PREFACE

The patient/family care study is a comprehensive document of the nursing care rendered to a
particular patient suffering from a particular disease condition from the period of admission and
after discharge.
It involves the interaction among the patient, his/her family, community members and the health
team. These interactions take place within a specific period of time as long as the health of the
patient/family is concerned.
This patient/family care was conducted and written as a necessary requirement in fulfillment for
the qualification of a Registered General Nursing (Diploma) as provided by the Nursing and
Midwifery council of Ghana
The patient/family care study provides the student nurse with skill of assessing, diagnosing patient
health problems, planning of nursing care to be given, implementing the set plans to meet the needs
of the patient and his/her family and finally evaluating the successful in producing a desired result
of nursing care provided by the student nurse during hospitalization and discharge of a patient and
family.
It also prepares and broadens the knowledge of the student nurse to become a critical thinker, good
researcher, professional service provider and client’s advocator to meet the demands of tomorrow
since a lot of different conditions are settling in every time of the day.
The patient/family care study offers the student nurse an opportunity to gain both theoretical and
practical knowledge. Conclusively, it serves as a source of literature review for other students on
the particular disease condition that has been handled by the student nurse.

i
 ACKNOWLEDGEMENT
First and foremost, all glory and thanks be to our Almighty God for giving me life, knowledge,
wisdom, protection and strength to come out with this script.
Secondly, I am also grateful to my patient Master N.K.K and his family for allowing me to use
them for this care study. May God bless them and may they continue to remain strong and healthy.
I wish to express my profound gratitude to the Principal of the Nursing and Midwifery Training
College - Sunyani and my supervisor Madam Ayamga Gifty for her support, guidance and
encouragement given to me for making this work successful. I am also grateful to the entire tutorial
staff of the Nursing and midwifery Training College-Sunyani for their contribution towards my
education.
My next appreciation goes to the entire staff of the Regional Hospital, Sunyani especially the ward
in-charge and all nurses at the Paediatric ward for their care and also for allowing me to use their
facility.
Finally, but not the least, I thank my parents Mr. Opoku Boateng Charles and Mad. Gyameah
Regina for their prayers and support throughout my education. May God give them long life in
their days to come and thanks goes to all my friends and colleague student nurses who in one way
or the other helped me and made this care study a success. God bless you all.
My sincere thanks also goes to all authors and publishers of the text books and journals I made
reference for my literature reviews.
I say thank you and May God bless you all.

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 TABLE OF CONTENTS
CONTENT PAGE
PREFACE ........................................................................................................................................ i

ACKNOWLEDGEMENT .............................................................................................................. ii

TABLE OF CONTENTS ............................................................................................................... iii

LIST OF TABLES .......................................................................................................................... v

INTRODUCTION ......................................................................................................................... vi

CHAPTER ONE ........................................................................................................................... 1

THE ASSESSMENT OF THE PATIENT .................................................................................. 1

1.0 Introduction ............................................................................................................................... 1

1.1 Particulars of the Patient ........................................................................................................... 1

1.2 Patient’s Medical and Socio-Economic History ....................................................................... 2

1.3 Patient’s Developmental History .............................................................................................. 2

1.4 Patient’s Life Style/ Hobbies .................................................................................................... 3

1.5 Past Medical / Surgical History ................................................................................................ 3

1.6 Present Medical/Surgical History ............................................................................................. 3

1.7 Admission of Patient ................................................................................................................. 4

1.8 Patient’s Concept of Illness ...................................................................................................... 5

1.9 Literature Review...................................................................................................................... 5

1.10 Validation of Data ................................................................................................................... 9

CHAPTER TWO ........................................................................................................................ 10

ANALYSIS OF DATA ............................................................................................................... 10

2.0 Introduction ............................................................................................................................. 10

2.1 Comparison of Data with Standard ......................................................................................... 10

2.1.1 Diagnostic Investigations/Test ............................................................................................. 10

2.2 Causes of Patient’s Condition ................................................................................................. 13

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2.3 Clinical Features ..................................................................................................................... 13

2.4 Surgical Treatment .................................................................................................................. 16

2.5 Complications ......................................................................................................................... 16

2.6 Health Problems ...................................................................................................................... 16

2.7 Patient and family strength ..................................................................................................... 16

2.8 Nursing Diagnosis ................................................................................................................... 17

CHAPTER THREE .................................................................................................................... 18

PLANNING FOR PATIENT/FAMILY CARE. ...................................................................... 18

3.0 Introduction ............................................................................................................................. 18

3.1 Objectives/Outcome Criteria .................................................................................................. 18

4.2 Preparation of Patient/Family towards Discharge (24th March, 2021) ................................... 28

4.3 Follow Up/Home Visit/Continuity of Care............................................................................. 29

CHAPTER FIVE ........................................................................................................................ 32

EVALUATION OF CARE RENDERED TO PATIENT/FAMILY ...................................... 32

5.0 Introduction to the chapter ...................................................................................................... 32

5.1 Statement of Evaluation .......................................................................................................... 32

5.2 Amendment of Nursing Care Plan for Partially Met or Unmet Outcome Criteria ................. 34

5.3 Termination of Care ................................................................................................................ 34

5.4 Summary ................................................................................................................................. 34

5.5 Conclusion .............................................................................................................................. 35

5.6 Recommendation .................................................................................................................... 35

BIBLIOGRAPHY ....................................................................................................................... 36

APPENDIX .................................................................................................................................. 37

SIGNATORIES ........................................................................................................................... 38

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 LIST OF TABLES
TABLES PAGE
TABLE 2.1: COMPARISON OF DIAGNOSTIC INVESTIGATION/TEST 11
TABLE 2.2: DIAGNOSTIC INVESTIGATIONS/TEST 12
TABLE 2.3: COMPARISON OF CLINICAL FEATURES 13
TABLE 2.4: COMPARISON OF SPECIFIC TREATMENTS 14
TABLE 2.5: PHARMACOLOGY OF DRUGS. 15
TABLE 3.1 NURSING CARE PLAN 19

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 INTRODUCTION
The ultimate goal of every nurse is to anticipate for complete recovery of his/her patient within the
shortest period of hospitalization. However, if all interventions to restore life fail, the patient is
expected to receive the best nursing care that will lead to a peaceful death.
This script is a patient/family care study carried out on Master N.K.K and HIS family. It contains
the care rendered to the patient during his period of hospitalization and after discharge.
On the 21st March, 2021 at about 7:30pm, Master N.K.K was brought into the Paediatric ward on
his mother’s back and accompanied by a nurse on the orders of Dr. A.S for admission. Patient had
a history of fever, headache, general body weakness and loss of appetite.
My first interaction with Master N.K.K and his family was on 21/03/21. After I read through the
folder, I developed interest in his condition. By so doing, I informed both the in charge and the
patient and family my desire to use them for my care study which they agreed. All the admission
procedures were carried out accordingly after which I started establishing a nurse-patient
relationship by introducing myself. I explained the rationale for the care study and they willingly
accepted my proposal.
A nursing care plan was formulated based on the identified patient problem which led to the
recovery of patient and he was discharged on 24/03/21 to continue treatment at home. The duration
of the care of Master N.K.K and family lasted for two weeks and one day, that is from the day on
admission to the last home visit.
The patient/family care study is categorized into five chapters. Each chapter covers specific aspect
of nursing care given to the patient and her family.
Chapter 1: Assessment of patient and family
Chapter 2: Analysis of data
Chapter 3: Planning of patient/family care
Chapter 4: Implementation of patient/family care
Chapter 5: Evaluation of care rendered to patient/family, Summary and conclusion

