CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment is the first phase of the nursing process. It involves the systematic way of

gathering data about a patient. The goal of the patient and family, assessment is to

determine the health needs of a patient and family. The data can be collected directly

from the patient, relatives, and friends and significant others to help plan an

individualistic care for the patient. Assessment can take different forms such as

Observation, interviewing, physical examinations, diagnostic investigations, etc. This

chapter gives information about the patient, her family and their relationship with the

community to identify their health problems. It involves the collection of data from

the patient and family. It includes; Patient’s particulars, Family medical and socio-

economic history, Patient’s lifestyle/hobbies, Past medical history, Present medical

history and Admission of patient.

PATIENT’S PARTICULARS

Mr. A.J, age 55, was born on the 1st September 1969 at Kwadaso in the Ashanti

Region of Ghana but now stays at Kojokrom in the Western Region. He is a Ghanaian

by Nationality. He comes from Kwadaso in the Ashanti Region born to Mr. and Mrs.

C.J who are both alive. Mr. A.J is the fifth out of seven children to his parent. He is

dark in complexion, thin, tall and weighs 65kilograms on admission. He is a taxi

driver by profession. He is a Christian and worships at the Pentecost Church at

Kojokrom. He is married to Mrs. W.J with 4 children namely; B.J, R.J, P.J and D.J.

He speaks Twi, Fante and English Language. Mrs. W.J, his spouse is his next of kin.

Patient is a subscriber of the National Health Insurance Scheme (NHIS).

FAMILY’S MEDICAL AND SOCIO-ECONOMIC HISTORY

According to the Mr. A.J, there are no family history of hereditary conditions like

diabetes, hypertension, asthma, sickle cell disease and mental disorders in the

families. Also, there are no known communicable disease in the family. He has been

admitted at the hospital couple of times with malaria. He also said the family at times

suffer from conditions such as Malaria, headache, body pains and cough as minor

ailments which they treat with over-the-counter drugs and some herbal medicine. His

source of income as a driver and that of his wife as a trader goes a long way to sustain

his family. He proclaimed there are no known allergies either food or drug. The

entire family are subscriber of the National Health Insurance Scheme. They have a

good interpersonal relationship with their neighbours, friends, co-workers and live

peacefully with everyone. Patient has no difficulty paying his bills.

PATIENT’S DEVELOPMENTAL HISTORY

According to Mr. A.J, on 1st September 1969 at Komfo Anokye Teaching Hospital,

he was delivered spontaneously per vagina at full term without any abnomalities. He

said, he weighed 3.5kg at birth. He was not exclusive breastfed and was introduced to

complementary feeds such as porridge during the fourth month. According to the

patient he was immunized against the childhood killer disease. He attained the normal

milestone of growth and development without any problem or disease and at the age

of four (4) months he could sit with pillows at his back. According to him, he said his

mom told him he had his teething at the seventh month, at the seventh month of

growth was a painful experience as he cried all night. At sixteen (16) months, patient
could mention some names and also make some sounds like Nana, Mama, and Papa

as he starts to talk.

At age three (3) he could dress without any assistance. According to him, he

developed his secondary characteristics including deepen voice, hair growth on the

face, chest, armpit and private part, and enlargement of the scrotum and testes. He

started schooling at Bethel Methodist International School at Kwadaso and moved

forward to the next class until Junior High School where he completed and did not

further on because of financial constraints.

PATIENTS LIFESTYLE / HOBBIES

Patient said he wakes up around 5:00am on weekdays and on Saturdays he goes to

work by 7:30am and on Sundays 8:00am he goes to church. He maintains his personal

hygiene which includes, mouth care once daily but sometimes twice daily with

toothbrush, toothpaste and water, bathing twice daily with a lukewarm water, sponge

and soap and cares for his hands and feet when necessary. Mr A.J empties his bowel

at least three times in a week before he takes his morning shower. He usually takes his

breakfast at his workplace at about 8:00am which usually consist of porridge, tom

brown with slices of bread and sometimes rice and stew.

He has no known allergies and his favourite food is rice and kontomire stew with fish

and egg. He sometimes visit one of his children who is in secondary school with his

wife and other kids. Patient hobbies include listening to music and watching football

and said he was once the football captain for his school team when he was in primary

six (6). After 7:00pm he closes from work and drives home. He takes supper at

8:00pm after having rested for a while from his work. He has time to watches

television for a while with his wife and goes to bed at 10:00pm.
PAST MEDICAL HISTORY

According to Mr A.J, he has been admitted ones with malaria and he has not been

hospitalized again until his present condition. He said whenever he felt any ache in

the body or fever he takes over-the-counter medicine or sometimes his wife prepares

herbal remedy in the house. He has no unknown allergy to either food or drug.

PRESENT MEDICAL HISTORY

Mr. A.J. was doing well until he started having chest pains, chills, dizziness, anorexia,

productive cough and then difficulty in breathing about five days ago which he took

some traditional medicine called (Taabia herbal mixture) and still did not go. He then

reported to Effiankwanta Regional Hospital with his son on 27th January 2024, at

12:30pm as the condition became unbearable. He was seen by Dr. O.S and was

diagnosed as Pneumonia, hence was admitted for further medical treatment.

ADMISSION OF PATIENT

On 27th January, 2024 at 12:30pm, Mr. A.J was admitted to the male medical ward at

Effiankwanta Regional Hospital through the Emergency Unit with the diagnosis of

Pneumonia by Dr. O.S the doctor on duty. Patient came into the ward by an admission

team porter and accompanied by his son and a nurse. Patient was ambulant. Patient

and relative were welcomed to the ward and were offered a seat at the nurses’ station.

I introduced myself and the nurses on duty to them. Patient’s folder was collected

from the accompanying nurse to confirm if he was the right patient in the right ward.

Patient’s drugs were collected from the accompanying nurse by the nurse in-charge
and cross-checked in the folder and they were correct drugs. All relevant information

was taken from his son. Patient relative was directed to the waiting area just outside

the ward and offered a seat. Patient was immediately made comfortable in an already

prepared admission bed, since he was feeling week on observation but was fully

conscious and could give good account of himself. Side rails of the bed were put in

place to prevent patient from falling. Mr. A.J. presented with the history of difficulty

in breathing, chest pains, anorexia and productive cough which started about five (5)

days ago. Family relatives were reassured that, all the necessary nursing and medical

intervention would be put in place to restore his normal health status. Due to

weakness experienced by the patient, he was not oriented to the ward and its annexes.

Patient’s valuables were kept in his bedside locker for his safe keeping. His vital signs

were checked and recorded as follows;

Temperature - 40.0 OC

Pulse - 125 beat per minutes (bpm)

Respiration - 40 cycle per minute (cpm)

Blood pressure - 80/60mmHg

SPO2 - 93%

The following drugs were prescribed for him:

 Azithromycin capsules 500mg daily x 3

 Paracetamol Tablets 1g tid × 5 days

 Normal Saline 1 Litre x 48hrs

 Dextrose Saline 2 Liters × 48hrs

 IV Benzyl Penicillin 4 MU start then 2 MU 6 hourly x 24hours

  Diclofenac sodium tablets 50mg 8 hourly x 7 days

Patient was told to have a bath due to his high body temperature of 40.00C. After

patient was tepid sponged, his temperature was re-checked and was recorded as 38.7
0
C. Another tray was set for setting of an intravenous line to administer intravenous

fluid Normal Saline 1 Litre and IV 4MU Benzyl penicillin. Since patient was

experiencing difficulty in breathing, he was put in semi fowler’s position to aid in

breathing, good ventilation was also provided by opening nearby windows. He also

complained of chest pain and prescribed analgesics were served with no side effects

observed. Patient was provided with a sputum mug, taught coughing exercise and

encouraged to bring out secretions since patient was having productive cough, he was

given cough and vomitus bowl and was encourage to vomit into the bowl if any water

was given to rinse the mouth, nauseating items removed and was monitored for signs

of dehydration such as poor skin turgor.

The following investigations were requested and they were all done:

 Chest x-ray

 Haemoglobin level estimation

 Blood film for malaria parasites

 White Blood Cell Count and total differential Count

 Urine for routine examination

I established rapport by introducing myself to him and also informed him that I am a

student nurse among the nurses who will help in giving him care. Later I made my

intentions clear to him concerning the patient/family care study. We conversed for a

while before a detailed explanation about the patient and family care study was made
known and he agreed to co-operate with me. He was made to understand that

admission is temporal and when his condition improves, he will be discharged.

