PATIENT AND FAMILY CARE STUDY
(NURSING PROCESS APPROACH)
ON
GASTROENTERITIS
WRITTEN BY
APPIAH THOMAS
( A620170031 )
A FINAL YEAR STUDENT OF
SAVIOUR CHURCH NURSING AND MIDWIFERY TRAINING COLLEGE, OSIEM
MAY, 2020
i
PREFACE
Patient and family care study is an academic exercise written by final year student nurse. It is
part of the requirement needed by the Registered General Nurses and Midwives Council of
Ghana.
A student is required to choose a patient with a particular disease condition and nurse him/her
from the admission day till discharge. Follow up visits are also done to maintain good health
of the patient.
The patient and family care study equips the student nurse with information on a particular
disease condition and the use of the nursing process concepts to provide efficient care for the
patient.
Again it also helps the student nurse to practice using the acquired skills and knowledge
gained from school.
It also serves as a record in training institutions to make references during academicc work.
ii
ACKNOWLEDGEMENT
My greatest thanks goes to the almighty God for his fortification, strength and wisdom which
has sustained me throughout the writing of this study. My sincere gratitude also goes to Miss.
T.K. and her family for their cooperation and support during the period of my interaction
with them which contributed immensely to the success of this care study.
My sincere appreciation also goes to the entire nursing and medical staffs of the kids ward of
Hawa Memorial Hospital who in diverse ways guided and assisted me throughout this study.
Much acknowledgement goes to my supervising tutor, Madam Leticia Dompreh and the
entire tutorial staffs of Saviour Church Nursing and Midwifery Training College for the
continuous support, patience, guidance and contributions that I received from them.
To my wonderful parents Mr. and Mrs. Peprah, my God father Mr. and Mrs. Darkwah your
prayers brought me this far. I will also like to express my profound gratitude to my siblings,
friends and colleagues of the noble profession who in diverse ways helped me to complete
this study.
Finally, I wish to acknowledge all the authors of the books from which relevant information
was picked for this study.
iii
INTRODUCTION
This script is a report on the Nursing care rendered to Miss. T.K. a 33-year-old woman who
was admitted to the female medical ward of the Hawa Memorial Saviour Hospital with the
diagnosis of Gastroenteritis on the 25th day of July, 2019 at 2‫׃‬30 pm. Implementation of the
care plan entails assisting the patient to gain comfort, especially relief from abdominal pain.
When patient‟s health status started to improve, she was educated on self-management after
discharge which included having enough rest, wash fruit and vegetables well before eating,
and maintaining personal and environmental hygiene. Patient was also educated on the need
to avoid excessive intake of irritating agents such as alcohol and drugs. The nurse-patient
contact was gradually reduced to promote independence of patient from health team.
This write-up describes how a patient with gastroenteritis was nursed in the context of
modern nursing practice and was grouped into five chapters.
Chapter one deals with the assessment of patient/family.
Chapter two involves analysis of the data gathered on patient/family.
The third chapter entails planning care for patient/family and compresses determining nursing
plans and strategies and expected outcomes.
The last two chapters, four and five are concerned with implementation and evaluation of
nursing actions respectively.
iv
TABLE OF CONTENT
PREFACE ..................................................................................................................................ii
ACKNOWLEDGEMENT ....................................................................................................... iii
INTRODUCTION .................................................................................................................... iv
TABLE OF CONTENT ............................................................................................................. v
LIST OF TABLES ................................................................................................................. viii
CHAPTER ONE ........................................................................................................................ 1
1.0 ASSESSMENT OF PATIENT AND FAMILY .............................................................. 1
1.1 Patient‟s Particulars .......................................................................................................... 1
1.2 Patient and Family‟s Medical and Socio – Economic History......................................... 1
1.3 Patient‟s Developmental History ..................................................................................... 2
1.4 Patient Lifestyle and Hobbies .......................................................................................... 2
1.5 Patient‟s Past Medical History ......................................................................................... 3
1.6 Patient‟s Present Medical History .................................................................................... 3
1.7 Admission of Patient ........................................................................................................ 4
1.8 Patient‟s Concept of Illness .............................................................................................. 5
1.9 Literature Review ............................................................................................................. 6
Definition ............................................................................................................................ 6
Incidence ............................................................................................................................. 6
Aetiology / Causes of Gastroenteritis ................................................................................. 6
Pathophysiology ................................................................................................................. 7
Clinical Manifestations ....................................................................................................... 7
Diagnostic Investigation ..................................................................................................... 7
Medical Management ......................................................................................................... 8
Complications ..................................................................................................................... 8
Nursing Management ......................................................................................................... 8
v
Prevention of Gastroenteritis .............................................................................................. 9
1.10 Validation of Data ........................................................................................................ 10
CHAPTER TWO ..................................................................................................................... 11
2.0 ANALYSIS OF DATA .................................................................................................. 11
2.1 Comparison of Data with Standard ................................................................................ 11
Factors That Caused Patient‟s Condition ......................................................................... 11
Table 1: Comparison of Causes to That of Standard ........................................................ 12
Clinical Manifestation ...................................................................................................... 12
Table 1: Comparison of Clinical Manifestation with Standards ...................................... 12
Diagnostic Investigations ................................................................................................. 13
Table 3: Diagnostic Investigations Requested and Carried Out On Miss. T.K. ............... 14
Table 4: Medical Treatment ............................................................................................. 15
Table 5: Pharmacology of Drugs ...................................................................................... 16
Continuation of Pharmacology of Drugs .......................................................................... 17
Complications ................................................................................................................... 18
2.2 Patient / Family Strengths .............................................................................................. 18
2.3 Patient‟s Health Problems .............................................................................................. 18
2.4 Nursing Diagnosis .......................................................................................................... 19
CHAPTER THREE ................................................................................................................. 20
3.0 PLANNING FOR PATIENT AND FAMILY CARE ....................................................... 20
3.1 Nursing Objectives / Outcome Criteria .......................................................................... 20
Short Term Objective ....................................................................................................... 20
Long Term Objectives ...................................................................................................... 21
Table 6: The Nursing Care Plan ....................................................................................... 22
The Nursing Care Plan ..................................................................................................... 23
The Nursing Care Plan ..................................................................................................... 24
The Nursing Care Plan ..................................................................................................... 25
vi
The Nursing Care Plan ..................................................................................................... 26
The Nursing Care Plan ..................................................................................................... 27
The Nursing Care Plan ..................................................................................................... 28
CHAPTER FOUR .................................................................................................................... 30
4.0 IMPLEMENTATION OF NURSING CARE PLAN .................................................... 30
4.1 Summary Of Actual Nursing Care Rendered To Miss. T.K. ......................................... 30
First Day of Admission (25th of July, 2019) ..................................................................... 30
Second Day in the Ward (26th of July, 2019) ....................................................................... 32
Third Day in the Ward (27st of July, 2019) ...................................................................... 33
Fourth Day in the Ward (28st of July, 2019)..................................................................... 34
Day of Discharge (29nd of July, 2019) .............................................................................. 35
4.2 Preparation of Patient/Family for Discharge and Rehabilitation ................................... 35
4.3 Follow Up Visit/Home Visits/Continuity of Care ......................................................... 36
First Home Visit (28st of July, 2019) ................................................................................ 36
Second Home Visit (4th of August, 2019) ........................................................................ 37
