PREFACE

The patient/family care study is a written report on the total nursing care rendered to a patient

and family within a specified period of time using a systematic approach to identify the specific

needs and problems of the client and help solve them. The systematic approach used is the

nursing process.

The study is undertaken by a final year student nurse to appropriately apply the knowledge from

various fields of study such as surgery, psychiatry, medicine, public health, sociology and

practical experiences to render quality care to the patient.

In this study, the student nurse is made to select a patient of choice, a critical analysis and

assessment is made on the patient/family health problems in order to render optimum care and

support.

The patient/family care study is written and presented in partial fulfilment for the award

of Diploma in Registered General nursing by the Nursing and Midwifery Council of Ghana at the

end of the three-year programme.

It helps the student nurse to have much insight and a broader idea of the patients’ condition so as

to prepare him/her to be able to manage and handle similar conditions in the work field.

It also enhances the development of good interpersonal relationship between the student nurse,

the patient/family and the community not forgetting the entire health team which is a vital and a

fundamental tool for good health care.

Again, it prepares the student nurse to take initiatives in emergency conditions that may

come his/her way by using the nursing process approach as a guide.

In order to maintain confidentiality, my patient will be referred to as Mr. W.R. throughout the

script.

1
 ACKNOWLDGEMENT

To God be the utmost Glory for the great things He has done for me throughout my life. For the

strength, wisdom, knowledge and the life he has given me and for helping me toward a

successful completion of this study. This work would never have been successful without the

assistance and support of some devoted individuals throughout this care study.

My first and greatest appreciation goes to Mr. W.R, and his family for accepting to partake in this

study and for their cooperation and tolerance throughout the study. For their availability

throughout our interaction and for willingly giving me all the information I required of them in

order to make my study a success. And for trusting and opening up to me.

I also express my profound gratitude to my supervisor Miss Nimatu, for her time and patience in

going through the script, helping me with the necessary corrections and alterations and giving me

all the assistance and guidance I needed to make a successful work. And to the entire tutorial

staff of the Nursing and Midwifery Training College-Agogo for their hard work and giving as

their best to enlighten us with all the knowledge we need to practice as qualified Registered

Nurses. And to our Principal, Miss. Carol Boateng for her active role in making our school one of

the best.

My gratitude also goes to the authors and publishers whose books I used for referencing and

retrieving the information that helped me in my study.

Finally, I share the joy and success of this study with my family for their immense support

especially my mother. And to my fellow colleagues who contributed in diverse ways in making

my study a success.

2
 INTRODUCTION

Nursing care is instrumental in all phases of acute care and the maintenance of general

well-being such as prevention of illness, rehabilitation, and a maximisation of health or where it

is impossible to attain complete well-being, the alleviation of pain and discomfort and a peaceful

death. To attain this, the nursing profession has identified a problem-solving process that

''combines the most desirable elements of the art of nursing with the most relevant elements of

systems theory, using the scientific method'' (Shore, 1988).

The Patient/Family Care Study is a report of the Nursing care rendered to a patient and

his/her family and involves the interaction between the patient and the health team. The

interaction occurs within a specified period of time and last as long as the patients care last. The

trend in nursing has undergone systematic development over the years. Currently, the holistic

approach is being emphasized. This stresses that the patient is a bio psychosocial entity and

require that the physical, emotional, social and spiritual needs of the individual within the contest

of his environment must be considered if he/she is to be held and cared for to regain optimal

health.

This report is made on the care rendered to Mr. W,R, a 54-year-old man who is dark in

complexion, and weighs 48 kilograms on admission. He was admitted on the 27th September,

2024, at 7:00 pm into the Medical Ward Annex of Agogo Presbyterian Hospital through the

Triage unit by Doctor B.E.D., on account of vomiting, abdominal pain associated with diarrhea,

anorexia and bitter taste and was diagnosed of Gastroenteritis.

I first encountered Mr. W.R., upon his arrival to the Medical Ward Annex, through the triage

unit, ambulant, accompanied by a nurse and his wife. On his arrival, assessment was done and

patient was well-oriented to time, place and person and could give a good account of himself and

also, patient was not in any obvious respiratory distress. They were warmly welcomed and were

offered a seat at the nurse’s station whilst all documents concerning the patient were collected

from accompanying nurse and the patient name was mentioned to confirm his identity. I prepared
3
an admission bed to receive Mr. W.R. in one of the rooms they allocated him. In his room, I

approached him and his family and introduced myself as Gloria a final year student nurse from

the Presbyterian Nursing and Midwifery Training College-Agogo. I went on to explain to them

that, as part of my academic work, it is required of me to provide a detailed written report on the

care I give to a patient chosen by myself till the patient recovers fully in health. After my

explanation, my request was gladly accepted and my care study report began right that moment.

Upon explaining to them that I may be taking a lot of information with which some may be quite

sensitive, they gave me their full assurance of active participation and cooperation.

Even though there were other clients on the ward that we cared for, I always ensured that I was

available as and when she needed my service.

My interaction with Mr. W.R, on the ward lasted for 5 days (27th September, 2024 to 2nd

October, 2024). I started preparing my client for discharge on the very first day of admission

(27th September 2024), with continuous reassurance of the optimum care and support he would

receive. I explained to him that, there will be continuity of care as I will visit him myself to check

up on him and also if he has any complaints he can report to the hospital even before the review

date.

On October 2nd, 2024, Mr. W.R. was discharged from the hospital by Doctor B.E.D. at 11 a.m.,

following a significant improvement in him physical and physiological health. Mr. W.R. and his

family were overjoyed with the exceptional care provided by the healthcare team, which

facilitated his rapid recovery. They expressed their heartfelt gratitude to the team for their

dedication and expertise.