PATIENT’S CONCEPT OF ILLNESS

Mr. A.J. had no idea about the cause of his condition however he did not attribute his

disease to any supernatural means. He believes that diseases are natural phenomena

that occur in the life of every individual, so with time and treatment he will be well

and discharged home.

LITERATURE REVIEW ON PNEUMONIA

Pneumonia is an inflammation of the parenchymal or alveolar of the lungs with

consolidation and exudation. In other words, it can also be described as an

inflammation of the parenchymal structure of the lung such as alveoli and

bronchioles. This causes an impairment of gaseous exchange in the alveoli which is

the microscopic air-filled sacs in the lungs.

CLASSIFICATION OF PNEUMONIA

Pneumonia can be classified into:

Anatomical changes or deviations in the lungs which are revealed by investigations

such as x-ray.

Microbiological organism
Combined clinical classification

According to anatomical changes in the lungs

Lobar Pneumonia: It is an acute infection involving a large portion of the entire lobe

of the lungs. It involves consolidation of the entire lobe; it can occur in either the left

or the right lobe or both at the same time.

Bronchopneumonia: This inflammation is found scattered in the bronchioles of the

lungs. It is commonly seen in children. In this type patchy areas of consolidation

occur throughout the bronchioles.

According to microbiological organism

Various laboratory investigations and tests are done and carried out to identify the

causative organism. It is also sub-grouped base on the organism responsible for the

infection.

Viral Pneumonia: Mainly caused by viruses when they reach the lungs when

airborne droplets are inhaled. Viruses responsible for this type include influenza

viruses, cytomegalovirus and varicella zoster etc.

Bacterial Pneumonia: This is caused by bacteria, grouped into one of the two large

categories by laboratory procedure used to identify them under microscope. They are

gram positive or gram negative. Examples are; staphylococcus aureus, homophilic

influenza but the commonest of all bacteria causes of pneumonia is streptococcus.

Parasitic Pneumonia: These are caused by parasites and they enter the body through

the skin or they can be swallowed.

Fungal Pneumonia: These are caused by fungi. It is uncommon but may occur in

individuals with low immune system due to Acquired Immune Deficiency Syndrome

(AIDS), Immunosuppressive.

According to combined clinical classification

This is known to be the most commonly used classification scheme. The advantage it

has over the microbiological classification is the selection of treatment before the

microbiologic cause of pneumonia will be ready in several days. This categorizes

pneumonia into two based on where the individual contracted the organism

responsible for the cause of the pneumonia. They are;

Community – Acquired Pneumonia

Hospital – Acquired Pneumonia

COMMUNITY– ACQUIRED PNEUMONIA (CAP)

This is an infectious pneumonia that a person acquires in the community. The

common cause varies with age but includes streptococcus pneumonia, viruses,

atypical bacteria and haemophilus influenza. It can also be described as the type of

pneumonia that occurs either in the community setting or within the first 48 hours

after hospitalization.

HOSPITAL - ACQUIRED PNEUMONIA (HAP)

This can be also known as Nosocomial Pneumonia. This is acquired during

hospitalization. The onset is after 72 hours on admission. Patients who are at risk of

developing hospital –acquired pneumonia include; patients on mechanical ventilation,

prolonged malnutrition and immune compromised patients such as severe anaemia

patient, sickle cell patient and HIV|AIDS patients etc. The organism that causes

nosocomial pneumonia includes resistance bacteria such as Pseudomonas

Enterobacter and Serratia.

OTHER TYPES OF PNEUMONIA

Severe Acute Respiratory Syndrome (SARS): This is highly contagious and a

deadly type of pneumonia, which first occurred in 2002 after an initial outbreak in

China. It is caused by Severe Acute Respiratory Syndrome Corona Virus.

Aspiration Pneumonia: This is caused by aspirating foreign objects which are

usually oral or gastric contents either by eating or vomiting which results in

bronchopneumonia.

Eosinophilic Pneumonia: This is caused by invasion of eosinophil of white blood

cells after exposure to certain types of environmental factors.

Chemical Pneumonia: This is caused by inhalation of toxicants or by contact with

the skin. An example of these chemicals is pesticide.

Idiopathic Interstitial Pneumonia: this is caused by an unknown factor but may be

precipitated by excessive smoking

LOBAR PNEUMONIA

It is an acute infection involving a large portion of the entire lobe of the lungs with

consolidation and exudation. This could affect the right lobe or the left lobe or both at

the same time. It is mostly caused by pneumococcus.

INCIDENCE
The condition affects all age group. In children, majority of death occurs in new born

babies. The World Health Organization (WHO) estimates that, about one third (1/3)

of new born babies’ death is due to pneumonia. Lobar pneumonia is commonly seen

in adults but uncommon in infants and elderly. The incidence of pneumonia is

approximately 6 cases for every 100 people between the ages of 18 -39 years and 75

cases of every 100 people worldwide in developing countries.

CAUSES

Streptococcus pneumoniae and staphylococcus are the most common organism

responsible for lobar pneumonia. Other organisms also include Haemophilus

influenzae and Mycobacterium tuberculosis. Inhalation of chemicals such as

pesticides and aspiration of gastric content are also other causes of lobar pneumonia.

PREDISPOSING FACTORS

 Physical injury to the lungs

 Lung Cancer

 Abdominal and thoracic surgeries

 Chronic illness and debilitating diseases

 Prolonged hospitalisation

 Atelectasis

 Immunosuppressive therapy

 Viral infection

 Prolonged malnutrition

 Tracheotomy

 alcoholism
MODE OF ENTRY

Inhalation of infectious microorganisms from the atmosphere.

Inhalation of normal flora in the mouth or aspirating gastric content into the lungs.

Infections can spread through the blood stream from other organs of the body to the

lungs.

PATHOPHYSIOLOGY

The upper airway is adapted to prevent potentially infectious particles from reaching

the lower respiratory tract. Inflammatory response as a result of invasion of micro-

organisms to the respiratory tract causes physiological changes which affect both

ventilation a diffusion. These organisms reaching the alveoli of the lungs through

inhalation of infectious organisms from the atmosphere, inhalation of normal flora in

the mouth or through circulation of infection from other body organs. The organisms

multiply and cause inflammatory response the immune system reacts to the invasion

of the organism. The inflammatory response that occurs can be grouped into 4 stages:

Congestion: This is the initial response and it is characterized by vascular

engorgement of the alveoli and transudation of serous fluid into the alveoli. This

period lasts about 24 hours.

Red hepatization: There are extravasations of red blood cells and fibrin into the

alveoli. The lungs become firm and red with liver appearance.

Gray hepatization: This stage is characterized by accumulation of fibrin and

disintegration of inflammatory white and red blood cells begin.

Resolution: This stage, there is enzymatic digestion and removal of the inflammatory

exudates from the affected area of the lungs either by cough up or removal by

macrophages.

The occlusion of the airways by secretion, mucosal oedema and bronchospasm lead to

poor oxygenation. The mixing of poor oxygenated blood and oxygenated blood

results in arterial hypoxia.

CLINICAL MANIFESTATIONS

 The onset is sudden, characterized by fever

 General malaise

 Coughing up greenish/ yellow/ bloody sputum

 Sweating

 Headache

 Chest pain

 Difficulty in breathing

 There may be cyanosis

 Increase in pulse rate

 Low blood pressure

 Nausea and vomiting

 There may be joint pains

 Loss of appetite
DIAGNOSTIC INVESTIGATIONS

 White Blood Cell Count: This may show high white blood cell, indicating that

there is presence of infection but in people with immunosuppressive diseases.

The White Blood Cell may appear deceptively normal.

 X- rays: Chest x- rays can reveal areas of opacity, which represents

consolidation.

 Physical Examination: This may show decrease in chest expansion of the

affected side. On auscultation with stethoscope, hash sounds are heard at the

affected area during inspiration. The affected area may be dull during

percussion.

 Blood Culture: This is done to determine the invasion of the microorganism.

 Computed Tomography Scan: They are x- ray procedures that combine

multiple images with the aid of a computer to generate the cross section of the

lungs to reveal the presence of an infection.

 Sputum Culture and Sensitivity Test: This test is done to determine the

causative organism and know the appropriate antibodies to treat the

pneumonia.

