PREFACE

The family and patient care study is a detailed individualized care given to the patient
and family throughout their admission until discharge.

The patient and family care study aimed at helping student nurses to apply knowledge
and skills acquired in the disciplines of the study to care for the patient to recover fully
without any complications. It also involves interaction between patient, his or her
family, the community in which they live and the health team.

It also enables the student nurse to improve upon the ability to work effectively with a
group to provide quality care to the patient and family, taking into consideration their
social, spiritual, psychological and physical needs.

The principle of nursing process approach which comprises of the nursing

interactions, implementation and evaluation is used by the student to enable her find
solution to the problem of the patient and family. In order to achieve these goals, the
student applies theoretical knowledge to the practical experience in the nursing
practice. The patient and family care study forms part of the assessment of the final
year nurse by the Nursing and Midwifery Council of Ghana to award the license to
practice as a Registered General Nurse.

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ACKNOWLEDGEMENT

My profound gratitude and appreciation go to the Almighty God for the granting me
the enough strength, guidance, protection, wisdom and knowledge to write this care
study. I express my sincere gratitude to my patient Mrs. C.A.M. and her family for the
support, participation, cooperation and information given while conducting this study.

I am also grateful for the health team at 37 military hospital (Opoku ward) for their
assistance in making the necessary corrections and also making the care study a
success.

My deepest thanks go to the Principal, Mrs. Theresa Antwi, my supervisor tutor Mr

Baidoo, for his tremendous supervision and guidance from the beginning to the end of
the study and also to the staff of Nursing and Midwifery Training college Teshie. I also
wish to express my gratitude to the authors and publishers whose books I used to
review the literature.

Finally, I express my sincere thanks to all family and friends especially to my sisters
for their support and my friends Master Simon Fudzi and Wisdom Apolo for their
advice and support they have given me. Not to get my own boss Mr. Michael Kofi
Gyewu for his financial support and others who in diverse ways contributed to the
successful writing and presentation of my care study.

May He the Almighty God richly bless you and keep his hand of favour and protection
on you all.

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 INTRODUCTION

The patient and family care study was about 29 years old women Mrs. C.A.M who
was admitted to the Opoku Ward of 37 Military Hospital through emergency ward
with a diagnosis of peptic ulcer disease. For the sake of confidentiality, my patient will
be known as Mrs. C.A.M and do same for all names regarding patient family and
health personnel. My first interaction with my patient was on admission 12th
June,2019 as she was fully conscious on her arrival but in pain. She arrived on the
ward in a wheelchair accompanied by a nurse and her grandmother, her condition on
admission was fair. Orientation for patient was postponed due to patient’s epigastric
pain but was done the following day. Her grandmother was introduced to the ward and
I also told her about visiting time and I made patient comfortable in bed. Mrs C.A.M.
spent 8 days on the ward during which actual and potential health problems were
identified.

She was treated on anti-ulcer proton pump inhibitors, anticholinergic, sterile isotonic,
antipyretic and after several diagnostic investigations were done.

By the use of nursing care process approach, quality and effective nursing care was
rendered which led to her discharge on the18th June, 2019 since her condition at the
time was satisfactory. Three home visits were carried out; one on during the period of
admission of patient and the other two after discharge.

The script has been organised base on the steps of the nursing process and as fellow;

Chapter one (1) - consisting of relevant data obtained during the assessment of the
family.

Chapter two (2) - deals with analysis of data.

Chapter three (3) - deals with planning of patient and family care plan.

Chapter four (4) - consist of implementation of planned patient and family care plan.

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Chapter five (5) - entails the evaluation of care rendered to patient and family.

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 CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY

Assessment is a systematic way of gathering information about the patient and the
family in order to give effective and holistic care.

It gives details about the particulars, lifestyle, hobbies, developmental history of the
patient, the socio-economic status, past and present medical and surgical history of the
patient as well as the family. This chapter also discusses details about patient’s
admission, concept of his illness, literature review on the condition and concludes with
validation of data collected.

PATIENT'S PARTICULARS
Mrs. C.A.M., is a 29 year old women, born on the 5 th February, 1990 at Kadjebi
hospital in the Oti region of Ghana. She is the first born of four siblings of which all
are alive to Mr N.A and Madam B.B. She is dark in complexion, has a round head
with brown eyes and a pointed nose. She has a round mouth with white teeth, well
moulded ear and a smooth face and weighs 72kg with a height of 1.70m on admission.

She is an Ewe and speaks the languages; Ewe, Twi and English. Mrs C.A.M. had her
primary education at Victory Preparatory School at Achimota and Junior Secondary
School at Asato Roman Catholic basic School in the Oti region and completed in the
year 2005. She furthered her education at Likpe Senior Secondary School from 2005
and dropped out in 2007 and joined Women’s Vocational Training Institute and
completed in 2011. And later went to Ho Polytechnic but deferred the course in April
2015 to join the service as a Naval Soldier currently at the rank of AB-1. She is a
Christian and fellowship at Christ Sanctuary at Cantonment-Accra.

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Mrs C.A.M. got married to Mr. A. K. in 2018 and lost their first and only child
through still birth. Her husband, Mr. A. K is referred to by her as the next of kin. She
lives in Burma Camp with the husband at Harakan Quarters, Block E (Room 6). She
confirmed that she is registered with the National Health Insurance Scheme.

Ensure to include the following:

physical impairment

PATIENT’S FAMILY MEDICAL HISTORY

According to Mrs. C.A.M., hereditary conditions such as Asthma, Diabetes Mellitus,

and Epilepsy do not exist in their family with the exception of Hypertension which
both parents are having and are currently on medication. She said whenever they
experienced any minor ailment such as fever, headache and diarrhoea, they visit the
pharmacy for over the counter drugs. When symptoms persist, they report to the
hospital for treatment.

Ensure to include the following:

Ascertain risk factors for certain diseases

• Current state of health of grandparents, parents and siblings

• Deceased members of the family and cause of deaths

• Disorders in the family - Acute & chronic diseases

-hereditary diseases e.g. hypertension, diabetes, mental illness etc.

• Hospitalizations -reason for hospitalization

• Sources of medical treatments —orthodox, traditional herbal

• Any known allergies

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 • Use of over the counter drugs

PATIENT’S SOCIO –ECONOMIC HISTORY

Mrs. C.A.M. earns a living as a Soldier from her monthly salary and also from her
savings over the years. She is also being supported financially and emotionally by her
husband. She belongs to a women fellowship group in her church of which she plays
her membership role effectively. She is friendly and relates well with other members
and neighbours of the family as they usually visit.

Ensure the following:

• Family relationships/social cohesion

• Support systems

• Religious activities

• Source of medical care/financing (NHIS)

• Parents' Employment /job, occupational hazards

• Income levels and wealth of family Traditions, norms, values, taboos,

cultural practices etc.

PATIENT’S DEVELOPMENTAL HISTORY

According to Mrs C.A.M., her mother told her that she was born at gestational age of
nine (9) months through spontaneous vaginal delivery with no complication. She was
breastfed for two (2) years though not exclusively and weaned off the breast with light
foods like Koko and tom-brown before introduced to other traditional foods like
mashed yam, rice and banku. She was supported to sit by six (6) months but at ten (10)

7
months, she could sit up without support and began to crawl. At 12 and 18 months she
started standing and walking respectively. Within the same 6-18 months period, she
begun saying two or three vocabularies such as “Da-da, Ma-ma” and No and also was
able to respond to her name. She was able to imitate sounds and comprehended
meaning of simple compound words around the same time and repeated words with
knowledge of their meaning.

She said she is very sure she took all her immunization and on observation of her
right hand, there is a visible scar of Bacilli Calmette Guerin [BCG]. She started
schooling at the age of 3yrs at Victory preparatory School at Achimota. According to
Mrs. C.A.M., she remembered she had her menarche at age 13years, her pubic and
axillary hairs started growing at about 10 years of age. She was advised by her mother
to bath twice daily and shave her pubic hair often and to use lime as deodorant to
prevent body odour.

According to Eric H. Erickson psychosocial theory of development, Mrs. C.A.M. falls

under Intimacy verses Isolation (20-40yrs). This is the period in early adulthood that
focuses on developing close relationship with others as lovers, friends leading to
marriage. My patient has attained the status of intimacy since she has been able to put
aside differences and disagreement for the sake of relationship through what Erickson
calls a ‘’mutuality of devotion’’.

Ensure to include the following:

• Define development, growth and maturation.

• Cover development from childhood through the years of lifespan to current

stage (Birth, infancy, childhood, adolescent, adulthood, old age)

• Milestones from birth, -infancy, toddler, pre-school, school going age ---
describe the milestones especially if patient is a child or adolescent e.g.
sitting up, standing, walking, talking etc.

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• The childhood period of an adult should be summarized

• Physical development

• Immunizations

• Puberty - explain /comment on experiences, age at puberty, growing pubic

hairs, voice breaking for men, menarche for girls.

• Adolescent period -relationships, heterosexual, adolescent health/crisis

• Aspiration, career plans

• Marriage ]

• Divorce ] mention experiences

• Widowhood ]

• Menopause ]

• Note-Application of growth theories to describe current stage (age) e.g.

• --Erikson's Psychosocial theories (8 stages), describe success versus failure

• --Piaget/s Cognitive theories (4 stages)

• - Freud's psychosexual stages (4 stages)

• State the specific stage patient is experiencing and its characteristics to

support the stage.

• Describe patient's educational history (formal education) from pre-school,

primary, secondary, tertiary.

• Difficulties with learning, if patient is studying full time or part time-

subjects or course offering, extra curricula activities etc

• --Non formal education programmes — apprenticeship in trades/vocation

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PATIENT’S LIFESTYLE/HOBBIES

Mrs. C.A.M. is very sociable and interactive as observed on my encounter with her
which she confirms she does same with relatives, friends and neighbours. According
to her, she wakes up around 5:00am almost every day starting the day in the company
of her husband with quiet time with the Lord which lasts for 15 minutes.

After devotion, she tidies up the house and prepares breakfast, usually oat, porridge or
milo tea. She brushes her teeth with a brush and tooth paste, visits the toilet before
taking her bath using soap, sponge and with warm water, wipe her body with towel
and groom herself ready for work. Mrs. C.A.M. says she usually takes her breakfast
when she gets to work at around 7:30am since work officially commences at 8:00am.
She usually takes fufu and palm nut soup or fried yam and fish as her lunch around
12:45pm followed by milo or water melon juice as snack. She also takes rice and soup
or fruits like banana, water melon as supper latest by 6:00pm.

According to my patient, she works for 24hours and gets 48hours off duty. She
usually baths twice daily when at home and three times daily when on duty due to the
sweat the uniform generates.

She visits the gym at her leisure time and likes reading story books and novels as well.

Usually on mondays, she goes to work at 7:30am and closes the next day due to her 24
hours shift.

On getting home, she takes her bath and gets some food to eat or some fruits to take.
After taking her meals she relaxes in her sofa to either watch movies or listen to news,
then she goes back to sleep

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According to my patient, when she at home on Tuesdays, she goes to the market to
buy food stuffs and store them in the fridge. she prepares food and keep in the fridge.

She then takes her bath and relax her body. At 5:30pm, she goes for Women’s
fellowship meeting and closes at 8:30pm. When she gets home, she takes her bath and
go to bed.