Third Home Visit (24th of August, 2019) ......................................................................... 37
CHAPTER FIVE ..................................................................................................................... 39
5.0 Evaluation of Patient / Family Care ............................................................................... 39
5.1 Statement of Evaluation ................................................................................................. 39
5.2 Amendment of Care ....................................................................................................... 41
5.3 Termination of Care ....................................................................................................... 41
5.4 Summary ........................................................................................................................ 41
5.5 Conclusion...................................................................................................................... 42
BIBLIOGRAPHY .................................................................................................................... 44
SIGNATORIES ....................................................................................................................... 45
vii
LIST OF TABLE
Table 2. 1: Comparison of Causes to That of Standard ........................................................... 12
Table 2. 2: Comparison of Clinical Manifestation with Standards .......................................... 12
Table 2. 3: Diagnostic Investigations Requested and Carried Out On Miss. T.K. .................. 14
Table 2. 4: Medical Treatment ................................................................................................. 15
Table 2. 5: Pharmacology of Drugs ......................................................................................... 16
Table 3. 1: The Nursing Care Plan........................................................................................... 22
viii
CHAPTER ONE
1.0 Assessment of Patient and Family
Assessment is the vital and initial step of the nursing process through which relevant
information about the patient and family is collected. It is done through observation,
interview of patient and family / significant others, performance of physical examination,
study of patient‟s health records during the period of admission. The relevance of assessment
is to enable the nurse to identify psychological, physical, social, emotional and spiritual needs
of the patient and family. It also helps the nurse to know the trend of the disease. The
information gathered can then be applied to render quality nursing care to the patient. This
section comprises the following: patient particulars, patient / family medical and socioeconomics history, her developmental history, lifestyle and hobbies, her past medical history,
present medical history and concept of her illness.
1.1 Patient’s Particulars
Miss T. K is a thirty (33) year old woman, who comes from Anyinam the Eastern part of
Ghana. She was born to Mr. F.P and Mrs. A. A on the 24th May 1986. She is a Ghana and
Christian by religion. she was born into a Christian home and worship with Presbyterian
Church of Ghana Anyinam. Miss T. K. has Ten siblings of which she is the only female and
2nd born to her parents. She speak Twi and a little of English only. She lives with her husband
in Anyinam, a few meters away from the Anyinam Market. Miss. T. K is a Trader and her
next of kin is A.I her brother. She is blessed with two children namely, J.N and D.K . My
client weighs 60kgs and her height is 160cm with BMI of 23.44
1.2 Patient and Family’s Medical and Socio – Economic History
According to my patient, it was revealed that there has never existed any hereditary disease
such as epilepsy, diabetes , sickle cell, hypertension, asthma and any mental disorders in the
family. Also no history of chronic diseases such as chronic liver cirrhosis chronic hepatitis,
and so on. However the families sometimes suffered from minor ailments such as headache,
abdominal pains, fever, common cold diarrhea and vomiting and are treated with over-the1
counter drugs like paracetamol, aspirin, ibuprofen, vitamin c, etc. and reports to the hospital
at times for treatment, (mostly Anyinam clinic) if it becomes severe. She however added that
she has ever been admitted in the hospital with malaria and was hospitalized for 3 days.
Miss T. K. stated that, she lives in a compound house with other tenants with a good source
of water (from treated well) which is just a few meters away from the house. They have no
toilet facility and hence defecate in the surroundings. She also said the family obtains
healthcare using the National Health Insurance Scheme.
Upon interacting with the patient, I realize she has a good interpersonal relationship with her
family, friends and neighbors.
1.3 Patient’s Developmental History
Growth and maturation according to (Scipien 2009) is an increase in height, weight personal
and behavioral characteristics which vary with age.
Development is defined as a gradual growth of an individual, change from a state to a more
matured and organized state.
Miss. T. K. was born on the 24th of May, 1986 at Anyinam. According to the patient, she was
told by her mother, Mrs. A.A that she was delivered at Anyinam Government Hospital. The
patient also stated she was immunized at the hospital but could not specify the protection.
Miss T. K. stated she was told by her mother that she passed through the normal growth
patterns, thus from sitting, crawling, and walking but could not tell the ages at which she
passed through these stages of development. According to Miss T. K. she was properly cared
for as a child and she never fell seriously sick during her tender ages. She started school at
the age of 5 years at Anyinam Methodist School and currently she is a Trader.
1.4 Patient Lifestyle and Hobbies
Miss. T. K. is a thirty (33) year old energetic woman who is very decent, sociable and
hardworking. According to her she likes playing (Ludu) with everyone especially elderly men
and women, making friends because she believes that having people is better than wealth.
She is calm and dresses decently which makes her more easily approachable. She spends
2
much time on her work and in her leisure time, she converse with friends and her favorite
game is ludu. She also appreciates hygiene condition and hence baths and brushes her teeth
twice daily. With respect to bowel movement, she does it twice daily but sometimes once.
She passes urine whenever she feels the urge to urinate, sometime three or more. She sleeps
around 10:00pm and wakes up every morning at 3:30am due to the nature of her work. She
feeds three (3) times a day. According to the patient, her favorite meal is Fufu and palm nut
soup. She does not smoke, but enjoys soft drinks.
1.5 Patient’s Past Medical History
According to Miss. T. K. she said she had been admitted in the hospital before and diagnosed
as having malaria only once before. She said she was admitted about two (2) years ago at
Hawa Memorial Hospital. She got well and was discharged home as she was given proper
care and medications whiles at the hospital. She added that she sometimes suffers from minor
ailments such as headache, abdominal pains, fever, and cold. She treated these ailments with
over the counter drugs such as paracetamol, aspirin, ibuprofen and diclofenac. She sometimes
reported to hospital for further treatment if signs and symptoms still persisted. She never had
any surgical operation nor accident.
1.6 Patient’s Present Medical History
Patient was well until 23th of July, 2019 when she came from work in the evening. She was
experiencing abdominal pain and passing watery stool. She did not take the signs and
symptoms serious but went ahead to take some medications form the drug store. The next
day, the signs and symptoms persisted to the extent that she was passing bloody mucous
stool, experienced severe headache and was vomiting. She tried to manage it till the second
day but she couldn‟t. She was then rushed to Hawa Memorial Hospital on the 25th of July,
2019 for medical intervention.
On arrival at 9:40am, she complained of abdominal pain, vomiting and diarrhea, bloody
mucous stool and headache, loss of appetite, fever and general body weakness. She was
examined by Physician Assistant Opoku. A provisional diagnosis of Gastroenteritis was
made, and she was admitted to the female ward of Hawa Memorial Hospital.
3
1.7 Admission of Patient
Miss T. K. was admitted to the female ward in the Hawa memorial hospital in the accompany
of her brother at about 2:30pm after seeing the physician assistant at the OPD with the
following complains; abdominal pain, vomiting, diarrhea, fever, headache, loss of appetite,
bloody mucous stool and general body weakness. She was diagnosed provisionally as having
Gastroenteritis which was later confirmed by laboratory investigations. I sighted Miss T. K.
and her brother at the OPD and upon initiating rapport with them, I introduced myself to the
patient and relative and assisted her on to a wheelchair to the female ward.
On arrival, the relative was given a chair whiles Miss. T. K. was put straight to an already
made simple bed since she was weak, tired and unsteady. She was put on bed number 5 with
her belonging placed on the bed locker. The patient and relative were reassured of early
recovery from the competent nursing care and with the help of the available potent drugs. At
the nurses‟ table, her particulars were cross-checked for confirmation from both patient‟s
folder and her relative. Her vital signs were checked and recorded as;
Temperature
-
38.00C
Pulse
-
82bpm
Respiration
-
27cpm
Blood Pressure
-
110/70mmHg
Client was examined from head to toe. The examination revealed severe abdominal pains,
and elevated body temperature (38.00C). The folder was handed over to a student nurse who
went to the pharmacy for the client‟s prescribed drugs. Whiles waiting for the drugs, client
was tepid sponged and was administered 1g of paracetamol to decrease the temperature to
normal. After a while, the temperature was rechecked and recorded as 37.2 0C. On admission,
client was put on the following treatment:
 IM Diclofenac 75mg stat
 Intravenous metronidazole 500mg 8 hourly for 24 hours.
 Ringer‟s lactate 1000mls over 24 hours.
 Intravenous Ciprofloxacin 200mg 12 hourly for 24 hours
 Intravenous Promethazine 25mg 8 hourly for 24 hours
 Intravenous Dextrose Normal Saline 1000mls for 24 hours
 Intravenous Amoxiclav 600mg 12 hourly for 24 hours
4
The drugs were brought and administered as prescribed and no drug reaction was observed.
Whiles patient was on bed, due to severe Abdominal pain, her relative was oriented to the
ward and it annexes especially the bathroom, toilet, dust bins as well as visiting hours, and
the routine of the ward on daily basis were all made known to him. The visiting hours are
from 6:30am every morning and 4:30pm to 6:00pm every evening. Client was introduced to
the other patient after the pain subsided. The other staffs were also introduced to her.
Patient‟s relative was made comfortable after interacting with her while admission
procedures were carried out.
A formal introduction as then made to Miss T. K. and her brother and explained into details
that I wished to use her for a case study. Both of them were happy and gave me their consent
to go ahead.
Client‟s particulars were entered into the admission and discharge book and the Daily Ward
State. The necessary sheets and charts for temperature, treatment, nurses‟ notes, intake and
output charts and others were assembled and the appropriate entries made and put in the
patient‟s folder. Blood specimen and other specimen were taken to the laboratory for the
following investigations requested;