 Arterial Blood Gas

MEDICAL TREATMENT

 Antibiotics: The treatment of pneumonia is based on the causative organism

known as Antibiotics Sensitivity. Since treatment should not delay, empirical

treatment is given. The drug of choice includes;

 a. Cephalosporin’s: The drug of choice is 3rd and 4th generations. Example is

ceftriaxone 1g × 3 days.

b. Microlides: Example is Tablet Erythromycin 500mg 8 hourly × 7 days.

c. Aminoglycosides: Example is Intravenous Gentamycin 2- 5mg per body

weight in divided doses.

d. Analgesics: Example is Diclofenac Tablet 50mg 8 hourly × 3 days.

e. Antipyretic: Example is Paracetamol Tablet 1g 8 hourly × 3 days

 Oxygen Therapy: Oxygen is given to patients with difficulty in breathing.

 Cough Mixture: Example is Syrup Brozedex 10mls 8 hourly × 5 days.

NURSING MANAGEMENTS

REASSURANCE

 Reassure patient that quality health care would be rendered to promote

recovery.

 Engage patient in diversional therapy like watching television, listening to

radio.

 Give spiritual care by inviting the hospital priest to pray with her.

 Introduce patient to other patient with similar condition who are now

improving on their health.

POSITION

 Put patient in an upright position and support her with pillows.

 Change position frequently to prevent accumulation of secretion in the lung.

MAINTENANCE OF PATENT AIRWAY

 Enhance breathing by opening the airways.

 If patient cannot cough up secretion, suction the airway under sterile

techniques.

 Encourage patient to cough and do deep breathing exercise every 2 hours.

 Turn the patient in bed to help open the airway and free aspiration of

secretions.

FLUID INTAKE AND OUTPUT

 Fluids are encouraged at least two litres a day because dehydration is a

potential problem due to fever.

 Balance intake and output chart should be done every 24 hours.

OBSERVATION

 Observe for vital signs which include temperature, pulse, respiration and blood

pressure.

 There should be a careful record on oral and parenteral intake and output

chart.

 Respiratory rate, depth of breathing pattern and breathing sound should be

observed two hourly by taking the patients respiration to identify signs of

respiratory failure.

 Signs of fluid overload should be watched for when patient is on intravenous

fluids.

 Intake and output and should be checked and recorded and intake and output

chart should be maintained every 24 hours.

NUTRITION

 Plan diet with patient to know her like and dislikes.

 Encourage drinking of fluid 3 liters daily.

 Oral toileting should do if possible before meals to increase patient appetite.

 Well-balanced diet containing carbohydrate for energy, protein for repairing

worn out tissue and others.

 Serve meals attractively and serve snacks in-between meals.

 Semi solid or liquid diet is served if patient has dyspnoea.

 Advice and enhance patient to take copious fluid to prevent dehydration.

 Encourage patient to eat in bits.

 Serve patient with food that contains proteins and calories.

MEDICATION

 Administer prescribed medications (bronchodilators, analgesics, antibiotics,

antipyretics, cough syrups).

 Oxygen should be administered with caution if patient has chronic lung

disease.

PERSIONAL HYGIENE

 Due to fever and dehydration, the lips usually appear dry and cracked.

 Mouth care is given regularly to combat it.

 Trim patients nail and ensure proper care of hair.

 Bath the patient twice daily to ensure proper circulation.

 Sputum mug should be disinfected and should be changed at least twice daily

to control spread of infection.

  Advice patient to sneeze and cough into disposable tissue and dispose properly

in a bag at the side to be disposed of properly.

 Changed dirty and soiled bed linen and clothing regularly to avoid infection.

 Advise patient to wash hands with soap and water before and after eating and

visiting the toilet.

PROTECTION FROM INJURY

 Delirium is common because of high pyrexia therefore observe for signs and

symptoms.

 Provision of side rails is ensured to avoid patient from falling.

 Patient nails should be trimmed well and sharp instruments should be kept

away from patient to prevent her from hurting herself.

REST AND SLEEP

 Ensure a quiet, calm and serene environment with dim light during sleep.

 Rest patient in bed to avoid exertion and possible exacerbation of symptoms

 Restrict visitors to avoid disturbance in patient sleeping pattern.

 Rest and sleep will promote healing, relax patient, reduce metabolic activity

and conserve energy for client.

PSYCHOTHERAPY

 Assess patient for verbalization of fear, inability and facial tension.

 Implement measures to reduce fear.

 Reassure patient that all will be well and she will resume normal life.

 Introduce patient to other patient who faced such condition and has

successfully recover.
PATIENT TEACHING

 Teach patient importance of adequate bed rest to promote recovery.

 Advice patient to adhere to drug regimen.

 Teach patient deep breathing and coughing exercise.

 Teach patient to take in 3- 4 liters of fluid daily to maintain hydration.

 Urge the patient to avoid environmental irritants that stimulate secretions such

as cigarette smoking, dust and industrial pollution.

 Teach patient proper hand washing to minimize the risk of spreading infection.

 Teach patient to avoid environment irritants such as fumes.

 Avoid prolonged use of immunosuppressive therapy

PREVENTION

 Cessation of smoking.

 The room of the person should be well ventilated.

 Avoid prolonged use of immunosuppressive drug.

 Patient should eat nutritious diet.

 Treat all underlying conditions with appropriate antibiotics.

 Suctioning of mouth and nose at infancy with meconium- stained amniotic

fluid to decrease the rate of aspiration pneumonia.

 Vaccination against haemophilus influenza and streptococcus pneumonia, and

other microorganisms.

 Avoid infections as much as possible.

COMPLICATIONS

 Respiratory Failure
  Pleural Effusion

 Emphysema

 Lung Abscess

 Sepsis

 Septic Shock

 Hypoxia

VALIDATION OF DATA

This is the act of confirming or verifying data. In other words, it involves the act of

measuring the extent to which the data collected possess the quality of being true and

free from errors and biases. The information taken from Mr A.J. was found to be the

same in the folder. All information collected from patient and family are free from

errors and we can conclude that the patient/ family care study data is genuine and

original.
 CHAPTER TWO

ANALYSIS OF DATA

It involves breaking down all the information gathered at the assessment phase to

arrive at a workable conclusion regarding the actual or potential health needs of the

patient. It involves:

1) Comparison of data with standards

2) Patient/Family strength

3) Health problems

4) Nursing diagnosis

COMPARISM OF DATA WITH STANDARDS

This comprises of:

1) Diagnostic investigations/tests

2) Causes

3) Clinical features

4) Treatment

5) Complications

DIAGNOSTIC INVESTIGATIONS

The following were the investigations carried out on Mr A.J;

  White blood count and differential.

 Chest x- ray

 Sputum analysis for Acid Fast Bacilli, culture and sensitivity.

 Blood for blood film to detect the presence of malaria parasites.

 Routine urine examination

The results have been tabulated on the next page;

 TABLE 1: DIAGNOSTIC INVESTIGATIONS TEST CARRIED OUT ON MR A.J.
DATE SPECIMEN INVESTIGATION RESULTS NORMAL INTERPRETATION REMARKS
RANGE
27-01-2024 Chest x- ray The right side of the There should be no This indicates there is The patient was diagnosed
lung was seen to be opacity seen on the presence of inflammation as right lobar pneumonia.
white and opaque. lung with fluid. IV Benzyl Penicillin 4MU
was prescribed
27- 01-2024 Blood White blood cell White blood cell White blood cell Patient’s WBC is normal, Prescribed antibiotics were
count, total and count: 4.1 × 10g/dL count: 2.5- 8.5 x neutrophils and given to fight against
differential count 10g/dL lymphocytes do not fall infection.
Neutrophils: 82% Neutrophils: 60- within normal range
75% indicating the presence of
Lymphocytes: 18% Lymphocytes: 30- infection.
45%
27- 01-2024 Urine Routine urine No abnormality seen There should be no The urine falls within the No treatment was given
examination or detected. abnormal normal constituents of
constituents such urine showing no urinary
as; pus, mucus, tract infection.
tissue necrosis seen
in urine.
27- 01-2024 Blood Blood film for No malaria parasites Malaria parasites This indicates that the No treatment was given
malaria parasites seen should not be seen patient does not have
in the blood malaria
27- 01-2024 Sputum Culture and Negative. No Acid- There should be no This is an indication of the To continue treatment of
sensitivity Fast Bacilli, acid-fast bacilli, patient not having TB pneumonia.
streptococci were streptococci and infection but pneumonia.
seen. pneumococcal
CAUSES OF PATIENT’S CONDITION COMPARED TO LITERATURE
REVIEW

In relation to the literature review, the cause of Mr A.J’s condition was unknown.