On Wednesday, when she gets up in the morning, she brushes her teeth and perform
her routine chores. After which she takes her bath and then some porridge to take. At
1:00pm, she goes to visit a friend in the barracks and normally come home at 3:00pm.
At 4:00pm she watches television or read some books. At 6:00pm, she usually listens
to news at Adom TV, which ends at 7:00pm. She then takes her bath and goes to bed.

Thursday when at home, after her daily routine, she goes to the gym at 6:30am and
usually closes at 7:30am, of which she comes home to take her bath, eat and the relax.

Friday is a busy day for her, after her morning chores, she washes cloths. She
normally finishes 10:00am to 11:00am of which she goes to take her bath and find
some food to take. At 6:00pm, she usually discusses family issues with the husband if
at home, after which they listen to news and later goes to take her bath and then sleep.

On Saturdays, after her routine morning chores, she takes her bath and then go to the
gym at 6:30 and close at 7:30am and then come to take her bath and take her
breakfast. She then relaxes for about 3 hour and then prepare some food to replace the
one in the fridge. Around 5:00pm, she normally does some general cleaning in her
room to put things in order. At 6:30pm, she goes to take her bath and eat after which
she listens to news.

On Sundays, my patient usually wakes up at 4:00am, brushes her teeth and then goes
about doing her routine chores for the morning. Because church normally begins at
6:30am, according to my patient she takes her bath at around 5:00 – 5:30am and then

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groom herself. By 5:30am to 6:00am, she gets ready for church. She takes taxi at her
junction to the church, church usually close at 9:30am.

At home, she gets some food to eat and then relax, at 1:00pm, she takes her bible to go
through everything the pastor preached about and after which she prepares her item for
work the next day.

Ensure to include the following:

• Activities of daily living

• Mouth care/oral hygiene, Personal hygiene

• Routines during weekdays school, Work Special assignments

• Routines during weekends — Saturdays and Sundays- -

religious/social/political

• Difficulties experienced in eating, grooming, dressing, and walking

• Personal Habits —use of tobacco, alcohol, coffee, illicit drugs and

recreational drugs

• Elimination-- bowel and bladder Patients Lifestyles/Hobbies

• Activities of daily living

• Mouth care/oral hygiene, Personal hygiene

• Routines during weekdays school, Work Special assignments

• Routines during weekends — Saturdays and Sundays- -

religious/social/political

• Difficulties experienced in eating, grooming, dressing, and walking

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• Personal Habits —use of tobacco, alcohol, coffee, illicit drugs and
recreational drugs

• Elimination-- bowel and bladder Patients Lifestyles/Hobbies

• Diet—typical diet/special diet, number of meals per day, snacks, who does
cooking, buying food

• Sleep/ rest patterns —usual daily sleep/wake times, difficulty in sleeping,

remedies used for insomnia, bed time rituals

• Instrumental activities of daily living — difficulties experienced in food

preparation, shopping, transportation, housekeeping etc

• Allergies — food,/drugs, ethnic food patterns

• Recreations — specific sport

• Hobbies- reading, what type of materials

• Exercise, activity and tolerance

• Other interests/sight seeing

• Vacations— how it is spent, where

• Social activities weddings, funerals, church, community picnics, excursions,

visit to places of interest

• Psychological data, emotions/Personal characteristics

• Major stressors experienced and patients perception

• Usual coping patterns and stressors

• Communication style, ability to verbalize appropriate emotions, verbal

expression

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 • Non verbal communication — eye movements, gestures etc. to speak to
children to desist from doing certain things

• Interaction with support persons

• Virtues and vices, Introvert/ Extrovert ,Caring, Hardhearted,

Philanthropist, Kind etc.

• Likes and Dislikes

• Sociable or individualistic —Family roles

• Interest caring for grandchildren other family members etc

• Pre Occupational activities- role as a father, mother, brother, sister, head

of family

• Other responsibilities as worker, church member, social groups,

development activities

• Personal impressions of patient

PATIENT’S PAST MEDICAL AND SURGICAL HISTORY

Mrs. C.A.M. made me aware that she has been admitted to the ward on countless
number of times. She suffered right shoulder joint dislocation and chicken pox at her
early childhood of which both were treated at Kadjebi hospital. At age 20, she felt
lump in both breasts so she reported to the 37 Military Hospitals. She was diagnosed
of Fibroadenoma. A surgical operation (excisional biopsy) was carried out on the left
and right breast in the year 2010 and 2012 respectively to remove the non-cancerous
tumour.

In the year 2017, she was admitted at Tema General Hospital and later referred to the
37 Military Hospitals for further management of Pneumonia. She spent 7days on

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admission but she can’t recall the medications she was managed on. Her last
admission before this current one was in February 2019 on the account of Peptic Ulcer
Disease and managed on triple therapy. Since then she has been coming for frequent
reviews at the 37 polyclinic till her recent admission. She is only experience itchy
sensation whenever she’s given pethidine.

Ensure the following:

• Childhood illness e.g. measles, whopping etc.

• Allergies to drugs, animals, insects etc. and how' reaction is treated

• Accidents and injuries, how and when, type of injury and treatment
received.

• Hospitalization for serious illness, reasons for hospitalization surgery,

course of recovery, complications

• Physical disability due to illness

• Medications — currently used drugs, over the counter drugs (OTC) e.g.
vitamins, laxatives, aspirin etc

• Resources of health care used — specialists — gynecologist -

Ophthalmologist- Dentist, Folk practitioners.

• General hospitals/clinics- access to health care whether easy or difficult.

• Application of health information regenerative health, personal and

environmental hygiene.

• Medical check ups

OBSTETRIC HISTORY

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Ensure the following:

• History of pregnancies- abortions complications

• Deliveries/births- spontaneous, vacuum, caesarean, complications,

puerperium

• Number of children- alive, dead

• Menstrual history„ menarche, menstrual flow menopause

• Contraceptive history

PATIENT’S PRESENT MEDICAL HISTORY

Mrs. C.A.M, a known peptic ulcer disease patient was doing well until 10 th June, 2019
at 11:00am, when she started experiencing epigastric and chest pain 3 hours after
eating jollof rice and chicken. The pain gradually worsened throughout the day. She
reported to the medical emergency unit of the 37 Military Hospitals in company of her
grandmother at about 8:00pm. She was seen and examined by Dr. M. K. W. and
diagnosed Peptic Ulcer Disease. Diagnostic Investigations such as full blood count,
BUE and creatinine and Liver Functioning Test was requested. She was detained and
managed on intravenous Buscopan 40mg stat, intravenous Dextrose Normal saline
1.5L, Intravenous Esomeprazole 40mg stat.

Ensure to include the following:

• Chief complaint or reason for visit to the hospital

• History of present illness

• - When signs and symptoms started

• -Onset whether sudden or gradual

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 • - How often problem occurs - Location of distress/pain, character of pain
e.g. intensity, quality of sputum, emesis, discharges Activities which
aggravates/alleviate problem

• Symptoms associated with chief complaint

ADMISSION OF PATIENT

Patient was admitted to the Opoku ward of 37 Military Hospital on the 12 th June, 2019
at 5:30pm by team A led by Dr. M. K. W. with the diagnosis of Peptic Ulcer Disease.
She was brought to the ward in a wheel chair in a fully conscious state accompanied
by a Nurse from the Medical Emergency Unit and her relatives with intravenous
dextrose Normal Saline 450mls in-situ.

They were welcomed to the nurses’ station and her identity was confirmed by
mentioning her name after the folder was collected from the accompanying nurse. A
quick assessment was made and patient complaints of epigastric pain. The relatives
were given a sit at the awaiting area whiles patient is put into already laid simple
unoccupied bed. Orientation was postponed due to her painful abdominal state. But
nearby patients were introduced to her. The intravenous infusion was hanged and
regulated to drip at 35 drops per minutes.

Patient particulars were recorded in the daily ward state and admission and discharge
book on admission. Vital signs were checked and recorded as follows;

Temperature - 37.0 degree Celsius (°C)

Pulse - 88 beats per minute

Respiration - 18 breathe per minute

Blood pressure - 110/70mmHg.

Oxygen saturation – 99%

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‘Rapid Blood Sugar – 5.9 mmol/L

The following treatments were prescribed on admission;

1. Injection Esomeprazole 40mg daily x 4/7

2. Tablet Buscopan 20mg three times daily x 5/7
3. Intravenous Dextrose Normal Saline 500mls 6hourly x 4/7
4. Syrup Maalox 10mls 8 hourly x 1/12

Mrs. C.A.M. and her relatives were reassured that she would soon recover and will
surely be discharge once the condition stabilises. They were informed about the
visiting hours which are 5:30 to 7:30am and 3:30pm to 5:30pm each day. The relatives
were asked to bring along some basic items such as the toiletries that Mrs. C.A.M
would use during her period of hospitalization and will be fed with breakfast, lunch
and supper.

The following investigations was requested and done;

1. Full Blood Count

2. Blood Urea Electrolyte and Creatinine

3. Liver Functioning Test

I establish rapport with them and assured them of the good treatment and care will be
given by the competent nurses, doctors and other members of the health team. Later
introduced myself as final year student of Nursing and midwifery Training College,
Teshie and asked the permission to use Mrs. C.A.M, for my patient and family care
study which is part of the school’s curriculum. We had a conversation and were in my
interest to study more into the condition, provide care effectively and efficiently. I
assured them of the confidentiality of all information collected from them and also
explained what the patient family care study entails and the role she and her family
would play which they readily agreed. I explained to them that the care will be

18
terminated some weeks after discharge. They assured me of their maximum co-
operation.

Ensure to include the following:

• Describe admission procedure

• -Date and time, reception of patient and relative

• -Ambulance/trolley/wheelchair patient, accompanying staff/relations

• - Planned/emergency admission

• Introduction of self/staff/patient/relatives

• Type of bed prepared

• Recording information — Admission papers, nurses notes , daily ward

state, chances book, admission and discharge book, rounds book etc.

• Vital signs- checking and recording

• Introduction to other patients,

• Orientation to ward and annexes

• Condition oi patient on admission

• Initial assessment- physical examination - nursing observations

• Drug treatment/other treatments

• Investigation/ tests

• Nursing care provided immediate (brief)

• Family participation in care

• Nutritional assessment

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 • Discharge planning

• Include a statement of reason or how you decided to select the patient for
the care study, reasons, how you communicated with the patient and
patient/family response.

PATIENT’S CONCEPT ABOUT ILLNESS

Upon interaction with Mrs. C.A.M, she said her condition has no spiritual backing but
she does not just understand why for some time now she had persistently suffered this
kind of illness. She believes now that she is in the hands of competent Doctors and
Nurses and that her health will be restored. She was ready to comply with any medical
instruction in order to have her health.

LITERATURE REVIEW ON PEPTIC ULCER DISEASE

INTRODUCTION

Literature review offers detailed guidance on how to develop, organize and write
research paper in the social and behavioural sciences.

This includes; definition, incidence, causes, types, pathophysiology, clinical

manifestations, risk factors, diagnostic investigations, management aims, medical
management, pharmacological therapy, surgical management, nursing management,
observation, prevention, patient education and complications.