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 CHAPTER ONE
THE ASSESSMENT OF THE PATIENT
1.0 Introduction
Assessment can be defined as a critical analysis and evaluation or judgments of the status or quality
of a particular condition, situation or other subject of appraisal.
Assessment, the first step in the nursing process is a systemic, comprehensive process of collecting,
organizing and documenting patient’s data gathered from various available sources.
The information is collected through interviewing, observation and laboratory investigations to
help in analysis and diagnosis of patient’s condition. This helps to render the exact nursing care to
the patient and family. Assessment also involves collection of data from patient’s past and present
medical history or record in the folder.
The assessment of patient and family is very important in the care of the patient since it helps the
nurse to collect data which is vital in planning the care of the patient and the family.
The information collected from the various sources was used to arrive at a solution to patient
complains made during hospitalization. The information also reflects on the historical and current
data about the physiological, psychological as well as environment and lifestyle factors, which
may affect health. The assessment includes;
Particulars of patient, Family Medical and Socio-Economic History, Present Medical History,
Patient’s Lifestyle / Hobbies, Admission of Patient, Patient’s Concept of His Illness, Literature
Review On the Disease Condition, Validation of Data
It is from these that the analysis can be made to identify the patient’s needs and problems to plan
the appropriate care.
1.1 Particulars of the Patient
This is the collection of personal data thus; name, data of birth, age, sex, marital status etc. about
patient in question. For the purpose of confidentiality, the subject of this care study will be N.K.K,
a four-year-old Ghanaian born to Mr. M. K. K and Mrs. C. M on the 4th February, 2017 at Chiraa,
a suburb in Sunyani in the Bono region where both parents hail from. N.K.K is the fifth born of
his parents and has four siblings who are all alive. He lives with both parents and other relatives
at Chiraa - Canada where they sleep in a well-constructed house. His next of kin is his father Mr.
M. K. K. He is chocolate in complexion, about 0.98m in height, weighs 16kg, MUAC of 18.8 and
do not have any physical impairment. N.K.K speaks Lobi and Twi. His parents are Christian and

1
worships in St. Francis Xavier Catholic Church at Chiraa Parish. He attends Majesty International
School and is in KG 1.
1.2 Patient’s Medical and Socio-Economic History
Medical history is the longitudinal record of what has happened to the patient since birth. It
includes diseases, major and minor illnesses.
According to the patient mother, there is no known hereditary or chronic disease such as epilepsy,
Diabetes Mellitus (DM), Hypertension, mental illness, leprosy, and tuberculosis in their family.
He continued to say that none of the family members had ever been hospitalized. He however
admitted that they sometimes experience minor ailments like headache and fever which they
usually buy some drugs from chemical shops to relieve them of the symptoms.
Socio-economic history is the status of the economic and sociological combined total measure of
a person`s work experience of an individual`s family economic and social position in relation to
others based on income, education and occupation.
Socioeconomically, patient’s family belongs to the middle class income group because the father
is a farmer precisely a cocoa farmer who earns adequate income, the mother is also a cocoa farmer
who is able to raise some money from her farm for the upkeep and of their children.
1.3 Patient’s Developmental History
Development is the process involving an increase in complexity of form and functional capacity.
Growth is the process which involves physical increase in size, height, structure and number of
cells whiles Maturation is the totality of growth and development and is not affected by
environment but hereditary factors.
Mrs. C. M narrated that he went through nine (9) months of normal pregnancy and had N.K.K
born at term by spontaneous vaginal delivery at Chiraa hospital. N.K.K was exclusively breastfed
for 6months and later introduced to complementary foods such as porridge, tuo-zaafi, and
sometimes light soup.
According to the patient mother, N. K. K followed the normal developmental milestone. He sat at
4 months, crawled around his seventh month, walked at 10months and can now clean his teeth and
undertake certain personal hygiene with a little supervision. N.K.K had his first tooth eruption at
his sixth month. Immunization is up to date as confirmed by the mother. According to Erik
Erikson’s psychosocial theory of development, N.K.K is at initiative versus guilt. At this stage,

2
N.K.K has learnt to explore himself beyond the world through directing play and other social
interaction.
1.4 Patient’s Life Style/ Hobbies
According to the patient’s mother, N.K.K likes playing with his age group. He sleeps early around
7:30pm and wakes up early around 6:00am. He is bathed twice daily and empties the bowel and
bladder when necessary. His favorite food is rice and stew with chicken. He currently school at
Majesty international school.
N.K.K does not have any known allergy concerning the food he eats, can rides bicycle the whole
day if permitted. Patient has the ability to verbalize appropriately.
1.5 Past Medical / Surgical History
This is the record of diseases, infections, deformities etc. that patient suffered from and the
treatments that were given to the patient.
Mrs. C. M indicated that child has not had any of the childhood illness such as measles, whooping
cough and the others. He does not have any drug allergy, has never been involved in an accident
which demands critical care and has never been hospitalized before, he confirmed that this is the
first time the child has been admitted in the hospital but sometimes experience some minor signs
and symptoms such as headache, fever and the like, normally buys drugs such as Syrup
paracetamol from the pharmacy shop to treat such.
1.6 Present Medical/Surgical History
This is the newly medical problem that the patient has been diagnosed with and the treatments
given to him.
Mrs. C. M said that her son was well until Thursday 18th March, 2021 when the child started to
complain of headache and abdominal pains and mother noticed a spike in temperature at night.
This was associated with general weakness and chills and administered syrup paracetamol, but
however noticed that the symptoms did not resolve so rushed patient to the Chiraa Health Center
on 21st March, 2021 but was referred immediately to Regional hospital - Sunyani for further
management. The doctor at the pediatric unit diagnosed him as having malaria. He was then
admitted at ward for further management.

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1.7 Admission of Patient
On 21st March, 2021, at 7:30pm, patient was brought to the pediatric unit by his mother in a
conscious state as a referral from Chiraa Health Center. She was seen by Dr. A.S and booked for
admission in this ward on account of malaria after malaria RDT proved positive. Mother of patient
was warmly welcome and was offered a seat. The child was immediately placed in a bed after a
comfortable bed was prepared for him to enhance rest and sleep. The patient’s mother was however
reassured and introduced to other patients and their relatives in the cubicle and certain particulars
such as name, age, sex, date of admission, residential address, next of kin, telephone number and
provisional diagnosis were recorded. The patient mother was later introduced to the ward and
reassured again by the nurses. Vital signs were checked and recorded as follows;
Temperature 37.8 degree Celsius
Heart rate 148 bpm (beat per minute)
Respiration 28 cycles per minute
SPO2 98%
He was therefore tepid sponged and the temperature reduced to 36.8oc. An intravenous line was
set up and blood samples were taken for laboratory investigations which included Bf for malaria
parasite and Full Blood Count. The following drugs were prescribed
 Intravenous Artesunate 48mg @ 0, 12, 24hrs
 Syrup paracetamol 125mg tds x 7days
 Susp. A/L 40/240 mg @ 0, 8, 24hrs then bd x 2 after Iv Artesunate
All these drugs were collected from the dispensary and administered accordingly.
The Cash and Carry systems as well as the National Health Insurance Scheme (NHIS) were
explained to the mother, so she could organize herself for the upkeep of the patient on the ward,
in terms of drugs and other necessities. The mother was informed to ask relatives to bring items
like soap, sponge, cup, spoon, plates, bowl, paste and brush, pajamas, towel, bucket, comb,
powder, pomade and others for the patient’s use. They were also made aware of the visiting time
and were orientated to the ward.
Later her particulars were recorded in the admission and discharge books and the daily ward state.
Self-introduction was made to the mother and other relatives available as being a student of
Sunyani Nursing and Midwifery Training College and informed them of my interest to use N. K.