However, he may have gotten the infection from inhalation of noxious gases and dust

from where he stays.

TABLE 2: COMPARISM OF PATIENT’S CLINICAL FEATURES WITH

THE LITERATURE REVIEW

CLINICAL FEATURES IN THE CLINICAL FEATURES PRESENTED BY

LITERATURE REVIEW MR. A.J
1. Onset is sudden, characterized by 1. Onset was sudden and temperature was
fever (40.00C)
2. General malaise 2. Patient complained of general body pains
3. Coughing out 3. Patient had a yellowish productive cough.
greenish/yellow/bloody sputum
4. Difficulty in breathing 4. Patient had difficulty in breathing
5. Increased pulse rate 5. Patient had an increased pulse rate (125
beats per minute)
6. Loss of appetite 6. Patient had no desire to eat any food
7. Chest pains 7. Patient complained of pains at the right
side of the chest
8. Sweating 8. Patient did not experience excessive
sweating
9. Cyanosis 9. Patient had no cyanosis
10. Low blood pressure 10.Patient’s blood pressure had reduced
(80/60mmHg)
11. Nausea and vomiting 11.Patient vomited twice on day of admission
TREATMENT

With respect to the literature review, Mr A.J was managed medically on these drugs;

• Intravenous Dextrose Saline 2 liters × 2 days

• Intravenous Benzyl penicillin 4MU stat then 2MU 6hourly x 24hrs

• Tablet Paracetamol 1g tid × 5 days

• Syrup Brozedex 10mls tid × 7 days

• Azithromycin Capsule 500mg daily x 3

• Diclofenac Tablet 50mg tid x 7 day

 TABLE 3: PHARMACOLOGY OF DRUGS ADMINISTERED TO MR.A.J
DATE DRUGS DOSAGE AND CLASSIFICATION DESIRED ACTUAL EFFECTS SIDE EFFECTS
ROUTE OF OF DRUGS EFFECTS OBSERVED
ADMINISTRATION
27-01-2024 Dextrose 2 litres x 48hours Isotonic Solution For fluid replacement Patient’s fluid and Confusion, fever, circulatory
Saline Intravenously and caloric electrolytes balance overload, pulmonary oedema,
supplement. was maintained. sloughing and tissue necrosis.
Patient experienced no such
effects.
28-01-2024 Benzyl 4MU stat then 2MU 6 Antibiotic It interferes with Patient’s condition Nausea, vomiting, diarrhoea,
penicillin hourly Anti - infective bacteria cell wall was improving. dizziness, urticarial rashes.
Intravenously (Penicillin) synthesis Patient experienced no such side
effects
28-01-2024 Tablet 1g 8 hourly x 5 days Antipyretic Inhibits synthesis of Patient was relieved of Less irritation of the gastric
Paracetamol Orally Non-opioid prostaglandin and moderate pain. mucosal overdose leads to liver
Analgesic reduces intensity of damage. Patient had no liver
pain stimulus damage.

28-01-2024 Capsule 500mg 8 hourly x 3 Macrolides It interferes with For treatment of Nausea, vomiting, drowsiness,
Azithromycin days bacteria cell wall infection. Patient was urticaria, abdominal discomfort.
Orally synthesis responding to
treatment.
28-01-2024 Syrup 10mls 8 hourly x 7 Cough Suppressant It dries up mucus and Patient was relieved of Headache, blood pressure
Brozedex days suppresses cough cough and congestion. changes, nausea and vomiting.
Orally Patient had no such effects.
28-01-2024 Tablet 50mg 8 hourly x 7 Non-steroidal Anti- Inhibits synthesis of Patient was relieved of Abdominal cramping,
Diclofenac days inflammatory Drug. prostaglandin and severe pain. constipation, nausea and
Orally reduces intensity of dyspepsia. Patient had no such
the pain stimulus. effects.
COMPLICATION EXHIBITED BY PATIENT

With reference to complications outlined in the literature review, Mr A.J. developed

no complications due to effective medical and nursing care rendered to him.

PATIENT/FAMILY STRENGTHS

Patient/family strength are the resources and abilities that the patient needs to speed

his rate of recovery and help patient cope with his disease condition. These resources

are the physical, psychological, spiritual and social as well as the economic needs of

the patient.

GENERAL STRENGTH

1. Patient cooperated with the health team in the performance of any procedure

on him

2. Patient was full conscious during his admission which made communication

easier.

3. Patient was willing to learn much about his condition which was pneumonia.

4. Patient did not react to any of the foods served.

5. Patient received maximum support from his family.

6. Patient was registered on the National Health Insurance Scheme to cover for

the care rendered.

SPECIFIC STRENGTH

1. Patient can be propped up in bed

2. Patient is willing to be tepid sponged

3. Patient can verbalise intensity of pain

4. Patient is willing to take medications

5. Patient can swallow to drink water

 6. Patient can feel for food when the mouth is cared for

7. Patient can be oriented to the hospital environment

PATIENT’S HEALTH PROBLEMS IDENTIFIED

With reference to the data collected the following health problems were identified

whiles Mr A.J. was on admission;

27-01-2024

1. Patient cannot breathe properly

2. Patient had high body temperature(40.00C)

3. Patient complained of pain at the right side of the chest

4. Patient had a productive cough

5. Patient complained of vomiting

28-01-2024

6. Patient complained of loss of appetite

29-01-2024

7. Patient was anxious

30-01-2024

8. Patient had little knowledge on his condition.

NURSING DIAGNOSIS

27-01-2024

1. Ineffective breathing pattern related to congestion in the lungs

2. Hyperthermia related to inflammation in the lungs

3. Acute pain (chest pain) related to respiratory distress

4. Ineffective airway clearance related to excessive mucosal secretions

5. Risk for fluid volume deficit related to vomiting

28-01-2024

6. Imbalance nutrition less than body requirement related to loss of appetite

29-01- 2024

7. Anxiety related to unknown outcome of condition

30-01- 2024

8. Deficit knowledge related to inadequate information about prevention of

disease
 CHAPTER THREE

PLANNING FOR PATIENT/ FAMILY CARE

The nursing care plan is part of the nursing process and it is the systematic approach

in carrying out individualized care to a patient. It is also the third phase of the nursing

process and the third chapter of the patient/ family care study.

In planning, the nurse discusses with the patient his problems and draws an

individualized care plan from the problems identified. The patient and the family are

involved in the planning for effective recovery.

OBJECTIVE AND OUTCOME CRITERIA

1. Patient will demonstrate the ability to breathe properly within 24hours as evidenced

by

a. Patient verbalizing the ability to breathe properly with ease

b. Nurse recording respiratory rate between 18-20cycles per minute

2. Patient will attain a normal body temperature (36.2oC-37.2oC) within 12hours as

evidenced by

a. Patient verbalising the absence of high body temperature

b. Nurse recording patient’s temperature within normal range

3. Patient’s pain will subside within 24 hours as evidenced by

a. Patient verbalising the absence of pain

b. Nurse observing patient with a relaxed facial expressions

4. Patient will be able to clear his airway within 48 hours as evidenced by

a. Patient verbalising the ability to clear airway

b. Nurse recording normal respiratory rates

5. Patient’s normal fluid volume will be maintained within normal levels within

24hours as evidenced by

a. Patient having a good skin tugor

b. Nurse observing blood pressure to be in the normal range

6. Patient’s nutritional status will be balanced within 48 hours as evidenced by

a. Patient showing interest in food

b. Nurse observing patient eat more than half of food served consistently

7. Patient’s level of anxiety will be reduced within 6hours as evidenced by

a. Patient having a relaxed facial expression

b. Nurse observing the patient interacting with other patient on the ward

8. Patient will demonstrate adequate knowledge on treatment within 6hours as

evidenced by

a. Patient answering about 80% of questions asked

b. Nurse observing patient answering 80% of questions asked satisfactorily

 TABLE 4: NURSING CARE PLAN FOR MR A.J
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME TIME
CRITERIA
27/01/2024 Ineffective Patient will 1. Reassure patient 1. Patient was reassured of the 28/01/2024 Goal fully met as A.A
breathing demonstrate the ability to breathe properly nurse recorded a
@ pattern related ability to breathe through competent nursing care. @ normal
to congestion properly within 24 respiratory rate
1:00pm in the lungs hours as evidenced 2. Put patient in a semi- 2. Patient was assisted into a 1:00pm of 20 cycles per
by fowler’s position. semi- fowler’s position and minute
a. patient hands supported by cardiac table
verbalising the with a pillow on it for comfort
ability to breathe and to facilitate breathing.
properly with ease
b. nurse recording 3. Teach patient how to 3. Patient was taught how to
respiratory rate splint the chest. splint the chest with a pillow
between 18- when coughing to provide
20cycles per minute comfort.