Haemoglobin level estimation (Hb)

Stool for routine examination

Erythrocyte Sedimentation Rate (ESR)

Blood film for Malaria parasites (BF for MPs)

Widal test for typoid.
The patient‟s relative was further reassured and asked to go home and bring the necessary
item such as; towel, sponge, soap and bucket, toothbrush and toothpaste etc. for the patient‟s
use.
1.8 Patient’s Concept of Illness
Miss T.K. did not attribute her illness to any spiritual force. She ascribed her illness could
have been something she might have eaten or recurrence of her usual illness. However, she
5
expressed her confidence in the doctors and nurses at the hospital and was ready to cooperate
with them for the management of her condition.
1.9 Literature Review
Definition
Gastroenteritis refers to the inflammation of the mucosal lining of both the stomach and the
intestines usually due to acute infection by bacteria, food poisoning or chronic intake of
toxins such as alcohol. It is also characterized by diarrhea (watery stools), bloody mucous
stool, vomiting, fever, loss of appetite etc.
Incidence
The disease affects all manners of people regardless the sex, race, age and they like. But is
more common in children and people exposed to irritants such as toxins and drugs.
Gastroenteritis is also common in areas where there is no good drinking water and bad
sanitary practices.
Aetiology / Causes of Gastroenteritis
Gastroenteritis can be either be acute or chronic. In chronic gastroenteritis, it is a result of
another gastrointestinal disorder like typhoid fever and ulcerative colitis, but in acute it is as a
result of pathogenic organism such as:

Bacteria: Streptococcus, staphylococcus and vibrocholerae.

Virus: the adenovirus, coxsackievirus, Norwalk virus.

Parasites like ascaris can also cause the disease.

Reactions to drugs such as antibiotics and also allergic reaction of poisonous food.

Ingestion of irritants such as alcohol, toxin food substances and Non-Steroidal AntiInflammatory Drugs (NSAIDS)

It can also manifest in people with immunological deficiency.
6
Pathophysiology
When the pathogens are ingested, they invade the gastrointestinal tract and multiply in
numbers and release exotoxins that bind to the mucosa, this triggers secretion of water and
electrolyte into the gastrointestinal tract and this is where the patient experiences water stool.
The pathogens also invade the epithelial cells of the gastrointestinal tract, destroying causing
inflammation leading to bloody mucous stool.
However, the pathogens can also penetrate the mucosa and gain access into the systemic
circulation. The inflammation process leads to stimulation and excretion of intestinal fluid.
The condition is characterized by severe diarrhea, vomiting, fever and abdominal cramps. If
this condition is not treated well and as early as possible it can lead to severe dehydration,
shock and circulatory renal impairment.
Clinical Manifestations
These include:

Diarrhea (watery stool)

Bloody mucous stool

Abdominal cramping

Vomiting and Nausea

Dehydration

Malaise

Loss of appetite

Rapid and weak pulse

Abdominal flatulence
Diagnostic Investigation
The condition can be confirmed through laboratory investigation such as:

Stool for routine examination

Rectal swab for culture and sensitivity
7

Blood for electrolyte imbalance

Blood for malaria parasite to rule out malaria

Sickling test to rule and sickling
Medical Management

Antibiotics are prescribed to counteract infectious organisms causing the condition.
Example ciprofloxacin, gentamycin, metronidazole, septrin, erythromycin.

Anti-diarrhea is also prescribed such as opium tincture.

Oral rehydration salt as well as infusions such as ringer‟s lactates and normal saline
can be given to replace loss fluid.

Antacid such as Magnesium Triscilicate can also be prescribed.

Anti spasmodics like Buscopam are given.

Analgesics can also be given to release pain. Example paracetamol.

Antiemetic can be given to control vomiting. Example promethazine. Miss. T. K. was
treated medically with some of the above.
Complications
Untreated Gastroenteritis can leads to

Severe dehydration

Bowel perforations

Hemorrhage

Circulatory and renal

Anemia

Meningitis
Nursing Management
The management of patient‟s with gastroenteritis includes some of the following
intervention;

Reassure patient to allay anxiety and fears.

Monitor and record vital sign every hour, report any abnormalities
8

Assist client to bath and wash the mouth both morning and evening.

Change patient linen every morning and whenever it is soiled

Encourage patient to always wash the hand with soap and water before and after
visiting the toilet, this is by way of preventing further infection.

Assist client to wear clean clothes.

Assist patient to cut fingernails when very long to prevent injury to him or her and
avoid harboring microbes.

Provide patient with non-fat and solid food to make the stool soft.

Serve patient with adequate fluid to replace the lost ones.

Serve patient with highly nourishing diet to facilitate patient recovery.

Plan diet with patient and serve it in an attractive manner.

Serve meals in bits but frequent.

Administer all prescribed medication as ordered and recorded

Ensure adequate bed ret to replace lost energy.

Monitor intake and output to prevent fluid overload and dehydration

Educate client on disease condition and explain rationale behind avoidance of
irritating agents such as alcohol.
Prevention of Gastroenteritis
The condition can be prevented by taken the following measures:

Health education on the condition should be given to the general public

Encourage the public to always heat leftover food before eating to prevent eating
contaminated food.

The public should be discouraged on the excessive intake of irritating agents such as
alcohol and drugs.

People should always wash their hands with soap and water before and after eating
and after visiting the toilet

The environment should always be made clean by clearing the bush and stagnant
water to prevent the breeding of flies and mosquitoes which will cause food
contamination.

Wash fruits and vegetables well before eating.
9
1.10 Validation of Data
The purpose of data collection is to gather genuine and quality data, free from errors or bias
and misinterpretations, for planning appropriate nursing interventions. This data collected
about Miss. T. K. was through a series of interviews, observations and interactions with the
patient and relatives. Information was also collected form doctors, nurses and in patient‟s
folder. Data was also collected from laboratory investigations request. The data collected
about Miss. T. K. is correct and devoid of errors, bias, doubt, and therefore valid for the care
of my patient.
10
CHAPTER TWO
2.0 Analysis of Data
This is the second step of the nursing process that seeks to analyze the data collected on Miss.
T.K. condition and compare it with the standard information about the condition in text books
and other reliable sources. This chapter entails the identification of the following:

Comparing data with standard.

Patient / family strengths

Patient / family health problems

Nursing diagnosis
2.1 Comparison of Data with Standard
This aspect helps in comparing some aspects of Miss. T.K. condition to standards in terms of
the following:

Factors that possibly caused the condition

Clinical manifestation

Diagnostic investigation

Treatment given

Complications
Factors That Caused Patient’s Condition
These are the factors that predispose a person to have gastroenteritis. The table below is a
comparison of the causes of gastroenteritis presented by Miss. T. K. with standards.
11
Table 2. 1: Comparison of Causes to That of Standard
Possible Causes Of Patient’s Condition
Standards Causes
Consumption of contaminated food
Miss. T. K. possibly ate contaminated food
containing causative organism
while at work
Consumption of irritating agent such as
Patient did not consume any known irritant
alcohol, non-steroidal Anti-Inflammatory
Drugs (NSAIDS).
Reaction to drugs such as antibiotics and
Patient did not react to any drugs
anti-viral agents
Immunological deficiency state
This was not present in Miss T. K.
Secondary to infection outside
Patient was not having any infectious
gastrointestinal tract example measles,
disease outside the gastrointestinal tract.
scarlet fever
Clinical Manifestation
With reference to the clinical manifestations outlined under the literature review in chapter
one and that of Miss. T. K. clinical presentation, the table below shows the comparison of the
clinical manifestation presented by Miss. T. K. with standards.
Table 2. 2: Comparison of Clinical Manifestation with Standards
Features According To Literature
Features Manifestered By Patient (Miss.
Review
T.K.)
Diarrhea (Watery Stool)
Patient experienced diarrhea
Bloody mucoid stool
Patient passed bloody mucoid stool
Dehydration
Patient was not dehydrated
Malaise
Malaise was not presented
12
Loss of appetite
Patient lost her appetite for food
Rapid and weak pulse
Patient‟s pulse was within normal range of
60 – 80bpm
Greenish watery stool
Patient‟s did not pass greenish watery stool
Fever (38.1 – 40 degrees Celsius)
Fever was present (38.50C)
Abdominal cramps
Patient had severe abdominal pains
Abdominal flatulence
This was not a common feature
Nausea and vomiting
Patient experienced nausea and vomiting
Diagnostic Investigations
Based on the clinical manifestations presented as well as physical examination done on Miss.
T. K. the following laboratory investigations were ordered;