4
K for a care study. They were also informed that patient would be nursed from the time of
admission till discharge. Upon hearing this, they were excited and granted me the permission to
use him for the care study. Patient was chosen for the care study because of the enthusiastic interest
to know more about the condition (Malaria).
1.8 Patient’s Concept of Illness
Patient mother confirmed that, it is normal for one to fall sick at a point in time and does not believe
that her son’s condition was being initiated by any witch or evil spirit. She attributed her son’s
condition to the excessive intake of oil and also poor sanitation. She was however anxious to when
her son was going to recover. After assuring her that, it will be well and educating on the disease
condition, she was relieved.
1.9 Literature Review
Definition
Malaria: Is an acute infectious disease that is characterized by periodic chills, fever, sweating,
anaemia and splenomegaly. It is transmitted by the bite of an infected female Anopheles mosquito.
Types of Malaria
1. Uncomplicated malaria (mild)
2. Complicated malaria (severe)
Incidence
Distributed in the tropics and sub tropics and India. It has been eradicated in Europe. Generally,
children and pregnant women get severe malaria.
Causes
Malaria is caused by a parasite of genius plasmodium [protozoa]. There are four[4] types of
plasmodium species. They are;
1. Plasmodium falciparum
2. Plasmodium Vivax
3. Plasmodium malariae
4. Plasmodium ovale
5. Plasmodium knowlesi (zoonotic)
The plasmodium falciparum is the commonest, forming 90% of infections in Ghana, plasmodium
ovale is rare parasite restricted to the tropical climate and found primary in East Asia. Plasmodium
vivax is widely distributed parasite in the temperate and tropical climate region. It has a cycle of

5
48hours and usually last for 3weeks.Plasmodium malariae are also found in the temperate and
tropical regions but it is less common than the plasmodium vivax.
Reservoir is Man
Incubation Period = Falciparium-12days
Ovale-14days
Malariae-30days
Vivax-14days
Mode of Transmission-Is by the bite of infected female anopheles mosquito which introduces the
parasites into the body of a human. It can be transmitted through blood transfusion and
contaminated shared needles and syringes among drug addicts.
Life Cycle of Plasmodium Parasite
The plasmodium species has two life cycles; one cycle in man the other in mosquito.
In mosquito, the gametocytes are the form that infect the mosquito and produces itself as if it were
both sexes. When the mosquito sucks the blood containing the gametocytes, they pass into the
salivary glands of the mosquito when they develop into new forms called sporozoites.
In the life cycle of mosquito in man, a bite from an infected female anopheles injects the saliva
containing sporozoites. The sporozoites travel in the blood to the liver and enter the liver cells. In
the liver cells, some of the sporozoites divides [tachysporozoites] and becomes thousands of
merozoites. The merozoites are released from the live to the blood where they attack the red blood
cells. Some of them turn into a ring from trophozoites which split again to form schizonts. The
schizonts burst the red blood cells at a certain moment releasing the merozoites. This release leads
to a violent rise in temperature during the attacks seen in malaria. The trophozoites that are left
over during division can in course of the next day develop into sexual form. The gametocytes
which can be taken up by the blood sucking mosquito and start another cycle.
Incubation Period-10-15days
Clinical Manifestations
1. High fever
2. Chills
3. Profuse sweating
4. Malaise
5. Headache

6
 6. Nausea and vomiting
7. Joint pains
8. Jaundice
9. Abdominal pain may be present
10. Bitter taste in mouth
11. Fatigue
12. Convulsion in children
13. Anorexia
14. Anaemia
15. Coma
16. Dehydration in children
17. Leucopenia
18. Enlargement of spleen
19. Enlargement of liver
Diagnostic Investigations/Tests
 Full blood count
 Blood film for malaria parasite estimation
 Signs and symptoms
 Laser test
 Rapid diagnostic test
Complications
 Miscarriage in pregnancy
 Cerebral malaria
 Liver failure
 Premature delivery
 Brain damage
 Anaemia
 Mental retardation in children
 Loss of weight
 Black water fever [severe breakdown of red blood cells causing a dark discoloration of the
urine]

7
Medical Treatment
1. Uncomplicated cases are treated with Artemisin in-based combination therapies
(Artesunate Amodiaquine); according to body weight [not recommended for pregnant
women]. Arthemeter Lumefantrine for those who cannot tolerate Artesunate,
Amodiaquine.
2. In severe malaria intravenous or intramuscular Quinine, followed by oral Quinine when
patient can swallow. Pregnant women can be given Quinine and Sulphadoxine
Pyremethamine.
3. Intravenous fluids such as normal saline, ringers lactate and others that can be useful in
hydrating the patient.
4. Analgesics, e.g. paracetamol is given for pains and fever.
Nursing Management
Bed Rest and comfort
1. The patient should be given complete bed rest in the phase of high temperature, joint pains
and anemia
2. The patient should be nursed in a highly ventilated room and on a comfortable bed.
3. Assist patient into comfortable position to aid rest.
4. Reduce noise in the ward and restrict visitors to promote rest and sleep.
5. Bed linen should be changed regularly to promote comfort and rest.
Nutrition
1. The patient should be given balanced diet especially high calorie diet to promote energy.
2. The patient is given fruit juice to enhance appetite.
3. Fluid intake is also increased and if possible forced fluids are enhanced. The force fluids
can be given intravenously or orally.
4. Patient should be served small but frequent since they usually have anorexia.
5. Meals should be served alternatively.
6. Meals should be prepared taking patient’s preference into consideration.
Observation
1. Monitor temperature, pulse, respiration, they should be monitored 4hourly but temperature
should be monitored closely.
2. Observe for signs of dehydration.

8
 3. Observe for jaundice and signs of anaemia.
4. Observe patient’s level of consciousness and orientation to time, place and person.
5. Observe unconscious patients for bed sores.
Personal Hygiene
1. Give bed bath or assist bed bath
2. Give oral hygiene to patient
3. Treat pressure areas and pressure sores if any.
4. Tepid sponge patient to reduce temperature
5. Use additional wet towels on arms and legs.
Protection from Injury
1. Monitor patient closely and ensure that all sharp objects are away from patient's reach.
2. Ensure that side rails are well fixed and in good use.
3. Ensure good lightening system in the ward.
4. Wet floors must be mopped and kept dry.
Education/Prevention
1. Wear protective clothing in endemic areas.
2. Educate patient on the need to sleep under treated mosquito net or use mosquito repellent.
3. Educate patient to spray room once every week.
4. Educate patient to make proper disposals of used cans.
5. Educate patient to clear all bushes around houses.
6. Educate patient to desilt all gutters.
7. Educate patient to report early for treatment and to avoid over the counter drugs.
8. Educate patient to cover all cans containing water in the house.
9. Educate patient to visit hospital at least twice a month for medical check-up.
1.10 Validation of Data
Validation is the act of checking or proving the accuracy of something. The data was collected
from the patient and the mother through interrogation and interview. I also visited their house to
acquire more information from family members and their home environment. The information
gathered proves that all the information given to me by the patient’s mother were valid. Rapid
diagnostic test for malaria was done to prove the diagnosis and full blood count was done to prove
complications.