4. Observe vital signs, 4. Patient’s temperature, pulse,

especially respiration blood pressure and oxygen
saturation were monitored
routinely every 4 hours,
respiration was observed every
15 minutes until patient’s
condition was stable.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME TIME

CRITERIA

5. Teach deep- 5. Patient was taught deep-breathing

breathing exercise. exercise and coughing exercises to
perform.

6. Ensure enough rest 6. Enough rest ensured by restricting

visitors and providing a conducive
environment.

7. Proper ventilation was provided

7. Provide proper
by opening nearby windows
ventilation
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J.

DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME ORDERS INTERVENTION TIME
CRITERIA
27/01/2024 Hyperthermia Patient will attain 1. Reassure patient. 1. Patient was reassured that 27/01/2023 Goal met as nurse A.A
related to a normal body his normal body temperature recorded
@ inflammation temperature will be maintained. @ patient with a
of the lungs (36.20C – 37.20C) normal
2:20pm within 12 hours as 2. Tepid sponge patient. 2. Patient was tepid sponged 2:20am temperature
evidenced by using tepid water and placing readings within
a. Patient wet face towels under the normal range
verbalising the armpit, the groin and on the (36.8OC).
absence of high head.
body temperature
b. Nurse 3. Monitor temperature 3. Patient’s temperature was
recording patient checked and monitored hourly
temperature
within normal 4. Ensure good 4. Adequate ventilation was
range (36.2-37.2) ventilation. ensured by opening all nearby
windows to allow the entry of
fresh air and fans were
switched on.

5. Administer prescribed 5. Paracetamol tablets 1g and

anti- pyretic and Benzyl Penicillin 4 MU were
antibiotics. administered as prescribed.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME TIME
CRITERIA
27/01/2024 Acute pain Patient’s pain will 1. Reassure patient 1. Patient was reassured that pain 28/01/2024 Goal partially A.A
(chest pain) subside within 24 that pain will subside will subside with appropriate nursing met as patient
@ related to hours as and medical measures. @ verbalized the
respiratory evidenced by absence of pain
1:40pm distress. a. Patient 2. Apply warm 2. Cold packs wrapped in towels 1:40pm
verbalizing the compresses. were applied to patient’s chest every
absence of pain 15minutes to help relieve pain.
b. Nurse
observing patient 3. Assist patient to 3. Patient was assisted to change
with a relaxed assume comfortable position every 2 hours into a position
facial expression upright positions. that helps him feel better and relieves
his pain.

4. Engage patient in 4. Patient was engaged in diversional

diversional therapy. therapy such as conversation,
watching TV of patient’s interest.

5. Teach patient deep 5. Patient was taught deep breathing

breathing and cough and coughing exercises and
exercises; and relaxation exercise such as body
relaxation techniques. massage, drinking warm tea before
sleep bath warm water before bed
time.

6. Administer 6. Paracetamol Tablet 1g was

prescribed analgesics. administered as ordered.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J .

DATE/ NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE/ EVALUATIO SIGN

TIME DIAGNOSIS OUTCOME ORDERS TIME N
CRITERIA
27/01/2024 Ineffective Patient will be to 1. Reassure patient. 1. Patient was reassured of 29/01/2024 Goal was fully A.A
airway clear his airway competent nursing care. met as patient
@ clearance within 48 hours as @ verbalizing the
related to evidenced by: 2. Encourage oral 2. Patient was encouraged to take ability to clear
4:30pm excessive a. Patient intake. in sips of fluid to thin mucus. 4:30pm the airway
mucosal verbalizing the
secretion ability to clear the 3. Encourage patient to 3. Patient was educated to cover
airway cover mouth when his mouth with tissues when
b. Nurse coughing. coughing to prevent the spread of
recording normal infection.
respiratory rate
4. Assist patient to 4. Patient was assisted to assume a
assume a comfortable semi fowler’s position as it made
position. him comfortable.

5. Encourage patient to 5. Patient was educated to properly

practise proper hygiene. dispose used tissues and practice
proper hand hygiene.

6. Administer prescribed 6. Syrup Brozedex 10mls 8 hourly

medication. x 7 was administered orally as
prescribed.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J.

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME TIME
CRITERIA
27/01/2024 Risk for fluid Patient’s normal 1.Reassure patient 1. Patient was reassured of 28/01/2024 Goal fully met as A.A
volume fluid volume will maintaining a normal fluid patient had good
@ deficit related be maintained volume. @ skin tugor
to vomiting within normal
3:30 pm levels within 2. Provide a vomitus 2. A vomitus bowl with a well- 3:30pm
24hrs as bowl. fitting lid was provided for
evidenced by; patient and emptied from time to
a. patient having time.
a good skin
turgor. 3.Remove nauseating 3. Urinals, soiled bed linens and
b. Nurse items from environment bed pans were removed from the
observing blood environment
pressure to in the
normal range. 4. Give water to rinse 4. Patient was served with water
mouth after vomiting. to rinse his mouth and discarded
after each episode of vomiting.

5. Provide oral hygiene. 5. Patient was assisted and

encouraged to maintain oral
hygiene by brushing his teeth
twice daily with toothbrush and
toothpaste.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J.

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME TIME
CRITERIA
6. Restrict oral intake 6. Oral intake restricted and IV
till vomiting ceases. therapy was initiated until
episodes of vomiting ceased.

7. Set flow rate to 7. Patient’s IV line was assessed

prevent over hydration. and secured and IV was
monitored hourly throughout the
period of IV therapy.

8. Encourage oral sips 8. Patient was encouraged to

as vomiting ceases. take in sips of soup and oral
fluids were encouraged.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J.

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATIO SIGN
TIME DIAGNOSIS OUTCOME TIME N
CRITERIA
28/01/2024 Imbalanced Patient nutritional 1. Reassure patient 1. Patient was reassured that 29/01/2024 Goal was fully A.A
nutrition less status will be measures will be put in place to met as nurse
@ than body balanced within regain his normal appetite @ observed
requirement 48 hours as patient eating
1:30pm related to loss evidence by; 2. Assist patient to 2. Patient was assisted to 1:30 pm more than half
of appetite a. patient showing perform mouth care in the perform mouth care with of food served
interest in food morning and evening. toothpaste and toothbrush twice
b. nurse observing daily, that is morning and
patient eat more evening.
than half of food
served 3. Give patient water to 3. Water was given to patient to
consistently rinse the mouth after each rinse his mouth after each
episode of vomiting. episode of vomiting to help
boost the appetite

4. Plan diet with patient 4. Patient’s diet was planned per

the hospital’s menu and he chose
the food of his preference.

5. Serve food in bit and at 5. Food was served in bits at

frequent intervals. regular intervals the as patient
can tolerate to help the patient
eat.
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION
TIME DIAGNOSIS OUTCOME TIME
CRITERIA
6. Serve meals rich in 6. Meals rich in calories and
calories and protein. protein were served, like agidi with
soup and fish.

7. Serve patient with fruits 7. Patient was served with fruits

like apples, oranges.

8. Monitor patient’s weight 8. Patient’s weight was monitored

at alternate days. every 48 hours and progress was
documented.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J.

DATE/ NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE/ EVALUATIO SIGN

TIME DIAGNOSIS OUTCOME ORDERS TIME N
CRITERIA
29/01/2024 Anxiety Patient’s level of 1. Reassure patient 1. Patient was reassured that his 29/01/2024 Goal met as A.A
related to anxiety will be stay in the hospital was temporal patient had a
@ unknown reduced within 6 and he may home early if he @ relaxed facial
outcome of hours as follows his treatment regimen expreession
11:00am condition evidenced by; correctly. 11:00am
a. patient having a
relaxed facial 2. Allow patient and 2. Patient and relatives were
expression family to express their allowed to allowed to express their
b. nurse observing worries grievances and worries and this
the patient helped reduce their anxiety
interacting with
other patient on 3. Provide diversional 3. Patient was made to watch
the ward therapy television and interact with his
family to keep his mind off his
condition

4. Explain the 4. Patient was told that

importance of hospitalization helps to monitor
hospitalization blood pressure effectively and
promptly to combat any signs of
complication and reduce Bp to
normal valve (120/80mmHg)
5. Educate patient on the 5. Patient was educated on
condition and explain the pneumonia and treatment regimen.
effect of anxiety
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J.