Hemoglobin level estimation (Hb)

Erythrocyte Sedimentation Rate (ESR)

Stoll for routine examination

Blood film for malaria parasite (BF for MPs)

Widal test for typhoid.
13
Table 2. 3: Diagnostic Investigations Requested and Carried Out On Miss. T.K.
Date
Specimen Investigation
Result
Normal Values
Interpretation And Remarks
25/07/2019
Blood
10.6g/dl
Female: 11g/dl –
Slightly below normal range indicating mild anemia.
16g/dl
Patient was advised to take vegetable foods.
Haemoglobin level
estimation (Hb)
Drugs such as multivitamins were given.
25/07/2019
25/07/2019
Stool
Blood
Routine examination
Erythrocyte
Macro: semi formed macro
No white blood cells
This indicates infection of the gastrointestinal tract.
white blood cells present
should be present
Antibiotics were administered.
82mm fall per hour
There should be less
This indicates infection and therefore antibiotics were
than 20mm fall per
prescribed
sedimentation rate
hour
25/07/2019
25/07/2019
Blood
Blood
Blood film for malaria Malaria parasite absent
No malaria parasite
Patient needed no treatment for malaria since results
parasite
(negative)
should be seen
were negative
Widal agglutination
Salmonella typhi O absent 1:20
No salmonella typhi
This indicates no typhoid infection therefore patient
should be presented
needed no treatment for typhoid.
test
Salmonella typhi TT 1:20
14
Table 2. 4: Medical Treatment
Standard medical treatment as compared to medical treatment given to Miss. T.K.
Comparison of Treatment for Patient with Standard
Statement Treatment From Literature
Treatment Given To Miss. T. K.
Review
Antibiotics such as Gentamycin,
Intravenous Ciprofloxacin 12 hourly X 24hours.
Ciprofloxacin
Intravenous Metronidazole 500mg 8 hourly X 24 hours
Antiemetic‟s for vomiting such as
Intramuscular promethazine 25mg 8 hourly was
promethazine
prescribed.
Fluid and electrolyte replacement such as
Ringer lactate 1000mls for 24 hours was prescribed as
ringers lactate and dextrose normal saline
well as Dextrose normal saline X 24 hours.
Analgesics for pain relief such as
Intramuscular Diclofenac 75mg stat was prescribed and
Diclofenac or paracetamol
Tablet paracetamol 1gram 8 hourly X 24 hours.
Antispasmodics such as Buscopam
Intravenous Buscopam 20mg 8 hourly X 24 hours
Antacid such as mist magnesium
No antacid was prescribed.
tricilicate can be prescribed
15
Table 2. 5: Pharmacology of Drugs
Date
Drugs
Dosage / Route
Classification
Action
Actual Action
Side Effects / Remarks
Observed
25/07/2019
25/07/2019
Ciprofloxacine 200mg 12hourly
Amoxiclav
Broad spectrum
It kills gram negative
Infection was
Restlessness, tremors,
X 24hours.
antibiotics.
organisms entro
prevented
headache, none of the above
Intravenous
(Flororoquinolone)
bacterial
600mg 12hourly
Broad spectrum
It inhibits the synthesis
Patient did not
Sore mouth, diarrhea,
X 24hours.
antibiotic
of cell wall of sensitive
manifest and signs
hallucination, nephritis.
micro-organisms,
and symptoms of
None was observed.
causing cell death.
infection
Intravenous
16
was observed
Continuation of Pharmacology of Drugs
Date
Drugs
Dosage / Route
Classification
Action
Actual Action
Side Effects / Remarks
Observed
25/07/2019
25/07/2019
Ringer lactate 100mls
Fluid and electrolyte
To replace loss fluid and No actual effect
Fluid overloaded, heart
intravenously over
containing more
electrolyte
failure, none was manifested
24hours
potassium.
Dextrose
100mls
Fluid and electrolyte
To replace loss fluid and Patient gain energy
Fluid overload, cardiac
normal saline
intravenously over
containing more
gives energy
failure. None was observed.
24hours
sodium and
observed
carbohydrate
25/07/2019
Paracetamol
Tablets 1gram 8
Analgesic and
Reduces mild pain and
Patient‟s headache
Dizziness, confusion, renal
hourly X 24 hours
antipyretic
high temperature
was subside as
stones. None was observed.
well as temperature
25/07/2019
Diclofenac
75mg stat
Analgesic (non-
It inhibits prostaglandins Patient‟s pain was
Insomnia, dysuria, dizziness.
intramuscularly
steroidal anti-
secretion preventing
relieved and high
None was observed.
inflammatory drug).
pain. Has an antipyretic
temperature
effect
subsided
17
Complications
There are many complications of gastroenteritis such as severe dehydration (dry skin, sunken
eyes etc.), hemorrhage, renal failure, intestinal perforation and meningitis. But Miss. T. K did
not manifest any complication throughout her period of hospitalization due to the prompt and
effective treatment regimen.
2.2 Patient / Family Strengths
When a patient and family successfully meet a health standard then they are said to have
health strength in that area. These strengths contribute to the patient‟s well-being and speedy
recovery. In assessing the patient, the following strengths were identified;

Patient could verbalize the location and severity of pain.

Patient can tolerate tepid sponging.

Patient understood every procedure explained to her and all necessary information
needed.

Patient can care for herself when assisted.

Patient can eat well when food is served in bits at frequent intervals.

Patient could tolerate all prescribed intravenous infusions.

Patient can sleep in a serine environment.
2.3 Patient’s Health Problems
The following were complains my patient made during my interaction and observation of my
patient as care was rendered to her and the family.

Patient complained of abdominal pains.

Patient had high body temperature (38.0°C)

Patient was anxious in bed.

Patient complained of general body weakness.

Patient could not eat well.

Patient complained of diarrhea and vomiting.

Patient could not sleep well.
18
2.4 Nursing Diagnosis

Acute pain (lower abdomen) related to erosion of the stomach and mucosal lining.

Hyperthermia related to bacterial infection.

Anxiety related to unknown outcome of disease condition.

Activity intolerance related to general body weakness.

Risk for nutritional imbalance (less than body requirement) related to loss of appetite.

Risk for fluid volume deficit related to vomiting and diarrhea.

Sleep pattern disturbance related to unfamiliar hospital environment.
19
CHAPTER THREE
3.0 Planning for Patient and Family Care
This is the third phase of the nursing process. It is a technique for solving patient problems. It
entails setting up objectives for the interventions.
3.1 Nursing Objectives / Outcome Criteria
This refers to the desired outcomes of the nursing diagnosis formulated on Miss. T.K‟s health
problems, and consists of long and short term objectives.
Short Term Objective

Patient‟s pain will be reduced within the next 2hour as evidenced by ‫׃‬
a. Patient verbalizing that there is a reduction of pain.
b. Nurse observing patient for showing cheerful facial expression.

Patient high body temperature will be reduced to the normal range (36.20C – 37.20C)
within the next 1 hour as evidence by;
a. Nurse observing patient temperature decreasing by one degree Celsius from 38.00C
– 37.00C.
b. Patient verbalizing that she is not warm to touch.

Patient anxiety level will be reduced within 24 hours as evidenced by‫׃‬
a. Patient verbalizing that she now understood the outcome of her disease condition..
b. Nurse seeing patient in a relaxed facial expression.

Patient will maintain normal fluid volume within 48hours as evidenced by;
a. Nurse observing patient maintaining normal skin turgor.
b. Patient exhibiting absence of dehydration.

Patient will regain normal sleep pattern (6 – 8 hours) uninterrupted within 24 hours as
evidenced by patient verbalizing that she slept well in the night.
20
Long Term Objectives

Patient will obtain optimum level of self-care during her stay in the hospital as
evidenced by ;
a. patient verbalizing she can take good care of herself.
b. Nurse observing patient performing activities of daily living without assistance..

