CHAPTER ONE

ASSESSMENT OF PATIENT/ FAMILY

Assessment is the first step of nursing process. It involves the collection of biographical

data from the patient him/her self or from his/her folder to help identify patients and

family well and also using the history and present information identify health problems

based on the patient’s condition.

Assessment is done to identify the patients health status and concerns to help in the

diagnosis and also enable and enhance efficient nursing care methods used for the

collection of data includes observation, interviews, history taking, literature reviews,

information from patient folder, relatives and from medical staff.

PATIENT’S PARTICULARS

Mohammed Ishmael is a 22 year old man, born on the 22nd February, 1988 to Mr. Ahmed

Abubakar and Mrs. Monica Adobea. He lives with his parents and siblings at Suame a

suburb of Kumasi Metropolis. He is the last born of his parents out of four children. He

has three female siblings who are all alive. He hails from Akomadan in the Ashanti

Region. He communicates in Twi and English language. He is fair in complexion, weighs

52 kg and has a height of about 1.3 metres tall. He is an introvert in nature. He is a

Muslim by religion and worships at the Suame Mosque. Client had his primary and junior

high school education in St. Georges Junior High School at Suame

and had his senior high school education at Adventist Senior High School at Suame. His

next-of-kin is his father Mr. Ahmed Abubakar.

1
FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY

During interactions with the parents of client and client himself, I got to know that both

parents were Genotype AS or have sickle cell traits and client is also a known sickle cell

disease patient. According to client and his parents, there are no known chronic diseases

such as Diabetes mellitus, Epilepsy, Hypertension, and mental disorder in their family.

However, the family members occasionally suffer from common ailments such as

headache, malaria and abdominal pains which are treated on Out-Patient Department

(OPD) bases and sometimes reported to a nearby pharmaceutical shop for treatment.

Socio-economically, Mohammed Ishmael belongs to the nuclear type of family although

they stay in their extended family house at Suame. The father Mr., Abubakar is a Cargo

Car driver who normally travels outside the country to neighbouring countries to deal in

general goods. The mother is also a trader who sells some of the goods brought by the

husband. Client’s family therefore belong to the middle class income group. His parents

are able to cater for his needs and that of his siblings.

Client completed his senior high school education last year and has plans to continue his

education at the tertiary level but currently he is unemployed and sorely depends on his

parents for livelihood.

2
PATIENT’S DEVELOPMENTAL HISTORY

According to client his parents told him there was no problem with his conception

through to birth. He was delivered at full term at spontaneous vaginal delivery and

weighed as a normal child. There were no congenital abnormalities. Client was

immunised against all the six killer diseases such as Poliomyelitis, Diphtheria, whooping

cough, yellow fever, measles, and tetanus. He has the BCG mark on the right shoulder.

According to client, his parents told him he was exclusively breastfed for only 2 months

and later supplementary food such as porridges was introduced alongside with breast

milk. He started having secondary characteristics such as pubic hair, breaking of voice,

and broadening of the shoulder at the age of 14 years. The information given by client

revealed that he went through a normal developmental milestone without any

complications.

PATIENT’S LIFESTYLE AND HOBBIES

According to client, after his completion of his Senior High School education, he

normally stays at home. He wakes up around 8:00am in the morning and brushes his

teeth, empties his bowel and takes his bath. He makes sure house chores assigned to him

are completed. Client is not selective with regard to food. He takes any food but likes rice

and tomato stew very much especially when it’s warm. Client enjoys reading story books,

watching television and listening to any kind of music.

3
PAST MEDICAL HISTORY

Information gathered from client revealed that at the age of 7 years he suffered an

Asthmatic Attack and was sent to Komfo Anokye Teaching Hospital (KATH) by his

parents for treatment. But since then, he has never suffered any of those attacks again.

According to client he has never undergone any surgical operation but normally suffers

from feverishness and general body pains which are mostly treated at Komfo Anokye

Teaching Hospital but sometimes get over-the-counter drugs from the nearest

pharmaceutical shops for pain relievers. Client also revealed that the sickling was

diagnosed at birth since both parents were carriers of the sickle cell traits.

PRESENT MEDICAL HISTORY

Client, who is a known sickle cell disease patient with Genotype SS, was in his usual

state of health until the sudden onset of general body pain especially at the waist and back

with chills, headache and joint pain around 10:00pm on the 29th March, 2010. He took in

1g of Paracetamol for the pain to subside but the pain resurfaced after a short relieve. He

later resulted to the use of an ointment (medical ointment) to rub his body, his back and

waist but the pain did not subside, so his parents and uncle brought him to the Komfo

Anokye Teaching Hospital for intervention and was admitted at the Medical Recovery

Ward with the diagnosis of sickle cell disease with vaso occlusive crisis.

4
ADMISSION OF PATIENT

On the 30th of March, 2010 at 12:00am, client was wheeled to the Recovery Ward from

Poly Clinic consulting Room 4 under the care of Dr. Asante. Client was accompanied by

his parents, uncle and a member of the admission team. They were welcomed to the ward

and client was immediately put into an admission bed and made comfortable after he was

reassured that adequate measures would be put in place to help manage his condition and

restore his health status. During admission, client was conscious and alert. Good

therapeutic relationship was established between client, relatives and staff at the ward.

Client appeared weak, dehydrated, and mild jaundiced.

Client’s personal information was taken and cross-checked with the information in the

folder, this included his name, age, sex, date, and next-of-kin to help confirm that he was

the right patient.

Quickly vital signs were taken which comprised of temperature pulse, respiration, and

blood pressure and recorded as follows;

Temperature - 38.20C (degree celsius)

Pulse- 92 beats per minute

Respiration - 24 cycles per minute

Blood Pressure - 130/80 millimetres of mercury

Since the temperature and respiration were above the normal ranges, night nurses reports

revealed that extra clothing were removed and tepid sponging done and recorded.

Anti- pyretic of injection Morphine 100 mg stat and Injection Tramadol 400mg in 500mls

of Normal Saline were administered as prescribed and client was advised to rest and

reassured again that if the pain subsides the temperature and respiration will return back

5
within the normal range. Side effects of these drugs such as dizziness and euphoria were

not seen on client. Client was introduced to some other patient on the ward responding to

treatment. Complaints made by client at the time of admission were chills, headache,

joint pains and general body pains.

All data collected from client were documented in the admission and discharged book

daily ward state form and daily changes book and nurses notes for continuity of care.

The following laboratory investigations were requested;

 Blood Specimen for Haemoglobin level

 White Blood Cell Count

 Differential White Blood Cell Count

 Blood film for malaria parasite

Cross-matching was not done because the client knew about the blood type and Rhesus

factor as indicated in his folder from previous hospitalization.

Drugs prescribed for client were;

 Injection Morphine 10 mg stat then PRN within 4 days

 Tablet Tramadol 400 mg in 500 ml of Normal Saline

 Intravenous Normal Saline 3.0 litres x 48 hours

 Intravenous Ciprofloxacin 400mg bd x 24hours

 Tablet Folic Acid daily x 30 days

 Injection Naklofen 75 mg daily x 5 days

 Tablet Lonart 4 tablet bd x 3 days

 Tablet Paracetamol 1g tds x 5 days

 Client’s condition on admission was weak and ill-looking.

6
CLIENT’S CONCEPT OF ILLNESS

Client’s knowledge about his illness was that he was experiencing general body pains

especially at the waist and back and was brought to Komfo Anokye Teaching Hospital

for admission.

Client did not attribute the disease to any spiritual cause. He was prepared to accept any

advice given him. He was optimistic that his signs and symptoms will be relieved

because he had the conviction that he was in the hands of competent health professionals.

7
LITERATURE REVIEW ON SICKLE CELL DISEASE

Sickle cell disease is the name of a group of disorder of red blood cells in which the

predominant haemoglobin in the red blood cell is Haemoglobin S, also known as sickle

Haemoglobin.

It can also be defined as a recessive hereditary blood disorder characterised by

erythrocytes that contain defective haemoglobin.

SICKLE CELL WITH VASO OCCLUSIVE CRISIS

This is the most common crisis of sickle cell disease. It is also known as painful crisis of

infection crisis. Usually it appears periodically after age five. It results from blood vessel

which obstruct by rigid, tangle sickle cell which causes tissue anoxia and possible

necrosis.

Vaso-occlusive crisis is characterised by severe abdominal pain thoracic muscle or bone

pain and possible increased jaundiced, dark urine low grade fever. Patient with long term

disease may experience autosplenectomy in which splenic damage and scaring is so

extensive that the spleen shrinks and become impalpable. This can lead to streptococcus

Pneumonia sepsis which can be fatal without prompt treatment.

INCIDENCE OF SICKLE CELL DISEASE

The disease is found predominantly in Africans and Black Americans. It occurs in people

from Mediterranean and Arab countries. It affects both male and females.

8
AETIOLOGY

The disease is inherited in origin. The transfers of sickle cell genes from parents to their

offsprings occur during mating when male and female gametes carry the sickle cell trait.