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATIO SIGN
TIME DIAGNOSIS OUTCOME TIME N
CRITERIA
30/01/2024 Deficient Patient will 1. Assess patient and 1. Patient and his family were 30/01/2024 Goal fully met A.A
knowledge demonstrate family’s knowledge assessed to find out their as patient was
@ related to adequate about the condition. knowledge about the condition. @ able to answer
inadequate knowledge on about 80% of
8:00am information treatment within 6 2. Educate them on the 2. Patient and his family were 2:00pm questions asked
about hours as evidenced disease. educated on the causes, sign
prevention of by; and symptoms, treatment,
disease a. patient answering preventions and complications
about 80% of of the disease.
questions asked
b. nurse observing 3. Encourage patient 3. Patient and family were
patient answering and family to ask encouraged to ask questions and
80% of questions questions. answers were provided in plain
asked satisfactorily language.

4. Answer 4. Patient/family questions were

patient/family’s answered correct fully and
questions correctly tactfully to their understanding
and tactfully.
 CONTINUATION OF NURSING CARE PLAN FOR MR.A.J.

DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME TIME
CRITERIA
5. Ask them questions 5. Questions were asked for
for feedback. feedback and patient and family
were able to state the causes,
signs and symptoms,
treatments, prevention and
complication of the condition.

6. Explain the 6. Treatment regimen for

treatment regimen to enteric fever was explained to
patient. patient.
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT/ FAMILY CARE PLAN

This chapter involves details of actual nursing care rendered during the course of admission as

described in the nursing care plan. This comprises of the summary of actual nursing care

rendered to the patient and family on daily basis in the ward, preparation of patient and family

for discharge as well as follow up home visits and continuity of care.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT AND FAMILY

DAY OF ADMISSION (27-01-2024)

Mr A.J was admitted into the male medical ward at Effia Nkwanta Regional Hospital through the

Emergency Unit on the 27th of January, 2024 at 12:30pm with the diagnosis of Right Lobar

Pneumonia by Dr. O.S. He came with the history of difficulty in breathing, high body

temperature, chest pains, productive cough and vomiting which started a week before. He was

warmly welcomed and reassured of quality nursing care. The admission papers were collected

and patient’s particulars entered into the Admission and Discharge Books as well as the daily

ward state. He was oriented and made comfortable in bed. His vital signs were checked and

recorded as follows;

• Temperature: 40.00C,

• Pulse: 125 beats per minutes,

• Respiration: 40 cycle per minutes

 • Blood pressure: 80/60mmHg.

The following treatments were prescribed for him;

• Azithromycin capsules 500mg daily x3 days

• Diclofenac tablet 50mg 8 hourly x 7 days

• Paracetamol tablet 1g tid × 5days

• Intravenous Fluid Dextrose Saline 2L x 48 hours

• Normal Saline 1 Litre x 48hrs

• Intravenous Benzyl Penicillin 4MU stat then 2MU 6 hourly x 24 hours

• Syrup Brozedex 10mls 8 hourly x 7 days.

The following investigations were requested and they were all done:

• Chest x-ray

• Haemoglobin level estimation

• Blood film for malaria parasites

• White Blood Cell Count and total differentials

• Urine examination

Mr. A.J was reassured of competent nursing care and was positioned in a semi- fowler’s position,

tight clothing around neck were removed, good ventilation was ensured by opening nearby

windows to facilitate breathing since patient was having difficulty in breathing. He was taught

how to splint the chest with a pillow when coughing to provide comfort.
A trolley was set for tepid sponging around 2:20pm due to his high body temperature (40.0 0C).

After 15 minutes of tepid sponging, the temperature was rechecked and had reduced to 38.7 0C.

His bed cover was removed and nearby window was opened to ensure good ventilation.

Patient was continuously reassured and assisted to assume a comfortable position which helped

to relief pain. Cold compress was applied every 15minutes within a period of 2 hours, also deep

breathing exercise was taught and encouraged to help relief pain. Patient was encouraged to take

in more fluids.

Patient was provided with vomitus bowl and was encouraged to vomit into the bowl, water was

also given to rinse the mouth after vomiting. Another tray was set for IV line to administer

intravenous fluid Dextrose 2L and intravenous Benzyl penicillin 4Mu stat was given. He was

reassured and the following treatment administered; Tablet Paracetamol 1g, Tab Diclofenac

50mg and Syrup Brozedex 10mls, and their therapeutic effects were also monitored.

Patient’s lunch was served around 3:45pm and it was banku and light soup with fish. Mr. A.J ate

only a small amount of the food. I sat by the patient and gave continuous reassurance. His

supper, rice and stew with fried fish were brought in around 5:30pm. Patient was not able to eat

half of the food served and drank a glass of water. His vital signs were checked at 6:00 pm with

the following readings;

 Temperature – 36.80C

 Pulse – 84 beats per minute

 Respiration – 28 cycles per minute

 Blood pressure 100/ 70mmHg

 SpO2 - 93%
Patient was engaged in diversional therapy like chatting on issues of his interest. Mr A.J was

encouraged to have enough rest by providing a calm environment and also provided bed free

from cramps.

At 10:00 pm, patient was served with Paracetamol tablet 1g, Diclofenac tablet 50mg, IV Benzyl

penicillin 2MU and Syrup Brozedex 10mls. His bed linen was straightened and the place kept

quiet to aid in his sleep. Patient was assisted to bath and slept at about 10:50pm after struggling

the whole day to sleep due to his chest pains. He was handed over to the night staff nurse for

continuity of care.

FIRST DAY POST ADMISSION (28-01-2024)

Mr A.J woke up around 5:30am and he was assisted to take his bath perform his oral hygiene

and take his bath. He was reassured and made comfortable in bed. His vital signs were checked

and recorded at 6:00 am as the following;

 Temperature – 36.90C

 Pulse – 83 beats per minute

 Respiration – 22 cycles per minute

 Blood pressure - 100/ 60mmHg.

 SpO2 – 95%

Mr A.J ate only about half of the bread served and drunk about 50mls of the milo. He was served

his medications thus Azithromycin capsule500mg, Paracetamol tablet 1g, Diclofenac tablet

50mg and Syrup Brondex 10mls. At 8:40am, patient was reviewed by the medical team. His

sputum was requested for cultural and sensitivity test and to continue previous treatment.

At 10:00am patient’s vital signs were checked and recorded as the following;

 Temperature – 36.50C
  Pulse – 80 beats per minute

 Respiration – 26 cycles per minute

 Blood pressure - 100/ 60mmHg.

 SpO2 – 98%

He took rice and stew for lunch. Patient complained of loss of appetite. Patient was reassured

that all measures will be put in place to regain his normal appetite. Nauseating items such as

urinals and sputum mug removed to stimulate patient’s appetite. Food was also served in bits and

on demand to help patient get enough time to chew and swallow. Waster was given to the patient

to rinse the mouth after vomiting. Patient diet was planned per the hospital menu and he chose

the food of his preference. Patient was also served with fruits such as apples and oranges, Mr A.J

ate one orange.

At 2:00pm his vital signs were checked and recorded and the readings were;

Temperature – 36.80C

Pulse – 78 beats per minute

Respiration – 24 cycles per minute

Blood Pressure - 110/ 60mmHg

SpO2 – 98%

His medications were served thus Tab paracetamol 1g, Tab Diclofenac 50mg and Syrup

Brozedex 10mls. Patient was visited by the family members at 4:30 pm. His family members

were reassured and encouraged to visit whenever possible. Patient was engaged in conversation

which helped to diverse patient’s attention from pain. Mr A.J was given continuous reassurance

and was monitored and observed for therapeutic effect of drugs served.
He had his super at 6:00 pm. He ate banku and groundnut soup which was brought from the

house. His vital signs were checked and recorded with the following readings;

Temperature – 36.80C

Pulse – 74 beats per minute

Respiration – 26 cycles per minute

Blood Pressure - 100/ 70mmHg

SpO2 – 96%

His medication; Tab. Paracetamol 1g, Tab. Diclofenac 50mg and Syrup Brozedex 10mls were

administered and recorded at 10:00pm. Patient was handed over to the night nurse for continuity

of care.