Patient will maintain normal nutritional status within her hospitalization as evidenced
by;
a. Nurse observing patient eating more than half of her food served.
b. Patient verbalizing return of good appetite.
21
Table 3. 1: The Nursing Care Plan
Date/Time
25/07/19
@
2‫׃‬00pm
Nursing
Objective/Outcome
Diagnosis
Criteria
Acute pain
Patient pain will be
(lower
reduced within the
abdomen)
related to
next 2hours as
evidenced by;
and mucosal
lining.
Nursing Intervention
Date/
Evaluation Sign
Time
1. Reassure patient.
1. Patient was reassured that she is in the
25/07/
Goal fully
hands of competent and qualified nurses.
19
met as
2. Patient level of pain was assessed to
@
2. Assess for level of pain using pain
rating scale of 0-10.
evidenced
by ;
know the severity of the pain using pain
erosion of
the stomach
Nursing Orders
1 .Patient
verbalizing that
there is a reduction
3. Assist patient to adapt a
rating scale.
comfortable position.
4‫׃‬00p
m
3. Patient was put in a fowler‟s position.
4.Apply warm compress at the site.
of pain.
5. Administer prescribe analgesics.
2. Nurse observing
that there is
a reduction
reduced patient pain.
of pain
5. Prescribed analgesics were
cheerful facial
administered to reduced patient pain.
22
verbalizing
4. Warm compress was applied to
patient for showing
expression.
a.Patient
AT
The Nursing Care Plan
Date /
Nursing
Objective
Time
Diagnosis
Outcome Criteria
Nursing Orders
Nursing Intervention
Date /
Evaluation
Time
25/07/19
Hyperthermia
Patient high body
1. Reassure patient that she is in the
1. Patient was reassured that she was in
25/07/19 Goal fully
@
related to
temperature will be
hands of competent health team.
the hand of competent health team.
@
met as
2:30pm
bacterial
reduce within 1
3:30pm
patient‟s
infection
hour as evidenced
(38.0°C)
by;
temperature
2. Tepid sponge patient and re-
2. Patient was tepid sponged to reduced
decreased
check temperature.
temperature to normal (37.0°C).
to normal
1. Nurse observing
patient‟s
Sign
(37.0°C)
3. Provide adequate ventilation.
temperature
3. Nearby windows were opened to
and she was
allay ventilation.
observed to
decreasing by
be calm in
1.0°C (38.0°C –
4. Serve patient with cold drinks if
4. Cold drinks such as coke were served
37.0°C) and being
she can tolerate.
to patient.
calm in bed.
2. Patient
5. Vital signs were checked and
verbalizing that she
5. Check vital sings especially
recorded especially temperature for
is not warm to
temperatures and record.
every 4 hours.
touch.
23
bed
AT
6. Administer prescribed
6. Prescribed antipyretics (paracetamol)
antipyretic.
was administered and recorded at
2:15pm.
The Nursing Care Plan
Date &
Nursing
Objective
Time
Diagnosis
Outcome
Nursing Orders
Nursing Intervention
Date &
Evaluation
Sign
Date
Criteria
25/07/201
Anxiety related Patient‟s anxiety
1. Reassure patient that effort will be 1. Patient was reassured on efforts to
26/7/19
Goal was fully
9@
to unknown
level will be
made for better outcome and
@
met as
6:45pm
outcome of
reduce within 24
recovery.
6:45pm
evidenced by:
disease
hours as
condition
evidenced by:
speedy recovery.
2. Patient was educated on her
Patient
2. Educate patient on disease
condition, causes, signs and
understood her
condition.
symptoms, prevention.
disease
1. Patient
condition and
verbalizing that
3. Educate patient on the available
3. Patient was educated on available
her anxiety
she now
potent drugs.
potent drugs.
level declined.
4. Introduce other patients who have
4. Patients who successfully
understands the
outcome of the
24
AT
disease
recovered successfully from the
recovered from gastroenteritis were
condition.
same condition to patient.
introduced to my patient.
patient in a
5. Encourage patient to ask
5. Patient was encouraged to asked
relaxed facial
questions about her condition
questions bordering her mind.
expression.
worrying her.
2. Nurse seeing
The Nursing Care Plan
Date &
Nursing
Objective
Time
Diagnosis
Outcome Criteria
Nursing Orders
Nursing Intervention
Date &
Evaluation
Sign
Date
26/07/19
Activity
Patient will regain
1. Reassure patient that she
1. Patient was reassured that she will be 28/07/19 Goal fully met
@
intolerance
optimum level of
will be able to do activities all
able to do activities of daily living all
@
as evidenced
9:30am
related by
self-care during
by herself.
by herself.
9‫׃‬30am
by patient‟s
general body
her stay in the
weakness
hospital as
2. Assist patient to wash her
2. Patient was assisted to do mouth
ability to
evidence by
mouth twice daily.
wash twice daily.
perform
increasing
activities
1. Nurse observing
3. Assist patient to bath at
3. Assistance was given to patient to
without
patient performing
least twice daily.
bath both in the mornings and evening.
assistance.
activities of daily
25
AT
living without
4. Encourage patient to do
4. Patient was encouraged to do passive
assistance.
some passive exercise that she exercises that she can tolerate to
can tolerate to prevent sores.
2. Patient
improve blood circulation to all part of
the body.
verbalizing that
5. Serve patient with food rich
she can take good
in carbohydrate and protein to
5. Food rich in carbohydrate and
care of herself
boost her energy.
protein was served for patient to boost
her energy.
The Nursing Care Plan
Date &
Nursing
Objective
Time
Diagnosis
Outcome Criteria
Nursing Orders
Nursing Intervention
Date &
Evaluation
Date
26/07/19 Risk for
Patient will
1. Reassure patient that she will
1. Patient was reassured that she
28/07/19 Goal fully
@
nutritional
maintain normal
regain her appetite.
will regain her appetite.
@
met as
9‫׃‬00am
imbalance (less
nutritional status
9:00am
patient could
than body
within her stay in
2. Give mouth wash before and after
2. Mouth wash was given to patient
eat all food
requirement)
hospital as
serving meals.
before and after meals.
served.
related to loss of
evidenced by;
3. Serve food in an attraction
3. Food was served attractively by
manner.
removing all nauseating objects
appetite.
1. Nurse observing
Sign
from patient‟s sight.
patient eating more
26
AT
than half of food
4. Serve food in bits at frequent
4. Patient food was served in small
served to her.
intervals.
quantities at frequent intervals.
2. Patient
5. Plan diet with patient and
5. Diet was planned together with
verbalizing return
dietician
the patient and dietician.
of good appetite.
6. Serve patient‟s preferable meals at 6. Patient favorite or preferably
all times.
meal were been served at all times.
The Nursing Care Plan
Date &
Time
Nursing
Objective
Diagnosis
Outcome Criteria
Nursing Orders
Nursing Intervention
Date &
Evaluation
Date
26/7/2019
Risk for fluid
Patient will
1. Explain the rational for
1. Patient was encouraged to take
28/07/19
Goal fully
@ 2:10pm
volume deficit
maintain normal
increased fluid intake.
liberal fluid to replace lost fluid.
@
met as
related to diarrhea
fluid volume
2:10pm
evidenced by
and vomiting.
within 48 hours as
2. Encourage patient to take
2. Patient was encouraged to take
patient
evidenced by:
liberal fluids if she can tolerate.
liberally, fluid to replace lost fluid.
maintaining
normal skin
1. Nurse observing
Sign
3. Monitor intake and output
27
3. Intake and output chart was
turgor.
A.T
patient
overload and excess fluid output.
monitored and recorded accordingly.
maintaining
normal skin turgor. 4. Observe patient‟s skin turgor
4. Patient‟s skin was observed for
to prevent dehydration.
signs of dehydration.
exhibiting absence
5. Administer prescribed
5. Medications and infusion such as
of dehydration.
infusion and drugs to replace
promethazine 25mg 1M, Ringers
loss of fluid and stop the
Lactate 1000mls IV, Dextrose
vomiting and diarrhea as well.
normal saline 1000mls Intravenous
2. Patient
were administered and recorded.
The Nursing Care Plan
Date /
Nursing
Objective
Time
Diagnosis
Outcome Criteria
Nursing Orders
Nursing Intervention
Date /
Evaluation
Sign
Date
27/07/2019
Sleep pattern
Patient will regain
1. Reassure patient that she will
1. Patient was reassured that she will
28/07/19
Goal was fully
@
disturbance
normal sleep
soon be familiar with her new
soon be familiar with the
@
met as
10‫׃‬25am
related to
pattern (6 – 8
environment.
environment.
10:25am
evidenced by
unfamiliar
hours) with 24
2. Provide a comfortable bed
2. A comfortable bed was made and
patient
hospital
hours as evidenced
and help patient assume
patient helped to assume position of
sleeping up to
environment.
by;
position of choice.
her choice.
6-8 hours
28
AT
1. Patient sleeping
3. Coordinates all nursing
3. All nursing activities were
for 6-8 hours
activities at once to prevent
coordinated at once to prevent
without
disturbance.
disturbances.
uninterrupted.
4. The ward environment was quiet
2. Patient
4. Ensure quietness of the ward
and calm as all visitors were
verbalizing that
environment by restricting
restricted.
she was able to
visitors.
5. Adequate ventilation was ensured
sleep in the night.
5. Ensure adequate ventilation.
by opening windows and doors for 34hours to ensure good ventilation.
6. Prescribed medication intravenous
6. Administer prescribed
Buscopam 20mg X 8 hourly X 24
medications.
hours was administered.
29
daily.
CHAPTER FOUR
4.0 Implementation of Nursing Care Plan
This is the fourth stage of the nursing process which entails putting into practice the planning
activities. This comprises of the summary of nursing care rendered; preparation of
patient/family towards discharge; follow ups and home visits; continuity of care and
rehabilitation.
4.1 Summary Of Actual Nursing Care Rendered To Miss. T.K.
The specific day to day care rendered to her throughout her hospitalization, are summarized
below.
First Day of Admission (25th of July, 2019)
Miss. T. K. was admitted into the female ward of the Hawa memorial Hospital at around
2:00am, after reporting to the OPD with the complains of abdominal pains, vomiting and
diarrhea, bloody mucous tool, headache, loss of appetite, fever and general body weakness.
She was in pain and could not walk. She was sent to the ward in a wheel chair. After
welcoming the patient and relative, her particulars was collected and cross-checked and
verified by mentioning her name, age, and diagnosis, to which she responded. They were
reassured of been in the hands of competent health team. Miss. T. K. was made comfortable
in an already prepared bed; her vital signs were taken and recorded as follows;
Temperature
-
38.00C
Pulse
-
82bpm
Respiration
-
27cpm
Blood pressure
-
110/70mmHg
Temperature was high, so a trolley was set for tepid sponging Miss. T.K. After her tight
clothes were loosened, adequate ventilation was ensured by opening nearby windows. She
was also served with cold drinks. After the tepid sponging her temperature was taken again
and found to be 37.00C and indicating goal was met. She was finally made comfortable in
bed.
30
On admission Miss T. K. presented the following clinical manifestation;