PREDISPOSING FACTORS OF SICKLE CELL CRISIS

The sickle cell disease may be triggered by the following

1. Infection

2. Exposure to cold

3. Dehydration

4. General Anaesthesia

5. Stress

6. Poor nutrition

7. Strenuous physical exercise

PATHOPHYSIOLOGY

The defects occur when there is a single amino acid substitution in the beta chain of

haemoglobin. The normal haemoglobin A contains two alpha and two beta chains. People

with the trait thus AS and Ac have inherited only one abnormal gene so their red blood

cell can synthesize both normal beta chains and beta sickling chains; thus they have A

and S haemoglobin. The inheritance of homozygous haemoglobin S gene cause

substitution of amino acid called Valine for glutanic acid in the beta haemoglobin chain.

9
The heterozygous AS or AC inherence of these gene result in sickle cell trait, a condition

with minimal or low symptoms of sickle cell disease.

Haemoglobin S is less soluble than haemoglobin A especially when it gives up its oxygen

to become deoxyghaemoglobin and when the PH of blood is below 7.4. When

haemoglobin is deoxygenated the molecule of the haemoglobin polymerise, thus single

molecule combining large molecules to form crystal- like substance called Tactoids. The

tactoids are firm and rigid and this brings a change in the red blood cell membrane. The

greater the concentration of sickle cell haemoglobin in the individual cells, the more the

tactoids is formed. These tactoids are usually in crescent shape, thus sickle shaped.

The ability of red blood cells to be in circulation depends on their flexibility. As the

sickle cell become rigid their movement in the blood is slowed. With low oxygen the cell

membrane are easily destroyed. Hence the blood becomes more viscous with obstruction

in capillary blood flow. A marked viscosity leads to local tissue hypoxia. Further

deoxygenating increases the rate of sickling in the red blood cells. The proportion of

irreversible sickle cells varies among homozygous sickles and this is directly related to

the severity of the disease.

FORMS OF SICKLE CELL DISEASE

There are several forms but the most common ones are;

1. SC – These are persons with sickle cell traits also called carriers 20% to 40% of

their total haemoglobin S the rest is normal.

2. SS – These are people with sickle cell, their total haemoglobin is Haemoglobin S

10
INDICATORS OF CRISIS

Suspect any of these crisis in a sickle cell patient; pale lips, tongue, palms or nail bed,

lethargy listlessness, sleeplessness with difficulty, awakening, irritability severe pains

temperature over 400C or fever of 37.80C that persist for 2 days.

CLINICAL FEATURES

1. In severe cases, there is enlargement of the liver and spleen.

2. There may be chronic anaemia

3. Severe abdominal pains may occur

4. Patient may complain of severe headache

5. Patient may experience severe joint pains

6. patient may experience loss of appetite

7. There is chest pain

8. There is shortness of breath

9. Patient with severe haemolysis becomes jaundiced

10. Irritability

11. Paleness or pallor

12. Weakness

13. Nausea and vomiting

14. Fever

11
TYPES OF SICKLE CELL CRISIS

A. Vaso Occlusive Crisis

1. Small blood vessels are occluded by the sickle shaped cells causing distal ischaemia

and infarction.

2. There is painful and swollen joints

3. Spleenomegally

4. Abdominal pain

5. Retinal damage leading to blindness

6. Seizures

7. Altered renal function, enuresis and hematuria

8. Impaired liver function

B. Splenic Sequestration Crisis

This occurs when large amounts of blood become acutely pooled into the spleen leading

to its massive enlargement. Disease in red blood cell and circulatory collapse develops

rapidly.

C. Aplastic Crisis

Bone marrow ceases production of red blood cells white blood cells and platelets.

D. Haemolytic Crisis

This is unusual but may occur in association with drugs or infection.

12
DIAGNOSTIC INVESTIGATION

In order to establish the correct diagnosis both parents needed to be tested and the

following investigation should be made.

1. Haemoglobin electrophoresis. This involves taking of blood sample on umbilical cord

at birth to provide sickle cell screening.

2. An opthalmoscopic examination to detect cork screw or coma shaped vessel in the

conjunctiva.

3. Positive family history and typical clinical features suggest cell anaemia.

4. Additional laboratory studies shows;

a. low red blood cell count

b. elevated white blood cell and platelets count

c. decreased erythrocytes sedimentation rate

d. increased serum iron level

e. decreased red blood cell serving rate

f. haemoglobin level may be low or normal.

COMPLICATIONS

1. Congestive Heart failure

2. Leg ulcer

3. Anaemia

4. Renal dysfunction

5. Delayed growth and development

6. Spleenomegaly

13
 7. Hepatomegaly

8. Progressive Hepatic dysfunction

9. Decrease life span.

SPECIFIC MEDICAL TREATMENT

There is no effective form of treatment for sickle cell disease. The use of drugs is often

for supportive and conservative treatment. The aim of treatment is to alleviate symptoms

and control painful crisis.

1. Antibiotics like ciprofloxacin are prescribed to control infection due to hypoxia

and other infection.

2. Analgesic example Morphine is given to alleviate pain of vaso occlusive crisis.

3. Folic acid supplement are given to help prevent anaemia.

4. Intravenous fluid like Normal Saline is prescribed to correct fluid and electrolyte

imbalance.

5. Malaria prophylaxis is given in endemic areas.

14
 NURSING MANAGEMENT

1. Reassurance

Client is reassured that he is in the hands of competent staff or health team, this will help

to relax client, relieve him of the fear of anxiety, restore comfort and co-operation and

establish good rapport.

Other measures that are put in place for reassuring client and giving psychological are

include giving diversional therapy such as listening to music, watching television and

movies to distract his attention especially during client’s periods of pain and anxiety.

Client could also be introduced to other patients responding to treatment to help boost

client’s confidence.

2. Position

Client is made to assume position that is not contraindicated to his condition to enhance

his comfort and promote early recovery.

3. Rest and Sleep

Rest and sleep is ensured to enhance recovery processes, conserve energy, reduce

metabolic activity, relax client and promote general wellbeing. Encourage bed rest with

head elevated to decrease tissue oxygen demand and conserve energy. This is ensured by

providing a comfortable bed which is free from creases and crumps. Remove unpleasant

odour from bedside and open nearby windows to provide adequate ventilation. All bright

lights should be switched off and dim lights replaced when necessary. Activities that are

15
going to be carried on client should be well organized not to interfere with client’s sleep.

Warm drunks should be served in the evening and provide warmth to stimulate sleep.

4. Observation

Monitor vital signs which consist of Temperature, Pulse, Respiration and Blood Pressure

and record them accordingly. Access patient’s hydration status. Thus monitor intake and

output and check for signs of dehydration such as cracked and dry lips. Record the results

in the intake and output chart.

Access for tenderness and swelling of the joints and joint deformities.

Observe patient’s level of consciousness, thus orientation to time, place person and

situation.

Monitor for signs and symptoms of sickle cell crisis and chronic complications like

congestive heart failure. Observe for signs and symptoms of infection such as fever or

chills.

Monitor patient’s respiratory status. Perform respiratory assessment including

auscultation of breath sounds regularly. Observe the rate of flow of intravenous infusion

to prevent fluid overload. Observe the amount odour and colour of client’s urine.

5. Provision of comfort

Apply warm compressors, warm thermal blankets and pads to painful areas of client’s

body to relieve pain. Never apply cold to painful areas

16
 6. Personal Hygiene

Ensure that client maintain adequate personal hygiene. Assist client to bath twice daily to

prevent body odour. Maintain adequate oral hygiene to prevent halitosis. Care for the

hands and feet of client to prevent infection. The hair should be cleaned regularly with

soap and water to prevent lice infestation.

7. Nutrition

Ensure that client receives adequate amount of folic acid rich foods such as green leafy

vegetables. Serve high caloric diet to give client energy and enough protein like fish and

eggs to build and repair worn out tissues. Encourage adequate fluid intake to hydrate the

patient. Meals served should be supplemented with fruits and vitamins to boost the

immune system. Ensure client’s mouth is well cleaned before serving his meals to

stimulate appetite.

8. Patient Education

Educate client to avoid cold temperatures, infection, strenuous exercise and high altitude

as these trigger sickle cell crisis. Emphasis on the need for prompt treatment of infection

to prevent sickle cell complication. Explain the need to increase fluid intake to prevent

dehydration. Stress on the need to inform all health care providers that he has sickle cell

disease before he undergoes any treatment. Suggest and encourage client to join an

appropriate support group such as the National Association for Sickle Cell Disease.

17
Encourage client to take in adequate amount of folic acid rich foods like green leafy

vegetables to prevent anaemia.

Teach client to take in meals that contain adequate amount of roughages to prevent

constipation and food rich in protein and carbohydrate to repair worn out tissues and give

energy as well.

9. Elimination

Serve client with bedpan and urinal on request. Observe amount, odour and colour of

stool and urine. Ensure that client meal contain adequate roughage to prevent

constipation. Encourage adequate fluid and intake to enhance free bowel movement.

10. Chemotherapy

Observe the rights of drugs administration such as right patient drug, route and time.