9
 CHAPTER TWO
ANALYSIS OF DATA
2.0 Introduction
This involves the comparison of laboratory investigations with standards. It is the second stage of
the nursing process. It also covers patients and family strengths, health problems and nursing
diagnosis of the various problems. It also illustrates the pharmacology of the drugs in the treatment
of patient’s condition.
Analysis of data collected deals with the critical examination and interpretation of the data
collected during the assessment phase of the patient family’s care study. It deals with the
comparison of the results of the investigation carried out with the normal values, comparing the
clinical manifestation and the causes of the condition to those of the literature review.
2.1 Comparison of Data with Standard
This involves the comparison of laboratory investigations considered during hospitalization with
standards. It also covers the causes of patient’s condition, clinical features, treatment and
complications of the disease condition.
Test: is simply a session in which a product or a piece of equipment is examined under every day
or extreme condition to evaluate its durability.
Investigation: this is simply the act of inquiring into a study in order to ascertain facts or
information. To investigate in simple terms means to look into, scrutinize in order to discover
something hidden or secret. Barbara F. Weller (25th Edition)
2.1.1 Diagnostic Investigations/Test
During the patient’s admission, the investigations performed to aid in the provision of appropriate
treatment and assess the progress of the patient’s condition.
The following investigations and tests were carried out on N.K.K to assist in diagnosis, treatment
and also to ascertain the progress of treatment.

10
Table 2.1: Comparison of Diagnostic Test Carried Out On Patient and with Those Outline
in The Literature Review
Diagnostic Tests in Literature Diagnostic Tests Carried Out On My
Patient
Full blood count Done for my patient
Blood film for malaria parasite estimation Done for my patient
Signs and symptoms Done for my patient
Rapid diagnostic test Done for my patient
Laser Test Not done for my patient

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Table 2.2: Diagnostic Tests/Investigation carried out on my Patient with interpretation
Date Specimen Investigation Results Normal Values Interpretation Remarks

21/03/21 Blood Full Blood Count

1.White Blood Cells 8.4k/ul 3.5-10.0k/ul Normal No treatment was given
2.Red Blood Cells 3.96 4.2-6.2 10^12/L Normal No treatment was given
3.Platelet 10^12/L 100-350 10^9/L Below Normal No treatment was given
4.Haemoglobin 57.0 10^9/L 11.0 – 17.5g/dl Below Normal No treatment was given
5.Haematocrit 10.9g/dl 33.3-51.0% Normal No treatment was given
40.6%
21/03/21 Blood Malaria RDT Positive Malaria parasite Positive There was malaria parasite
present indicating present in the blood.
presence of
malaria
infection
21/03/21 Blood Blood film for Malaria Indicating child Anti – malaria treatment
malaria parasites parasite seen has malaria regiments were initiated
(1050
parasites/ul)

12
2.2 Causes of Patient’s Condition
With reference to the literature review, the cause of patient condition was due to plasmodium
falciparum. There are also predisposing factors which contributed to patient condition which serve
as breeding places for the mosquitoes. These include poor personal hygiene that is choked gutters,
refuse dump and weeds around her house.
2.3 Clinical Features
With reference to the literature review above, it has been noticed that patient was suffering from
malaria exhibits numerous signs and symptoms based on the week at which the disease condition
has extended to, that is to say how far the disease has been in the system of the individual. From
the literature review, a patient with a malaria must exhibit the following signs and symptoms which
include: severe headache, abdominal pains, fever or chills, general body weakness, anorexia (loss
of appetite) and others, these signs which include headache, chills, fever, vomiting seen in N.K.K
as signs and symptoms confirms that he was battling with malaria as a disease condition and thus
need to be treated as such.
Table 2.3 Comparison of Patient’s Signs and Symptoms with that of the Literature Review
Clinical Features
According to Literature As Presented by Patient
1. Fever Patient had fever
2. Chills Patient had chills
3. Profuse sweating Patient did not experience profuse sweating
4. Malaise Patient had malaise
5. Headache Patient had headache
6. Nausea and vomiting Patient did not have nausea and vomiting
7. Joint pains Patient did not experience joint pains
8. Jaundice Patient did not experience jaundice
9. Abdominal pain may be present Patient had abdominal pains
10. Bitter taste in mouth Patient had bitter taste in mouth
11. Fatigue Patient had fatigue
12. Convulsion in children Patient did not experience convulsion
13. Anorexia Patient had anorexia

13
 14. Anaemia Patient did not experience anemia
15. Coma Patient did not experience coma
16. Dehydration in children Patient was not dehydrated
17. Leucopenia Patient did not experience leucopenia
18. Enlargement of spleen Patient did not experience splenomegaly
19. Enlargement of liver Patient did not experience hepatomegaly

Treatment
Treatment is the mode of dealing with the patient or disease. It could be in the form of active,
conservative, empirical, palliative or prophylactic. (Weller,2018).

Table 2.4: Comparison of Some Specific Treatment given to patient to that of Literature
Review
Drugs in Literature Drugs Given to the Patient

Anti – malaria therapy Intravenous Artesunate, Susp Arthemeter

Lumefantrine were administered
Analgesics Paracetamol was served

14
 Table 2.5: Pharmacology of Drugs Given
Date Name of Drug Dosage and Route Classification of Action of Drug Actual Action Side
of Administration Drug Observed Effects\Remedies
21/03/21 Intravenous Dosage: 48mg 0, Anti-malaria Inhibits nucleic acid and It helps control Headache, nausea,
Artesunate 12, 24hrs protein synthesis symptoms exhibited by vomiting,
clients such as general dizziness, tinnitus,
Patient dosage: weakness headache, visual disturbance,
48mg 0, 12, 24hrs fever ,rapid pulse rate abdominal pain,
etc. hypoglycemia
Route: Intravenous
21/03/21 Paracetamol Dosage 125mg Antipyretic and Activates Client’s temperature Anorexia, liver
three times a day analgesic cyclooxygenase enzyme reduced from 37.8oC to damage skin
that initiates formation 36.8oC. Headache also rashes, anemia,
and therapy preventing subsided. hypoglycemia.
its effects on the body.
None observed.
22/03/21 Artemether Dosage 40/240mg Anti-malaria Artemether and It helps control Nausea, vomiting,
Lumefantrine @ 0, 8, 24hrs then Lumefantrine inhibits symptoms exhibited by dizziness, tinnitus,
bd x 2 nucleic acid and protein clients such as general headache,
Route: Oral synthesis weakness, headache, abdominal pain,
fever etc. hypoglycemia.

15
2.4 Surgical Treatment
No surgical treatment was given to my patient
2.5 Complications
This is a disease or a condition arising during the course of or as a consequence of another disease.
With reference to the literature review, N.K.K had no complication because of the well-
coordinated medical and nursing care that was given to him.
2.6 Health Problems
Health problem is any stress in the patient which is detrimental to his health therefore ; there is
the need for effective nursing intervention in order to either manage or alleviate it. From the
patient, family and the observations made, the following problems were identified.
1. Patient had fever (37.80 C)
2. Patient was not able to feed as expected (anorexia)
3. Patient complained of headache
4. Patient had general body weakness
5. Mother and family do not have adequate knowledge on patient’s condition
2.7 Patient and family strength
This is explained as the ability of the patient and her family to participate in the care for the
achievement of the stated goals. The following are some identified strength of patient and her
family:
1. Patient can cope with tepid sponging
2. Patient can eat one third of food served
3. Patient can tolerate pain medications when served to relieve pain
4. Patient can perform certain activities such as eating and walking with assistance
5. Mother and family were very cooperative and ready to learn.

16
2.8 Nursing Diagnosis
The diagnosis helps the nurse to provide appropriate nursing care for the identified problems.
Based on the problems identified, the following nursing diagnoses were made;
1. Hyperthermia (37.8oC) related to infectious process.
2. Imbalanced nutrition (less than body requirement) related to anorexia (loss of appetite).
3. Acute pain (headache) related to disease condition.
4. Activity intolerance related to general body weakness.
5. Deficient Knowledge (causes, signs and symptoms, management, prevention and
complications of malaria) related to inadequate education on malaria.