DEFINITION

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Peptic ulcer is an excavation (hollow-out area that forms in the mucosal wall of the
stomach), and or in the duodenum (First part of the small intestine or in the
oesophagus), (Hinkle & Cheever 2014)

Peptic ulcer is the erosion of the gastrointestinal mucosa. The most frequent sites of
the ulcer are the stomach (Gastric ulcer) and the proximal portion of the duodenum
(duodenal ulcer) but the oesophagus or jejunum or any other part of the
gastrointestinal mucosa can be affected. (Weller, 2014)

INCIDENCE

The incidence of peptic ulcer occurs in approximately 10% of the population. It occurs
about equally in males and females. It occurs with the greatest frequency in people
between the ages of 40 and 60 years. Its relatively uncommon in women of child
bearing age, but it has been observed in children and even infants. Gastric ulcers
commonly strike people with blood group A. Duodenal ulcers occur with greater
frequency than the other types of peptic ulcer. Its incidence is greater in males than in
females. It tends to develop in people with blood group O. It’s incidence with family
history is positive but cancer risk is minimal. After menopause the incidence of peptic
ulcer in women is almost equal to that in men. (Hinkle & Cheever 2014).

CAUSES/ ETIOLOGY

The causes found by researchers are;

1. Infection with Helicobacter pylori (formerly Campylobacter pylori): It secrets

toxins that cause persistent inflammation. It is gram negative bacteria.
2. Injury: such as those produced by extensive burns may develop severe peptic
ulceration. Pancreatitis, hepatic disease and zollinger-ellison syndrome. In

21
 zollinger-ellison syndrome, gastronomas stimulate gastric acid secretion which
erode the gastric mucosa and contributes to the development of an ulcer.
3. Heredity: Genetic factors have a role, since studies on incidence show there is a
tendency for peptic ulcer to occur in families and in persons of certain blood
types. There is correlation between duodenal ulcer and blood type O while gastric
ulcer patients are more often of the blood group A, B, or AB.
4. Certain medications: (ulcerogenic drugs): Salicylates such as Bismuth
salicylates, Non-steroidal anti-inflammatory drugs (NSAID’s). Reserpine or
caffeine, nicotine may erode the mucosa lining. NSAID’s can cause a gastric ulcer
by inhibiting prostaglandins.
5. Emotional factors: Emotional tension, anxiety, frustration and stress may cause
an imbalance in the autonomic nervous system, resulting in increased vagal
stimulation of gastric secretion. (Hinkle & Cheever 2014)
6. Histamine promotes stimulation of acid secretion, Histamine 2-receptor
antagonist which inhibits histamine action has been found in gastric parietal cells.
7. Aging: The pyloric sphincter may wear down in the course of normal aging which
in turn permit the reflux of bile into the stomach. This appears to be a common
contributor to the development of gastric ulcers in the elderly persons.
8. Smoking and excessive amount of alcohol or coffee increase risk of gastric
ulcer.

TYPES OF PEPTIC ULCER

1. Gastric ulcer
2. Duodenal ulcer
3. Stress ulcer

Gastric ulcer is an ulceration in the mucosal lining of the stomach by gastric secretions

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Duodenal ulcer is the erosion of the mucosa lining of the duodenum by gastric
secretions.

Stress ulcer is an ulcer which occur after major stress or trauma

PATHOPHYSIOLOGY OF PEPTIC ULCER

The presence of food in the stomach results in the release of HCl from the parietal
cells of the stomach. The mechanism for HCl release is multiple and for the most part,
interrelated. Stimulation of acid secretion includes the vagus nerve which releases
acetycholine which then stimulates the parietal cells to secrete HCl.

Central nervous system control over acid secretion is mediated by the vagus nerve.
The antral hormone gastrin, which is released in response to food in the stomach,
stimulates the release of HCl. The release of HCl is also stimulated by histamine
which is present in the gastric mucosa. When acid is secreted and the gastric pH drops
to 2 or 3, the conversion of pepsinogen (inactive forms of enzymes secreted by the
gastric chief cells) to pepsin is facilitated. Under normal circumstances, the gastric
mucosa is protected from auto digestion by pepsin and HCl because of the presence of
gastric mucosal barrier.

The anatomical components of this barrier is composed of the following protective

element;

1. The mucus secreted by cells lining the stomach.

2. Tight junctions between the epithelial cells which prevent the back diffusion of
HCl.

23
3. The regenerative ability of the epithelial cells which permits rapid recovery from
mucosal injury is a contributing factor to the barrier. The mucus absorbs pepsin
and protects the underlying tissue from autodigestion by HCl.

Alteration or damage to the mucosal barrier by factors such as infection by

Helicobacter pylori, long time use of Non-steroidal anti-inflammatory drugs
(NSAIDs) such as Ibrufen, and any condition that leads to hyper secretion of HCl e.g.
Zollinger-Ellison Syndrome causes diffusion of HCl which erode the mucosal lining,
underlying tissues and blood vessels.

The damage triggers the inflammatory response setting a destructive process in

motion. Histamine is released, stimulating the gastrointestinal tract to secrete more
pepsin and HCl. Histamine also increase capillary permeability, so proteins and fluids
leaks out. As a result, mucosa becomes oedematous and mucosal capillaries start to
bleed.

SIGNS AND SYMPTOMS

1. Haemorrhage

2. Decreased body weight

3. Aching epigastric pain which frequently radiates to the back sternum or lower
abdomen. May be left upper epigastrium(gastric) or right epigastrium (duodenum)

4. Nausea and vomiting (may be perceived as uncomfortable fullness or hunger)

5. Nocturnal epigastric pain occurring 1-2 hours after going to bed

6. Repeated episodes of gastro intestinal bleeding

7. Feeling of fullness and distension after eating

8. Eating triggers and aggravates the pain

24
9. Gastric ulcer disease produces loss of gastric epithelial cells and thus reduces acid
secretion or achlorhydria which may also produce anaemia due to decreased intrinsic
factor and decreased absorption of vitamin B12 in the small intestine.

10.Bloody emesis (hematemesis)

11.Tas stool or melena

DIAGNOSTIC INVESTIGATIONS/ TESTS

PHYSICAL EXAMINATION

A physical examination may reveal pain, epigastric tenderness, or abdominal

distention

HISTORY TAKING

LABORATORY INVESTIGATIVE TESTS

1. Full blood count (FBC) with decreased haematocrit and haemoglobin values may
indicate bleeding.
2. Cytologic studies and biopsy to rule out Helicobacter pylori or cancer.
3. A fasting gastric level to determine and rule out Zollinger-Ellison syndrome
because these patients have high level of the hormone secreted by the pancreas.
4. Serology test may disclose clinical signs / manifestations such as increased WBC
count. Serology also documents the presence of H-pylori based on antibody
assays.
5. Occult blood test (stools may be tested until they are negative for the presence of
occult blood).

25
IMAGING

1. Upper Gastrointestinal Endoscopy or Oesophagogastroduodenoscopy to

confirm the size and depth of the ulcer. The oesophagogastroduodenoscopy is
the definitive diagnosis of peptic ulcer and may be repeated to evaluate the
effectives of the treatment. Gastric samples are collected to test for H-pylori.

MANAGEMENT

The aim of management for peptic ulcer is to

1. Decrease the amount of gastric acidity

2. Enhance mucosal defence mechanism

3. To relieve pain

4. Optimize the conditions that promote ulcer healing

MEDICAL MANAGEMENT

Medications are vital part of therapy. They are given to fight causative organism that
is the helicobacter pylori, to reduce gastric secretions, alleviation pain and to protect
the mucosa of the stomach. The client must be informed on each drug prescribed, why
it is ordered and the benefits. Strict adherence to the prescribed regimen is mandatory.
Medications for peptic ulcer disease fall into three categories;

1. Acid-Neutralizers Example Antacids: These neutralize gastric acid (HCl)

which will then promote healing and prevent tissue breakdown and inhibits the

26
 conversion of pepsinogen to pepsin. Examples include; Calcium carbonate
(Alka-2) 350mg to 1500mg per os and at bed time, as needed, Magnesium
hydroxide 140mg per os with water or milk after meals, Aluminium hydroxide.
(500mg to 1500mg per os three to six times daily between meals and at
bedtime.
2. Anti-secretory agents’ example Histamine (H2) receptor antagonists and
anticholinergics: decrease amount of HCl produced by parietal cells in the
stomach by blocking the H2-receptors. Examples; Cimetidine (Tagament)
400mg bd or 800mg at bedtime, Ranitidne (Zantac) 150mg bd or 300mg at
bedtime, Famotidine 20mg bd or 40mg at bedtime. Proton Pump Inhibitors of
Gastric Acid (PPls) Examples; Omeprazole 20mg daily, Lansoprazole 30mg
daily, Esomeprazole 40mg daily.
3. Cytoprotective agents: They are substances that help protect the tissue that line
the stomach mucosa. Example Misoprostol (cytotec) 200mg twice daily.
4. Antibiotics are also given in conjunction with other drugs;
A. Tetracycline (plus metronidazole, proton pump inhibitors and Bismuth salts).
B. Amoxycillne (plus Clarithromycin and proton inhibitors such as prilpseel).
Clarithromycin (Biaxin); used with proton pump inhibitors and amoxycillin.
metronidazole (Flagyl), amoxicillin (Amoxil), Clarithromycin (Biazin), and
tetracycline (Achromycin V).

SURGICAL TREATMENT

In spite of medical treatment, many persons with peptic ulcer experience

complications that require surgical interventions. The aims of surgery are removal of
ulcerated tissue and reduction of the secretion of HCl acid. Surgery is indicated when
medical management does not result in symptom relief.

Indications for surgical Treatment

27
1. Intractability: failure of the ulcer to heal and or recurrence of the ulcer following
medical therapy.

2. Previous history of haemorrhage or increased risk of bleeding during medical

treatment.

3. Multiple ulcer sites.

4. Possible existence of a malignant ulcer

The most common types of surgical interventions are gastrectomy, vagotomy and
pyloroplasty.

1. Antrectomy; This is the removal of the lower part of the stomach (antrum)
which produces a hormone that stimulates the stomach to secrete digestive
juices. Sometimes a surgeon may remove an adjacent part of the stomach that
secretes pepsin and acids.
2. Vagotomy: This procedure involves cutting part of the vagus nerve (a nerve
that transmit messages from the brain to the stomach) to interrupt messages sent
through it therefore reducing aid secretion. The types of vagotomy are truncal,
selective and parietal.

a. Selective Vagotomy – This vagotomy transects only the branches of the

vagus which supplies the stomach, preserving the vagal innervations of the
other abdominal viscera.

b. Parietal vagotomy – This denervates only the acid-secreting portion of the

stomach, sparing the branches of the vagus which innervates the antrum.

c. Tuncal vagotomy – With this, only the vagal trunks are transected.

3. Pyloroplasty: Is the reopening of the pylorus and it is performed to enhance gastric

emptying. Vagotomy with pyloroplasty is the procedure of choice for elderly patient
and for individuals who are considered as poor surgical risks.