Administer prescribed antibiotics such as Ciprofloxacin to treat infection. Assist

physician to administer intravenous fluids to correct dehydration. Administer folic acid

therapeutic and side effects of drugs administered.

VALIDATION OF DATA

This is the act of verifying data collected from client. The purpose is to keep data free

from biases, error and misinterpretation as possible. Validation of data is done when there

are discrepancies or lack of objectivity in the data collected.

18
With reference to the data collected the signs and symptoms which client exhibit is true

clinical manifestation of Sickle Cell Disease with Vaso-Occlusive as confirmed by

literature review of the condition. Data collected from client and relatives were cross

checked with health workers, client’s folder, laboratory investigation and physical

assessment.

All these provided confirmed that client suffered from Sickle Cell with Vaso- Occlusive

Crisis.

19
 CHAPTER TWO

ANALYSIS OF DATA

Analysis of data is the second stage of nursing process. It involves the separation of

materials or information into constituent parts, the critical examination that defines

essential features and their relatives so that client and family problems are identified and

nursing diagnosis are formulated.

COMPARISM OF DATA WITH STANDARD

Comparison of data with standard is made between the cause, diagnostic investigation,

treatment, clinical features and complications relation of the information gathered from

literature review.

DIAGNOSTIC INVESTIGATION

1. Blood for malaria parasite

2. Blood for haemoglobin level estimation

3. Blood for which blood cell count

4. Blood for differential white blood cell count

20
TABLE ONE: DIAGNOSTIC INVESTIGATION DONE ON CLIENT

DATE SPECIMEN INVESTIGATION RESULTS NORMAL INTERPRETATION REMARKS

30-3-10 Blood Malaria parasite Negative No malaria Client had no malaria Client was put on

parasite present parasite in the system an antimalaria drug

( negative) tablet Lonart 4

tablets bd x3days as

prophylaxis but

upon diagnostic

investigation it was

revealed that client

had no malaria

parasite in his

system so drug

administration was

discontinued.

21
30-3-10 Blood Haemoglobin level 8.35g/dl Male Client had anaemia Haematinic such as

estimation 12-18g/dl folic acid 1 daily

Female x30 days was

11-16g/dl administered

30-3-10 Blood White Blood cell 8.21x 109 2.60-800 x 109 The total White blood Antibiotic such as

count cells were lower than Intravenous

the normal which Ciprofloxacin

indicates that client 400mg bd x was

had infection. given

22
30-3-10 Blood Differential white Client had infection Antibiotic such as

Blood cell count intravenous

Neutrophils 65.4g/dl 25.00-75.00g/ Ciprofloxacin

Lymphocyte 15.0g/dl dl 400mg bd x 1 was

Monocyte 16.9g/dl 25.00-60g/dl given

Esinophil 1.63g/dl 2.00-10g/dl

Basophil 0.2g/dl 1.0-10g/dl

0.0-1.0g/dl

23
 TABLE TWO: PHARMACOLOGY OF DRUGS ADMINISTERED TO CLIENT

DATE DRUG DOSAGE DOSAGE ROUTE CLASSIFIC ACTION ACTUAL SIDE

IN PRESENT -ATION ACTION EFFECTS
TEXT ED TO OBSERVED
BOOK CLIENT
30-3-10 Intravenous 1 litre 3.0 litres x Intravenously Sodium and To restore Client sodium Aggravation of
Normal saline within an 48 hours chloride normal saline and chloride heat, oedema,
hour. Rate replacement and chloride level was hypothermia.
and amount level maintained. Client became
is being Client was well slightly
determined hydrated oedematous but
by condition later became
normal after
medical and
nursing
intervention such
as allowing the

24
 leg to rest on a
pillow at the tail
end of the bed,
no other side
effect were
detected.

30-3-10 Tablet 1 daily for 1 daily for Orally Vitamin and Stimulate the Clients blood Respiratory
Folic Acid 30 days 30 days mineral normal count bronchiospasm,
supplement erythropoiesis improved skin-allergic
(Haematinics synthesis. reaction (rashes,
) Nutritional purities) none
support was observed
30-3-10 Tablet 4 tablets bd 4bd x Orally Antimalaria For treating Client did not Nausea and
Arthermeter/ x 3days 3days malaria show any signs vomiting,
Lumenfantrine infection and symptoms diarrhoea,
of malaria coughing. None
was observed on
client

30-3-10 Injection Clients with 10mg stat Intramuscularly Narcotic For analgesic Client did not Hypotension,

25
 Morphine weight Analysis affect complain of urine retention,
greater than pain again. itchy skin,
50kg are blurred vision,
given 4-10 sweating and
mg within bradycardia.
3-4 hours None was
observed on
client
30-3-10 Injection 100 mg 75mg daily Intramuscularly Non- opoid inhibit Client did not Oedema,
(Naklofen) initially then for 5 days analgesic, prostaglandin complain of prolonged
Diclofenac 50 mg 3 non steroidal synthesis and pain bleeding,
times daily anti suppression of heartburn,
as needed inflammatory pain and hypertension,
agent inflammation dysurea, acute
renal failure.
None was
observed on
client.

30-3-10 Intravenous 400mg bd 400mg bd Intravenous Antibacterial Inhibit bacteria Client was Vasodilatation,
12 hours x 24 hours DNA synthesis relieved of sign cardiac

26
 Ciprofloxacin by inhibiting of infection arrhythmias,
Fluroquinolo DNA gyrase such as fever intestinal
ne and death of cystitis, rash,
susceptible phlebitis. None
bacteria. was observed on
client.
30-3-10 Injection 50-100mg 400mg in Intravenous Analgesic Binds to non- Client did not Visual
Tramadol within 40- 500ml of Opoid receptors complain of disturbances,
6hours Normal and inhibit pain Vaso-dilatation,
Saline reuptake of dry mouth,
seronin and urination
norephinephrine retention and
in the central frequency purist.
Nervous System None was
and decrease observed on
pain client

30-3-10 Tablet 1g tds 1g tds for 5 Orally Antipyretics Inhibits the Client was Urticaria, rash,
Paracetamol 24hours days non opoid synthesis of relieved of liver cirrhosis,
(Acetaminophe prostaglandin renal failure,

27
 n) analysis that may serve pain and fever sodium
as mediators of retention. None
fever and pain was observed on
client
1-4-10 Intravenous 1 litre 2 litres Intravenously Intravenous Fluid Client fluid Circulatory
Ringers Lactate within 24 within 24 fluid and replacement and intake and overload,
hours rate hours electrolyte maintenance of output as well hyperglycaemia.
and amount sodium chloride as input and Client had slight
is level electrolyte oedema but
determined level was subsided after
by condition maintain medical and
nursing
interventions
were employed.

1-4-10 Intravenous 1 litre 2 litres Intravenously Intravenous Fluid Client’s fluid Cardiac
Dextrose Saline within 24 within 24 fluid and replacement and intake and overload, fluid
hours, rate hours electrolyte maintenance of output and overload,
and amount sodium chloride electrolyte electrolyte

28
 is level were imbalance.
determined maintained. Client
by condition experienced
slight oedema
and measures
were put in place
to relieve him off
signs.
30/3/10 Intravenous 20-80mg 60mg stat Intravenously Loop Inhibit the re- Client was Hearing loss,
Lasix daily Diuretic absorption of relieved of Hypotension,
sodium and being Hypoglycaemia
chloride from oedematous dyspepsia. Client
the loop of did not
Henle and distal experience any
renal tubules of these signs.
and increases
renal excretion
of water,
sodium,
chloride.

29
MEDICAL TREATMENT

1. Intravenous Normal Saline 3.0 litres within 48 hours.

2. Tablet Folic Acid 1 daily for 30 days.

3. Tablet Lonart 4 tablets bd within 3 days.

4. Injection Morphine 10 mg stat

5. Injection Naklofen 75 mg daily within 5 days

6. Intravenous Ciprofloxacin 400 mg bd within 1 day.

7. Intravenous Ringers Lactate 2 litres within 24 hours

8. Tablet Paracetamol 1g tds within 5 days.

9. Intravenous Dextrose Saline 2 litres within 24 hours.

10. Injection Tramadol 400 mg in 500ml of Normal Saline.

11.Intravenous Lasix 60 mg stat.

CAUSES

With reference to the causes in literature review there was every indication that client had the

disease through inherited Haemoglobin S gene from parent but the current aggravating factor

was presence of infection in the system of client.

30
TABLE THREE CLINICAL FEATURES OUTLINED IN THE LITERATURE
REVIEW AS COMPARED WITH THOSE EXHIBITED BY CLIENT
CLINICAL FEATURES INDICATED CLINICAL FEATURES EXHIBITED
IN LITERATURE REVIEW BY CLIENT
1. Pain at the joints 1. Client had joint pains

2. Abdominal cramps 2. Client complained of abdominal

cramps on the second day of
admission.
3. Anorexia 3. Client experienced anorexia.

4. Dehydration 4. Client was dehydrated

5. Chest pain 5. Client had no chest pain.

6. Shortness of breath 6. Client complained of shortness of

breath on the day of admission.
7. Anaemia 7. Client was anaemic on observation
of the skin, mucus membrane and
was also confirmed with results of
haemoglobin level.