17
 CHAPTER THREE
PLANNING FOR PATIENT/FAMILY CARE.
3.0 Introduction
This chapter is the third phase of the nursing processes and it deals with stating an objective to
meet over a specified time frame with the implementation of specific nursing interventions for a
particular patient problem. Objectives are then evaluated after the period of time to assess whether
the set goal was met or unmet. Planning is defined as a formulated or detailed method by which a
thing is done (Abate 2010) and is very important as it helps in the efficacy of care rendered to
patients and their families.
3.1 Objectives/Outcome Criteria
Below are the objectives set to meet in accordance with the problems of patient identified
throughout patient’s stay in the hospital;
1. Patient’s body temperature will be reduced from 37.8oc to a normal range of (36.2-37.2oc) within
2hours as evidence by
a) Patient and mother verbalizing that the warmth has subsided.
b) Nurse observing that the patient’s body temperature record within normal range (36.2oC –
37.2oC) by the use of a clinical thermometer.
2. Patient will maintain adequate nutritional status within 48hours as evidence by;
a) Patient and mother verbalizing that he has appetite for food and requesting for food to eat.
b) Nurse observing patient eat at least half of the meal served.
3. Patient’s pain will be reduced within 2hours as evidence by;
a) Patient and mother verbalizing relief of pain.
b) Nurse observing patient looks cheerful and relaxed in bed.
4. Patient will be able to perform activities of daily living within 48hours as evidence by;
a) Patient and mother verbalizing that he is able to perform activities of daily living without
support.
b) Nurse observing that patient is able to perform activities of daily living without assistance.
5. Patient and family will have knowledge about the disease, treatment and diagnosis about the
disease within 3hours as evidence by;
a) Patient and family’s ability to answer simple questions on the disease, treatment and
diagnosis.

18
 Table 3.1: Nursing Care Plan for N.K.K
Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing Interventions Evaluation
Criteria
21/03/21 Hyperthermia (37.8ºC) Patient’s body 1) Reassure patient and 1) Patient and mother Goal fully met as;
at 7:30pm related to infectious temperature will be mother. were reassured. Patient and mother
process reduced to normal (36. verbalized that the
2ºC – 37.2ºC) within 2) Tepid sponge patient. 2) Patient was tepid warmth has reduced
2hours as evidence by; sponged to reduce and nurse observed
temperature. and recorded a
1) Patient and mother 3) Open nearby 3) Nearby windows body temperature
verbalizing that warmth windows. to ensure were opened to ensure of 36.8oC with the
has reduced. adequate ventilation. adequate ventilation. help of a clinical
thermometer.
2) Nurse observing the 4) Remove excess 4) Patient’s excess on 21/03/21 at
patient body temperature clothing from patient. clothing was removed. 9:30pm
record within normal
range (36. 2ºC – 37.2ºC) 5) Check vital signs 5) Vital signs were A.B.S
by the use of clinical especially temperature checked and recorded.
temperature. and record.
6) Administer 6) Syrup paracetamol
prescribed anti- pyretics. 125mg was
administered

19
Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing Interventions Evaluation
Criteria
21/03/21 Imbalanced Patient will regain (1) Reassure patient and 1). Patient and mother were Goal fully met
at 7:35pm nutrition(less than adequate nutritional mother that his nutritional reassured that his nutritional status as; patient and
body requirement) status within status will be restored with will be restored with effective mother
related to anorexia 48hours as effective nursing care. nursing care and his cooperation. verbalized that
(loss of appetite) evidenced by; (2) Plan patient’s diet taking 2). Patient’s diet was planned with a his appetite for
1.Patient and into consideration his dietician taking into consideration food has been
mother verbalizing preference. patient’s preference. restored and
that he has appetite (3) Provide mouth care to 3). Mouth care was provided to Nurse observed
for and requesting stimulate and boost patient stimulate patient’s appetite. that patient ate
for food to eat. appetite. at least half of
2.Nurse observing 4). Serve food high in 4). Patient was served with high the meal
patient eating at calories, proteins and calories, proteins and vitamins to served. On
least half of meal vitamins to provide energy boost the immune system. 23/03/21 at
served. and boost the immune 7:30pm
system.
5). Serve food in attractive 5). Patient’s food was served A.B.S.
manner and remove any attractively and nauseating items
nauseating items from the were removed.
site of the patient.

20
Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing Interventions Evaluation
Criteria
22/03/21 Acute pain(headache) Patient’s pain 1) Reassure patient and 1) Patient and mother were Goal fully met as;
@7:00am related to disease (headache) will be mother that pain(headache) reassured that pain(headache) patient and
condition relieved within 2hours will subside with will subside with appropriate mother verbalized
as evidenced by; appropriate nursing care nursing care relief of pain and
nurse observed
1) Patient and mother 2) Engage patient in a 2) Patient was engaged in that patient
verbalizing relief of diversional therapy diversional therapy looked cheerful
pain. and relaxed in
3) Patient should assume a 3) Patient was put in a bed.
2) Nurse observing comfortable position comfortable position to on 22/03/21 at
patient looks cheerful reduce level of pain 9:00am
and relaxed in bed. 4) Check vital signs and 4) Vital signs were checked
record and recorded

5) Administer prescribed 5) Syrup paracetamol 125mg A.B.S

analgesics was administered

6)Restrict visitors to 6) Visitors were restricted to

prevent disturbances prevent disturbances

21
Date/Time Nursing Diagnosis Objective/Outcome Nursing Orders Nursing Interventions Evaluation
Criteria
22/03/21 at Activity intolerance Patient will be able to 1) Reassure patient and 1) Patient and mother Goal fully met as;
5:20PM related to generalized perform activities of mother that measures will were reassured of helping patient and
weakness daily living within be put in place to help patient to perform activity mother verbalized
48hours as evidenced patient perform activities of daily living that he is able to
by; of daily living perform activities
2) Assess the patient’s 2) Patient’s level of of daily living
1)Patient and mother level of physical activity physical activity and without assistance
verbalizing that he is and mobility mobility was assessed and nurse
able to perform observed that
activities of daily living 3) Assist patient with 3) Patient activity of daily patient performed
without support activity of daily living to living to meet self-care activities of daily
meet self-care needs needs was assisted living without
2) Nurse observing that assistance. on
patient is able to 4) Check and record 4) Patient’s vital signs 24/03/21 at
perform activities of patient’s vital signs were checked and 5:20pm
daily living without recorded
assistance 5) Encourage 5) Patient’s independence
independence in self-care in self-care activities that A.B.S
activities that can be can be tolerated were
tolerated encouraged

22
Date/Time Nursing Objective/Outcome Nursing Orders Nursing Interventions Evaluation
Diagnosis Criteria
23/03/21 Deficient Patient and family 1) Reassure the patient and 1) Patient and family were Goal fully met as;
at 8:15am knowledge related will have knowledge family reassured patient and family
to information about the disease, were able to
misinterpretation treatment and 2) Provide less stimulating and 2) A less stimulating and noise free answer simple
diagnosis about noise free environment for the environment was provided for the questions on the
disease within 3 education education causes,
hours as evidenced prevention, sign
by; 3) Ask them about previous 3) Patient and family previous and symptoms,
a. Patient and knowledge and clear all knowledge about the disease was treatment and
family’s ability to misconceptions about the assessed and all misconceptions diagnosis.
answer simple condition were cleared
questions on the 23/03/21 at
causes, prevention, 4) Ask patient and family 4) Patient and family were asked 11:15am
sign and symptoms, questions in simple and clear questions in simple and clear
treatment and language language
diagnosis. 5) Encourage patient and family 5) Patient and family were A.B.S
to ask questions to clarify any encouraged to ask questions in
misconceptions about the disease order to clarify any misconceptions
about the disease.