28
SPECIFIC NURSING MANAGEMENT

Rest and Sleep

1. Ensure adequate rest to retain and sleep to regain and restore energy of patient

2. Provide a quiet and comfortable environment to decrease anxiety.

3. Provide dim light and ensure room is well ventilated to enhance sleep

4. Straighten patient’s bed linen to prevent creases

5. The elimination of stressors will help to decrease the stimulus for over production
of gastric secretions

Observation

1. Check and record patient’s temperature, pulse, respiration and blood pressure 4
hourly to know if there is any change in patient’s condition

2. Check patient’s weight daily to monitor the weight loss of the patient since weight
loss is one of the signs and symptoms of peptic ulcer disease(gastric)

3. Observe patient for the therapeutic and of side effect of drugs administered.

4. Monitor stool for presence of occult blood (tar stool) to know if there is any internal
bleeding.

5. Monitor albumin and haemoglobin levels.

6. Send all specimens to the laboratory for prompt investigations.

Diet

29
1. Patient is encouraged to eat any food but should avoid foods that result in pain or
discomfort to her.

2. Food acts as a buffer for gastric secretions, so client is encouraged to eat on regular
schedules and take snacks in between meals so that motility is decreased and gastric
acid is neutralized

3.Foods known to irritate the gastric mucosa such as hot, spicy foods and pepper,
alcohol, carbonated beverages, tea, coffee and broth extracted meat should be avoided.

4. Foods high in roughage such as raw fruit, salads, and vegetables may irritate an
inflamed mucosa but if well chewed can be a less problem.

5. Give milk which cannot only neutralize gastric acidity but contains prostaglandins
and growth factors both of which are known to protect the gastrointestinal mucosa
from injury.

6. Teach patient the importance of the diet restrictions.

7. Plan diet with a dietician and the patient considering his favourite meals.

8. Encourage clients to take more fluids at least 2-3 litres of water daily

9. Serve easily digestible foods e.g. agidi and light soup

10. Tell patient to avoid smoking and alcohol.

Medication

1. Serve prescribed drugs and monitors their effect.

2. Stress the importance of continuing medication for the specified period of time.
3. Inform patient about the side effects of medication and advise them to look for
them and report if any.
4. Discourage use of over-the-counter drugs without physician’s consultation.

30
5. Instruct patient to avoid antacids that induce diarrhoea.

Personal Hygiene

1. Assist patient to have his bath twice daily when necessary.

2. Provide meticulous skin care to avoid any trauma that can be a site for infection.

3. Ensure mouth care twice daily.

4. Care for patient’s hair, hands and feet.

PREVENTION

1. Individuals belonging to blood group type A and O should adapt to good lifestyles,
such as avoiding stress, good dieting in order not to be predisposed to the
condition.
2. High intake of spicy and hard fried foods should be avoided as much as possible.
3. A regular eating pattern should be established and abnormal long period between
meals should be discouraged.
4. Smoking and alcohol consumption should be avoided
5. Intake of ulcergeronic drugs such as non-steroidal anti-inflammatory drugs and
corticosteroids should be avoided.

PATIENT EDUCATION

1. Advice patient not to eat too hot or too cold food since this irritates the mucosal
lining of the gastrointestinal tract.

31
2. Advice patient to avoid eating spicy and hard fried foods because this increases the
acidic content of the stomach.

3. Educate patient to reduce or stop smoking or the intake of alcohol.

4. Advice patient to stop intake of gaseous or carbonated drinks and intake of milk
(fruit juice, sweeten fruit, milk shakes, honey, syrup, jelly).

5. Educate patient to stop eating acidic fruits such as orange, apple, pineapple as this
also increases the acidity of the stomach. Foods in bits but at frequent intervals rather
than large meals at a time.

6. Educate patient to adopt good eating habit.

7. Educate patient to consume foods in bits but at frequent intervals rather than large
meals at a time.

COMPLICATIONS

1. Intractability: When ulcer symptoms are not well resolved with medication, the
symptoms are termed intractable. It is the most common complication of peptic ulcer.
It has a significant impact on a person’s lifestyle and is the most common reason for
gastric surgery.

2. Haemorrhage: Ulceration leading to erosion of blood vessels occurs in 25% of

patients. The common site of haemorrhage is the posterior aspect of duodenal bulb. It
is manifested by haematemesis and melaena.

3. Perforation: When the ulcer erodes the entire thickness of the gastric or duodenal
mucosa and muscular wall, perforation may extend into the peritoneum resulting in
peritonitis.

32
4. Stenosis/Obstruction: Stenoisis is due to inflammation, oedema, scarring and
pylorospasm. Depending upon the degree of inflammation or scar tissue, complete
obstruction of pylorus or intestine may occur. Severe obstruction results in vomiting
which may be projectile and fowl-smelling due to prolonged stasis of stomach content.

5. Malignancy: Some gastric ulcers may undergo malignant changes. Duodenal ulcers
rarely become malignant.

Ensure to include the following:

Anatomical review if the stomach and the duodenum.

• Include Nursing Management —specific and general

VALIDATION OF DATA

This is the act of confirming or verifying data to keep the data free from errors and
misinterpretation. With regards to the information collected from Mrs. C.A.M, and his
family, diagnostic investigations, signs and symptoms exhibited compared to the
literature review confirms the validity of data. For this reason, it is clear that the data
collected is valid and free from bias.

Ensure to include the following:

• Include a statement of how validation was done e.g. during home visits,
questioning members to confirm patient's responses

• Reassess patient when severe symptoms abate, when family members calm
down and are less anxious.

33
 • Laboratory tests

CHAPTER TWO

ANALYSIS OF DATA

This is the second stage of the Nursing Process. It involves identification of patient's
actual and potential problems with regards to the data gathered to formulate nursing
diagnosis. It compares the data with standard which consist of diagnostic
investigations, causes of patient's illness, clinical features, treatment ordered and
complications. It also covers patient/family strength, health problems and nursing
diagnosis.

Comparison of Data with Standards

In comparison of data, diagnostic investigations, causes, clinical features presented by

the patient, pharmacology of drugs given to patient and complications are compared
with standards in acknowledged textbook and other sources of information.
34
Diagnostic Investigations/ Tests

With reference to the diagnostic investigations under literature review, the following
investigations were requested and done;

1. Full Blood Count

a. Haemoglobin level
b. White Blood Cell (total count)
2. Blood Urea Electrolyte and Creatinine (BUE & Cr)
3. Liver Functioning Test
4. Computerized Tonography of Abdomen
5. Endoscopy

35
 Table 1 : Diagnostic investigation/ Test

Date Specimen Investigation Result Normal Values Interpretation Remarks

11/06/201 Blood a. White blood cell 4.39 2.5- 10.0 x Is within normal range No treatment
9 count. x10^3/uL 10^3/uL indicating no infection ordered.
in the blood.
11/06/201 Blood b. Haemoglobin 12.9g/dL Males:13.0- Is within normal No treatment
9 Level Estimation 18.0g/dL indicating patient is not ordered.
Females 12.0- aneamic
16.0g/dL
11/06/201 Blood c. Platelet count 228x10^3/uL 150- 400 Platelet count was No treatment
9 x10^3/uL within normal range. ordered.

36
 CONTINUATION OF TABLE ONE: Diagnostic Investigation/Test

Date Specimen Investigations Results Normal Interpretations Remarks

Values
11/06/19 Blood Blood Urea
Electrolyte and
Creatinine:
- Sodium 145mmol/L 135-150 Value is within No treatment
mmol/L normal range. ordered.
- Chloride 108mmol/L Value is within
95-110mmol/L normal range. No treatment wa
-Potassium 4.0mmol/L Value is within to the patient
3.5-5.2mmol/L normal range. No treatment wa
-Urea 1.5mmol/L Value is below to the patient.
2.8-7.2mmol/L normal range No treatment
-Creatinine 61mmol/L Creatinine level is ordered.
62-106mmol/L slightly below
normal. No treatment
37
 ordered.
CONTINUATION OF TABLE ONE: Diagnostic Investigation/Test

Date Specimen Investigations Results Normal Interpretations Remarks

Values
11/06/19 Blood Liver Function
Test 34U/L 3-40U/L All values were No treatment
-SGOT(AST) 29U/l 10-36U/l within except for ordered.
SGPT(ALT) 110U/l 35-105U/l Alkaline Phosphate
Alkaline 24U/l < 38 U/l (high) which may
Phosphate 5.7umol/l 1.7-21umol/l indicate mild liver
GGT 3.67umol/l 0-5.27umol/l disease.
Total 2.17umol/l 0-19umol/l
Bilirubin(SI)
Direct Bilirubin 73g/l 66-88g/l
Unconjugated 46g/l 35-52g/l
Bilirubin 27g/l 25-45g/l
Total Protein (SI)
38
 Albumin (SI)
Globulin

Table 1: Diagnostic investigation/ Test

Date Specimen Investigation Result Normal Values Interpretation Remarks

12/06/201 Abdomen Abdominal CT Show Normal Result indicate mild No treatment

9 Scan increased in abdominal organ hepatomegaly ordered but
size of liver, sizes with no patient was infor
all other masses, lesions, about the result.
organs are excessive
normal dilation or
constriction
18/06/201 Upper Endoscopy Ulceration of Helicobacter Result indicate the Patient was put
9 gastro the mucosa pylori should be presence of peptic ulcer nexium 40mg d
intestinal is seen. negative and the disease and
tract Helicobacter mucosa lining Maalox 10mls t

39
pylori was should be intact. times daily
positive.

40
Causes of Patient’s Condition

With reference to the causes of peptic ulcer disease in the literature

review Mrs. C.A.M.’s condition was caused by helicobacter pylori
(H. pylori) and her bad eating habit.

Table Two: Comparison of Clinical Features in Literature

Review with That Exhibited By Mrs. C.A.M

Review

Clinical Features Under Clinical Features Exhibited

Literature Review By Mrs. C.A.M

1. Pain occurring in the 1. Patient presented with

epigastric region. epigastric pain.

2. Pain increases when the 2. Patient did present with

stomach is empty, epigastric pains when the
approximately two hours stomach is empty.
after eating.

3. Pain is relieved after 3. Patient’s pain was subsides

ingesting food or antacid after eating and taking
antacids

4. Weight loss 4. Patient experienced weight

loss from 74kg to 70kg

5. Reflex vomiting 5. Patient did not vomit.

6. Gastrointestinal bleeding 6. Patient did not present

evidenced by blood found blood in stool
in stools.

7. Pyrosis 7. Patient did present Pyrosis.

41
 8. Constipation or diarrhoea 8. Patient had no diarrhoea.

9. Headache 9. Patient had headache.

10.Dizziness 10.Patient experienced

dizziness.

11.Palpitation 11.Patient had palpitation.

12.Fatigue 12.Patient was fatigued.

13.Haematemesis 13.Patient did not experience

haematemesis.

14.Anorexia 14.Patient did not complain

anorexia.

15.Fever 15.Patient did experience

pyrexia.

Medical Treatment Prescribed and Given to Mrs. C.A.M.