Abdominal pains

Nausea and vomiting

Diarrhea

Bloody mucous stool

Headache

Loss of appetite

Fever (38.00C)

General body weakness
A provisional diagnosis of Gastroenteritis was made and she was put on the following drugs;

Intramuscular diclofenac 75mg stat.

Intravenous Ciprofloxacin 200mg 12hourly for 24hours.

Intravenous ringers Lactate 100mls over 24hours.

Intravenous metronidazole 500mg 8 hourly for 24 hours.

Intravenous Amoxiclav 600mg 12 hourly for 24 hours.

Intravenous Dextrose Normal Saline 100mls for 24 hours.

Intramuscular promethazine 25mg 8 hourly for 24hours.

The drugs were collected and administered as ordered and were recorded accordingly.
The following laboratory investigations were ordered.
The drugs were collected and administered as ordered and were recorded accordingly. The
following laboratory investigations were ordered;

Hemoglobin level estimation (Hb)

Stool for routine examination.

Erythrocyte Sedimentation Rate (ESR)

Blood film for Malarial Parasite (BF – MPs)

Widal test for typhoid.
Blood and stool samples were taken for the investigation.
Miss. T.K.‟s brother was oriented to some facilities in the ward. He was oriented to the nurses
table and was told to always inform the nurses if he had any complains. He was also
31
orientated to the toilet, urinal, and bathroom and told the visiting hours and meals times
which is three times daily.
Miss. T. K. and her brother were also informed of doctor‟s ward rounds every morning at
8:30am. They were introduced to the ward mates and encouraged to chat with them. Miss.
T.K. was not looking cheerful. Upon questioning she responded that she did not know the
outcome of her condition. A nursing diagnosis was drawn as „anxiety related to unknown
outcome of disease condition”. She was reassured that she will be well soon as she was in the
hands of competent health team. She was then educated on the condition, and introduced to
patients who have successfully recovered from similar condition. The goal set was achieved
as the patient looked cheerful and happy after the interactions.
Miss. T.K.‟s brother was advised to bring items such as sponge, soap, towel, bucket,
toothbrush, cup, pomade etc., for patient‟s usage during her hospitalization.All the necessary
documentations were done in the Admission and Discharges Book, Daily Ward State. The
interventions were also written, in the nurses notes.
Second Day in the Ward (26th of July, 2019)
I got to the ward around 7:25am and patient was not in bed, her brother was asked and he said
she has gone to toilet. When she came back, she complained of frequent diarrhea and
vomiting which led to her loss of appetite. Her vital signs were taken and recorded as
follows:

Temperature
-
36.90C

Pulse
-
70bpm

Respiration
-
22cpm

Blood Pressure
-
120/70mmHg
The night nurses reported that patient could not eat food served her. A nursing diagnosis
drawn as “risk for nutritional imbalance (less than body requirement) related to loss of
appetite. Objective was to maintain patient‟s normal nutritional status.
Patient was given mouth wash before and after meals and was encouraged to eat. Food was
served attractively and served in bits but frequently 4 times a day. Nauseating items such as
32
soiled bed sheets, bed pans were cleared from patient‟s sigh. With the above interventions,
Miss. T.K. could eat better than before. Following patient‟s frequency of diarrhea and
vomiting, a diagnosis of “risk for fluid volume deficit was made. The objective was to
maintain normal fluid volume as far as her stay in the hospital and even after discharge is
concerned. Patient was encouraged to take plenty oral fluids of her choice. The rational for an
oral fluid intake was explained. Patient‟s skin turgor was observed and prescribed infusion
administered and recorded. At 8:40am her doctor came on ward rounds and reviewed Miss
T.K, when he saw the laboratory results. He ordered for continuation of previous treatment.
The drugs that were collected were administered as ordered and recorded; the patient was
made comfortable in bed and reassured of early recovery.
Third Day in the Ward (27st of July, 2019)
On this day, the patient woke up early but was looking weak and tired. She said that the
previous day‟s diarrhea and vomiting had made her weak. She said she couldn‟t do anything
by herself. This called for a nursing diagnosis of activity intolerance related to general body
weakness. Objective set was to make patient resume her daily routine activities during her
stay in the hospital. Miss. T.K. was assisted to wash her mouth and to bath. She was assisted
to walk round her bed as she tolerated to improve circulation and prevent bed sores. She was
also encouraged to do passive exercises that she could tolerate. Energy boosting meals rich in
carbohydrate and protein was served. Prescribed infusion, dextrose 5% was administered and
recorded as well. Patient‟s vital signs were checked and recorded as follows:
Temperature
-
36.20C
Pulse
-
68bpm
Respiration
-
22cpm
Blood pressure
-
120/70mmHG
During the doctors rounds her condition was reviewed. She complained of abdominal pains,
and inability to sleep. The doctor prescribed Intravenous Buscopam 20mg, 8 hourly for 24
hours.
Nursing diagnosis of sleep pattern disturbance related to abdominal pains was set. Patient was
reassured that she will obtain maximum sleep. A comfortable bed was made to aid sleep;
quietness of the ward environment was ensured by restricting her visitors; adequate
33
ventilation as ensured. Patient was also placed in a comfortable position that will suit her.
Medications were collected, administered and recorded accordingly. Patient was made
comfortable in bed.
Fourth Day in the Ward (28st of July, 2019)
Miss. T.K. was full of smiles on the fourth day. The night nurses notes revealed that patient
slept well but only had slight headache in the middle of the night meaning my goals was
partially met. Her vital signs were checked and recorded as;
Temperature -
-
36.9°C
Pulse
-
76bpm
Respiration
-
24cpm
Blood Pressure
-
120/70mmHg
An amendment to the nursing care plan was made to help patient obtain maximum sleep.
Additional interventions were considered. Patient was reassured; good ventilation was
ensured; cold compress was applied to patient‟s forehead; quietness of the ward environment
was ensured a comfortable bed was made for patient relaxation. Upon observation, Miss. T.
K.‟s skin was normal and showing absence of dehydration indicating that the goal was fully
met, and there was no actual fluid volume deficit.
During the doctor‟s rounds at 8:40am, the patient appeared healthy, but complains of a mild
headache. The doctor prescribed Tablets Paracetamol 1gram 8 hourly x 24 hours. The doctor
informed my patient and her brother, that they could be discharged the next day if God
permits. In order to be sure of the knowledge of my patient on her condition, I asked her
about it but she couldn‟t remember anything. I realized that my patient has knowledge deficit
related to inadequate information on her disease condition. The objective was to educate
patient on the disease condition and treatment before goes home, so education given to Miss.
T.K. on gastroenteritis that is the cause, signs and symptoms, the treatment, and preventive
measures. She said to be sure that she understood the education. Patient was made
comfortable in bed and reassured.
34
Day of Discharge (29nd of July, 2019)
By 9:40am Miss. T.K. had taken her bath, brushed the teeth and taken her breakfast. This
indicated that goals for self-care were met. Patient could do groom by herself and eat well.
While waiting for the doctor to discharge her, the vital signs were taken and recorded as
follows;
Temperature
-
36.50C
Pulse
-
68bpm
Respiration
-
20cpm
Blood Pressure
-
110/70mmHg
She also looked cheerful. After the doctor reviewed her condition she was discharged and
was asked to continue treatment in the house with the following drugs.