During his admission and after his discharge, I made three home visits to Mr. W.R. to provide

continuous care, eventually handing his over to the Community Nurse for further follow-up. This

experience has broadened my understanding of healthcare delivery, the importance of therapeutic

communication in patient care, and the application of the nursing process in achieving optimal

patient outcomes.
4
I chose to focus on Mr. W.R.'s case and Gastroenteritis due to the common misconception and

lack of awareness about the condition, which is often confused with peptic ulcer, gastritis, and

acute abdomen. Through this study, I aim to raise awareness about gastroenteritis and its distinct

characteristics, encouraging individuals with similar symptoms to seek prompt medical attention.

Throughout Mr. W.R.'s care, the nursing process was diligently applied, comprising five phases:

assessment, analysis, planning, implementation, and evaluation. Each chapter of this study

corresponds to a specific phase, detailing the collection and analysis of patient data, care

planning, implementation, and evaluation of outcomes.

Chapter 1; Deals with an assessment which involves the collection of data about patients and

families through processes like observations, history taking, and interviews

Chapter 2: Deals with analysing the data obtained, it involves the process of sorting, classifying

and making decisions on the data collected

Chapter 3: Deals with the planning of care, it is the setting of priorities based on the patient's

problems that have been identified. It involves the use of the nursing care plan, setting of both

long- and short-term goals.

Chapter 4: Deals with implementing the plans that has been set to achieve the goals and

highlighting on the actual nursing care provided to the patient and family.

Chapter 5: Deals with evaluation of the care rendered to the patient and family. It determines

whether the objectives set have been achieved or not.

5
 TABLE OF CONTENT
PREFACE i
ACKNOWLDGEMENT ii
INTRODUCTION iii
TABLE OF CONTENT iv
LIST OF TABLES vii
CHAPTER ONE 1
ASSESSMENT OF PATIENT AND FAMILY 1
PATIENT PARTICULARS 1
FAMILY MEDICAL SOCIAL ECONOMIC HISTORY 1
PATIENT DEVELOPMENTAL HISTORY 2
PATIENT’S LIFESTYLE AND HOBBIES 3
PAST MEDICAL HISTORY 4
PATIENTS PRESENT MEDICAL HISTORY 4
ADMISSION OF PATIENT 4
PATIENT CONCEPT OF ILLNESS 6
VALIDATION OF DATA 13
CHAPTER TWO 1
ANALYSIS OF DATA 1
COMPARISON OF DATA WITH STANDARDS 1
DIAGNOSTIC INVESTIGATIONS/TESTS 1
STATEMENT OF COMPARISON 3
COMPARISON OF PATIENT COMPLICATIONS TO THAT IN THE
LITERATURE REVIEW 7
PATIENTS/ FAMILY STRENGTHS 7
PATIENT HEALTH PROBLEMS 7
NURSING DIAGNOSIS 8
CHAPTER THREE 9
PLANNING FOR PATIENT AND FAMILY CARE 9
SETTING OF PRIORITIES 9
ESTABLISHING PATIENT GOALS AND OUTCOME CRITERIA 9

i
OBJECTIVE/ OUTCOME CRITERIA 9
NURSING ORDERS AND INTERVENTIONS 10
THE NURSING CARE PLAN 10
CHAPTER FOUR 21
IMPLEMENTATION OF PATIENT / FAMILY CARE PLAN 21
SUMMARY OF ACTUAL NURSING CARE RENDERED TO MR. W.R. AND HIS
FAMILY 21
DAY OF ADMISSION (29/10/2023) 21
FOURTH DAY OF ADMISSION (01/10/2024) 26
PREPARATION OF PATIENT AND FAMILY FOR DISCHARGE AND
REHABILITATION 28
HOME VISIT AND CONTINUITY OF CARE 28
CHAPTER FIVE 31
EVALUATION OF CARE RENDERED TO THE PATIENT AND FAMILY. 31
STATEMENT OF EVALUATION 31
AMENDMENT OF NURSING CARE FOR PARTIALLY MET OR UNMET
GOALS 33
TERMINATION OF CARE 33
SUMMARY 33
CONCLUSION 33
BIBLIOGRAPHY 36
APPENDIX 37
SIGNATORIES 39

ii
 LIST OF TABLES

Tables Pages

1: Comparison of Diagnostic Investigation and Test Carried Out On Patient 16

With Those Stated In Literature Review/ Textbooks

2: Laboratory Investigations 17

3: Comparison of Clinical Manifestations Presented By the Patients 18

With That of Text Books

4: Comparison of the Patients Treatment with That of Literature 19

5: Pharmacology of Drugs 20

6: Patient Care Plan 28

i
 CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment is the first step in the nursing process, involving the collection of subjective and

objective data to make informed decisions about the patient, family, and community. This

data helps the nurse identify health problems and the patient's health status. The assessment

process includes gathering information about the patient's health status, analyzing and

synthesizing the data, and making a critical nursing judgment.

PATIENT PARTICULARS

Mr. W.R. is a 54-year-old man who comes from Agogo in the Ashanti Region of Ghana. He

was born on May 16, 1970, to Mr. K.A. and Mrs. C.K., both Ghanaian, and both are

deceased. Mr. A.K. is the third of four children of his parents, thus two males and two

females. Mr. W.R. is a farmer by occupation, where he harvests fruit and vegetables such as

tomatoes, onions, cabbage, pepper, orange, pineapple, etc. He resides with his wife and

children at Bontoduase, in the Asante Akim Agogo. He is an Akan. Mr. W.R. is a member of

the National Health Insurance Scheme (NHIS), as are his family members. He is married to

Mrs. S.D

Mr. W.R attended Agogo States College, where he had his highest level of education, He

speaks English and Asante Twi. He is 172cm tall and weighed 58kg on admission. He is dark

in complexion. He has five children: three males and two females. His next of kin is his first

child, Mr. K.D. Mr. W.R. is a Christian and worships with the Believers Worship Center at

Bontoduase in Agogo.