23
 CHAPTER FOUR
IMPLEMENTING PATIENT/FAMILY CARE
4.0 Introduction
Implementing is the fourth phase of the nursing process and it is the process of putting the nursing
care plan which includes both medical and nursing intervention into action in order to obtain the
desired outcome criteria (American Nurses Association, 2018). The nursing priority of
implementing patient/family care is the provision of individualized self-nursing orders given. The
patient and mother were encouraged to participate by playing their part towards his recovery. It
also comprises of nursing procedures made for the patient throughout his period of hospitalization,
preparation for discharge and rehabilitation, follow-up/home visits and continuity of care.
4.1 Summary of actual nursing care
The nursing care rendered in the management of Master N.K.K began on the 21st March,2021 the
day of admission throughout the time of discharge on the 24th March,2021.
Day on Admission (21st March, 2021)
On 21st March,2021, Master N.K.K was admitted at the paediatric ward of the Sunyani Regional
Hospital at 7:30pm. Master N.K.K came in restless and very weak, they were introduced to the
staff on duty and warmly welcome. It was an emergency admission so mother had to rush him to
the hospital while his father went home to prepare and bring stuff like bowl, cup, bucket, clothes,
towels etc. to the hospital. Master N.K.K was very weak so a comfortable bed was prepared for
him immediately and was given the prescribed emergency drugs and the mother was oriented to
the ward after Master N.K.K was being stabilized. I later introduced myself to Mrs. C.M since
Master N.K.K is still young to understand. Master N.K.K’s particulars were written in the
admission and discharge book, nurses note, daily ward state, rounds book and changes book.
Before the medical officer came his vital signs were checked and recorded as
Temperature; 37.8 degree Celsius
Pulse; 148 beat per minute
Respiration; 28 cycle per minute
SPO2; 98%
He was diagnosed of severe malaria by Dr. A.S. and prescribed the following drugs for him;
 Intravenous Artesunate 48mg @ 0, 12, 24hrs
 Syrup paracetamol 125mg tds x 7days

24
 Susp. A/L 40/240 mg @ 0, 8, 24hrs then bd x 2 after Iv Artesunate
Dr. A.S ordered for a full blood count specifically for haemoglobin level, blood film for malaria
parasite and blood sample was taken to the laboratory. Mrs. C.M was reassured that her son will
be well. Mrs. C.M and Mr. M.K.K were educated on the condition of their child, nutrition, cleaning
of the house and their personal hygiene. I told both parents that I will like to use Master N.K.K for
a study and they gave me permission to do so. A care plan was made for Master N.K.K.
On admission my patient was having high body temperature of 37.8oC and my objectives was to
reduce patient’s body temperature of 37.8oC to fall within the normal range therefore a nursing
diagnosis of hyperthermia related to plasmodium infection was made to normal (36.2-37.2) within
2 hours. The following nursing interventions were put in place, patient was reassured, wearing of
loose clothing, adequate ventilation and tepid sponging was done, patient was served with Malt,
vital signs were monitored and prescribed medication was served.
On the same day, I visited my patient around 7:35pm. By that time my patient’s mother had already
bathed and brushed his teeth. Bed making was done for him and the doctor came for review around
8:05am. He was comfortable in bed and his vital signs were checked and recorded. My patient’s
fever had subsided but his mother complained that her child had loss appetite and also added that
patient complains of hunger but cannot feed well hence an objective was set to restore patient’s
appetite within 48 hours by the help of nursing interventions such as; patient and mother were
reassured that his nutritional status will be restored with effective nursing care and his cooperation,
patient’s diet was planned with a dietician taking into consideration patient’s preference, mouth
care was provided to stimulate patient’s appetite, patient was served with high calories, proteins
and vitamins to boost the immune system and patient’s food was served attractively and nauseating
items were removed.
Patient slept around 9:00pm after his mother persuaded him.

25
First Day of admission (22nd March, 2021)
On this day, patient woke up around 5:45am, he was assisted to care for his oral and personal
hygiene, his due medications were served, vital sign checked and recorded and he was fed with
Hausa Koko and milk which he was able to eat ¾ of it.
Around 7:00am, patient complained of headache and hence an objective was set to relieve patient
of headache within 2hours by the help of nursing interventions such as: patient and mother were
reassured that pain(headache) will subside with appropriate nursing care, patient was engaged in
diversional therapy, patient was put in a comfortable position to reduce level of pain, vital signs
were checked and recorded, visitors were restricted to prevent disturbances and syrup paracetamol
125mg was administered.
The objective set for patient to regain his normal body temperature to normal was visited and goal
was fully met as patient and mother verbalized that the warmth has reduced and nurse observed
and recorded a body temperature of 36.8oc with the help of a clinical thermometer.
The objective set for patient to regain his appetite was revisited and the nursing interventions were
re-enforced.
Patient had general body weakness and therefore, an objective was set to relieve patient of general
body pain within 48 hours with the use of nursing interventions such as; patient and mother were
reassured of helping patient to perform activity of daily living, patient’s level of physical activity
and mobility was assessed, patient’s activity of daily living to meet self-care needs was assisted,
patient’s vital signs were checked and recorded and patient’s independence in self-care activities
that can be tolerated were encouraged.
I informed the mother of my intention to visit their home the next day of which she agreed and
said I can go with Master N.K.K’s father.
Routine vital signs were checked, recorded and due medications were served and patient was
served with rice and tomatoes stew with an egg and he was able to eat almost half.
He was given a warm bath and served with warm Milo with bread for supper and he retired to bed
around 10:10pm.

26
Second Day of admission (23rd March, 2021)
On the second day of admission, patient woke up from bed around 5:50am. Patient’s personal and
oral hygiene were ensured by his mother. His due medications were served, vital signs checked,
recorded and patient was served with tom brown and bread.
On observation, patient’s condition was improving and he looked healthy. Nevertheless, on having
an interview with his mother, it was realized that she does not really have knowledge on patient’s
condition, therefore an objective was set for patient and family to have adequate information on
the causes, prevention, signs & symptoms and treatment on the condition within three hours by
the help of nursing interventions such as; patient and family were reassured, a less stimulating and
noise free environment was provided for the education, patient and family’s previous knowledge
about the disease was assessed and all misconceptions were cleared, Patient and family were asked
questions in simple and clear language and patient and family were encouraged to ask questions
in order to clarify any misconceptions about the disease.
Doctor came on ward rounds and thus no new treatment regimen was prescribed for my patient
and the doctor tipped them for possible discharge tomorrow and to be monitored for 24hours. Bed
linens were changed to enhance patient’s comfort and he was then made comfortable in bed.
Around 11:15am, the objective set to equip patient and family with adequate information on the
causes, prevention, signs & symptoms and treatment on the condition within three hours was
visited and goal fully met as patient and family were able to answer simple questions on the causes,
prevention, sign and symptoms, treatment and diagnosis.
Routine vital signs were checked and recorded in the nurse’s note, due medications were served
and patient was served with tuozafi with ayoyo soup for lunch and rice and groundnut soup for
supper.
Around 7:35pm, the objective set for patient to restore his appetite to normal was visited and goal
fully met as; patient and mother verbalized that his appetite for food has been restored and Nurse
observed that patient ate at least half of the meal served. All procedures performed on patient were
duly recorded.