SECOND DAY POST ADMISSION (29-01-2024)

Patient slept well over the night and made no complaints. His dirty bed linens were changed and

replaced with clean ones. He took his bath and had his oral hygiene before taking his breakfast.

He took tom brown with bread for breakfast. His vital signs were checked and recorded as

follows;

Temperature – 36.70C

Pulse – 78 beats per minute

Respiration – 22 cycles per minute

Bp - 110/ 70mmHg

SpO2 – 98%

His medication; Tab. Paracetamol 1g, Tab. Diclofenac 50mg, Cap Azithromycin 500mg and

Syrup Brozedex 10mls were administered as prescribed and recorded.

At 9:00 am, patient was reviewed by the medical team and was to continue treatment. His vital

signs were checked at 10:00am and the following readings were recorded;

Temperature – 36.80C

Pulse – 78 beats per minute

Respiration – 24 cycles per minute

Bp -110/ 70mmHg

Patient’s hands and feet were cared for, he was also educated on the need to keep hands and feet

clean. Patient was anxious on the outcome of his condition. Patient was reassured that his stay in

the hospital was temporal and he may home early if he follows his treatment regimen correctly.

Patient was allowed to express his worries and I explained the importance of hospitalisation

which allayed his anxiety. He was engaged in conversation which he was cooperative. Patient

was allowed to watch television.

At 2:00pm he took plantain and palaver sauce with fish for lunch and he ate everything. He was

served with his prescribed medication Tab. Paracetamol 1g, Tab. Diclofenac 50mg, and Syrup

Brozedex 10mls. His vital signs were checked and recorded as follow;

Temperature – 370C

Pulse – 76 beats per minute

Respiration – 22 cycles per minute

BP 110/ 60mmHg

SpO2 - 98%

His family paid him a visit at 4:30pm.

At 6:00pm patient was served with rice and fish stew. He ate well and was congratulated for

eating everything. He was served with his prescribed medication; Paracetamol Tablet 1g,
Diclofenac Tablet 50mg and Brozedex Syrup10mls around 10.00pm and his vital signs were

checked and recorded as follows

Temperature – 36.80C,

Pulse – 74 beats per minute,

Respiration – 23 cycles per minute

Blood Pressure -100/75mmHg.

SpO2 – 98%

He took his bath and went to bed around 10: 45 pm. He handed over to the night staff nurse for

continuity of care.

THIRD DAY ON ADMISSION 30-01-2024

Mr A.J slept well throughout the night without complains. He had his bath and his oral hygiene.

He took rice pudding and bread for breakfast. His vital signs were checked and the following

readings recorded;

Temperature – 36.70C

Pulse – 72 beats per minute

Respiration – 24 cycles per minute

Blood Pressure - 110/ 72mmHg

SpO2 – 98%

The following medications were served; Tab. Paracetamol 1g, Tab. Diclofenac 50mg, Syrup

Brozedex 10mls for patient.

At 8:30am he was reviewed by the medical team.

He took rice and stew with fish for lunch and ate everything. He took his prescribed medication;

Paracetamol Tablet 1g, Diclofenac Tablet 50mg, Brozedex Syrup at 2:00 pm. His vital signs

were checked and recorded as the following;

Temperature – 37.00C

Pulse – 76 beats per minute

Respiration – 22 cycles per minute

Blood pressure 110/ 70mmHg.

His relatives came around during the visiting time, a conducive environment was provided and

relatives were encouraged to reassure and interact with him to relief anxiety.

Patient had little knowledge about his condition. Patient and family were assessed to find out

their knowledge about the condition. Patient was educated on the causes, signs and symptoms,

treatment, prevention and complications. They were encouraged to ask questions and they were

all answered in clear simple language for them to understand. The treatment was explained to

them.

At 6:00 pm, patient took banku and okro soup. He was congratulated for eating everything. His

vital signs were checked and recorded as following;

Temperature – 36.70C

Pulse – 72 beats per minute

Respiration – 24 cycles per minute

Blood pressure 100/ 65mmHg.

SpO2 – 98%
He was served with his prescribed medication; Paracetamol Tablet 1g, Diclofenac Tablet 50mg,

and Brozedex Syrup at about 9:50pm. He took his bath and return to bed at 10:00 pm. He was

handed over to the night staff nurse for continuity of care.

DAY OF DISCHARGE (31-01-2024)

Mr A.J slept well without any complaints. He woke up in the morning with smiles on his face

knowing that today was going to be his day of discharge. His condition was actually fair. He

took care of his personal hygiene after which his vital signs were checked and recorded the

following readings;

Temperature – 36.90C

Pulse – 71 beats per minute

Respiration – 22 cycles per minute

BP - 110/ 70mmHg

SpO2 – 98%

He took his breakfast with such joy which was oats and bread with fried eggs. His prescribed

medication; Paracetamol Tablet 1g, Diclofenac Tablet 50mg, and Brozedex Syrup were

adminnistered at 8:40am and was then reviewed by the medical team on ward rounds.

He was discharged due to his stable condition and was asked to come for review the following

week on 7th February, 2024. But could come before the said date if he experiences any problem.

Patient was to continue treatment on discharge. His medication was given to him and was

emphasized on the treatment protocols and preventive measures. He did well by repeating

everything he was educated on. He was encouraged to have enough rest and sleep in order to

promote his full recovery. The discharge papers were signed by the Dr O.S and entered into the
Admission and Discharge Books as well as the Ward States. His bills were processed at the

billing station. I called home for Mr A.J and informed them about the good news. They came for

him around 12:00pm. He was helped to pack his belongings. They all thanked the staff and left.

His bed linen was removed and sent to the sluice room. All items used for him were

decontaminated.

PREPARATION OF PATIENT/ FAMILY FOR DISCHARGE AND REHABILITATION

The preparation of the patient and family towards discharge was started on the day of admission

throughout the period of hospitalization, when our interaction started with the aim of promoting

and maintaining health and prevention of complications. Mr A.J was admitted into the male ward

through the Emergency Unit on the 27th of January, 2024 at 12:30pm with the diagnosis of Right

Lobar Pneumonia by Dr O.S. Patient came with the history of chills, difficulty in breathing, chest

pains and anorexia. He received quality nursing care for 5 days and condition improved which

led to his discharge. Mr A.J and his family were advised to maintain good personal hygiene and

also to maintain good environmental hygiene Mr A.J was educated on his treatment protocols

and preventive measures. They were educated on eating good nutritious diets such as green leafy

vegetables, example; kontomire, fruits such as bananas, oranges, apples, and pawpaw to build

their immune systems and haemoglobin levels to prevent them from getting infections. They

were educated on the need for adequate rest and sleep. He was discharged on that 31 st of January,

2024. His discharge papers were entered into the Admission and Discharge Books as well as

Ward States. His bills were processed at the billing section and settling of bills was not a

problem since he was registered with the National Health Insurance Scheme. The need for

continuity of care was emphasized and I informed them of my next home visits.
HOME VISIT/FOLLOW UP AND CONTINUITY OF CARE

Home visiting is the visit made to patients in their homes to prevent illness and disability, to

promote and maintain health, encourage individuals and family to live a healthy life and improve

their health status.

FIRST HOME VISIT (29/01/2024)

My first home visit was made on the 29th of January, 2024, when patient was still on admission.

The main purpose was to familiarize myself with patient’s home environment and assess the

health -related factors and ways of solving them. I did not have difficulties locating the house.

His wife was aware of my visit, therefore was expecting me. He warmly welcomed me at the

entrance of the house. The environment of the house was kept tidy having no health problems.

Their room was somehow packed, with baggage, utensils dresses and furniture. The room was

not that much spacious to contain their baggage and other items. They however, have a good

source of light and water. Ventilation was not all that good because the house was surrounded by

bushes and there was dust all over, the room has a small window which is always closed so I

advised them as much as possible to keep their belongings especially clothes in their bags when

they do not need them. I also asked them to be weeding around the house when necessary and

always leave their windows open when they are inside to give them fresh air. I encouraged her

wife to give Mr A.J all the support needed before he is discharged, (his nutritional status,

personal health and his sleep pattern). I reassured her of Mr A. J’s improvement in his condition

and assured her of seeing him very soon. I told her of my next visit, which was going to be after

Mr A.J is discharged. I thanked her for her hospitalisation and asked permission to leave.
SECOND HOME VISIT (3-02-2024)

My second home visit was made on the above date that was three days after Mr A.J’s discharge.