FAMILY MEDICAL SOCIAL ECONOMIC HISTORY

Mr. W.R. and his family have no history on disease conditions such as asthma, hypertension,

epilepsy, sickle cell or any mental illness. He said sometimes members of his family do suffer

from minor headaches, common cold and depending on the severity of the condition then do

1
they seek medical attention from any hospital, poly clinic or get themselves some drugs from

the pharmacy. He has no allergy pertaining to food or drugs. He is also a member of the

National Health Insurance Scheme (NHIS), as are his family members.

He is a farmer who harvests vegetables and fruits such as cabbage, onion, peeper, tomatoes,

orange, pineapple etc. He earns income when he sells the foodstuffs after harvesting them. He

is the breadwinner of the family, and he provides for the family. Sometimes he gets support

from his elder brother who is a retired teacher.

PATIENT DEVELOPMENTAL HISTORY

Mr. W.R. was born on May 16, 1970, in Agogo, in the Ashanti Region of Ghana. According to him,

he was delivered at home by a traditional birth attendant at term with no complications. The patient

stated that he was immunized at the hospital but could not specify the protection he received. He had a

scar on the right upper arm (deltoid muscle), which suggested that he received the Bacillus Chalmette-

Guerin (BCG) vaccination. He was circumcised at a very tender age.

According to Mr. W.R, he was breastfed alongside complementary feedings at the age of 7 months,

such as porridge and soup without pepper, as told by his mother. He started crawling at the age of

seven (7) months and learned to stand and walk at the age of ten (10) months to one (1) year.

His speech development was normal when he was one-half years old and older. He experienced a

break in his voice and also started seeing changes on his chest, which are secondary sexual

characteristics, at the age of thirteen (13) years. He attended Agogo State College, which was his

highest level of education. According to Mr. A.K., he got married to Mrs. S.D at the age of twenty

(22) years and had his first child at the age of twenty-two (23). He currently stays with his wife and

children in Agogo.

Erik Erickson's theory of psychosocial development states that there are eight psychosocial

development stages in the human life cycle, starting at conception and ending with death. The

notion focuses on the psychological activities carried out during the course of a lifetime.

Trust versus Mistrust (birth to 12 months), Autonomy versus Shame or Doubt (ages 1-3

2
years), Initiative versus Guilt (ages 3-6 years), Industry versus Inferiority (ages 6-12 years),

Identity versus Role Confusion (ages 12-18 years), Intimacy versus Isolation (ages 19-40

years), Generativity versus Stagnation (ages 40-65 years), and Integrity versus Despair are

the stages (65years and above).

According to Erikson’s psychosocial theory my patient falls under stage seven {age 40 to 65

years} which is ‘Generative versus Stagnation’. During middle adulthood that is between

ages 40 and 65 years the individuals establish their careers, settle down within a relationship,

begin their own families and develop a sense of being a part of the bigger picture. We give

back to society through rising of our children being productive at work and becoming

involved with community activities and organizations. By failing to achieve these objectives,

we become stagnant and feel unproductive. Success in this stage will lead to virtue of care.

This is evident in my patient as evidence by patient occupation is farming, is married and

have children.

PATIENT’S LIFESTYLE AND HOBBIES

Mr. W.R. usually wakes up around 4:30 a.m. daily and performs his oral hygiene with his

soft

toothbrush and toothpaste, especially Pepsodent, he moves his bowel twice a day and takes

his bath twice a day with cold water. He always drinks his green tea before he takes his

breakfast, which is Tom Brown with bread, especially wheat bread, before he leaves for the

farm. His wife does the preparation of the food for him, his favorite foods are yam and palava

sauce. Mr. W.R takes his lunch normally at the farm and takes his supper around 5:30 p.m.

According to Mr. A.K., he is sociable and easily interacts with his family, friends, and even

strangers. His hobbies include listening to news and storytelling. He sometimes attends social

gatherings such as naming ceremonies, funerals, and birthday parties on Saturday and attends

3
church services on Sunday. He relaxes outside sometimes, before he takes his bath, and then

goes to bed around 8:30 p.m. with a prayer of thanksgiving to God for His protection.

PAST MEDICAL HISTORY

Mr. W.R. confirmed that he had not suffered any major illness that called for hospitalization

since childhood, nor had he undergone any surgery before. He admitted that he sometimes

suffers from minor ailments like headaches, fever, or stomach upsets, for which he seeks

medical attention through the purchase of medicines such as Panadol and Aspirin for the

headache and Imodium and Buscopan Ibs Relief tablets for his stomach upsets from the

pharmacy to treat his ailments. If his ailments become serious, he goes to the Agogo

Presbyterian Hospital for medical care.

PATIENTS PRESENT MEDICAL HISTORY

On the September, 26th 2024, Mr. W.R. claims he ate yam with vegetable stew around 5pm.

He however started having diarrhea in the midnight. Early the next morning he was still

passing a lot of watery stools about 5 times in the morning. He took in charcoal with water

but the diarrhea did not subside. During the evening, he bought some drugs from one of the

drug stores yet he was still passing out stool. In the night he had fever and started vomiting.

