doing very well and he had no complains. Since I arrived with the

community health nurse a brief introduction was done. I congratulated them for

complying with the advice given to them. I finally told them that it was my last visit and

that, the community health nurse from Kenyasi will continue with the care and follow

ups. Care was finally terminated as discussed during the admission period

75
 CHAPTER FIVE

EVALUATION OF CARE RENDED TO CLIENT/FAMILY

The final phase of the nursing process is evaluation and it involves testing the outcome of

nursing orders against previously set goals.

STATEMENT OF EVALUATION

On the 6th of January, 2010 at 8:10am, the objective set to relieve client of anxiety was

fully met on the 7th January, 2010 at 8am as client and family were observed to have

cheerful facial expression and client verbalized that they are not anxious but rather gave

feedback information on hospital routines and assisted in care activities in bed.

Also, on the 6th January,2010 at 9:15am objective set to relieve client of an abdominal

pain which was stabbing in nature was fully met on the 9th January,2010 at 8 am as client

exhibited a cheerful facial expression and also verbalized that his pain had subsided

within three days.

Another objective which was set to relieve client of general body weakness within four

days was fully met on the 10th January, 2010 at 11am with good nursing management, as

client resumed his normal activities (bathing and grooming, walking around). Client’s

nutritional status was also maintained as nurses observed that client was able to eat well

and also gained weight by 1.2kg after the end of the week.

76
 Objective set on the 7th of January, 2010 at 8 am to help client to maintain his

personal hygiene was achieved on the 11th January, 2010 at 8am as nurses observed that

client had an assisted bed bath after the second day and client looked neat and well

groomed in bed.

On the same day at 4 pm, the objective set to improve client sleeping pattern was fully

achieved on the 9th January,2010 at 8am as nurses observed that client slept well.

Objective set on the 8th of January, 2010 at 10:30am to educate client on the

causes, signs and symptoms and treatment was achieved on the same day at 12:30 pm as

he was able to answer questions about the condition.

Objective set on the 10th of January, 2010 at 8am, to reduce client of pyrexia

(37.8ºC) to normal was achieved at 1pm the same day as nurses observed thermometer

reading of a gradual reduction in temperature to normal (37.2 oC) within 5 hours.

AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET

OR UNMET OUTCOME CRITERIA

Due to a careful nursing care and interventions all set goals were fully met.

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TERMINATION OF CARE

Termination of client’s care is the last phase of intervention between the nurse and the

client. Parting ways was not easy but since it was discussed on admission before

discharged they accepted it. Therefore on the last home visit which was on the 10th

February, 2010, the care was terminated successfully after seeing client to be well and

condition satisfactory.

I thanked him for his co-operation and they were grateful for the care rendered them.

SUMMARY

Mr. Thomas Gyamfi, a 41year old man was admitted to the Accident and Emergency

Unit of Komfo Anokye Teaching Hospital (KATH) as a referral case from a clinic at

Sepebuokrom. He came with a diagnosis of spleenomegaly on account with a history of

abdominal pain which was stabbing in nature and was associated with sensation of mass

in the abdomen, palpitation, dizziness, easily fatigueability , weight loss and anorexia. He

was later transferred to medical ward D3 of the same hospital on the 6th of January, 2009

at 6:00am.

Client’s health problems identified during his admission period were abdominal

pain which was stabbing in nature, altered thermoregulation, activity intolerance, anxiety,

altered nutrition, insomnia, knowledge deficit on spleenomegaly, self care deficit.

Measures were taken to care for client based on the problem identified until eventually

client was discharged on the 15th of January, 2010. His condition improved after

discharge, follow up visits were made to ensure continuity of care. Mr. Thomas Gyamfi

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was handed over to a community health nurse from Kenyasi clinic on the 10th of

February, 2010.

CONCLUSION

In conclusion, it is worth noting that the patient and family care study has benefited client

and family tremendously as their health needs were identified and necessary measures

were taken to resolve them

The sturdy has helped me gain in depth knowledge and skills in attending to client

on individualized basis.

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BIBLIOGRAPHY

Armitage ,J. (2007). Approach to the patient with lymphadenopathy and splenomegaly.

In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders

Elsevier.

Grover, S.A., Barkun, A.N., Sackett, D.L. (1993). “The rational clinical examination.

Does this patient have splenomegaly?”JAMA 270 (18): 2218–2221.

Roder ,T. (2004). Springhouse Nurse’s Drug guide. ( 5th Edition), Lippincott Williams

and Wilkins Company New York .

Lewis, H. D. (2000). Medical-Surgical Nursing, Assessment and Management of Clinical

Problems.(5th Edition), A Harcourt Health Sciences Company, Westline Industrial Drive,

St. Louis, Missouri, Ppg 1371-1378

Welle,r B.F. (2005). Bailliere’s Nurses’ Dictionary. (24th Edition), Elsevier Limited,

China.

Client’s Folder Number 37154

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 SIGNATORIES

 NAME OF CANDIDATE: PATIENCE KAI TETTEH

SIGNATURE:

DATE:

 WARD IN-CHARGE: FLORENCE APPIAH MENSAH (MRS)

SIGNATURE:

DATE:

 NAME OF SUPERVISOR: OLIVIA ESHUN (MRS)

SIGNATURE:

DATE:

 NAME OF PRINCIPAL: MATILDA A. BANSAH (MRS)

SIGNATURE:

DATE:

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