8. Jaundiced 8. Client looked jaundiced but was

mild.
9. Pallor 9. There was slight paleness evidenced
on the sclera, palms and mucus
membrane.

10. Severe headache 10. Client complained of headache.

11. Spleenomegally 11. There was no enlargement of the

31
 spleen on abdominal palpitation by
the doctor.
12. Hepatomegally 12. There was no hepatomegally on
abdominal palpitation during
physical assessment of the
physician.

COMPLICATIONS

With reference to literature review the complication of sickle cell disease include

1. Delay in puberty

2. Child appear small for age

3. Retinopathy and Nephropathy

4. Infections

5. Repeated occlusion of small blood vessel and consequent infection or necrosis of major

organs.

6. Premature death

7. Body build tends to be spider like with narrow shoulder and hip long extremities curved

spine barrel chest and elongated skull. None of these complications were observed with

client.

32
CLIENT AND FAMILY STRENGTHS

Strength is a resource and ability that an individual has which can help him or her cope with the

stress resulting from his/her condition. It also involves those that the family can also do to help in

speedy recovery of client.

 Client and family strength includes health, physiological functioning coping skills,

communication skills, financial support and cognitive abilities. The strength of the client

and family will help the nurse to be able to plan effective nursing care for the client.

 Mohammed Ishmael could communicate well both in English and Twi language hence

there was effective communication with health team.

 Client could again provide information about himself and family, he was conscious of his

environment and could walk, eat, and stand with assistance.

 He was also co-operative with healthcare providers.

 Client had been insured with the National Health Insurance Scheme so all his medical

bills were catered for by the Scheme.

 Client’s family supported him emotionally and psychologically. These and more

opportunities enjoyed by client contributed to his recovery.

33
CLIENT HEALTH PROBLEMS

A health problem is any stress; be it mental, social or physical in a patient that prevents him or

her from meeting a certain health standard. Hence the client may need some professional service.

Health problems identified on client were as follows;

1. Client complained of acute joint, waist and back pain.

2. Client and family were anxious of hospitalization and unknown outcome of disease

condition.

3. Client had pyrexia of 38.20C on admission.

4. Client complained of headache.

5. Client complained of abdominal cramps on the second day of admission.

6. Client complained of insomnia resulting from changes in sleeping environment and

prognosis of disease condition.

7. Client complained of loss of appetite resulting from vomiting.

8. Client complained of constipation.

9. Client could not maintain his personal hygiene because of bodily weakness and dizziness.

10. Client had inadequate information about the precautions and management of crisis at

home.

11. Prone to oedema.

34
NURSING DIAGNOSIS

1. Pain related to tissue anoxia from disease process.

2. Anxiety related to unknown outcome of disease process and hospitalization.

3. Altered body temperature (pyrexia of 38.20C) related to infection as confirmed by an

increase levels in white blood cell count.

4. Alteration in comfort (headache) related to stress and anaemia.

5. Sleep pattern disturbance (insomnia) related to changes in environment and unknown

outcome of prognosis of the disease condition.

6. Alteration in body comfort (abdominal cramps) related to gastro- intestinal disturbance.

7. Altered nutrition (less than body requirement) related to vomiting and inadequate intake

of balanced diet.

8. Altered bowel movement (constipation) related to decrease gastro- intestinal motility

resulting from decreased activity.

9. Self care deficit (total) related to general bodily weakness and dizziness.

10. Knowledge deficit related to precautions and management of crisis at home.

11. Risk for fluid and electrolyte volume excess (oedema) related to vigorous intravenous

therapy.

35
 CHAPTER THREE

PLANNING OF CARE ON CLIENT AND FAMILY CARE

This is the third stage of nursing process. In planning, objectives are set and prioritize in short
and long term goals. Goals set are developed upon and a plan of care drawn to resolve the
nursing diagnosis within a stipulated time frame.

OBJECTIVE OUTCOME CRITERIA

1. Client will be relieved of on joints, back and waist pains within 24 hours as evidenced by
client verbalizing that he does not feel pains anymore and the nurse observing that client
has a relaxed and cheerful facial expression.

2. Client will demonstrate a decrease level of anxiety within 15 hours as evidenced by nurse
observing that client has a relaxed and cheerful facial expression.

3. Client will be able to maintain a normal body temperature within 12 hours as evidenced
by thermometer readings by the nurse showing that client’s temperature reduces into
normal range (36.2 – 37.20C).

4. Client will be relieved of headache within 24 hours as evidenced by client verbalizing

that he is relieved of headache and feel comfortable and relaxed in bed.

5. Client will be relieved of acute abdominal cramps within 24 hours as evidenced by client
verbalizing the absence of abdominal cramps.

36
6. Client will resume a normal sleep patterns within 2 days as evidenced by

i. Client demonstrating ability to fall asleep within few minutes of lying down.
ii. Night nurses’ observation that client sleeps at between 6-8 hours at night
uninterrupted.

7. Client will be able to regain his normal appetite for food within 3 days as evidenced by
nurse observing that client consumes at least half of meal served each period of feeding
each day.

8. Client will regain his normal bowel movement within 3 days as evidenced by client
verbalizing that there is absence of constipation and he is able to pass a normal
consistency and frequent at least once daily.

9. Client will be able to maintain his personal hygiene within 72 hours as evidenced by
nurse’s observation that client demonstrating decreased need for assistance for self care
activities.

10. Client will have adequate information about precautions and management of sickle cell
crisis at home within 2 hours as evidenced by client answering questions being put to him
after procedure.

11. Client will not experience excessive fluid and electrolyte imbalance after infusion therapy
within the period of hospitalization as evidenced by the absence of dyspnoea and excess
oedema, stable blood pressure and a balanced intake and output.

37
 TABLE FOUR: NURSING CARE PLAN

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGNS

TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
30/03/10 Pain related to Client will be 1. Reassure client. 1. Client was reassured that pain 31/03/10 Goal fully met as
At tissue anoxia relieved of pain will be relieved within a short At client verbalized
9: 00am from disease within 24 hours period by both nursing and 9:00am that he was no
process. as evidenced medical intervention as being more in pain and
by; put in place. was also well
1. Client relaxed in bed.
verbalizing that 2. Remove all 2. All tight clothes over joints

he is not feeling constricted clothes and and other painful areas were

the pain bed linen over painful removed and bed linen was

anymore. areas. elevated over painful areas using

2. Nurse a bed cradle.

observing that
3. Open nearby 3. All nearby windows were
client is relaxed
windows and adjust opened to improve circulation
in bed.
client’s bed. and client’s bed was elevated
from the foot end to also
improve breathing.

38
4. Reduce metabolic 4. Metabolic activities at the
activity of the affected painful areas were reduced
area and apply warm through its immobilization and
compresses over less activity. Warm compressors
painful areas. were also applied at painful area
to help reduce pain.

5. Assist client into a 5. Client’s bed was well

comfortable bed. prepared with clean sheets and
enough pillows without creases
and cramps to enhance rest and
reduce pain.

6. Divert client’s 6. Client’s attention was diverted

attention from pain. from pain by engaging client in
conversation, and watching T.V
with a lowered volume.

7. Serve prescribed 7. Prescribed analgesic Injection

analgesic. Naklofen 75 mg was
administered to relieve pain and

39
 procedure was recorded in the
drug administration chart and
the nurse’s notes.

8. Administer oxygen 8. Prescribed Oxygen of 4 liters

PRN as prescribed. was administered to client as and
when needed to enhance tissue
respiration.

40
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
30/03/10 Anxiety Client will 1. Reassure client and 1. Client and relatives were 31/03/10 Goal fully met as
At related to demonstrate a relatives. reassured that adequate at nurse observed
3:30pm hospitalization decreased level measures will be put in place to 6:30am that client
and unknown of anxiety help mange his condition. showed a
outcome of within 15 hours decreased level
disease as evidenced by 2. Educate clients and 2. Client and relatives were of anxiety
process. nurse observing relatives on the educated that there was the need through his
that client’s importance and need for client to be admitted for relaxed and
facial of hospitalization. further observation and cheerful facial
expression continuity of care for a couple of expression and
looks relaxed. days to ensure full recovery. She that of his family
was also orientated to the ward on visitation.
and its routines.

3. Educate client and 3. The disease condition causes

family about disease signs and symptoms and its
process. trigger factors were explained to
client and relatives. Prognosis of

41
 condition was made known to
them so they should not worry.

4. Questions were later poised

4. Allow client and from client and relatives and
family to ask answers were provided
questions. accordingly.

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

42
 DIAGNOSIS OUTCOME ORDERS
TIME CRITERIA INTERVENTION TIME
30/03/10 Alteration in Client will be 1. Reassure client. 1. Client was reassured that 31/03/10 Goals fully met
At body able to maintain measures will be put in place to At as night nurse
10:00am temperature a normal body control the rise in temperature. 10:00 pm observed that
(pyrexia temperature client’s body
38.20C) within 12 hour temperature
related to as evidenced by 2. Assess vital 2. Clients’ vital signs were again reduced to
infection as night nurses signs of client checked and were still outside the normal range
confirmed by observing that again. normal body temperature range (36.2 – 37.20C)
an increase client’s body (38.10C) to confirm nursing
levels in white temperature diagnosis.
blood cell reducing to
count. normal range 3. Remove extra 3. Extra clothes around client were
(36.2 – 37.20C). and constricted all removed to improve circulation
clothes from around client.
client.