Early morning on the September, 27th 2024, he came to the Triage unit of the Emergency and

Casualty Department of the Agogo Presbyterian Hospital, with chief complain of vomiting,

abdominal pains, diarrhea and fever. W.R. was examined by Doctor B.E.D and diagnosed of

Gastroenteritis. W.R. was detained at the Emergency Unit where treatment was started and

later was admitted to the Medical Ward Annex.

ADMISSION OF PATIENT

Mr. W.R. was admitted through the Triage Unit of the Agogo Presbyterian Hospital, at

9:30am on September, 27th 2024 by Dr. B.E.D with the diagnosis of Gastroenteritis. Patient

came into the ward accompanied by a nurse and his wife on account of vomiting, abdominal

4
pain, fever associated with anorexia and bitter taste. They were warmly welcomed and were

offered a seat at the nurse’s station. All documents concerning the patient were collected

from accompanying nurse and the patient’s name was mentioned to confirm his identity.

Patient was assured of competent medical team and competent nursing care and that he would

be fine. Mr. W.R. was taken to his bedside and was introduced to patient near him. On

assessment, patient was well oriented to time, place and person and could give good account

of himself. On observation, patient was not in any obvious respiratory distress. His name was

quickly entered into the admission and discharge book as well as the daily ward state,

monitoring sheet such as the four hourly temperature, pulse and respiration chart blood

pressure chart and nurses’ notes after it has been confirmed. He was made comfortable in bed

and his vital signs checked and recorded as follows;

Temperature - 37.8‘C

Pulse - 76 bpm

Respiration - 22cpm

Blood Pressure - 110/70 mm Hg

The following laboratory investigations were requested and done;

 Hemoglobin level estimation

 Blood firm for Malaria parasite

 Stool for routine examination

Doctor B.E.D prescribed the following medications;

 Intravenous Ringers Lactate-1 liter in 24 hours

 Intravenous metoclopramide 10mg stat.

 Intravenous Normal Saline 1-liter in 24 hours

 Oral Rehydrated Salt,3 sachets in 72 hours

 Intravenous Flagyl 500mg every 8 hours for 48 hours

5
 Intravenous Ciprofloxacin 40mg bd x 24hours

 Tablet Paracetamol 1gram every 8 hours for 5 days

Patient was assisted to change into hospital gown. He had no valuables with him, his

belongings were kept in the bedside locker. National health insurance scheme was checked

for its validity and it was active. Patient was oriented to the ward, its protocols, personnel,

routines and its annexes. Much emphasis was made on visiting hours to patient husband and

relatives. Patient reassured of competent and efficient nursing care. All procedures on the

patient were documented in the nurse’s note. I introduced myself to him and his wife and

asked permission to use him for my studies as a student nurse which they agreed. I also

informed him that a time will come that the care will be terminated.

PATIENT CONCEPT OF ILLNESS

Mr. W.R. stated that even though the pain was unbearable he felt it and believe that his

condition and the pain he is going through had no spiritual interference. However, he hoped

to get well soon.

LITERATURE REVIEW

DEFINITION

Gastroenteritis is an inflammation of the mucosa lining of the stomach and the small intestine

characterized by abdominal scamps, diarrhea, and nausea and vomiting (Cahill, 1996)

Anatomy And Physiology of The Stomach and The Small Intestine

The stomach is situated in the upper portion of the abdomen to the left of the midline, just

under the diaphragm. It is a distensible pouch with a capacity of approximately 1500ml.The

inlet to the stomach is called the cardiac sphincter with no contraction closes the stomach

from the esophagus. The small intestines accounts for about 2/3rd of the gastrointestinal tract

and it folds back and forth on itself providing approximately a surface of 7000cm for

secretion and absorption. The small intestine is divided into three anatomical parts called the

6
Duodenum, the middle part called the Jejunum and the lower part called the Ileum. Bile,

pancreatic secretions empty into the Duodenum at the ampulla of vagum. The junction

between the small and large intestine is called Caecum, which is located in the right lower

portion of the abdomen and controls the passage of small intestinal content into the large

intestine and prevent reflex of bacterial into the small intestines. Feaces are the particles of

waste matter that is left over after the body has processed and absorb nourishment from the

food we eat. It consists of undigested foodstuffs, inorganic material, water and bacterial.

Feacal matter is about 75% fluid and 25% solid material. The breakdown of bile by the

intestinal bacterial results in giving feces its brown color. Chemicals formed by intestinal

bacteria are responsible in large part for the fecal odour. Feces first enter the colon in liquid

form. During digestion, chemicals and muscular actions work towards changing the foods we

eat into a nutrient-rich liquid called chyme. The muscles that surround the small intestines

contract and relax in a wave like motion called peristalsis to move the chyme through the

small intestine. After the nutrients are absorbed, the small intestines pass the remaining liquid

into the colon through ileocecal valve. Through peristalsis, the muscles of the colon and the

abdomen advance the liquid feces through the colon and compress the fecal matter into

stools. There is absorption of water in colon, making feces more solid. Elimination of stools

begins with distention of the rectum which initiates reflex contractions of the rectal

musculature and relaxes the normally closed internal anal sphincter. During defecation the

external anal sphincter voluntarily relaxes to allow colonic content to be expelled.

CAUSES/ETIOLOGY

 Bacteria such as Escherichia Coli, Staphylococcus, Salmonella and Clostridium

 Parasite such as Ascaris, Trindenella ad Spirochete

 Viruses such as Adenovirus, Rotavirus

 Poisonous food substance example berries, mushroom, and seeds bulbs

7
 Ingestion of toxins

 Immune reaction such as food allergies and drugs

 Drug reaction from Antibiotics such as Ampicillin, Cephalosporin, Tetracycline

INCIDENCE

It occurs in all ages and is a major cause of mobility leading to mortality in underdeveloped

countries. Also common in areas of poor sanitary conditions.