With reference to the treatment of peptic ulcer disease, the following

drugs were prescribed and administered to Mrs. C.A.M.,

1. Injection esomeprazole 40mg stat

2. Injection Hyoscine Butylbromide 40mg stat
3. Intravenous normal saline 500mls 6hourly
4. Intravenous dextrose normal saline 500mls 6hourly
5. Intravenous esomeprazole 40mg daily x 48 hours
6. Tablet Hyoscine Butylbromide 20mg three times daily x 48
hours
7. Tablet nexium 40mg daily x 14/7
42
8. Tablet paracetamol 1g three time daily x 5days
9. Syrup Aluminum-Magnesium Hydroxide 10mls x 14/7

43
 Table Three: Pharmacology of Drugs Given To Mrs. AB-1 C.A.M

Date Drugs Dosage/Route Classification Desired Effect Actual Effect Side Effect/Remar
Of Observed
Administration
12/06/19 Injection 40mg stat Antiulcer Suppresses gastric Patient was Tinnitus, he
Nexium intramuscularly proton pump secretions by inhibiting relieved of dizziness. None obs
inhibitor hydrogen. or potassium gastric
AT Phase enzyme discomfort
system in the gastric
parietal cells

12/06/19 Injection 40mg stat Anticholinergic To relax the smooth Patient says she Headache, difficu
hyoscine intramuscularly muscle in the does not feel any swallowing was
butylbromid gastrointestinal tract. epigastric pain. observed.
e
12/06/19 Normal 3liters Isotonic To increase patient’s Patient was Swelling of hands a
Saline Intravenously for solution fluid and electrolyte hydrated with confusion, Breathl
48 hours containing epigastric pain increase heart rate
44
 sodium level. subsiding. was observed.
chloride.

Table Three: Pharmacology of Drugs Given To Mrs. AB-1 C.A.M

Date Drugs Dosage/Route Classification Desired Effect Actual Effect Side Effect/Remar
Of Observed
Administration
12/06/19 Intravenous 500mls 6 hourly Isotonic To maintain fluid, Patient is Confusion and sl
Dextrose intravenously. Solution with glucose and electrolyte hydrated and were not observed.
saline glucose balance. feels relaxed in
bed.
12/06/19 Intravenous 80mg daily x 48 Antiulcer Suppresses gastric Patient was Tinnitus, he
esomeprazol hours proton pump secretions by inhibiting relieved of dizziness. None obs
e intravenously. inhibitor hydrogen. or potassium gastric
AT Phase enzyme discomfort
system in the gastric

45
 parietal cells

14/06/19 Tablet 20mg 8hourly x Anticholinergic To relax the smooth Patient says she Headache, difficu
hyoscine 48hours orally. muscle in the does not feel any swallowing was
butylbromid gastrointestinal tract. epigastric pain. observed.
e

Table Three: Pharmacology of Drugs Given To Mrs. C.A.M

Date Drugs Dosage/Route Classification Desired Effect Actual Effect Side Effect/Remar
Of Observed
Administration
14/06/19 Tablet 40mg daily x Antiulcer Suppresses gastric Patient was Tinnitus, he
46
 esomeprazol 14/7 orally. proton pump secretions by inhibiting relieved of dizziness. None obs
e inhibitor hydrogen. or potassium gastric
AT Phase enzyme discomfort
system in the gastric
parietal cells

16/06/19 Tablet 1gram three Antipyretic and It produces analgesic Pain subsided Rash, urticarial, c
times daily x analgesics effect by inhibiting renal failure and
Paracetamol
5days orally prostaglandins and collapse, hypogly
other substances that None was observed
sensitize pain receptors.

16/06/19 Syrup 10mls three Antacid To treat symptoms of Patients was Nausea, cons
Aluminum- times daily x too much stomach acid relieve of diarrhea or headach
Magnesium 14/7 orally such as hard burns and stomach upset was observed.
Hydroxide acid indigestion. Also and heartburns.
relieve symptoms of
extra gas such as
belching, bloating and
47
 filling of discomfort in
the stomach/ gut.

48
Complication

With reference to the literature, Mrs. C.A.M did not develop any of the
complications during her admission and after discharge, due to good nursing
and medical care rendered to her.

Ensure to include the following:

Statement of comparism as seen in the sample I gave you.

Patient and Family Strengths

Patient’s strength is the resources and abilities that help her to

recover quickly or cope with the condition. These include
physiological, emotional, social, financial and spiritual support of
the patient. Below are Mrs C.A.M.’s strength identified during my
interaction with her and the family.

1. Patient can verbalize the location and intensity of pain.

2. Patent can communicate pain and willing to comply with
therapy.
3. Patient was willing to cooperate with health personnel
4. Patient can tolerate oral fluid and willing to cooperate with
intravenous fluid administration.
5. Patient willing to comply with nursing interventions.
6. Patient can communicate pain.
7. Patient can wake up from bed with assistance and can tolerate
some activities.
8. Patient can assume a position to help subside pain.

49
 9. Patient can turn in bed for tepid sponging and can tolerate oral
fluid.

Patient’s Health Problems

Health problem is a physical, emotional, social or psychological

stress that can cause a negative reaction to patient’s health and
therefore needs medical attention and nursing management. Based
on the data collected on Mrs. C.A.M., the following are patient’s
health problems identified on admission

12/06/19

1. Patient complaints of abdominal (epigastric) pains.

2. Patient made complaints of chest pain

3. Patient was anxious.

13/6/19

4. Patient looks dehydrated.

5. Patient complaints of not being able to sleep at night

14/6/19

6. Patient complaints of headache.

15/6/19

7. Patient complaints of dizziness.

16/6/19

8. Patient complaints of epigastric pain

50
Nursing Diagnosis

12/06/2019

1. Acute pain (epigastric region) related to irritation of ulcerated

mucosa of the stomach.
2. Impaired comfort (chest pain) related gastric acid reflux.
3. Impaired emotional status (anxiety) related to unknown outcome
of condition.

13/06/2019
4. Risk for fluid volume deficit related to frequent urination.
5. Sleeping pattern disturbance (insomnia) related to epigastric
pain.
14/06/2019
6. Acute pain (headache) related to insomnia

15/06/19

7. High risk for injury related to dizziness

16/06/2019

8. Pain (epigastric region) related to irritation of ulcerated mucosa

of the stomach.

Ensure to include the following:

51
 Patient Family/strengths

• Define strengths

• Specific- relate strength to specific problems identified e.g.

-Problem-patient has abdominal pain. - Strength- patient
is able to express intensity and aggravating factors
associated with the pain.

• General strengths–

-- Social

—Economic

—educational

--psychological/emotional

--physical strength

At least six or more strengths to be stated

Health problems

• Define problems

• Problems should not center on only signs and symptoms,

but risk factors and problems that may arise as a result of
signs and symptoms

• Write problems in a statement form e.g. She has pain in

the right side of the abdomen.

• Do not write problem as NANDA TOXANOMY e.g. Fluid

volume deficit

• Prioritize the problems

52
• Write dates against the problems

Nursing Diagnosis

• Explanation

• Write out all the nursing diagnosis and number them

• Prioritize and date the nursing diagnosis

• Format for writing nursing diagnoses - problem related to

cause (in two parts or three parts with defining
characteristics).

53
 CHAPTER THREE

PLANNING FOR PATIENT/FAMILY’S CARE

This is the third phase of the nursing process and it is a written guide
for nursing care actions. This deals with the actions taken by the
nurse to enable him or her meet the patient’s identified problems and
it stated goals. It entails the nursing diagnosis based on patient’s
identified health problem, objective /outcome criteria to meet the
health needs of patient, the intervention that was implemented to
solve the problem and evaluation. The patient/ relatives and other
members of the health team were involved in the planning of the
care process.

The care plan for Mrs. C.A.M is shown on the subsequent pages

OBJECTIVES AND OUTCOME CRITERIA

The following objectives and outcome criteria were set for Mrs.
C.A.M and family.

1) Patient will be relieved of epigastric pain within 3 hours as

evidenced by;
a. Patient verbalizing that she is relived of pain.
b. Nurse observing patient with cheerful facial expression.
2) Patient’s body comfort will be restored within 2 hours as
evidenced by:
a. Patient verbalizing that pain has subsided.
b. Nurse observing that patient is cheerful in bed
3) Patient will be no more anxious within 1 hour as evidence by;
a. Patient verbalizing absence of anxiety
b. Nurse observing that patient is in a relaxed mood.

54
4) Patient will maintain her normal fluid status within period of
hospitalization as evidenced by:
a. Nurse observing that patient has good skin turgor moist
mucous membrane.
5) Patient’s sleeping pattern will be restored to normal within
48hours as evidenced by;
a. Nurse observing that patient sleeps uninterrupted for 6 to 8
hours at night.
b. Patient verbalizing that she had a sound sleep
6) Patient will be relieved of headache within an hour as evidenced
by;
a. The patient verbalizing that headache has subsided.
b. The nurse observing that patient is cheerful and interacting
with other patients.
7) Patient will be protected from injury within 6 hours as evidenced
by;
a. The nurse observing that patient has no bruises and any
obvious bleeding on the skin.
8) Patient will be relieved of epigastric pain within 3 hours as
evidenced by;
a. Patient verbalizing that she is relieved of pain.
b. Nurse observing patient with cheerful facial expression.

55
 Table Four: Nursing Care Plan for Mrs. C.A.M

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evalua

Time Diagnosis Outcome Time
Criteria
12/06/19 Acute pain Patient will be 1. Reassure patient. 1. Patient reassured that she will 12/06/19 Goal fu
@ (epigastric relieved of be relieved of pain. @ met as
5:30pm region) epigstric pain 2. Assess patient’s level 2. Patient facial expression 8:30pm verbali
related to within 3 hours as of pain on the scale of shows that level of pain is that the
irritation of evidenced by; (0-10) where 0 is no severe. intensi
ulcerated 1. Patient pain and 10 is severe pain ha
mucosa of verbalizing pain. reduce
the stomach. that she is 3. Place patient in a 3. Patient placed in a lateral
relived of comfortable position. position.
pain. 4. Serve non-irritating
2. Nurse fruits and spice free 4. Patient was served with
observing diet. banana, melon-juice, pepper
patient with 5. Encourage intake of
56
 cheerful water free light soup and rice.
facial 5. Patient was encouraged to
expression 6. Serve prescribed drink more water to dilute
analgesics HCL
6. Prescribed Injection Hyoscine
Butylbromibe 40mg stat has
been administered.

Table Four: Nursing Care Plan for Mrs. C.A.M (Continued)

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evalua

Time Diagnosis Outcome Time
Criteria
12/06/19 Impaired Patient’s body 1. Reassure patient to 1. Patient was reassured that 12/06/19 Goal
@ comfort comfort will be alley anxiety. with the appropriate nursing @ met
5:30pm (chest pain) restored within 1 intervention, chest pain will 6:30pm verbali
related to 2 hours as 2. Assess the degree of be relieved. that

57
gastric acid evidenced by: pain using the numeric 2. Degree of pain assessed using pain
reflux. 1. Patient rating scale. the numeric rating scale. subsid
verbalizing 3. Check and record vital
that pain has signs. 3. Patient’s vital sign was
subsided. checked to ascertain any
2. Nurse abnormal blood pressure,
observing that 4. Encourage patient to pulse or respiration rate.
patient take in adequate fluid
conversing about 2-3litres per day. 4. Patient was encouraged to
with nearby take water and soft drink
patient about 2-3litres per day.
cheerfully. 5. Serve prescribed 5. Injection hyoscine
medication. butylbromide 40mg stat was
administered to relieve pain

58
 Table Four: Nursing Care Plan for Mrs. C.A.M (Continued)

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evalua

Time Diagnosis Outcome Time
Criteria
12/06/19 Impaired Patient will be no 1. Reassure patient to 1. Patient was reassured to alley 11/08/17 Goal
@ emotional more anxious alley fear and anxiety. fear and anxiety. @ met
5:30pm status within 4 hours as 2. Explain all procedures 2. All procedures were 10:00pm patient
(anxiety) evidence by; that will be carried out explained to patient to seen
related to 1. Patient on patient to enhance enhance cooperation such as relaxed
unknown verbalizing cooperation. checking of vital signs and mood.
outcome of absence of 3. Encourage patient to administration of medication.
condition as anxiety ask questions 3. Patient’s fears and worries
evidenced 2. Nurse concerning the state of were addressed through
by insomnia observing that her condition and

59
 and patient is in a answer appropriately. answering of his questions.
restlessness. relaxed mood. 4. Engage patient in
diversional activities. 4. Patient was engaged in a
conversation and watching
5. Ensure adequate rest her favorite movie on the
and sleep television.
5. All nursing cares were
grouped to avoid interruption
of sleep.