4. Tepid sponge 4. Client was tepid sponged with

client. tepid water and towel .this was

43
 carried out in strokes leaving
traces of water n the skin to
evaporate bringing about a cooling
effects.

5. Open nearby 5. Nearby windows were opened

windows for to for fresh air to improve air
ventilation. circulation in the room.

6. Serve client 6. Cold Sprite was served to client

with cold drink. to help him loss some bodily heat.

7. Administer 7. Prescribed antibiotics and

prescribed antipyretics, intravenous
antipyretics and Ciprofloxacin 400mg bed within 1
antibiotics. day and tablet Paracetamol 1g
were administered respectively to
control infection and to reduce
pyrexia.

DAT/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

44
 TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
30/03/10 Alteration in Client will be 1. Reassured 1. Client was reassured that he will 31/03/10 Goal fully met as
At comfort relieved of client. be relieved of pain and also At client verbalized
12:00 (Headache) headache within measures will be put in place to 12:00 that he was
noon. related to 24 hours as ensure that headache is relieved. noon. relieved of
stress and evidenced by headache and
anemia. client also felt
verbalizing that 2. Apply cold 2. Cold compressors were applied comfortable and
he is relieved of compressors on on client’s forehead to help reduce more relaxed in
headache and client’s forehead. pain. bed.
felt comfortable
and relaxed in
bed. 3. Assess whether 3. Client bowel movement was
client has empty assessed and it was revealed that
bowel. client had not empty his bowel so
client was encouraged to empty his
bowel.

4. Educate client to 4. Client was educated to always

try and have have enough sleep because fatigue

45
 enough sleep. could cause severe headache.

5. Educate client to 5. Client was educated to always

avoid stress. try to avoid stress. Client was
encouraged to converse with
others either staff or patient to
share problems.

6. Administer 6. Prescribed analgesic such as

prescribed Tablet Paracetamol 1g and tablet
analgesic and folic acid one tablet daily were
hematinics and administered and recorded in the
record. drug administration chart and the
nurse’s notes respectively.

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

DIAGNOSIS OUTCOME

46
 TIME CRITERIA ORDERS INTERVENTION TIME
31/03/10 Sleep pattern Client will 1. Reassure client. 1. Client was reassured that 2/04/10 Goal fully met as
At disturbances resume a measures will be put in place to At night nurse’s
10:00am (insomnia) normal sleeping ensure adequate sleep. 10:00am. observed that
related to change within 2 days as client
of environment evidenced by 2. Open nearby 2. Nearby windows were opened demonstrated a
and prognosis of client windows for good to promote enough circulation. resumption of
condition. demonstrating ventilation. normal sleeping
ability to fall pattern and
asleep within 3. Provide enough 3. Warm bath, drinks and enough ability to fall
few minutes of warmth to avoid blankets were provided for client. asleep within
lying down and cold. few minutes of
night nurse’s lying down and
observation that 4. Restrict 4. Visitors were restricted from night nurse’s
client sleeps at visitors. interrupting in client’s sleep. observation that
least 6-8 hours patient slept for
uninterrupted. 5. Minimize noise 5. Nurses and other health staff about 7 hours
at the ward. were encouraged to speak uninterrupted
undertone and volumes of T.V each night
and Radios were lowered to help

47
 patient sleep.

6. Organize all 6. All interventions either

activities and medical or nursing were
perform them at a organized not to interfere with
go to limit client’s sleep.
interference.

7. Make client bed 7. A comfortable bed with clean

and assist in sheets with enough pillows were
bathing. provided for client the bed was
free from creases and cramps.
Client was also assisted to have a
bed bath to enhance comfort.

8. Adjust close 8. A dim light as preferred was

light to client’s provided to client to enhance
preference. sleep.

48
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA

49
31/03/10 Alteration in Client will be 1. Reassure client. 1. Client was reassured that 31/03/10 Goal fully met as
at body comfort relieved of abdominal cramps will be At client expressed
9:00am related to acute acute relieved within a few periods. 11:00am. an absence of
abdominal abdominal abdominal pain.
cramp due to cramps within 2 2. Assist client 2. Client was put into a
gastrointestinal hours as into a comfortable comfortable position with
disturbances. evidenced by position. assistance to help ensure comfort.
client
verbalizing the 3. Assess client’s 3. Pain assessment was done on
absence of the pain. client using the P,Q,R,S,T,U
cramps. method to note for the palliative
measure to determine the
quantity and quantity, radiation,
severity, and time of the pain and
how client perceived or
understood the pain.
Also, the numerical scale (0 - 9)
was used for client to identify the
extent of pain.
4. Keep client as 4. Foods were restricted from
nil per Os until

50
 abdominal cramps client until cramps were relieved.
subsides.
5. Educate client
on dietary 5. Client was educated on the
changes. need to avoid food until cramps
were reduced and also after
relieved of cramps, oral sips will
be given proceeding to semi
solids.
6. Encourage
diversional
6. Television was switched on for
therapy and
client to watch with volumes
restrict visitors.
lowered. Visitors were restricted
to reduce interruption.
7. Administer
prescribed 7. Injection Naklofen 75mg was
analgesic. administered intramuscularly.

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA

51
1/04/10 Altered nutrition Client will be 1. Reassure client 1. Client was reassured that he 4/04/10 Goal fully met as
At (less than body) able to regain was in the hands of competent at client was able to
3:30pm requirement his normal staff and everything will be made 6:30am. consume and
related to appetite within to enhance his appetite and tolerate half of
vomiting and 3 days as recovery. each meal served
inadequate evidenced by 2. Plan meal with 2. Meals were planned with client on after the
intake of client tolerate client. and his likes and dislikes were second day of
balanced diet. consuming at taken into consideration. identifying the
least half of 3. Maintain 3. Client was assisted to maintain problem.
each meal adequate oral his oral hygiene using mouth
served. hygiene. wash before and after each meal
to stimulate appetite. Also, she
was encouraged to brush her
teeth twice each day (morning
and evening) to keep the mouth
refreshed.
4. Organize 4. All interventions either
activities at once medical or nursing were done at a
to prevent goal to prevent interruption.
interruption Painful procedures were either
during feeding. suspended or done 30 minutes

52
 before and after meal.

5. Ensure that the 5. Nauseating items like blood

ward is clean. and vomitus were cleaned on the
ward.

6. Serve meal 6. Meal was served attractively

attractively but with flower decoration to
frequently and in stimulate appetite.
bit and also Client’s meal was served
administer frequently and also in bits to
prescribed stimulate appetite. Prescribed
hematinics. hematinics of tablets Folic acid 1
daily was recorded in drug.

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
1/04/10 Altered bowel Client will 1. Reassure client. 1. Reassurance was given to 3/04/10 Goal fully met
movement regain his client that he will regain his as client

53
At (constipation) normal bowel normal bowel movement to At verbalized that
10:00am. related to movement relieve anxiety. 7:00 am there is no
decreased within 3 days as constipation but
gastrointestinal evidenced by 2. Client was encouraged to eat rather he moved
motility client 2. Encourage foods with high fibre content. He his bowels twice
secondary to verbalizing that client to take in was served with cabbage stew each day.
decreased there is an foods rich in fibre and boiled rice in the afternoon.
activity. absence of to enhance Oranges were served to client
constipation. peristaltic after meal and he was
movement. encouraged to eat the fibre in the
orange.
3. Client was again encouraged
3. Encourage to take in more fluids like water
copious fluid to enhance intestinal motility.
intake.

4. Client was educated to do

4. Encourage exercises such as range of motion
early ambulation. exercises, breathing and
coughing exercises and also
walking around the ward with

54
 assistance to promote bowel
function.

5. Client was served with bedpan

promptly on request. Colour,
5. Serve bedpan amount, and odour stool were
promptly on observed.
request.

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
31/03/10 Self care deficit Client will be 1. Reassure 1. Client was reassured that 2/04/10 Goal fully met as
At (Total) related to able to maintain client. activities related to self care At client verbalized
general body his personal throughout stay at ward would that she relieved of

55
6:00am weakness and hygiene within be maintained with assistance 6:00am. bodily pains and
dizziness. 72 hours as from care givers. dizziness which
evidenced by made client
client 2. Client was assisted to bed maintained
demonstrating 2. Assist client to bath twice daily with warm personal with little
no need for bath in bed for water, soap and sponge and after assistance daily.
assistance with the first two days a period of two days he was
self care and subsequently encouraged to bath with little
activities. allow client to assistance.
perform personal
hygiene with
little assistance. 3. Client was assisted to brush
3. Assist client to his teeth with tooth brush and
maintain oral tooth paste daily.
hygiene daily.
4. Client finger nails and toes
4. Assist client to were trimmed with nail cutter
care for hands the nails were filed and washed
and feet if to remove foreign materials it
needed. was then lubricated with

56
 Vaseline.

5. Client was assisted in

5. Assist client in applying pomade, combing of
grooming daily. hair and wearing of clothes. He
was made comfortable in bed
and looked relaxed.