INCUBATION PERIOD

Few hours after the entry of the organism up to 12-24 hours.

PRE-DISPOSING FACTORS

 Drinking contaminated water

 Eating contaminated food

 Poor environmental hygiene

 Eating of cold foods

 Infants are more susceptible

MODE OF TRANSMISSION

The major mode of transmission is faeco-oral. The human hand is the main mode of

transmission assisted by flies or infective materials which spread to the hands and to the

mouth and causes this condition to spread from an infected individual to another.

TYPES OF GASTROENTERITIS

1. Enteral gastroenteritis; this type occurs as a result of inflammation of the gastrointestinal

tract.

8
2. Parental gastroenteritis: This type occurs due to conditions affecting other systems of the

body other than the gastrointestinal tract such conditions include measles and whooping

cough

The classification can also be put as either acute or chronic

Acute gastrointestinal is common in infants or children. It has a sudden onset. Predisposing

factors include poor nutrition, prematurity in infants and immunodeficiency, common causes

include: virus, parasites example ascaris.

Chronic gastrointestinal; it occurs as a result of secondary infection outside the

gastrointestinal tract. Example Acquired Immune Deficiency Syndrome (AIDS).

PATHOPHYSIOLOGY

Bacteria or any of the causative organisms in the gastrointestinal tract uses certain

mechanism to bring out the condition, these mechanisms are:

1. Enterotoxin Production:

With this the organism in the gastrointestinal tract multiplies an releases toxins that bind with

the mucosa. This leads to profuse secretion of water and electrolyte

2. Invasion of Epithelial Cells:

The causative organism invades and causes destruction to the cells of the intestinal

epithelium. This causes superficial ulceration of the mucosa leading to the passage of bloody

mucoid stool.

3. Penetration and systematic invasion:

This is marked by a local inflammation in which the organism tries to penetrate the mucosa

and gains access into the systematic circulation. This inflammatory process leads to

stimulation and secretion of intestinal fluids. Due to the inflammation of the tract, food

cannot be retained and it’s either vomited out or passed out as watery stool. This leads to

dehydration since the infected individual loses a lot of fluid through vomiting and diarrhea.

9
General body weakness results due to inability to retain food which provides energy and loss

of body fluids through vomiting and diarrhea. This also results in dehydration with signs such

as a little concentrated amount of urine.

CLINICAL FEATURES

 Diarrhea is characteristic of initial presentation. There is a watery or loose greenish or

yellowish stool which later may be accompanied by a visible blood or mucus.

 Abdominal cramps usually precede the diarrhea

 Audible rumbling of the intestine may occur

 Nausea and vomiting

 Dehydration may occur as a result of diarrhea and vomiting

 The patient becomes generally weak and sick

 Sudden loss of appetite

 Headache

 Dark and little urine

DIAGNOSTIC TEST

 Stool for Routine examination is done for identification of the causative organism

 Stool Culture for isolating the specific causative organism

 Hemoglobin level estimation to know if patient has become anemic due to disease

condition

 By the signs and symptoms

COMPLICATIONS

 Peritonitis

 Bowel Perforation

 Hypovolemic shock as a result from diarrhea and vomiting

 Electrolyte imbalance resulting from excessive diarrhea and vomiting

10
  Malnutrition

MEDICAL TREATMENT

The main aim of medical treatment is to replace the fluid lost, to prevent serious

complications and to give antibiotic therapy to destroy causative organism.

1. Intravenous fluids are administered to maintain fluid and electrolyte balance example

Normal saline, Ringers Lactate.

2. Prescribed antibiotics example Ciprofloxacin is administered after culture and sensitivity

test

3. Anti pyretic example Paracetamol to reduce temperature

4. Oral Rehydration Salt (ORS) is given to correct dehydration

NURSING MANAGEMENT

PSYCHOLOGICAL CARE:

 Reassure patient that his condition will improve

 Allay anxiety by introducing other patients who has suffered from same condition and is

recovering to him.

PERSONAL HYGIENE

 Patient’s personal hygiene is maintained it includes bathing, oral care, nail and hair care

 Soiled linen should be disinfected, wash and dry in the sunlight

 Proper hand washing with soap and water after visiting the toilet and before handling food

 Encourage the use of good drinking water to avoid infection by microbes

NUTRITION

 A well-balanced diet is encouraged and spicy foods are discouraged to minimize mucosal

lining irritation.

 Patient is encouraging to take in plenty water and fluid diet such as soups, rice porridge.

11
 Serve diet according to patient preference and should be rich in proteins, calories,

vitamins and be served bit by bit in frequent intervals.

 All diet should be served attractively to boost up appetite

OBSERVATION

 Monitor vital signs especially temperature, pulse, respiration and blood pressure closely

to note any deterioration in patient’s condition

 Monitor a strict fluid intake and output chart

 Monitor patient weight daily or alternatively to know whether patient is losing or gaining

weight

 Observe the side effects of the administered drugs as well as their therapeutic effects

REST AND SLEEP

 Explain to patient that rest and sleep is very important for recovery

 Rest and sleep is ensured by providing a comfortable bed free from creases, cramps and

offensive odour.

 The environment should be well ventilated and free from noise.

 Nursing procedures should be properly made to avoid interfering with patient sleep

 Visitors should be restricted to ensure enough rest and sleep

HEALTH EDUCATION AND PREVENTION

 Patient and family are educated on proper hand washing techniques that is washing hands

with soap under running water before and after visiting toilet to avoid harboring

microbes.

 The patient and family are encouraged to eat a well-cooked food and avoid cold foods.