Table Four: Nursing Care Plan for Mrs. C.A.M (Continued)

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evalua

Time Diagnosis Outcome Time
Criteria
13/06/19 Risk for Patient will 1. Reassure patient. 1. Patient reassured that fluid 13/06/19 Goal
@ Fluid maintain his volume will be restored to @ met

60
8:00am volume normal fluid 2. Encourage patient to normal. 8:00pm patient
deficit status within take in copious fluid 2. Patient was encouraged take good
related to hospitalization such as water and fruit to in copious fluid by sips, turgor
frequent period as juice. such as water and fruit juice. moist
urination. evidenced by: 3. Monitor fluid intake 3. Fluid intake and output was mucou
1. Nurse and output. monitored and balanced at the membr
observing that end of each day to prevent
patient has fluid overload.
good skin 4. Observe for signs for 4. Good skin turgor and moist
turgor and rehydration. mouth were observed.
moist mucous
membrane. 5. Serve prescribe 5. Prescribed 3 liters Normal
intravenous fluids Saline and 500mls Dextrous
normal saline 6hourly x
48hours was administered.

61
 Table Four: Nursing Care Plan for Mrs. C.A.M (Continued)

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evalua

Time Diagnosis Outcome Time
Criteria
13/06/19 Sleeping Patient’s sleeping 1. Reassure patient that 1. Patient reassured that she will 15/06/19 Goal
@ pattern pattern will be her sleep pattern will be able to sleep well as @ met
10:10am disturbance restored to normalize again. condition improves. 10:10am patient
(insomnia) normal within 2. Plan and group all 2. Nursing activities such as verbali
related to 48hours as nursing activities vital signs and medication that sh
epigastric evidenced by; were organized in order not to a s
pain.. 1. Nurse interfere with patients sleep sleep
observing 3. Give warm bath 3. Patient was served with warm
that patient water for bathing to enhance
sleeps

62
 uninterrupted circulation to induce sleep.
for 6 to 8 4. Put patient in a position 4. Patient was assisted to assume
hours at comfortable to her. right lateral position to relieve
night. pain.
2. Patient 5. Ensure dark, quiet and 5. Dark, quiet and comfortable
verbalizing comfortable atmosphere was provided by
that she had a atmosphere. switching off TV or radio set
sound sleep and lights on the ward.
6. Intravenous esomeprazole
6. Administer prescribed 40mg and tablet hyoscine
medication and butylbromide 20mg were
documents administered and recorded.

63
 Table Four: Nursing Care Plan for Mrs. C.A.M (continued)

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evalua

Time Diagnosis Outcome Time
Criteria
14/06/19 Acute pain Patient will be 1. Ensure adequate bed 1. Adequate rest and sleep was 14/06/19 Goal f
@ (headache) relieved of rest. ensure by providing a well @ as e
10:00am related to headache within ventilated room, bed made 11:00am by
insomnia. an hour as free from creases. The n
evidenced by 2. Check vital signs and 2. Vital signs were checked and observ
1. The patient record 4hourly. recorded 4hourly. patient
verbalizing 3. Cold apply compress to 3. Cold compress was applied to cheerfu
that headache the forehead. her forehead. expres

64
 has subsided. 4. Put patient in 4. Patient was put in a prone interac
2. The nurse comfortable position. position to help reduce pain. other p
observing that 5. Provide diversional 5. Diversional l therapy was
patient is therapy. done by tuning on the radio
cheerful and for patient to listen to music.
interacting 6. Assess patient level of 6. Patient level of pain was
with other pain. assessed with the pain rating
patients. scale.
7. Tablet Paracetamol 1g was
7. Serve prescribed
served as prescribed.
analgesics

65
 Table Four: Nursing Care Plan for Mrs. C.A.M (Continued)

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evalua

Time Diagnosis Outcome Time
Criteria
15/06/19 High risk for Patient will be 1. Reassure patient that 1. Patient reassured that she will 15/06/19 Goal f
@ injury protected from she will be secured be secured from injury. @ as
7:00am related to injury within 6 from injury. 1:00pm observ
dizziness hours as 2. Monitor vital signs and 2. Vital signs were checked and patient
evidenced by: record recorded 4hourly injury
a. The nurse 3. Ensure complete bed 3. Patient was encouraged to rest body.
observing that rest adequately in bed
patient has no 4. Patient assisted in his daily

66
bruises and 4. Assist patient in daily activities such as bathing.
any obvious activities. 5. Patient was instructed to
bleeding on 5. Instruct patient to call always call for help when
the skin. for help when getting getting out of bed.
out of bed. 6. All items needed were placed
6. Put all items needed by within patient’s reach.
the patient within his 7. Patient evaluated for signs of
reach. injury such as bruises on the
7. Evaluate patient for skin.
signs of injury after
6hours.

67
 Table Four: Nursing Care Plan for Mrs. C.A.M (Continued)

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation

Time Diagnosis Outcome Time
Criteria
16/06/19 Acute pain Patient will be 1. Reassure patient. 1. Patient reassured that she will 16/06/19 Goal fully met
@ (epigastric relieved of be relieved of pain. @ as patient
5:30pm region) epigstric pain 2. Assess patient’s level 2. Patient facial expression 8:30pm verbalized that
related to within 3 hours as of pain on the scale of shows that level of pain is the intensity of
irritation of evidenced by; (0-10) where 0 is no severe. pain has
ulcerated 3. Patient pain and 10 is severe reduced.
mucosa of verbalizing pain.
the stomach. that she is 3. Place patient in a 3. Patient placed in a lateral
relived of comfortable position. position.
pain. 4. Serve non-irritating
4. Nurse fruits and spice free 4. Patient was served with
observing diet. banana, melon-juice, pepper
patient with free light soup and rice.
cheerful 5. Encourage intake of

68
 facial water 5. Patient was encouraged to
expression drink more water to dilute
6. Serve prescribed HCL
analgesics 6. Prescribed Injection
Buscopan 40mg stat has been
administered.

Ensure to include the following:

• Explain planing

• Write out the objectives/outcome criteria. It should correspond with patient's problem and the nursing diagnosis
which have been stated earlier.

• State two or three evidences

Care plan

• Components

-Nursing Diagnosis

69
-Objective/Outcome criteria

-Nursing orders (about six to eight)

-Interventions

-Evaluation

CHAPTER FOUR

IMPLEMENT PATIENCE\FAMILY CARE PLAN

70
Implementation involves putting a plan care into am effort. It can also be defined as a deliberate action performed to

achieve a good and it’s the fourth step or phase of the nursing process. This chapter summarizes the actual nursing care

rendered to patient and family throughout the period of interaction until termination of care during the third home visit. It

consists of the following:

1. Summary of actual care rendered to patient/family

2. Preparation of family/patient for discharge and rehabilitation

3. Follow up /home visits /continuity of care.

SUMMARY OF THE ACTUAL NURSING CARE RENDERED

DAY OF ADMISSION (12/06/2019)

Mrs. C.A.M, a 29 years old lady, as admitted into the Opoku medical ward through the medical emergency unit of 37 Military
hospital on the 12th of June 2019 at 3:30 pm by Dr. M.K.W.

Patient presented with history epigastric pain and Chest pain; she was diagnosed of peptic ulcer disease.

She was brought into the ward in a wheelchair in a fully conscious state accompanied by a nurse from the medical emergency unit
and her relatives with intravenous dextrose. Normal saline 500mls in-situ.

71
They were welcomed to the nurses’ station and her identity was confirmed by mentoring her name after folder was collected from
the accompanying nurse. A quick assessment was made and patient complains of epigastric pain. Relatives were given a seat at the
waiting area whiles patient is put into already laid simple unoccupied bed. Orientation was postponed due to her painful state. But
nearby patient was introduced to her. Patient particulars were recorded in the daily ward state and ad mission and discharge book
on admission vital signs that is temperatures, pulse, pulse, respiration, blood pressure and oxygen saturation was checked and
recorded as,

Temperature - 37. degree celcius (C).

Pulse - 88 beats per minute

Respiration - 18 breathe per minute

Blood pressure - 110/70 millimeters of mercury

Oxygen saturation - 99%

Random blood sugar - 5.9 millimoles per litre (mmol/L)

The following laboratory investigation were requested

1. Full blood count

72
 a. Haemoglobin level
b. white blood cell (total count)
2. Blood urea, electrolyte and creatinine (BUE & Cr)
3. Liver functioning test
4. Computerized Tomography Scan of Abdomen
5. Endoscopy
She was managed on the following medications
1. Injection esomeprazole 40mg stat,
2. Injection Hyoscine Butylbromide 40mg stat
3. Intravenous Normal Saline 500ml 6hourly x 48hours
4. Intravenous Dextrose Saline 500ml 8hourly x 48hours
5. Intravenous Esomeprazole 80mg daily x 48 hours
6. Tablet Hyoscine Butylbromide 20mg 8hourly x 48 hours
7. Tablet Esomeprazole 40mg daily x 14 days.
8. Tablet Paracetamol 1g 8 hourly x 5days

Ensure to include whatever nursing care was rendered till the patient slept and till the next day

73
FIRST DAY OF ADMISSION (13/06/2019)

Mrs. C.A.M. woke up at 5:30am, she was assisted to take her bath, well-groomed and made comfortable in bed. She was served
with for her breakfast. At 6am routine vital signs were checked and recorded and prescribed medications were administered and
recorded which include intravenous Dextrose saline 500ml, injection Esomeprazole 80mg and syrup Aluminum-Magnesium
Hydroxide 10ml given. At 8am, she complained of frequent urination. An objective was set that patient will maintain her normal
fluid status within the period of hospitalization. Nursing interventions were implemented to achieve the goal of encouraging the
patient to take copious fluids such as water and fruit juice, monitor fluid intake and output and observe vital signs for rehydration.