6. Observations of his coping

6. Observe client abilities were carried out and
level of physical were improving day after day.
coping with
activities and
routine cares.

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
3/04/10 Knowledge Client will have 1. Reassure 1. Client was reassured that he 3/04/10 Goal fully met as
At deficit related to adequate client. would be able to know and At client gave
precautions and information manage and prevent crisis at feedback

57
8:00 am management of about home. 10:00 am information on
crisis at home. precautions and what has been
management of 2. Client was educated on the taught. Also he
sickle cell crisis 2. Educate client predisposing factors such as answered correctly
within 2 hours on the infection exposure to cold, all question asked
as evidenced by predisposing stress, poor nutrition and on the education
client answering factors of disease strenuous physical exercise and given.
questions being condition. the need to avoid them.
put to him after
teaching. 3. Client was educated that
3. Educate client sickle cell disease is a hereditary
on the disease disease which can be transferred
condition and its to offspring by sickle cell traits
prevention and and the need to prevent it by
harmer on home choosing a life partner with no
management. trait. With home management
stress, infection and adequate
nutrition was also emphasized.

4. Client was again educated on

4. Emphasis on the need for frequent follow-ups

58
the need for and review to prevent
frequent follow- complications. Signs such as
ups and review fever, mild joint pains were
and also how to signs of onset of crisis and the
detect the onset need to know its detection.
of crisis.
5. Client was educated to join an
5. Encourage association such as the National
client to join a Association of sickle cell.
sickle cell
association.

6.Questions were poised to

6. Ask client for client and answers were
feedback. provided by client

59
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
2/04/10 Risk for fluid Client will not 1. Reassure 1. Client was reassured that he 3/04/10 Goal fully met as
at volume excess experience client. would not have fluid and At client was free
11:00am. (Prone to excessive fluid electrolyte imbalance after fluid 11:00am from the signs and
edema) related and electrolyte symptoms of fluid

60
to vigorous fluid imbalance after therapy. volume excess.
therapy for infusion therapy
rehydration. with a day as 2. Maintain fluid 2. Client’s infusion therapy was
evidenced by restriction as restricted to prescription. The
the absence of ordered. type amounts of infusion as well
dyspnoea, as rate flow were all restricted as
excessive prescribed.
oedema, stable
blood pressure 3. Keep strict 3. A strict intake and output
and a balance intake and output chart was kept by measuring or
intake and chart. observing the amount of fluid
output. diets and drinks and urine and
watery faeces passed by client.
Also, all infusion administered
were recorded and the chart was
balanced daily at the same time

4. Encourage 4. Client was educated to lie on

client to rest

61
periodically in a his back if he could tolerate.
recumbent
position if
tolerated.

5. Encourage a
reduction of 5. Client was encouraged to
sodium based reduce the intake of sodium
foods. based foods such as salt and the
need and importance for this was
made known to him.

6. Administer 6. Prescribed diuretic Lasix 60

prescribed mg was administered
diuretic if ordered intravenously to client and was
and record. recorded in the intake and output
chart and in the nurses’ notes.

62
 CHAPTER FOUR

IMPLEMENTATION OF CLIENT/FAMILY CARE PLAN

Implementation is the fourth phase in the nursing process. It is the process of putting into

action nursing orders and interventions designed for the management of the patient.

It involves the actual task and procedure performed on the patient throughout the period

of hospitalization till the time of discharge.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO CLIENT

On the 30th of March 2010 at 12:00am, client was admitted at the Medical Recovery

Ward of Komfo Anokye Teaching Hospital (KATH) through the Polyclinic Department.

The diagnosis made was Sickle Cell Disease with Vaso Occlusive Crisis. He came to the

ward conscious and alert but in a wheel chair. He was accompanied by his parent, uncle

and a member of the admission team. Client’s information was taken and cross-checked

with information in the folder to verify if he was the right patient after welcoming them

to the ward.

Client and relatives were reassured about the competency of health team at the ward after

introducing them to other nurse and staff on duty at the ward.

Since client was in pain and weak, he was put into an admission bed and made

comfortable. Relatives were provided with seats while client was being taken care of.

63
Vital signs were checked and recorded as follows: Temperature 38.20C, pulse 92 beats

per minute, Respiration 24 cycles per minute and Blood Pressure 130/80mmHg.

Since the temperature and respiration were above normal ranges, night nurses report

revealed that extra clothing were removed and tepid sponging was done and an

Antipyrexia Injection Tramadol 200mg in 500ml of Normal Saline was administered to

help reduce the temperature and respiration to normal.

Medications prescribed for client included: Intravenous Normal Saline 3.0 litres within

48 hours, Tablet Folic Acid 1 daily within 30 days, Tablet Lonart 4 tablets bd x 3days,

Injection Morphine 10mg stat, Injection Naklofen 75mg daily x 5 days, Intravenous

Ciprofloxacin 400mg bd x 1day, Tablet Tramadol 400mg in Normal Saline and Tablet

Paracetamol 1g tds x 5days.

Laboratory investigation requested include; White Blood Cell Count, Differential White

Blood Cell Count, Blood film for Malaria Parasite and Blood Specimen for Haemoglobin

level.

Stat medications were reported to have been administered and infusion Intravenous

Normal Saline stat insitu and charted in the drug administration sheet.

Client was oriented to the other patients closer to him and later to the nurses’ office, toilet

and bathroom facilities available at the ward.

Client was covered under the National Health Insurance Scheme, so there was no need

for explanation of cash and carry system. Consent form was explained to client and he

signed it accordingly.

Relatives of client were allowed to bid farewell to client after visiting time and ward

protocols were made known to them.

64
Client information was documented in the admission and discharge book and daily ward

state.

One problem identified on client was pain. He was reassured that pain would subside

within few minutes after both medical and nursing intervention was done. All tight

clothing and bed linen over painful areas were removed and elevated using a bed cradle

respectively. Painful areas were immobilised to reduce metabolic activity after client was

educated for its need. Warm compressors were later applied at painful areas. Client was

induced to rest by making a comfortable bed with clean sheets and linen. Diversional

therapy was employed by engaging client in conversation and switching on the television

for client to watch. Prescribed analgesic was administered and oxygen administered to

increase oxygen content in circulation.

Vital signs were checked and client recorded an increase in temperature of 37.70C at

10:00am. He was reassured that temperature will be reduced to normal range.

Constrictive clothes were removed from client for him to loss heat. He was tepid sponged

with tepid water and nearby windows was opened to improve circulation. Cold sprite was

served to client and prescribed antibiotic and antipyretic such as Intravenous

Ciprofloxacin 400mg and Paracetamol 1g was administered respectively to help control

infection and pyrexia.

Client had his body temperature reduced to 37.50C around 12:00noon in the afternoon.

He complained of severe headache which was due to changes in thermoregulation due to

stress and anaemia. He was reassured that pain would be relieved in no time. Cold

compressors were applied to client’s forehead. Client was again encouraged to empty

65
bowel which could also cause headache. He was urged to have enough rest and try to

avoid stress by conversing with other patients and watching television. Prescribed

analgesic Tablets Paracetamol 1g and Haematinics of Tablet Folic Acid once daily was

also given.

Client had his lunch after which medication was served. He was then encouraged to rest.

Around 3:30pm, client received visitors which were his parents and a sibling. Client and

relatives showed sign of anxiety toward hospitalization and outcome of disease process.

They were reassured that adequate measures would be put in to help manage his

condition.

They were educated on the need and importance for client to be admitted for further

observation and continuity of care for a couple of days to ensure full recovery. The

disease condition, causes, signs and symptoms were made known to client and family.

Prognosis of disease was made known to them. They were allowed to ask questions and

answers were provided accordingly. They later became less anxious and this helped

promote cooperation and established a good therapeutic relationship between them and

health providers.

Client had his supper around 6:30pm in the evening. He was then handed over to the

night nurse for continuity of care.

66
SECOND DAY OF ADMISSION (31ST MARCH 2010)

Client woke up around 5:30am in the morning. He complained of having bodily

weakness so could not maintain his personal hygiene. He was reassured that he would be

assisted to maintain his personal hygiene. He was given an assisted bed bath with warm

water and soap and sponge. During bathing warm applied to joints to reduce pain since

client was still in pain. Pressure areas were treated to prevent pressure sores from

developing. Oral hygiene was maintained with toothbrush and toothpaste to help prevent

complications such as halitosis and sordes. After bathing, client was assisted in his

grooming and made comfortable. Client hands and feet were accordingly cared for.

Finger and toe nails were cut, trimmed and cleaned to remove foreign materials

embedded in them.

Observations of his coping ability were carried out and were improving day after day.

Client had his breakfast around 7:00am which was a cup of oats and a slice of bread.