 The patient and family are educated to keep their environment and surroundings clean,

which includes proper disposal of excreta to avoid infection.

 Emphasize the need to wash fruits and vegetables well with salt solution before usage

12
 Patient and family are educated on the mode of transmission, cause, signs and symptoms

of the condition.

VALIDATION OF DATA

Validation is to state officially that something is useful and of an acceptable standard, Oxford

Advance Learners Dictionary, 6th edition. This is the act of confirming or verifying that the

data collected from patient and relatives is correct and free from bias, errors, and

misinterpretation. With regards to the information collected from Mr. W.R, 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.

13
 CHAPTER TWO

ANALYSIS OF DATA

This chapter is a detailed and scientific study of all the data gathered. It comprises the

comparison of data collected with standards, patients and family strengths, health problems and

nursing diagnosis. A systematic look at the data helps to identify any deviation and problems

which require nursing intervention.

COMPARISON OF DATA WITH STANDARDS

This is where all the data collected from the patient are compared with standards from the

literature review. This includes diagnostic investigations, causes, treatment and complications.

DIAGNOSTIC INVESTIGATIONS/TESTS

The following diagnostic investigations were requested and done on Mr. W.R, at the Out-Patient

Department to confirm his diagnosis and help in treatment.

 Hemoglobin level estimation

 Blood firm for Malaria parasite

 Stool for routine examination

1
TABLE 1: DIAGNOSTIC INVESTIGATIONS/TESTS CARRIED OUT ON MR. W.R.
DATE SPECIMEN INVESTIGATION RESULTS NORMAL VALUES INTERPRETATION REMARKS

27/09/2024 Blood Malaria Parasite Negative Normal blood films do not Patient is not suffering from No treatment was given

contain malaria parasite. Malaria

27/09/2024 Blood Hemoglobin level 15.2g/dl Male:14 – 18g/dl Hemoglobin is within No specific treatment was

estimation Female:12-16g/dl normal range given

27/09/2024 Stool Routine Examination Red blood cells Normal stool is not watery Results indicate that there is Intravenous Flagyl 500

found in and does not contain any an inflammatory process in mg every 8 hours for 48

specimen of abnormality such as red the gastrointestinal tract. hours was administered.

watery tools blood cells

2
 STATEMENT OF COMPARISON

The various tests that were carried out have been compared with the normal standards as shown

clearly above. There was no variation from the normal range

CAUSES OF MR. W.R. CONDITION

The cause of Mr. W.R., disease is as a result of dietary indiscretion—the person eats food that is

contaminated with disease-causing microorganisms or that is irritating or too highly seasoned.

The cause as stated by the physician is what has predisposed Mr. W.R, to his current condition

and as compared to the literature review, is one of the causes of the disease.

Table 2: CLINICAL MANIFESTATIONS

Literature Patient

1. Nausea and vomiting Patient complained of nausea and vomited

2. Diarrhea Patient was passing frequent watery stools

3. Abdominal cramping Patient complained of abdominal cramps

4. Sudden loss of appetite Patient had loss of appetite as such could not eat meals

served.

5. General malaise Patient complained of malaise

6. Distended abdomen Patient abdomen was not distended

7. Dehydration Patient was dehydrated (mild).

Statement of comparison: the features presented by Mr. W.R. have been compared to the

accepted characteristics of the condition and she exhibited more than half of these manifestations

as stated above which confirms the diagnosis given by the doctor.

TREATMENT

The medical treatment given to Mr. W.R. were;

3
  Intravenous Ringers Lactate 1liter in 24hours

 Intravenous metoclopramide 10mg stat.

 Intravenous Normal Saline 1liter in 24hours

 Oral Rehydration Salt 3sachets in 72hours

 Tablet Paracetamol 1g every 8hours for 48hours

 Intravenous Flagyl 500mg every 8hours for 48hours

Table 3: Comparison of the Patients Treatment with That of Literature

Literature Patient

I. Intravenous fluid therapy such as; Ringers 1 liter Ringers lactate and 1 liter Normal Saline

lactate, Normal saline in24hours was prescribed and administered.

II. Oral Rehydration Therapy such as; Oral Oral Rehydration Salt 3 sachets in 72 hours was

Rehydration Salt administered.

III. Antipyretic example Paracetamol Tablet Acetaminophen 1gram every 8 hours for 5 days

was prescribed and administered.

IV. Antibiotic example Flagyl Intravenous Flagyl 500mg every 8 hours for 48 hours

and intravenous Cefuroxine750mg every 8 hours for

48 hours were prescribed and administered.

4
Table 4: Pharmacology Of Drugs

DATE DRUG DOSAGE ROUTINE CLASSIFICA DESIRED EFFECT ACTUAL SIDE EFFECTS REMARKS

ON TION ACTION

ADMINISTRATION OBSERVED

27/09/24 Injection 10mg stat dose Anti emetics Suppresses the Vomiting reduced Sedation No side effects were

Metoclopra intravenously vomiting Restlessness observed

mide

27/09/24 Injection 1 liter for 24hours Isotonic It replaces body fluid Lost fluid and Circulatory overload No side effects were

Ringers Intravenous solution and electrolyte electrolyte were Pulmonary oedema observed

Lactate replaced

27/09/24 Injection 1 liter for 24hours Isotonic It replaces body fluid Fluid and electrolyte Hypernatraemia No side effects were

Normal Intravenous solution and electrolyte were replaced and Circulatory overload observed

Saline patients was Pulmonary overload

rehydrated

28/09/24 Oral 3 sachets in 72 hours Hypertonic It replaces body fluid Patient’s fluid level Pulmonary oedema, No side effects were

Rehydration
5
 Salt oral Solution and electrolyte was maintained circulatory overload observed

28/09/24 Tablet 1g every 8 hours for 5 Analgesics It acts by blocking Body pain relieved Gastric irritation, Patients did not

Paracetamol days prostaglanding gradually liver damage, experience any side

Oral synthesis there by vomiting effects

reducing body

temperature and

relieving pain.