Everyone was happy to see me; they warmly welcome me and offered me a seat. The main aim

was to remind the patient of his review date and also to know how he was responding to the

education and treatment after discharged. I took some fruits to Mr A.J. I met Mr A.J, his

children, his wife and his brothers sitting in front of the house. They all looked cheerful. They

welcomed me and Mr A.J thanked me as I handed over the gifts to him. This time around, we

took a stroll around the house while talking. I asked about their welfare placing much emphasis

on Mr A. J’s health. As we went around the house, I found out that their bathroom was a bit

slippery so I advised them to scrub with a hard brush and soap. Behind the house was a very big

gutter which was chocked with rubbish and refuse tied in polythene bags floating in it. I educated

them on the hazard of the state of the gutter on their health. They were encouraged to drain it and

remove the bags and also prevent other people from throwing refuse into the gutter. I also

educated them to cover their foods with net or well-fitting lid and try as much as possible to eat

hot foods, aside that they should also wash fruits and vegetables with salt solution before eating

them. I took the opportunity and asked Mr A.J to educate his friends on his condition. This was

to find out whether Mr A.J would remember everything he was educated on about his condition

and ways of prevention. He did exactly what was expected of him. I practically, added little

knowledge to what he said by touching on their nutrition to build a strong immunity against all

infections and the need for early treatment. I reminded him of the review date which he actually

had not forgotten. He was also encouraged to have at least 2 hours rest and sleep in the day and 6

hours at night. His wife, children, and brothers were advised to give him all the encouragement

to achieve it. I told him to have enough rest and sleep and asked the wife to see to that as much
as possible. He was so happy to hear that since Mr A.J would not listen to anything the wife and

children says but now that I had said it, they knew he was going to do as they will tell him or

else, they would report him to me. I made mention of introducing a community health nurse from

Fijai Hospital, who would be taking over from me after I am done with my interaction with them

and they would actually meet him on my next visit which was going to be on 17-02-2024. We

talked for a while and finally had to leave. I thanked them for their company and they thanked

me for keeping to my promise by visiting.

THIRD HOME VISIT 17-02-2024

I made my third home visit which was the final home visit on 17th February, 2024. The main

reason for this visit was to hand over my patient to the Community Health Nurse whom I had

already informed and therefore was aware of our meeting that day. I called the Community

Health Nurse and arranged for her to meet me at Fijai junction so we could go to the house

together. Mr A.J was happy to meet the community Nurse. This time he was there with her

mother and they welcomed us. I introduce the Community Nurse to Mr A.J and her mother. I

told them that, she was going to continue the care I had already started. I asked him about the

review and Mr A.J told us everything went on successfully and the Doctor had assured him that

everything was fine with him. The Community Nurse also interacted with them to boost their

confidence in her and assured them of her support during her visit to them. I thanked Mr A.J and

his relatives for their cooperation and thanked the Community Health Nurse for taking over from

me. I asked them to be in touch if there was anything they needed from me and I said goodbye to

them.
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO THE PATIENT AND FAMILY

This is the final stage of the nursing process. The chapter talks about whether the desired goals

set have been met or not. However, the plan of care is amended if the set goals are not met or

they are partially met. The chapter involves the following;

1. Statement of evaluation

2. Amendment of care.

3. Termination of care.

STATEMENT OF EVALUATION

Mr A.J was admitted into the male ward through the Emergency Unit on the 27 th of January,

2024 at 12:30pm with the diagnosis of Right Lobar Pneumonia by Dr. S.O. Patient came with the

history of chills, difficulty in breathing, chest pains and anorexia which started a week ago.

Health problems were identified and objectives set. He was given quality nursing care using a

care plan as a tool for nursing him. All objectives set were met.

On 27th January, 2024, patient complained of not breathe properly, a nursing diagnosis

‘ineffective breathing related to congestion in the lungs’ was made. An objective was made that

patient will demonstrate the ability to breathe properly within 24hours. With effective medical

and nursing care the goal was met as patient verbalised the ability to breathe properly with ease.
On the same day, patient had high body temperature. A nursing diagnosis ‘hyperthermia related

to inflammation in the lungs’ was made. An objective was made that patient will attain a normal

body temperature (36.2oC-37.2oC) within 12hours. With effective nursing care and interventions

the goal was met as patient verbalising the absence of high body temperature.

Again, patient complained of chest pain. A nursing diagnosis ‘acute pain related to respiratory

distress’. An objective was made that patient’s pain will subside within 24hours. Due to effective

medical and nursing care the goal was fully met as patient verbalised the absence of pain.

Also, patient had productive cough. A nursing diagnosis ‘ineffective airway clearance related to

excessive mucosal secretion’ was made. An objective was made to clear his airway within 48

hours. Goal was fully met as patient verbalised the ability to clear the airway.

And, patient complained of vomiting. A nursing diagnosis ‘risk for fluid volume deficit’ was

made. An objective was made to maintain patient’s normal fluid volume within 24 hours. Goal

was fully met as patient had good skin tugor.

On 28th January, 2024, patient complained of loss of appetite. A nursing diagnosis ‘imbalanced

nutrition less than body requirement related to loss of appetite’ an objective was made that

patient’s nutritional status will be balanced within 48hours. Goal was fully met as patient was

able to eat more than half of food served.

On 29th January, 2024, patient was anxious about the unknown outcome of condition. A nursing

diagnosis ‘anxiety related to unknown outcome of condition. An objective was made to reduce

patient’s level of anxiety within 6hours. Goal was fully met as patient had a relaxed facial

expression.

On 30th January, 2024, patient had little knowledge about his condition. A nursing diagnosis

‘deficient knowledge related to inadequate information about prevention of disease’. An

objective was made that patient will demonstrate knowledge on treatment within 6 hours. Goal

was fully met as patient was able to answer about 80% of question asked.

AMENDMENT OF NURSING CARE PLAN

The objectives set during the hospitalization of Mr A.J, goals was fully met hence no

amendments were made.

TERMINATION OF CARE

This is the aspect of care study, where the nurse- patient/ family relationship comes to an end.

Preparation towards the termination of care began from the first day I came into contact with Mr

A.J and his family. It was made known to them that my interaction with them would last for a

short period. However, he was reassured that he will be handed over to a Community Health

Nurse who will continue the care. On admission, there was a good interpersonal relationship

between the nurse and the patient and patient’s family but was temporal. I made them understood

that, I was not going to be present at the ward everyday due to my academic work and so the

need to cooperate with the other staffs. I assured them of the competency of the other staffs.

During my second home visit, I informed the patient about the community health nurse who

would take over from me for continuity of care and on my third home visit which was my last

home visit. Patient was handed over to the Community Health Nurse. They were therefore not

surprised when I finally told them that my interaction with them has come to an end and I handed

over to the community health nurse. I expressed my greatest gratitude for their cooperation

throughout our interaction and encouraged Mr A.J to visit the health centre anytime he has a

health problem. They also showed appreciation for my assistance, visits and care rendered to

them.
SUMMARY

This study is about Mr A.J, who is 55 years of age, was admitted to the male medical ward at

Effia Nkwanta Regional Hospital at Sekondi on the 27 th of January, 2024 by Dr. O.S. He was

diagnosed with Right Lobar Pneumonia. On admission, the nursing process was used to give the

necessary care to the patient. Patient and his family were reassured and educated on the disease

condition. Laboratory investigations requested were done and prescribed medications were

administered. Mr A.J and family were cooperative and this allowed him to be nursed without

complications. He was on admission for five days and was discharged on 31 st January, 2024 and

came back for review on the 7th of February, 2024. Three home visits were made to the patient’s

house for the continuity of care. During my third home visit, Mr A.J was handed over to a

Community Health Nurse for continuity of care.

CONCLUSION

The patient / family care study I undertook has been educative, helpful and an interesting

experience. It has given me the opportunity to improve on my nurse- patient and family

relationship and total individualized nursing care which will help me render care to all patients

entrusted in my care using a scientific nursing approach.

It is therefore my great desire that, anyone who reads this script will be educated on Right Lobar

Pneumonia and most importantly, serving as a resource base script for other health professionals.
 BILIOGRAPHY

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