Client later complained of having acute abdominal cramps and was reassured that pain

will be relived and that measures would be put in place to ensure that. Client was put into

a comfortable position with assistance to help ensure comfort. Pain assessment was done

on client using the P, Q, R, S, T, U method to note for the palliative measure to determine

the quality and quantity, radiation, severity and time of the pain and how client perceived

or understood the pain. The numerical scale (0-9) was also done for client to identify the

extent of pain. Client was later put on nil per os until cramps were relieved. Client was

educated on the need and importance to avoid food, later sips of water will be given

proceeding to semi solid. Television was switched on for client to serve as a diversional

67
therapy to help reduce pain. Prescribed Naklofen 75mg was administered to help relieve

pain.

Client again complained of inability to sleep the previous night. He was reassured that he

would be able to have a sound sleep after lying down. Open nearby windows to promote

enough room circulation. Warm bath, drinks and enough blankets were provided for

client to avoid cold. Visitors were restricted from coming into contact with client. Noise

was minimized for client to sleep and all activities were organized in such a way not to

interfere with client’s sleep. Client’s bed was made with enough linen and pillows to

enhance comfort and lights were adjusted to suit client’s preference.

Client woke up to have his lunch in the afternoon which was rice and tomato stew with

fried fish. Medications were administered and client was allowed to rest. He had his

supper around 6:30pm in the evening and was handed over to night nurses for continuity

of care.

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THIRD DAY OF ADMISSION (1ST April, 2010)

On the third day of admission, client’s condition had improved than the previous day.

Client was assisted to take a warm bed bath and to maintain his oral hygiene. Vital signs

were taken and found to be within normal range.

Client complained of constipation and was reassured that measures were being taken to

ensure free bowel movement. Client’s diet was assessed and it was revealed that his diet

contains little or no roughages. So he was encouraged to eat foods that contained

adequate amount of roughage. Client was served with cabbage stew and rice as lunch

with oranges as dessert. He was encouraged to eat all the fibre in the orange. He was

educated to take enough fluids like water to enhance intestinal motility. Active and

passive exercise to help in peristaltic movement. Bed pan was later requested by client

and was served promptly. Colour, amount and odour of stool was observed and recorded.

Client later in the afternoon complained of anorexia and could not eat meals that were

served him when he was visited. He was reassured that measure would be taken to help

him promote appetite and that he was in the hands of competent staff. Meals for supper

were discussed with client to help induce his appetite. He was assisted in maintaining his

oral hygiene with toothpaste and brush. All painful procedures that were supposed to

have been done within that time frame were all suspended 30 minutes before and after

meal. The ward was cleaned off all nauseating items. Client’s supper was served

attractively and in bits. All these procedures helped improved clients appetite and were

able to eat almost half of his supper.

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FOURTH DAY OF ADMISSION (2nd April, 2010)

Client’s condition had improved on the fourth day of admission. He was able to walk to

the bathroom to take a warm bath and clean his teeth without assistance. Client was

reviewed on ward rounds and on complain was made but client looked puffy and slight

oedematous. He was reassured that he would have a fluid and electrolyte balances after

measures were put in place. Client’s infusion therapy were restricted to flow as order and

encourage to rest periodically and to lie in a recumbent position if tolerated. Prescribed

diuretic Lasix 60mg stat was administered intravenously.

FIFTH DAY OF ADMISSION (3RD APRIL 2010)

On the fifth day of admission, client looked better and had a cheerful facial expression.

Mediations were served and vital signs monitored and recorded. They were within

normal range.

Interactions with client revealed that he had little insight into the management and

precautions of crisis at home. He was reassured that he would have knowledge about the

management and precaution of crisis at home. Client was educated on the predisposing

factors such as exposure to cold, infection, stress, poor nutrition and strenuous exercises

and the need to avoid them. He was again educated on the diseases sickle cell and that it

is transferred from parents with sickle cell traits to their offspring and the need to choose

a life partner with no sickle cell trait. The importance and need for frequent follow-ups

and reviews to prevent complications was emphasized upon. He was again encouraged to

join a sickle cell organization such as the National Association of Sickle Cell Patients to

70
know more about disease condition. Client was asked questions for him to give answers

and he provided answers accordingly.

In the afternoon client was reviewed again by doctor on ward rounds and client

verbalized that his pain had subsided and he was feeling better. After thorough physical

examination the doctor ordered that client should continue with his medications with

assurance the he would be discharge the next day. Client’s relations were informed about

discharge on the next day when they visited client, so they were urged to prepare for

clients arrival home.

CLIENT’S DAY OF DISCHARGE (4TH APRIL 2010)

On the day of discharge, client looked healthy and cheerful. He was grateful to the

nursing and medical staff. He took his warm bath and maintained his oral hygiene.

Medications were served as ordered and vital signs monitored and recorded.

During ward rounds, the doctor examined client physically and discharge him home to

continue his home to continue his medication especially Tablet Folic Acid.

Around 10:00am client’s relatives came to the ward and were informed about client’s

discharge. They were so grateful to the medical and nursing staff for helping their ward to

recover without any complication. Client and relatives were educated on the need to take

nutritious diet which was rich in folic acid from green leafy vegetables and iron rich

foods to prevent anaemia.

High caloric diet is recommended to be given to client for energy, also, protein to build

and repair worn out tissue and supplemented with vitamins and fruits to boost immune

71
system. Client and his relatives were again educated to avoid predisposing factors of

sickle cell crisis such as infections, exposure to cold, poor nutrition strenuous physical

exercise and stress. They were later asked and answers were provided and this revealed

that they had understood everything made known to them.

Client and relatives were informed about the review date which was 12th of April 2010

and was asked to report at consulting room five on the said date. After telling them about

the day of review they were helped to pack their belonging after which they said goodbye

to the health staff and other clients on the ward and were escorted to the car park for a

bus home.

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PREPARATION OF CLIENT AND FAMILY TOWARDS DISCHARGE AND

REHABILITATION

Preparation of client and family toward discharge started as soon as client was admitted

to the ward. They were given insight into sickle cell disease and how best to prevent

future occurrence. While client was on admission, relatives and client were informed that

he will go home as soon as his condition improves. They were therefore encouraged to

take active part in the care to ensure speedy recovery.

On the day of discharge, which was 4th April, 2010, client and relatives were educated on

the need to complete his medication. They were also educated on the need to serve client

with nutrition diet rich in protein carbohydrates and vitamins.

FOLLOW-UP/HOME VISIT/CONTINUITY OF CARE AND REHABILITATION

This is the act of rendering health service to a client in her or his home environment to

ensure continuity of care. It also determines the health status of the patient following

discharge, identify other problems and help find solutions to the identified problems.

This involves visiting the patient home before and after discharge to have first hand

information on the condition of the house and its influence on the patient’s health. This is

of a great importance in the care of the patient.

FIRST HOME VISIT

The first home visit was made on the 2nd of April, 2010 while client was still on

admission. I went to clients house write his mother at Suame, a suburb of Kumasi with

the aim of finding out much about client’s vicinity and environmental conditions to help

in the giving of health education.

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On reaching the house I was warmly welcomed by client’s father and siblings. We had a

conversation concerning client’s current condition and the way to ensure client’s speedy

recovery. The two bedroom house had a kitchen, bathroom and toilet with well ventilated

rooms and a good sanitation facility. I took the opportunity to educate the family on

client’s condition and measures to be taken to prevent future occurrence of sickle cell

crisis.

SECOND HOME VISIT

The second home visit was made on 9th April, 2010. The purpose of the visit was to find

out how client was fairing and to ensure possible termination of healthcare given to

client.

Education was given to client and family to ensure that client avoid stressors such as

infection, extreme cold and physical exertion as these trigger sickle cell crisis. I

emphasized on the need to serve client with nutritious diet and the importance of

completing medication as prescribed. I also took the chance to educate the entire family

on the cause of sickle cell disease and encouraged them to ensure that their children

marry partners who are without sickle cell trait to prevent occurrence.

Client was later reminded on the review date with the promise to meet them on the day at

the Out- Patient Department.

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REVIEW

Client came for review on the 12th April, 2010. I met client and his mother at the Out

Patient Department as planned. I ensured that client’s folder was retrieved from the

records room and taken to see his doctor in consulting room five.

On examination client was declared fit and the doctor informed him to continue with his

folic acid therapy as ordered. I saw them off but reminded them about the advice given

by the doctor to client and mother. I promised to visit them again.

THIRD HOME VISIT

On my third visit which was on the 1st of May, 2010 at 11: 00 am, I observed that client

was very fit and looked good.

On arrival, his relatives were very happy about his improvement and told me about his

performance in school.

Client told me that he felt good as if he never felt sick. I encouraged them to care for him

and keep their environment as clean possible.

Finally, client was not handed over to the community health nurse because her condition

was not a communicable disease but rather he was advised with his relatives to visit the

sickle cell clinic for further continuity of care and they were made aware that the care has

been terminated from that day.

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Any other health problem pertaining to the condition should be discussed at the sickle

cell clinic but when the condition needs further management, they should report to the

nearest hospital. I finally terminated the care after congratulating them for the effort to

comply with the instruction given during the care.

After some few interactions with them, I asked of their permission to leave. I also

thanked them for their cooperation.