29/09/24 Injection 500 mg every Anti-Protozoal It kills protozoa that Protozoal was killed Unpleasant taste in No side effects were

Flagyl 8 hours for 48 hours fights against and infection was the mouth, nausea, observed

intravenous infection treated vomiting

6
COMPARISON OF PATIENT COMPLICATIONS TO THAT IN THE LITERATURE

REVIEW

From the literature review; Malnutrition, Dehydration, Hypovolemic shock, Anemia,

Electrolyte imbalance were some complications of Gastroenteritis. However, with effective

medical and nursing management, patient did not exhibit any complications during the period

of study. Patient was most likely dehydrated.

PATIENTS/ FAMILY STRENGTHS

Strength refers to the ability, capability, or resource that can aid the patient to cope with

stress specifically health problems thereby contributing to his or her speedy recovery. This

could be physical, psychological, social, and spiritual. During Mr. W.R., care, the following

strengths were identified;

 Patient could express the intensity of pain

 Patient could rest in the day time

 Patient could verbalize her fears and express herself in Twi

 Patient and family were willing to know more on the condition

 Patient was very co-operative in all nursing procedures

 Patient was willing to provide vital information

 Patient was able to take care of her personal hygiene

 Patient family was very supportive

 Patient had national health insurance

PATIENT HEALTH PROBLEMS

If a patient doesn't meet any health needs than he/she has a health problem. Health problem is

the limitation to certain health standards. Such health problems are identified by the nurse

and stated in order of priority. Health problems are of two types; the Actual problem and the

Potential problem. The health problem is solved by motivating patients and relative with

coping mechanism to work towards improvement of patient health. These health problems
7
were shown during Mr. W.R. hospitalization from time of admission till time of discharge in

order of priority

27/09/24

Patient complained of abdominal cramps.

Patient was passing diarrhea stools and vomiting.

Patient complained of general body weakness

28/09/24

Patient refused to eat

Patient was anxious

29/09/24

Patient was ignorant about her disease condition

NURSING DIAGNOSIS

A nursing diagnosis is a statement about the patient actual or potential health concerns that

can be manage through independent nursing interventions. The statement is made by

associating the health problems with the likely causes of the problem.

These statements are concise, clear and patient centered. The following nursing diagnoses

were made on Mr. W.R. during his admission.

1) Acute Pain (abdominal) related to inflammation of the gastrointestinal tract.

2) Risk for fluid volume deficit related to loss of fluid from the gastrointestinal tract

through vomiting and diarhea

3) Activity intolerance related to loss of fluid and electrolyte

4) Altered nutrition (less than body requirement) related to inflammatory process in the

gastrointestinal tract.

5) Anxiety related to unknown outcome of disease process.

6) Knowledge deficit related to lack of exposure to information.

8
 CHAPTER THREE

PLANNING FOR PATIENT AND FAMILY CARE

This is the third step in the nursing process. It aims towards designing measures or

interventions required to prevent, reduce or eliminate the patient’s health problems that were

identified during the analysis.

SETTING OF PRIORITIES
During planning, the nurse organizes diagnosis according to priority guidelines. That is

considering the life-threatening problems before material problems (resources) – Maslow’s

hierarchy of needs. Then the nurse establishes outcome criteria, nursing orders and writes the

nursing care plan.

ESTABLISHING PATIENT GOALS AND OUTCOME CRITERIA

A goal or an objective of nursing care is the desired outcome of the nursing intervention.

Outcome criteria on the other hand are statements that describe the standard against which the

goal was set. The set goals should be specific, measurable, achievable, and realistic and time

bound. The set goals are;

OBJECTIVE/ OUTCOME CRITERIA

1. Patient pain will reduce within 2 hours and relieved completely within 24 hours as

evidence by;

a) Patient verbalizing reduction of abdominal pain

b) Nurse visualizing patient having a cheerful and relaxed facial expression.

2. Fluid and electrolyte balance will be maintained as evidenced by;

a) Patients not presenting any sign or symptoms of fluid volume deficit.

b) Nurse recording a balanced intake and output chart.

3. Patient will regain her strength within 24 hours as evidenced by;

a) Nurse observing patient engaging herself in activities of daily living.

b) Patient verbalizing that she has her strength back.

9
4. Patient will gain her normal nutrition within 48hours as evidenced by;

a) Patient verbalizing a return of her appetite

b) Nurse observing patient eat at least half of meals served

5. Anxiety will be allayed within 2hours as evidenced by;

a) Nurse observing patient being calm and having cheerful facial expression

b) Patient verbalizing absence of anxiety

c) Patient co- operating very well with another patient on the ward

6. Patient will have adequate information about the disease condition within an hour as

evidenced by;

a) Patient mother answering at least 70% of questions asked correctly.

b) Patient verbalizing an understanding in the cause, treatment, prevention and

complication of condition. (gastroenteritis).

NURSING ORDERS AND INTERVENTIONS

Nursing orders are instructions written on the care plan to be carried out by the nursing staff.

The process of carrying out the orders is called intervention. They are performed to achieve

established goals and objectives.

THE NURSING CARE PLAN

The nursing care plan is a guide to the nurse in the care of his/her patients. It helps the nurse

to set goals, implement his/her orders and evaluate to see if the set goals have been met. The

nursing care plan consists of the nursing diagnosis, objective and outcome criteria, nursing

orders and evaluation.