27
Third Day on Admission/Day of Discharge (24th March,2021)
On this day, patient woke up around 5:30am, his personal and oral hygiene were taken care of by
his mother. His due medication was served, vital signs were checked, recorded and corn dough
porridge with bread was served.
The objective set on 22/03/21 for patient to be able to perform his activities of daily living within
48hours was visited and goal fully met as; patient and mother verbalized that he is able to perform
activities of daily living without assistance and nurse observed that patient was seen playing with
other kids in his cubicle.
During ward rounds, patient’s condition was clinically stable therefore, he was discharged home.
Patient and family were informed about the discharge after which their bills were settled, I asked
Patient mother and her relatives to re-echo all that I have taught them about the condition which
they were able to do. I informed them about the date of review, and advised them on how to
administer the drugs and the need to continue with medication at home. Patient’s name was entered
into the admission and discharge book as well as the daily ward state before I saw them off to the
car park.
On return, the mattress and pillows used were disinfected with the bed clothes and pillow cases
were rinsed and sent to laundry. The mattress and pillows were cleaned and allowed to dry before
new bed linens were used to cover them.
All bed accessories were returned to the store and bed lockers and bed stead cleaned with parazone
at the same strength. The bed then was prepared for a new admission.
4.2 Preparation of Patient/Family towards Discharge (24th March, 2021)
The preparation of patient and family towards discharge started on the day of admission till the
day he was discharged. Master N. K. K`s family were reassured that patient would recover and be
discharge home. Health education on the condition was given to the family right from admission
till discharge of patient from hospital. Much emphasis was laid on environmental hygiene, the
need to sleep under a treated mosquito net and also the use of mosquito repellent for my patient
and also the family as a whole.
Master N.K.K mother and her family were educated much about some preventive measures which
include the following in other to improve a healthy living for herself and the entire family.
Patient mother was educated properly on the need to ensure proper drainage of gutters as well as
proper refuse disposal as they serve as a medium for breeding mosquitoes which can result in

28
malaria. Mother was offered this education because she had a perception that malaria was caused
by the intake of excessive oil.
Patient and family were advised on the importance of review and to keep to the said date (31/03/21)
and also to report to the hospital for proper management if any change occurs in patient’s condition
before the review date is due.
Assessment of patient’s hospital bill was done with the help of the National Health Insurance
Scheme, patients mother was not to pay any other bills. They were helped to pack their belongings
and patient’s remaining drugs were given to mother and were educated on the need to observe the
dosage, time and importance of taking the prescribed drugs. Patient’s mother thanked the staffs
and told them how grateful she was after she bid them goodbye. Patient and his mother were then
seen to the car station and they boarded a car home. The discharge procedure was documented in
the admission and discharge book and in the daily ward state as well as in the nurses’ notes.
4.3 Follow Up/Home Visit/Continuity of Care
A home visit is done before the patient is discharged. It is a friendly but purposeful visit to the
home of the patient with the aim of promoting and maintaining patient and family at large so as to
prevent the further occurrence of diseases.
First Home Visit (23rd March,2021)
My first home visit was made on the said date when master N.K.K was still on admission. The aim
of the visit was to know the community, to validate the information provided by the family, to
identify health hazards in my patient’s home and its environment and give health education and
also the presence of any health facility in my patient’s community.
On 23rd March,2021 master N.K.K’s father visited and he sent me to their house. We left the ward
around 11:00am and walked to the entrance of the hospital and he took me on his motorbike. We
got to their house at Chiraa (Canada) around 11:40am. On arrival, patient and family live in a three
rooms apartment one wooden-structure kitchen which is on the right side of the three bedrooms, a
toilet and a bathroom also behind the rooms. The rooms are not fenced and there are bushes around
the house and also a small farm in front of the house with a mango tree which provides shade to
them when its sunny. They dispose their refuse in a pit just behind the house. I advised Mr M.K.K
to weed around the house to prevent malaria and other diseases that the bushes and refuse disposed
at the back of the house can cause diseases like cholera, typhoid etc. I also suggested that they
should get the zoomlion dust bins and request that the rubbish should be collected by them at least

29
every week. I also encouraged the use of mosquito nets, repellent cream etc. to prevent malaria. I
sought for permission to leave because Mr N.K.K needed to pick some few things and take care
of Master N.K.K’s siblings before going back to the hospital. He expressed his gratitude for my
visit and saw me off but before I left, I learnt that the nearest health facility to their home was
Chiraa Health Centre.
Second Home Visit (27th March,2021)
My second home visit was on the 27th March,2021 which was a Saturday. The aim was to find out
how the patient was doing, whether he was taking his drugs and following instructions given at
the hospital, to remind them of the review date, re-educate them and also make them understand
the need for termination of care. I began the journey around 10:35am and arrived 11:20am. When
I got to the compound, I realized there is a locally made dustbin in front of the house, the bushes
around the house has been cleared and Mrs C.M was sitting under the mango tree with my patient
resting on her lap. I greeted and they were very happy to see me as promised, I was welcomed,
offered water, a seat and as custom demanded, I was asked why the visit and I made my mission
known to them. I asked of patient’s father, Mr M.K.K and the mother said he has gone to the farm
with the other siblings and she did not go with them because she had to take care of my patient. I
then re-educated her on the causes of malaria, mode of transmission, signs and symptoms, etc. and
prevention of malaria. I also educated her on the importance of personal and environmental
hygiene and stressed on the review date which was 31st March,2021 and I also made her aware
that, I will terminate my interaction with them on my next visit. I then asked for permission to
leave after having scheduled to visit them again.
Day of Review (31st March,2021)
On the day of review which was 31st March,2021, Master N.K.K in company of his mother came
for review as expected. Mrs C.M reported at the Outpatient Department and called while I was on
break from class, so I rushed to the hospital and I went to the record department for his folder, I
checked his vital signs and recorded as follows;
Temperature 36.90C
Pulse 98 beat per minute
Respiration 26 cycles per minute
We entered the consulting room after we were been called and luckily we met Dr. A.S in the
consulting room again. After the physician’s review, he said Master N.K.K is very well and said

30
what he needs to do is to continue his medication and stick to the advice to live healthy. We thanked
the physician and left the consulting room with a smile on Mrs C.M’s face. I told her to visit the
hospital when any of the family member is not well. We said goodbye to ourselves and they
boarded a taxi and left after I had informed them of my third and final home visit.
Third Home Visit (5th April, 2021)
My third and final home visit was made on the said date. I arrived at the patient’s house around
10:50am. I was welcomed on arrival by his parents. The main reason for the visit was to terminate
the care I was offering to Master N.K.K and family to enable me to concentrate on my studies at
school. The patient was in good health and his parents were grateful for the care I gave to their
son. I advised them to visit the nearby health center anytime they have a health concern. I informed
them that the meeting was my last interaction with them but as promised, I brought a Public Health
Nurse from Chiraa Health Centre to continue with the care. They were not happy about it but they
agreed that I have to go and continue my studies hence I promised them of a visit anytime am less
busy at school which won’t be official and will be calling them from time to time. I thanked them
for their co-operation and patience. They also expressed their appreciation. I finally left their house
around 1:15pm after biding them goodbye.

31
 CHAPTER FIVE
EVALUATION OF CARE RENDERED TO PATIENT/FAMILY
5.0 Introduction to the chapter
Evaluation in simple terms is the outcome of nursing actions against the anticipated goals and it is
the final step in the nursing process, (Bare and Smeltzer, 2018). This is the last phase of the nursing
process. The chapter gives information about the statement of evaluation, amendment of goals and
the termination of care rendered to the patient and family.
5.1 Statement of Evaluation
During the act of evaluating the nursing care rendered to patient, all objectives set were fully met
and her condition improved. In the light of this, patient developed no complications. The goals set
and evaluated are as follows;
Patient Was Relieved of Fever
On 21st March, 2021 around 7:30pm, patient developed high body temperature (37.8oC). An
objective was set to help reduce patient’s body temperature from 37.8oC to a normal range of
(36.2oC-37.2oC) within 2hours with the help of the following nursing intervention: patient and
mother were reassured of competent health care, patient’s temperature was monitored 2hourly,
tepid sponging was done, excess clothing was removed, patient was served with Malt and a
prescribed Syrup Paracetamol 125mls was served.
On the same day at 9:30pm, goal was fully met as; patient and mother verbalized that the warmth
has subsided and nurse observed and recorded a normal body temperature of 36.8oC with a clinical
thermometer.
Patient Regained His Nutritional Balance Within 48hours
On the same on admission at 7:35pm, patient’s mother complained of patient having loss of
appetite therefore an objective was set for patient to regain his appetite within 48 hours with the
help of nursing intervention such as; patient and mother were reassured, measures have been put
in place for patient to regain his appetite, patient’s meal were served in bits, patient’s diet was
planned with him taking into consideration his preference. Oral care was ensured twice a day and
a mouth wash served for patient to rinse his mouth to stimulate and boost patient appetite, food
high in calories, proteins and vitamins were served to provide energy and boost the immune system
in an attractive manner and all nauseating items were taken away from the site of the patient.