Patient complained of not being able to sleep at night. Nursing Diagnosis of sleep pattern disturbance (insomnia) related to
epigastric pain was formulated. An objective as set that patient sleep pattern will be restored to normal within 48hours. Nursing
interventions were implemented to achieve the set goals which included assuring the patient that her sleep pattern ill normalize
again, all nursing activities were performed at a time, patient took a warm bath, patient was assisted into a comfortable a position,
a quiet and comfortable atmosphere as ensured. Mrs. C.A.M. was served with rice and vegetable stew for lunch was well tolerated.
At 2pm, Intravenous Dextrose Saline 500ml was served. At 3pm, she ate 2 fingers of banana and her relatives visited at 4:30pm.
She took her supper which was pepper-free light soup and she willingly took her bath afterwards.

At 6pm patient was not due for medication. When it was 7pm, patient went out of bed to take a walk without assistance in the
ward and came to bed. At 8pm, intravenous Dextrose saline as set up. All interventions carried out ere documented.

Vital signs monitored for the day are as follows:

74
 TIME TEMPERATURE PULSE RATE RESPIRATION BLOOD OXYGEN
RATE PRESSURE SATURATION
(%)
6am 36.6 80 20 120/70 98
10am 37.0 75 18 104/81 97
2pm 36.6 77 22 130/90 100
6pm 36.2 71 24 115/82 97
10pm 36.5 75 18 99 97

SECOND DAY OF ADMISSION (14/06/2019)

Mrs. C.A.M woke up around 5:30 am, emptied her bowel, brushed her teeth and took her bath. She took Tombrown without bread
for breakfast. At 6am, routine vital signs were checked and recorded and her medications were served. During ward rounds at
around 8:30am, the doctor ordered for new prescription of medications. Tablet Hyoscine Butylbromide 20mg daily for 48hours
and Tablet Esomeprazole 40mg daily for 14 days.

At 10 am patient complained of headache. Nursing diagnosis acute pain (headache) related to insomnia as formulated. Nursing
interventions were employed to help in the relief of the headache and these include assessment of pain using pain rating scale of 0-
10, adequate rest and sleep was ensured by providing a Well ventilated environment, bed made free from creases and crumps, vital

75
signs checked and recorded 4 hourly, cold compress was applied to her forehead, patient as assisted into prone position to help
relieve pain, diversional therapy as provided by turning the TV on and tablet paracetamol was served.

She ate rice ball and palm nut soup for her lunch and as given water to rinse her mouth to remove food particles.

During ward round the doctors told her that everything seems to be well and that she would be discharged after a repeated
endoscopy was performed. I therefore asked permission from her to do my first home visit so that after her discharge I
would visit her and she agreed

At around 3pm, she took kenkey with pepper-free stew and two fingers of banana after 20 minutes. On this day my first home
visit was carried out. At around 3pm I embarked on a journey to my patient’s home at Burma Camp (Harakan Quarters).
I boarded a taxi together with my patient’s grandmother from the 37 Military Hospital. We alighted in front of the house
into which the grandmother welcomed and offered me a seat and water.

Vital signs monitored for the day are tabulated as follows:

Time TEMPERATURE PULSE RATE RESPIRATION BLOOD OXYGGEN

(C) (bpm) (c/m) PRESSURE. SATURATION
(mmHg) (%)
6AM 36.8 67 18 110/50 97
10AM 36.6 59 18 115/82 100
2PM 36.5 62 19 110/80 97
76
 6PM 36.7 68 20 116/68 98
10PM 36.6 61 19 121/70 96

THIRD DAY ON ADMISSION (14/06/2019)

Mrs. CA.M. had a sound sleep at night and woke up at 5:30am with no new complaints lodged. She was assisted to willingly
take her bath, well, groomed and made comfortable in bed. Her vital signs were checked and recorded. She was served
with rice porridge for breakfast of which she took about 70% of it. Her due medications were served as prescribed and
recorded. The objective set on 13/06/2019 for nursing diagnosis of sleeping pattern disturbance(insomnia) related to
epigastric pain was evaluated and goal was fully met.

At 7pm, patient complained of dizziness. A nursing diagnosis of high risk for injury related to dizziness was formulated. An
objective was set to protect patient from injury within 6 hours. Nursing interventions were implemented to achieve the
set goals which include reassurance of patient that she will be protected from injury, vital signs checked and recorded 4
hourly, patient encouraged r\to rest adequately in bed, patient assisted in her daily activities patient was encouraged to
always call for help when getting out of bed and all items were placed within reach of the patient.

77
 Evaluation as made for the objectives set on 15/06/2019 for nursing diagnosis High risk for injury related to dizziness was fully
met. In the afternoon, she ate salad and waakye with pepper free stew.

In the evening, she took her favorite diet fufu and palm soup and melon juice 20 minutes later. Her medications were served to
her including tablet Hyoscine Butylbromide 10mg and syrup Aluminum-Magnesium Hydroxide 10ml. She was able to
take a fair amount of the meals served her, rinsed her mouth with water to remove food particles. She later emptied her
bowel and bladder before engaging herself in a conversation with one of her sisters who came to visit. She later had her
bath around 7:30pm and went to bed.

TIME TEMPERATUTURE PULSE RESPIRATION BLOOD PRESSURE OXYGEN

(C) (bpm) (cpm) (mmHg) SATURATION (%)
6am 36.2 68 18 110/60 98
10am 36.3 70 20 112/60 99
2pm 36.7 74 22 110/70 99
6pm 36.4 70 20 110/66 98
10pm 36.4 64 21 102/70 98

FOURTH DAY ON ADMISSION 16/ 06/2019

78
Patient had uninterrupted sleep during the night and woke up at 5:30am very cheerful. She took her bath and performed oral
hygiene unassisted. Her vital signs were checked and recorded and due medication served.

At 7:00am patient took rice porridge with a slice of bread for breakfast.

During ward rounds at 9:00am patient lodge no new complaints. Team of doctor’s review patient to continue current treatment.

At 10:00am patient vital signs checked and recorded. At 10:05am, patient took melon juice and relax for some 30 minutes and
then sleep for an hour. At 1:30pm, patient took fufu and palm soup and eat about satisfied amount.

At 2:00pm, patient vital signs check and recorded. Due treatment given.

At 3:00pm patient ask for the television on the ward on for her and she watched as she interacts with another patient.

At 4:30pm, patient took her bath and groom herself. At 5 20pm, her sister came to visit and she interact with her. At 5:30pm,
patient complained of pain at the epigastric region. Nursing diagnosis, acute pain (epigadtric region) related to irritation of the
ulcerated mucosal lining of the stomach was formulated. Nursing interventions were employed to enable the patient have relieve
of pain within 3 hours these include; patient been reassured, patient level of pain was assessed on a scale (0-10) where 0 is no pain
and 10 is severe pain. Patient was positioned laterally and made comfortable in bed. Patient was served with banana. Patient was
encouraged to drink more water to dilute the HCL. Prescribed tab paracetamol 1gram administered. At 6 pm routine vital signs
checked and recorded and due medication administered. At 8:30pm, evaluated objective that was set to relieve patient of the
epigastric pain was fully met.

79
Vital signs for the day is tabulated below;

TIME TEMPERATURE (0C) PULSE (bpm) RESPIRATION BLOOD PRESSURE OXYGEN

(cpm) (mmHg) SATURATION (%)

6 am 36.1 67 18 100/50 97

10 am 35.6 56 18 120/80 97

2 pm 36.2 64 20 124/80 98

6 pm 36.0 60 20 122/80 98

10 pm 36.1 64 18 120/80 98

FIVETH DAY ON ADMISSION

Mrs. C.A.M had a sound sleep and woke up at 5:30am with no complaints.

She took her bath, maintained oral hygiene and groomed herself.

80
Her 6:00am vital signs checked and recorded. She was served with oat and slice of bread and she ate 70 percent of it. Prescribed
medications served.

At 9:00am during ward rounds, patient did not lodge any problem but the doctor told the nurse to observe her until the following
day for possible discharge and after her endoscopy result is ready. Mrs. C.A.M was given a prior notice that she would be
discharge the next day. Evaluation was made for the objective on 13/06/2019 for nursing diagnosis of risk for fluid volume deficits
related to frequent urination was fully met. In the afternoon, she ate jollof and stew with egg as lunch.

In the evening, she took her favourite meal fufu with palm soup and mango juice after 20minutes. Her medication was served
served to her including Tablet esomeprazole 20mg, Tablet Hyoscine Butylbromide 20mg and syrup Aluminum-magnesium
hydroxide 10mls. She was able to eat all food served and rinse her mouth after eating. She later emptied her bowl and bladder
before engaging in a dialogue with other patient on the ward. She took her bath and slept around 9:00pm.

TIME TEMPERATURE (0C) PULSE (bpm) RESPIRATION BLOOD PRESSURE OXYGEN

81
 (cpm) (mmHg) SATURATION (%)

6 am 36.0 70 18 100/50 98

10 am 36.0 72 20 110/80 98

2 pm 36.2 68 20 120/80 99

6 pm 35.8 60 20 122/80 98

10 pm 36.0 64 18 120/80 98

SIXTH DAY ON ADMISSION

82
Patient had uninterrupted sleep during the night woke at 5:30am very relax and cheerful. She took her bath and perform oral
hygiene unassisted. Her vital sign was checked and recorded. During review with team of doctors, she was told about she been
discharged and also need to abide by dietary restrictions. She was informed about the review date which is on 22/07/2019.

She was finally discharged and was asked to continue with the following medications, syrup Aluminum -magnesium
hydroxide10mls three times daily after meal, tab paracetamol 1gram PRN, Tablet esomeprazole 40mg daily and Hyoscine
Butylbromide 20mg three times daily.

The compilation of her was done by the revenue officer, because she is a soldier, her bill was sought by the military. Around
2:3pm, her grandmother came to assist in packing things. She was discharged in the admission and discharge book as well as in
the daily ward state and was informed about her discharge and educated on the need to continue with treatment and to honour
follow-up patient remaining drugs were given to her and she was educated on how to take the medication and the possible side
effects. Patient was assisted to pack her belongings. They express their appreciation to the staff on duty for their care and support
throughout Mrs. C.A.M at the hospital. The bed and the locker were disinfected with 0.5 percent chlorine solution and the bed was
made ready for new admission. Her family friends finally came in to pick with the car they brought. They were encouraged and
educated to support her emotionally and the need for dietary restrictions to avoid reoccurrence of the disease. She was educated on
the need for fellow up review and rehabilitation, and finally report to the hospital with any health problem before the review date.
They were seen off in the at the entrance of the hospital.

Ensure to include whatever nursing care was rendered till the patient slept and till the next day

83
Just give us the significant vital signs for each day. Remove the tables and send them to the appendices.

Ensure to include the following:

• Summarize care daily then group into days or weeks

• Summarize routine care

• Care provided by nursing staff

• Investigation requested, preparation and support given

• Dependent nursing actions

• Interdependent nursing actions

• Independent nursing actions

• Medication orders, commencement and date completed

• IV fluids, charting and monitoring

• Observations done on patient -- response to therapy, reassessment of presenting problem

84
• Prevention of complications

• Patient/Family participation in care

• Home visits- discussion with patients/family

• Preparation for discharge, termination of care

• Evaluation of care, meeting goals

• Amendment of care

• Other treatments employed - physical therapy, traction, dietherapy, postural/chest drainage,

abdominal paracentesis

• Other procedures- catheterization, wound debridement, naso-gastric suctioning.