Tablets Ciprofloxacin 500mg 12 hourly x 6 days

Tablets 1 gram paracetamol 8 hourly x 7 days

Tablets Buscopam 20mg 8 hourly x 6 days
The drugs were collected and Miss. T.K. and her relative were informed of the discharge.
They were educated on how to take drugs. The prevention of the condition was emphasized.
The need for review in two weeks‟ time was also mentioned thus (16th of August, 2019) but
they were informed that if any signs and symptoms reappeared before the two weeks, they
should report back to the hospital. Since she was covered by national Health Insurance, she
was not required to pay any bill. I emphasized on the need to renew the National Health
Insurance anytime it expires. I helped them pack their belongings. Miss. T.K. was formally
discharged in the Admission and Discharges books as well as the Daily Wards State. I
promised them of a home visit, and bid them goodbye. The bed linen was collected to the
soiled bin and the bed was decontaminated for the bed to be made later.
4.2 Preparation of Patient/Family for Discharge and Rehabilitation
The preparation of Miss.. T.K. and family towards discharge started on the day of admission
(25th of July, 2019). They were made to understand that the hospital is temporal place, and
that Miss. T.K. will go home as soon as she gets well. Miss. T.K. and family were educated
on the cause, signs and symptoms, treatment and prevention of gastroenteritis. They also
35
advised to report to the health facility as early as possible whenever they detect the signs and
symptoms of ill-health. They were also made to understand that once she is registered with
the national health Insurance Scheme. She will not pay any bill except for drugs which were
not captured under the National Health Insurance Scheme, those not available in the hospital
and also half the amount for some laboratory investigations. They were congratulated for
that, and the family was encouraged to register other switch the national health Insurance
Scheme.
At home visit was made to Miss. T.K.‟s family, on 28st ofJuly, 2019, to assess the preparation
her relatives before her discharge. The house was big enough to contain them; it had large
windows for good ventilation.
The surroundings was however not clean. Health education was given to them on the need for
clean environment. Clearing the bushes and covering their food and water pots with fitting
lids as well as education on meals to take such as food rich in carbohydrates and proteins like
rice and stew or fufu with light soup with vegetables to boost their nutritional status were
emphasized.
The family was informed that Miss. T.K. will be joining them soon, therefore should be fed
on balanced diet at home. Education was also given to them on the need to avoid selfmedications which can cause harm to them. The family was also informed of my intention to
visit them another time to assess Miss. T.K.‟s health status as well as the whole family and
environment.
4.3 Follow Up Visit/Home Visits/Continuity of Care
This is an essential part which deals with home visits and handing patient over to the
community health or public health nurse for continuity of care, and also assessing patient and
family environment and educating them on the necessary things to do to prevent illness.
First Home Visit (28st of July, 2019)
This was made to know Miss T.K.‟s house for continuity of care and subsequent visit to be
made, and to also prepare relatives mind and environment to receive patient back home. I was
escorted by Miss. T.K.‟s brother. I was welcomed by Miss. T.K.‟s family. They gave me seat
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and water. I told them of the reason of this visit to inform them of preparations towards Miss.
T.K.‟s discharge.
They were living in a compound house roofed with zinc; the house was having large
windows for good ventilation; wide doors for exit. The environment was to quite clean;
emphasis was made on good environmental hygiene. I educated them on the need to cover
their pots containing water with well-fitting lids and clear all bushes, and clear all stagnant
waters. The family cooperated and accepted my education in good faith. I finally bid them
goodbye and left for school.
Second Home Visit (4th of August, 2019)
On the 4th of August, 2019, I made a home visit to Miss. T.K‟s house to assess her health
status and continuity of care the family welcomed me and gave me a seat. Miss. T.K. was
relaxed on her chair. She said she felt strong, and got up to shake my hand, with a broad
smile on her face. I was very pleased that she was better. She told me that she has been taking
her drugs and strictly followed the preventive measures taught them. The other family
members testified to that. The environment looked cleaned; pots covered with well-fitting
lids signifying that they paid heed to what was said. I congratulated them on that. I also
emphasized on personal hygiene and Miss. T.K.‟s medication and diet again. She was also
reminded on the need to come for the review on 5th of July, 2019.
I also told them my intention of handing over of Miss. T.K.‟s to the community Health Nurse.
Though they did not appear happy about that, I reassured them that he or she will be a
competent nurse who can handle Miss. T.K. at home. Finally, I thanked them and said
goodbye before departing.
Third Home Visit (24th of August, 2019)
The final home visit was made on 24th of August, 2019. I went with a Community health
Nurse from Anyinam clinic to Miss. T.K.‟s house. We were warmly welcomed and offered
seats. The family was informed that Miss. T.K.‟s was to be handed over to the Community
Health Nurse as earlier promised and that they should cooperate with the nurse for maximum
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results. Emphasis was also made on children‟s immunization, personal hygiene and sending
their children to school, Madam T.K. and family were also reminded again on prevention of
gastroenteritis and other related diseases. I handed over Miss. T.K to the community health
nurse.
The patient said she was glad and did not know how to thank me enough. I thanked Miss.
T.K. and family very much for their co-operation and attention which made the interventions
useful to her rapid recovery.
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CHAPTER FIVE
5.0 Evaluation of Patient / Family Care
This part of the nursing process involves evaluation of care rendered to parent/family in order
to determine whether the set goals are fully met or unmet. Goals which are unmet or partially
met are reset and additional nursing interventions implemented to ensure that the goals are
fully met.
5.1 Statement of Evaluation
On Admission 25th of July, 2019 at 2‫׃‬00pm Miss. T.K. had high body temperature (38.00C).
(Hyperthermia related to bacterial infection) An objective was set to reduce the temperature
within 36.2°C-37.2°C within 1 hour. Patient was tepid sponged and adequate ventilation was
ensured. Miss. T.K. was served with cold drinks and her tight clothes were loosened.
Prescribed antipyretics were administered and recorded. Goal was fully met on 25th of July,
2019 at 3‫׃‬30pm and throughout her admission her temperature remained within the normal
range.
On 25th of July, 2019 at 2:10pm, patient complains of abdominal pain (Acute pain related to
erosion of the stomach and mucosal lining). An objective was set to reduce patient pain
within 2hours. Patient level of pain was assess using the pain rating scale, patient was put in a
fowlers position, cold compress applied, and prescribe analgesic was administered to reduced
pain. Goal was fully met as evidence by patient verbalizing the reduction of pain at 4:00pm .
On 25th of July, 2019 at 6‫׃‬45pm, patient was anxious (Anxiety related to unknown outcome
of disease condition). An objectives was set to support reduced patient‟s anxiety level with an
expectation that patient will express absence of anxiety. Patient reassured of rapid recovery.
She was educated on the disease condition. Patient who had recovered form gastroenteritis
were also introduced to Miss. T.K. Goal was met as evidenced by patient expressing absence
of anxiety and showing relaxed facial expression on 26th of July, 2019 at 6‫׃‬45pm.
On 25th of July, 2019 at 2‫׃‬10pm, patient complains of diarrhea and vomiting. (Risk for fluid
volume deficit related to excessive diarrhea and vomiting). The outcome criteria was patient
will maintain normal fluid volume as evidenced by patient maintaining normal skin turgor
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throughout hospitalization. Patient was encouraged to take oral fluids. Rationale for oral fluid