32
On the 23rd March,2021 at 7:30pm goal was fully met as; patient and mother verbalized that his
appetite has been restored and nurse observed patient eat at half of meals served.
Patient Was Relieved of Pain (Headache)
On 22nd March,2021 at 7:00am patient complained of headache through the mother and
immediately an objective was set for patient to be relieved of headache within 2hours, with support
of nursing interventions such as: patient and mother were reassured that, appropriate nursing care
has been put in place for patient to be relieved of headache, patient was engaged in diversional
therapy, all nursing activities were performed at a go, patient was also put in a comfortable
position, Syrup Paracetamol 125mls was served
On the same day at 9:00am, goal was fully met as; patient and mother verbalized relief of pain and
nurse observed that patient looked cheerful and relaxed in bed.
Patient Was Able to Performed His Activities of Daily Living.
On the second day of admission (22nd March,2021) at 5:20pm, patient was noticed to be very weak
and an objective was set for patient to be able to perform his activities of daily living within
48hours by using nursing interventions such as; patient and mother were reassured of competent
nursing care, patient’s activity level was assessed by providing patient toys to play with, patient’s
mother was assisted with bathing, feeding and grooming of patient.
On the 24th March,2021 at 5:20pm, goal was fully met as; patient and mother verbalized that he is
able to perform activities of daily living without assistance and nurse observed that patient was
seen playing with other children in his cubicle.
Patient and family Gained Adequate Knowledge On Condition Management
On the 23rd March,2021at 8:15am patient’s mother verbalized that the condition was caused by
excessive intake of oil therefore a nursing diagnosis of knowledge deficit related to management
of condition was made. An objective was set to help patient’s mother gain adequate knowledge on
patient’s condition. The following nursing intervention were given; patient’s mother was reassured
of effective nursing care, rapport was established, patient’s mother was reassured of confidentiality
of patient’s information collected, patient’s mother was allowed to ask questions, patient’s mother
was politely asked to repeat what she was taught.
On 23rd March,2021 at 11:15am goal was fully met as; patient’s mother was able to answer
questions correctly on patient’s condition management, nurse observed patient’s mother practiced

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some of the teachings she was taught, that is applying mosquito repellent on patient’s skin after
evening bath.
5.2 Amendment of Nursing Care Plan for Partially Met or Unmet Outcome Criteria
With good nursing care and medical management all goals were fully met, therefore no
amendments were made.
5.3 Termination of Care
Termination of care is a gradual process which starts right from the day of admission till the day
of last home visit. It is done to enable the patient and family to understand, cope and accept that
the care would not be there forever. On 5th April,2021, I visited my patient’s home for the last time
and to terminate my care. Patient’s health or condition had remarkably improved due to good
nursing and medical management. Patient and her family did their best by cooperating and
adhering to advice and education given during admission and after discharge.
Even after discharge, home visits were made and necessary education was given during each visit.
Patient was told about the termination of care on my second home visit, which was on the 27 th
March,2021 and on the third home visit patient and family were advised to visit Chiraa health
centre whenever they are not well. I thanked them and bid them goodbye.
5.4 Summary
Master N.K.K, a 4year old child was admitted to Regional Hospital - Sunyani Paediatric Ward on
21st March,2021 under the care of Dr. A.S who diagnosed him of malaria.
Patient’s nursing problems were identified upon assessment after admission to the ward were
pyrexia (37.8oC), loss of appetite, headache, total self-care deficit and lack of knowledge on the
disease condition on the part of both the mother and family members. His condition improved
gradually and he was discharged on 24th March,2021. Care given to the patient and family at home
was beneficial. Patient and family were educated on personal and environmental hygiene and the
need to report to the hospital as early as possible when sick rather than practicing self-medication.
Patient and mother came for review on 31st March,2021 and was advised and encouraged to
continue with medication given to enhance a full recovery. Patient’s mother and family had it re-
emphasizes to them that if any member of the family experiences any ill health, they should attend
to Chiraa health centre for immediate treatment and prevention of complications.

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5.5 Conclusion
The patient/family care study truly is of great help to the student nurse in the sense that, writing
these scripts has helped me gain more knowledge on hypertension and also given me more insight
as to what holistic nursing care entails. This is because it has afforded me the opportunity to put
and apply theoretical knowledge acquired from the classroom into the clinical setting. Even though
the patient/family care study is demanding in terms of finance and time, it is a worthwhile
academic exercise; it also helps the student nurse to gain insight in nursing research.
5.6 Recommendation
The patient/family care study is good as it is about holistic approach to nursing patients. It is also
very effective and should be encouraged as the core of nursing management in all health care
facilities.

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 BIBLIOGRAPHY
Lewis, S.M and Collier, I.C (2017), Assessment and Management of Clinical Problems,

Medical-Surgical Nursing, 3rd Edition, Mosby Cooperation, Philadelphia

Magus M. (2018), Essentials of infectious disease Epidemiology, Jones and Barlett

publishers, 40 tall pine Drive, Sudbury.

Smeltzer, S.C and Bare (2018), Brunner and Suddarth’s Medical-Surgical Nursing 10th

Edition-Lippincott Williams and Wilkins, U.S.A

Weller B.F(2018). Bailliere’s Nurses’ Dictionary for Nurses, (24th Edition) London Tindall

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 APPENDIX
Vital signs for Master N.K.K during admission
Date Time Temperature Pulse Respiration
21/03/2021 7:30pm 37.8oC 148bpm 28cpm
8:30pm 37.4oC 128bpm 27cpm
10:00pm 36.7oC 106bpm 25cpm
22/03/2021 6:00am 36.4oC 101bpm 26cpm
10:00am 36.6oC 110bpm 20cpm
2:00pm 36.5oC 100bpm 28cpm
6:00pm 36.4oC 105bpm 22cpm
10:00pm 36.6oC 90bpm 27cpm
23/03/2021 6:00am 36.10C 90bpm 24cpm
10:00am 36.40C 99pbm 25cpm
2:00pm 37.00C 100pbm 22cpm
6:00pm 36.6oC 106bpm 28cpm
10:00pm 36.8oC 90bpm 24cpm
24/03/2021 6:00am 36.40C 101pbm 20cpm
10:00am 36.80C 100pbm 22cpm
1:55pm 36.10C 100pbm 28cpm

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 SIGNATORIES

NAME OF PRINCIPAL: ………………………………………………………………………...

SIGNATURE: …………………………………………………………………………………….

DATE: ………………………………………………………………….………………………….

NAME OF SUPERVISOR: …………………………………………………………………….......

SIGNATURE: ...................................................................................................................................

DATE: ……………………………………………………………………………………………

NAME OF NURSE IN-CHARGE: ………………………………………………………………

SIGNATURE: …………………………………………………………………………………….

DATE: …………………………………………………………………………………………….

NAME OF STUDENT:

SIGNATURE: …………………………………………………………………………………….

DATE: …………………………………………………………………………………………….

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