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 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO CLIENT AND FAMILY

This is the final and the fifth component of the nursing process which is used to deduce

whether goal set for client and family were either met, partially met or unmet and unmet,

what other goals was set to solve the problem including amendment

STATEMENT OF EVALUATION

During the care of Mohammed Ishmael, objectives were set for problems identified.

With good nursing management and co-operation from client and family, all objectives

were fully met and client’s health condition improved remarkably

On the 30th of March, 2010, at 9:00am an objective was set to relieve client off pain

within 2 hours. This goal was fully met at 11:00 am on the same day as client verbalised

that he was no more in pain and through the nurses own observation that client was

feeling relaxed in bed.

On the same day at 10:00am, an objective was set to relieve client from pyrexia within 24

hours. This goal was fully achieved the next day at 10:00am as clients body temperature

reduced to the normal range.

At 12:00pm on the same day, client complained of headache and objective was set to

relieve him from the headache within 24 hours. This goal was fully achieved as client felt

comfortable and relaxed in bed the next day at 12:00 pm.

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Also on the same day, at 3:30pm an objective was set to relieve client off anxiety within

15 hours. This objective was fully met as client had a cheerful facial expression on the

next day at 3:30am.

On the 31th of March, 2010, at 6:00am, an objective was set to enable client maintain his

personal hygiene within 72 hours. This goal was fully met on the 3rd day of April, 2010 as

client demonstrated no need for assistance in maintaining his personal hygiene.

On the same day, at 9:00am, an objective was set to relieve client from abdominal cramps

within 2 hours. This goal was met at 11:00 am as client verbalised the absence of cramps.

Moreover, at 10:00am on the same day, client complained of insomnia so an objective

was set to enable client resume a normal sleeping pattern within 2 days. This goal was

fully met on the second of May as client demonstrated ability to fall asleep within few

minutes after lying down.

An objective was set on the 1st day of April 2010 at 10:00am to relieve client off

constipation and regain his normal bowel movement within 72 hours. These goals were

fully met as client verbalised the absence of constipation and also regained his normal

pattern of bowel movement.

On the same day, at 3:30pm, an objective was set to enable client regain his normal

appetite within 3 days. This goal was full met on 4th April, 2010, as client consumed at

least half of his meals served.

On the 2nd day of April, 2010, at 11:00am, the client appeared puffy and slightly

oedematous so an objective was set to relieve the client of fluid volume excess after

infusion therapy. This goal was fully met as client had no signs and symptoms of fluid

volume excess.

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On the 3rd April, 2010, at 8:00 am, a goal was to educate client on the disease condition

and its management within 2 hours. This goal was fully met at 10:00am as client

answered all questions put to him correctly.

AMENDMENT OF NURSING CARE FOR PARTIALLY MET OR UNMET

OUTCOME CRITERIA

Throughout client’s stay on the ward, good nursing and medical interventions were

instituted. Coupled with cooperation from client and his relatives, all goals and objectives

that were set were fully met. Therefore there was no amendment to be made.

TERMINATION OF CARE

Termination of care is the end of the care rendered to the client and relatives by nurse.

Interactions with client and relatives started on the 30th of March, 2010 and went for

discharge on the 4th of April, 2010 after condition became well and satisfactory. Client

was in good state of health and his condition had improved during discharge.

Finally, after three home visits the care was finally terminated on the 1st May, 2010

11:00am on the third home visit.

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SUMMARY

The care of Mohammed Ishmael, a 22 year old man started on the 30th of March 2010,

when he was admitted at Komfo Anokye Teaching Hospital at the Medical Recovery

ward with diagnosis of Sickle Cell Disease with Vaso Occlusive Crisis. Client who was

in pain during admission was reassured together with his relatives and measures were

taken to relieve their anxiety and pain.

Health problems identified on client during the period of hospitalization included pain,

anxiety, increased body temperature, headache, insomnia, acute abdominal cramps, self

care deficit, loss of appetite, constipation, risk for management of disease condition crisis

at home and prone to oedema . All these problems were attended to with appropriate

nursing and medical interventions.

The following drugs were prescribed for client and they were served accordingly;

Intravenous Normal Saline, Injection Naklofen 75mg daily x 5 days, Injection Tramadol

400mg in 500ml of Normal saline. Intravenous Ciprofloxacin, Injection Morphine 100mg

stat, Tablets Folic Acid, table Paracetamol 1g tds x 5, Intravenous Ringers Lactate.

All goals and objectives set for clients health problems were full met due to effective

nursing and medical care rendered leading to his recovery and discharge of 4th April,

2010. Two follow-up visits were made to client home until he was declared fit on the

review date.

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CONCLUSION

In conclusion the client and family care study has not only broadened my knowledge in

sickle cell disease but also helped me to put the knowledge I have required from the three

year nursing course intro practice. It has also helped me to understand comprehensive

nursing care that has to be given to individual patient and also improved my interpersonal

relationship with clients. I recommend that the nursing process should be focused on in

the care of patient at the ward, thus each patient should be given a close holistic care as

the nursing care plan is instituted at the ward to help arrive at a good care delivery.

Finally, more workshops should be organised for preceptor student and practicing nurse

to keep them abreast with the nursing process approach in health care delivery.

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BIBLIOGRAPHY

Davis, F.A. (2003). Nurses’ Drug Guide, (8th Edition), Davis Company1915Arch Street,

Philadelphia PA 19103.

Hovard, C. et al, (1986). Tropical Disease (1st Edition) Macmallian Publishers, London.

Lukmann, J. (1980). Medical Surgical Nursing- A psycho-physiologic Approach, (2nd

Edition), W.B. Saunders Publishing Company, West Washington Square, Philadelphia

PA 19105.

Smeltzer S.C and Bare, B.F (1980). Brunner and Saddarth Medical Surgical Nursing.

(4th Edition) J.B. Lippincott Publishers Company, Philadelphia.

Swearingen, PL. (2004). All-in-one Care Planning Resource (medical Catalonging in

surgical ,paediatric, maternity and psychiatry nursing care plan. Elseviers’ Health

Sciences Publication Philadelphia

Weller, F.B. (2001). Bailliers Nurses Dictionary (23 Edition Bailliere Tindal, London.

82
 SIGNATORIES

Name of Candidate:......................................................................................

Signature:

Date:

Name of Supervisor......................................................................................

Signature:

Date:

Name of Nurse In-Charge: ………………………………………………

Signature:

Date:

Name of Principal: ……………………………………………………..

Signature:

Date...............................................................................................................

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 APPENDIX
FLUID CHART

DATE/TIME INTAKE OUTPUT

30-3-2010 KIND OF FLUID AMOUNT KIND OF FLUID AMOUNT

12:45 am Normal Saline 500mls

2:30am Normal Saline 500mls

6:00am Beverage 300mls urine 200mls

10:00am Normal Saline 500mls urine 300mls

11:15am Sprite 300mls urine 100mls

2:30pm Normal Saline 500mls urine 50mls

TOTAL INTAKE 2600mls TOTAL OUTPUT 650mls

Balanced on 31/3/2010 at 6:00 am

Balance = intake-output

2600-650

=1950ml

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DATE/TIME INTAKE OUTPUT

31-3-2010 KIND OF FLUID AMOUNT KIND OF FLUID AMOUNT

10:00am Ringers Lactate 500mls

10:30 am Ringers Lactate 500mls urine 200mls

11:45am Normal saline 500mls urine 300mls

2:00pm Ringers Lactate 500mls urine 200mls

3:00pm urine 200mls

4:00pm Ringers Lactate 500mls

8:00pm urine 300mls

TOTAL INTAKE 2500mls TOTAL OUTPUT 1200mls

Balanced on 1/4/2010 at 6:00am

Balance =intake-output

2500-1200

=1300ml

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DATE/TIME INTAKE OUTPUT

1-4-2010 KIND OF FLUID AMOUNT KIND OF FLUID AMOUNT

7:00am urine 600mls

8:30am Dextrose Saline 500mls

9:00am porridge 600mls

10:45am Water 500mls

12:00 pm Dextrose Saline 500mls urine 400mls

12:30pm Normal saline 500mls

1:45pm Dextrose Saline 500mls urine 500mls

4:30pm Dextrose Saline 500mls urine 400mls

7:00pm Fruit juice 500mls

9:00pm urine 750mls

TOTAL INTAKE 3600mls TOTAL OUTPUT 2650mls

Balanced on 2/4/2010 at 6:00am

Balance =intake - output

4100 - 2650

=1450mls

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 TIME INTAKE OUTPUT

2-4-2010 KIND OF FLUID AMOUNT KIND OF FLUID AMOUNT

7:00am urine 300mls

9:00 am Milo beverage 400mls

11:30am urine 600mls

1:00 pm Water 500mls

1:45pm Fruit juice 200mls urine 400mls

3:30 pm Light Soup 400mls

4:00pm Water 500mls

7:50pm urine 500mls

TOTAL INTAKE 2000mls TOTAL OUTPUT 1800mls

Balance on 3/4/2010 at 6:00 am

Balance = intake - output

2000 - 1800

=200mls

87