intake was explained, intake and output chart was maintained and prescribed IV fluid was
administered. Goal was fully met as patient maintained normal skin turgor on 27st of July,
2019 at 2‫׃‬10pm.
On the second day of admission 26th of July, 2019 at 9‫׃‬30am, a complain of loss of appetite
was lodge from the patient. Nutritional imbalance (less than body requirement) related to loss
of appetite. The outcome criteria was patient will maintain normal nutritional status within
period of hospitalization as evidenced by patient eating more than half of food served her.
The patient was reassured of support to regain her appetite. She was given mouth care before
and after meals, and her food was served attractively and in bits but frequently. All
nauseating items were removed. Goal was fully met as evidenced by patient eating more than
half of food served her by the third day.
On the same day of admission (26 of July, 2019) at 9:30am Patient complained of general
body weakness. The objective / outcome criterion was that patient will maintain optimum
self-care. Patient was reassured, and assisted to bath. She was encouraged to do passive
exercises in which she can tolerate. The goal was fully met as patient could perform certain
self-care activities all by her.
On the third day of admission (27th of July, 2019) at 10‫׃‬30am patient complained of inability
to sleep (Sleep pattern disturbance related to unfamiliar hospital environment. The
objective/outcome criterion was set to regain normal sleep pattern. Patient was reassured and
made comfortable in bed. Adequate ventilation as ensured as well as quite environment. The
prescribed medications were administered. Goal was partially met as evidenced by patient
verbalizing that she slept well but woke up in the middle of the night due to a slight headache
on 25st of July, 2019 at 10‫׃‬00am.
On the last day (29nd of July, 2019): Miss T.K. was discharged home without any problem.
She was advised on continuity of treatment at home and to practice good sanitary habits. She
was also educated on the kind of meals to take.
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5.2 Amendment of Care
On evaluation all set goals were met except that patient could not sleep undisturbed within 24
hours. The nursing orders were; reassure patient; make a comfortable bed, ensure quite
environment and administer prescribed drugs. Goal was only partially met as patient was
disturbed at midnight by slight headache.
Goals were, patient will sleep soundly in bed within 24hours as evidenced by patient
verbalizing that she slept soundly. Patient was reassured of maximum sleep, she was given
cold compress on the forehead, adequate ventilation was ensured, comfortable bed was made,
the environment was made quite, and prescribed medications were served and recorded. With
the extension of time and additional orders, goal was fully met as patient verbalizing that she
slept well the whole night.
5.3 Termination of Care
Miss. T.K. was discharged on (29nd of July, 2019). The family and patient were not surprise
since their minds were already prepared towards discharge. I paid a number of home visits to
Miss.. T.K. and her family, they were also educated on the need to practice good personal and
environmental hygiene to prevent illnesses. They were also educated on early signs of
gastroenteritis and the need for early reporting to the health facility to avoid complications.
Miss. T.K. was also educated on the importance of taking her prescribed drugs at home.
The plan of handing over patient/family care to a Community health Nurse for continuity of
care was mentioned to them during the second home visit. A community health nurse form
Anyinam clinic was introduced to Miss T.K. and the family, on the third home visit. Miss
T.K. was encouraged to forward their health problems to the Community health Nurses for
her advice and support Miss. T.K. and family as well as community .Health Nurse was all
thanked very much for their co-operation with me to bring this study to a successful end.
5.4 Summary
Miss. T.K. is a thirty three old woman, born on the 24th of April, 1986 at Amosiaso, a small
town along the Anyinam high street in the Eastern Region. She is Akyem by tribe and
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Ghanaian by nationality. She was admitted into the female ward of Hawa memorial Hospital,
Osiem on the 25th of July, 2019 at 2;10pm through the Outpatient Department (OPD) with the
complains of abdominal pains, nausea and vomiting, diarrhea, bloody mucous stools,
headache, loss of appetite, fever and general body weakness. She was provisionally
diagnosed of gastroenteritis which was later on confirmed by laboratory investigations.
Through a series of interactions, observation and assessment, the health problems identified
included pyrexia, anxiety, loss of appetite, sleeplessness, and general body weakness during
her hospitalization.
Some objectives/goals were set to assist in reducing fever, pain and sleeplessness as well as
improve appetite. She was also assisted to walk around the ward, the ward environment was
also quite to aid Miss T.K. sleep. Her vital signs were regularly checked and recorded and
prescribed oral medications and infusion were administered. Goals were fully met and patient
was discharged home without any complications of gastroenteritis.
Patient/family preparation towards discharge started on the day of admission till the day of
discharge with health education, reassurance. Specifically, patient and family were educated
on how drugs should be taken and need for good personal and environmental hygiene. My
patient was discharged on 29nd of July, 2019. She spent five days in the ward from 25th of
July, 2019 to 29nd of July, 2019.
At home, series of home visits were carried out to assess the environment and patient status.
Miss T.K. and her family‟s care were finally handed over to a Community Health Nurse at
Anyinam health center for continuity of care and rehabilitation.
5.5 Conclusion
The patient/family care study, using the nursing process approach has equipped me with
knowledge and experience to improve upon the care of patient and my charge. It has afforded
me in-depth knowledge on the causes, signs and symptoms, the complications associated with
the condition, diagnosis and management gastroenteritis. The writing of the care study has
helped me put into practice procedures and skills learnt in theory or in this classroom such as
data collection, interviewing and other components of the nursing process as well as some
general nursing procedures.
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The patient/family care study gives students the opportunity to manifest what was taught
theoretically in a practical situation. It also prepares the student nurse to interact with the
family and the community as a whole to develop relationship skills. The care also broadens
the student‟s knowledge on the condition he/she is writing on as well as how to use the
nursing process in rendering care.
The patient/family case study however involves a lot of energy and is time consuming.
However I still recommend that the patient / family care study be maintained as a
requirement for the award of the Certificate in Registered General Nursing Certificate as it is
proper way of making the student nurse to practice the nursing process which forms the base
patient / family care.
I therefore hope I would be able to nurse a patient who would come under my care to recover
fully even when the unfortunate happens, to die peacefully with the knowledge and skill I
have required.
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BIBLIOGRAPHY
1. Barbara, F.W and Watson, C (2014), Bailliere’s Nurses’ dictionary. 26rd Edition.
London: Bailliere Tindal Publishing Company.
2. Brunner, S.L and Suddarths, S.D (2010), Textbook of Medical and Surgical Nursing.
12th Edition. Philadelphia: J.B Lippincott Company.
3. MacKay, AS (1998), Gastro Intestinal Pathology and Surgical Nursing. 7th Edition.
Pennsylvania: Springhouse Co-operation.
4. Patient Folder.
5. Walsh, M and Alison, C (2007), Watson’s Clinical Nursing and Related Sciences. 7th
Edition. China: Elsevier Limited.
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SIGNATORIES
1. NAME OF STUDENT:
SIGNATURE…………………….…........…….…..….………
DATE……………………………………..…….……..………
2. NAME OF CLINICAL SUPERVISOR:
SIGNATURE………………………….…..……….…………
DATE…………………………………………………………
3. NAME OF SUPERVISOR:
SIGNATURE………………………………..……..……..……
DATE………………………………………….….……………
4. NAME OF PRINCIPAL:
SIGNATURE………………………..………………………..
DATE………………………………..………………………..
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