85
PREPARATION OF PATIENT/FAMILY FOR DISCHARGE

assured of competency of health ‘theme is managing the condition which will enable her gain strength and go home within some
few days. The patient and the family members were educated on the causes of the condition, which include hereditary, Infection of
which Helicobacter pylori, excessive use of NSAID’s, smoking and excessive use of alcohol, signs and symptoms includes
epigastric pain, vomiting, chest pain dizziness and eight loss. Treatment regimen include pharmacological and non-
pharmacological treatment and some preventive measures include the individual belonging to blood group O should adapt to good
lifestyles, such as avoiding stress, good dieting in order not to be predisposed to the condition and high intake of spicy and high
fried foods should be avoided as much as possible.

The first home visit was made on 14/06/19 to find out any health problem and the necessary action taken to solve this problem
before her his discharge.

Ensure to include the following:

• Should be featured throughout admission

• Patient/relatives informed

• Preparation of home

• PHN/Physical therapist/dietician referral

86
 • Medication

• Transport required

• OPD review

• Wound checked/dressing required

• Education of condition

• Valuables returned

• Rehabilitation

-physiotherapy

-changing jobs

-assisting child to learn in hospital

-excuse duty

-ambulation

FOLLOW-UP / HOME VISIT / CONTINUITY OF CARE

87
Home visits are planned by the health worker in the community to study and know the home and environmental conditions of the
patient before and after discharged. It enables the nurse to identify and prevent, illness, promote and help to maintain good health.
It also helps to find out the actual and potential health problems in the home environment and community of patient and relatives.
Mrs. C.A.M. and his family were informed of home visit on three occasion.

Ensure to include the following:

• Include follow up care/review- preparation and education, referrals, use of other health facilities

• Continuity of care by PHN- notifiable condition tracing of contacts

• Explain what home visit is

-state the purposes of home visits

- do at least three home visits and state purpose for each visit

(application of community study and home visiting)

FIRST HOME VISIT 14/06/2019

88
This was done on the 14/06/2019 while patient was on admission. The visit was made with Mrs. C.A.M grandmother who took me
to their house, on reaching the house, I greeted the other tenants in the house and was welcomed. My patient grandmother offered
me a seat in their room. I introduce myself once again to her and the purpose of my visit to their house. This visit was to assess the
home environment and prepare the household to receive him when she is discharge.

We got to the house at 3:30pm. Mrs. C.A M leaves in soldier’s quarters built with blocks and roofed with cement roofing sheets.
The house is painted with yellow, patient together with the grandmother leaves in single room and a pouch of which they have
their own toilet and bath inside. It’s a house of six slit with other co-tenants live in the rest of the five. They had; two utensils
which were washed and well arranged in the cabinet. There room was well arranged, bath room well cleaned, but they have only
one window which they usually do not open. They feel the wind will blow dust into the room. Based on this, her grandmother was
educated to open the window for fresh air circulate in the room, even though they use air- conditioner. Their source of light is
electricity. After the education, I bid the grandmother farewell and assured her of my next visit. Upon getting to the junction that
leads to their house, I boarded a moving “trotro” to Boko Junction and later boarded another one to Teshie where I live.

SECOND HOME VISIT (20/06/2020).

My second home visit as made on 20/06/2020 at 10:40am to assess the condition of Mrs. C.A.M. and also to remind her of her of
review date, as well as verifying whether the education given at the hospital was being practiced at home. They warmly welcome
me and offered me a seat in the room. Mrs. C.A.M. and grandmother were glad to see me and told me that she had been doing

89
very well. She also told me that she had not presented any signs and symptoms shown on admission and has also stopped taking
spicy foods as confirmed by the grandmother. I checked her medications and realized she was complying with them. The
education on the need to avoid spicy and hard fried food was re-emphasized in order to aid healing of the ulcer and prevent future
complications. She was educated to complete all medications given to her and also remind her of the review date which is on
21/07/2019. This time round they opened their window to allow fresh air in. Their compound looked cleaner than before and I
congratulated her for that. I asked permission to leave and promised my next visit after the review. Mrs. C.A.M. and her
grandmother were informed that on my next visit I would be coming with a Community Health Nurse who would continue the
care.

REVIEW 21/07/2019

On review date, I called my patient to inform her that review was the said date. I also informed her that she would meet me at the
hospital. At 7:30, I was at the hospital waiting for her, she came in with her grandmother. I welcomed them and proceed to the
nurses table to have her vital signs checked. Her details were entered onto the computer. We were asked to wait for about twenty
minutes after which we were called to the consulting room. All conscience on her medication and her condition came up and there
was a need for further education. She was educated to continue the rest of the medication and also were educated on the things not
to do in order to worsen the condition or aggravate the pain. After we left the consulting room, I told her of my next visit an I
escorted them to the taxi station to pick a taxi and I bid the good bye.

90
THIRD HOME VISIT 02/08/2019

My third home visit was on the 02/08/2019 at 11am. My motive was to hand over my patient to the community health nurse. We
were welcomed and I introduced the community health nurse to Mrs. C.A.M and her grandmother. I told her that it was my last
visit and made her aware that the community health nurse will continue the care for her till she finally recovers. I told them her
purpose was to follow up after discharge, checked if she has been taking her medication as prescribed and educate them on
personal hygiene

Emphasis was made on the prevention of the condition from reoccurring, therefore Mrs. C.A.M was advised against taking
alcoholic beverages, spicy foods, smoking, and to try to avoid stress as well as this will only worsen her condition. The need to
adhere to treatment plan was also stressed on. I thanked my patient and their family for their cooperation and also allowing me to
take her as my patient. And we asked for permission and left,

Ensure to include the following:

• Include description of the community and its resources to meet health needs

-water, housing, electricity, schools, markets,

91
 -health facilities, and financial institution, boundaries, network

• Weather and climate conditions, humidity and temperature, political administration, churches

• Culture, ethnic groups, beliefs, cultural practices

• Population characteristics

• Assess of home/neighborhood condition

• Assess family members past/present heath status.

• Validate any data collected from patient

• General observation

• Identify factors that can affect patient and family's health.

• Create scenes of humour and interest

• Collect more data on family history

• Identify vulnerable groups in the house and community- Children, pregnant women, adolescents, aged. people with
chronic health problems.

• General health education on current health issues

92
 -HIV/AIDS, malaria, tuberculosis, hereditary conditions, drug abuse, social issues, NHIS.

• Reproductive health, health promotion, psychosocial issues

• Regenerative health and nutrition adolescent health, aging, prevention of accidents in children,

• Educate family members on patient's condition

Students should apply guidelines for community study

93
 CHAPTER FIVE

EVALUATION

• Explain evaluation before moving to the next paragraph.

Mrs. C.A.M was nursed using the nursing process approach as a result, few health problems were identified and objectives were
fully met. They include;

1. Patient had pain in the epigastric region. Patient’s level of pain will be reduced within 3 hours as patient verbalized no pain.

2. Patient complained of chest pain. Patient body comfort will be restored within 1 to 2 hours as evidenced by patient verbalized
relieve of pain, as nurse observed patient looks cheerful in bed.

3. Patient was anxious towards unknown outcome of hospitalization. Patient was allayed of her anxiety within an hour as
evidenced by nurse observing patient in a relax mode.

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4. Patient looks dehydrated. Patient will maintain normal fluid status within the period of hospitalization as evidenced by nurse
observing patient has a good skin turgid, moist mucous was membrane.

5. Patient complained of difficulty sleeping. Patient sleeping pattern will be restored to normal within 48 hours as evidenced by;
nurse observing that patient sleeps uninterrupted for 6 to 8 hours at night.

6. Patient complained of head ache. Patient will be relieved of headache within an hour as evidenced by, nurse observing patient
with cheerful facial expression.

7. Patient complained of dizziness. Patient will sustain no injury throughout hospitalization as evidenced by patient having intact
skin and verbalizing absence of dizziness.

8. Patient had pain in the epigastric region. Patient will be relieved of epigastric pain within 3 hours as evidenced by, patient
verbalizing pain has been relieved and nurse observed patient with cheerful facial expression.

Ensure to include the following:

• Make a statement on each problem and extent of meeting goal, as goal fully or partially met or not met as stated in
the plan of care.

AMENDMENT OF NURSING CARE PLAN FOR PATIENT AND PARTIALLY MET OR UNMET OUTCOME CRITERIA

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All the goals set to solve Mrs. C.A.M.’s problems were fully met, because of quality nursing and medical care rendered to her and
the maximum cooperation of the patient and family.

TERMINATION OF CARE

Termination of care is a process of ending the care rendered to the patient and family during the period of hospitalization and after
discharge. The preparation of Mrs. C.A.M termination of care started on the 12th June, 2019, the first day of admission when the
interaction between them, the entire nursing and medical staffs was temporary one which would end after discharge. She and her
family were encouraged to accept care from other staffs and not to depend on me alone for her care.

My interaction with her was cordial throughout as she was educated on her condition, consequences of failure to take the drugs
prescribed. So that after discharge, she would be able to take care of herself.

The interaction was terminated on the third home visit 2nd August 2019, I thank them for their cooperation and they also express
their gratitude for the care rendered to Mrs C.A.M.

SUMMARY

This script is an account of the individualized nursing care to Mrs. C.A.M, 29 years old women and her
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family. She was admitted on 12th June, 2019 with a diagnosis of peptic ulcer disease. Various investigation were carried out to
help in the diagnosis and treatment of the condition which includes; full blood count (Haemoglobin level and white blood count),
Blood urea Electrolyte and creatine(BUE & Cr), Liver functioning Test, Computerized Tomography of the Abdomen and
Endoscopy.

She was managed on injection esomeprazole 40mg Stat, injection Hyoscine Butylbromide 40mg Stat, intravenous normal saline
500mls 6hourly times 48 hours, intravenous dextrose normal saline 500mls 8hourly x 48 hours, Tablet Hyoscine Butylbromide
20mg three times daily x 48 hours, Tablet esomeprazole 40mg daily x14/7 and Tablet paracetamol 1 gram three times daily x 5
days.

The nursing process was used to offer quality individualized care and her condition to improve considerably. She was
discharged on the 18th June 2019 after identified health problems have been solved.

Three home visits were carried out as part of the nursing care rendered to her. The first home was performed while patient was on
admission and subsequent ones done after discharge.

Finally, the interaction was terminated on the third and a last home visit.

Ensure to include the following:

• Brief description of care from admission till termination of care to be done by summarizing each chapter.

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 • Health education given

• Condition of patient

CONCLUSION

The patient and family care study has been very educative. The use of the nursing process approach in the nursing of the patient
has helped me gain better understanding.

It has also prepared me for any other patient under my care. Besides it has strengthened my interpersonal relationship with patient,
their family and the health team I interacted with.

The patient and family gave me the opportunity to learn about condition of peptic ulcer and treatment. It has also prepared me to
appreciate the activities of nursing and medical team.

Ensure to include the following:

• Lessons leant

• Satisfaction of student for work done

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 • Significance of the study to the student, patient/family, the hospital, institution and the profession in general.

• Implication for nursing practice, education, administration and research.

• learning experience and reference material in the school library

BIBLIOGRAPHY

Ensure to use APA referencing.

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 APPENDICES

• Temperature charts

• Blood pressure charts

• Fluid charts

• Weight

• Pain scale chart

• Routine care

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