10
Table: 5 PATIENT CARE PLAN
DATE/ NURSING OBJECTIVES AND NURSING ORDERS NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME INTERVENTIONS TIME

CRITERIA

27/09/24 Acute Pain Patient pain will reduce 1. Reassure patient. 1. Patient was reassured that 28/9/24 Goal fully met. Patient

at (abdominal) within 4 hours and with the nursing care to be at verbalized a reduction

3:30 pm related to relieved completely given abdominal pain will 3:30 pm and absence of

inflammation of within 24 hours as be reduced. abdominal pain

the evidence by; 2. Explain the cause of 2. The Cause of abdominal

gastrointestinal a. Patient verbalizing a pain to patient. pain was explained as due to

tract. reduction of abdominal the inflammation process in

pain. the abdominal tract.

b. Nurse visualizing 3.Assist patient to 3.Patient was assisting to

patient having a assume a comfortable assume the prone position as

cheerful and relaxed position. that was comfortable.

facial expression 4. Engage patient in a 4. Patient was engaging in

diversional therapy. watching television as a

11
 diversional therapy.

5. Serve prescribe 5.Prescribed tablet 1g

medications. paracetamol was served

DATE/ NURSING OBJECTIVES AND NURSING ORDERS NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME CRITERIA INTERVENTIONS TIME

27/09/24 Risk for fluid Fluid and electrolyte 1. Reassure patient. 1.Patient was reassured 29/09/24 Goal was fully met

at volume deficit balance will be maintained that diarrhea and at Fluid and electrolyte

3:30pm related to loss of within 48 hours as vomiting will be 3:30pm balance was

fluid from evidenced by; ceased. maintained.

gastrointestinal tract 1.Patient not presenting any 2.Served fluid diet. 2.Fluid diet such as As nurse did not

through vomiting sign of symptoms of fluid mashed kenkey and observe patient

and diarrhea. volume deficit beverage were served to presenting any sign

2. Nurse recording a patient. and symptoms of

balanced intake and output 3.Serve copious fluid. 3. Fluid such as plain fluid deficit such as,

chart. water, fruit juices were

12
 served in bit but in sunken eyes

frequent intervals.

4. A strict intake and

4.Monitor a strict intake output was monitored

and output chart. and balanced every

24hours.

5.Prescribed

5. Administer intravenous fluid of

prescribed intravenous Normal Saline, Ringers

fluid and monitor flow lactate [1 litre in 24

rate. hours) was

administered.

DATE/ NURSING OBJECTIVES AND NURSING ORDERS NURSING DATE/ EVALUATION SIGN
13
TIME DIAGNOSIS OUTCOME INTERVENTIONS TIME

CRITERIA

27/9/24 Activity Patient will regain his 1. Reassure patient that 1.Patient was reassured that 28/9/24 Goal fully met. Patient

at 4:00 intolerance strength within 24 hours he will regain his she will gain her strength back. at 4:00 verbalized gaining his

pm related to as evidenced by; strength. pm strength back and also

general body a. Nurse observing as nurse observes that

weakness. patient engaging himself 2. Assess patient to 2. Patient as assessed in he was engaged in

in activities of daily identify the activities he activities he can tolerate and activities of daily

living. can tolerate and those he those she cannot tolerate. living.

b. Patient verbalizing cannot tolerate.

that he has his strength 3. Assist patient in 3. Patient was assisted to

back. activities he cannot perform activities he could not

tolerate and those he and encouraged to perform

cannot tolerate. those he could.

4.Patient was encouraged

4.Encourage patient to to rest for at least 30 minutes

rest in between activities.

14
 in between activities.

DATE/ NURSING OBJECTIVES AND NURSING ORDERS NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME CRITERIA INTERVENTIONS TIME

28/9/24 Altered nutrition Patient will gain her 1.Reassure patient. 1. Patient was reassured 30/09/24 Goal fully met. Patient

at (less than body normal eating habit within that his nutritional status at was able to eat half of

12:00p requirement) 24 hours as evidenced by; will improve with effective 12:00pm meals served.

m related to A. Nurse observing patient management and his

inflammatory eat at least half of meals cooperation.

process in the served 2. Assess patient for 2.Patient was assessed for

gastrointestinal b. Patient verbalizing a preferred meals and preferred meals at each

tract. return of his appetite. served. meal and these were

served.

3.Serve light and easily 3.Warm milo tea with

digestible foods bread was served.

4. Fruit juices and warm

15
4.Serve appetizers. drinks were served as

appetizers.

5.Oral hygiene was

5.Give oral hygiene. maintained before and after

meals.

16
DATE/ NURSING OBJECTIVES AND NURSING ORDERS NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OUTCOME INTERVENTIONS TIME

CRITERIA

29/09/24 Anxiety related to Anxiety will be allayed 1.Reassure patient. 1. Patient was reassured that 29/09/24 Goal fully met. Patient

at unknown within 2hours as with effective management, at verbalized an absence

2:00pm outcome of evidenced by; her condition will improve 4:00pm of anxiety.

disease process. a. Nurse observing and she will be discharged

patient being calm and home.

having cheerful facial 2. Encourage patient to 2. Patient was encouraged to

expression. express her fears and express his fears and

b. Patient verbalizing concerns about his concerns about his

absence of anxiety. hospitalization. hospitalization.

3. Encourage patient to 3.Patient was encouraged to

c.Patient co- operating ask questions. asked question about his

very well with another condition(gastroenteritis) as

patient on the ward. these were addressed

17
 tactfully.

4. Involve patient in his 4. Patient was involved in his

care and establish good care and good nurse patient

nurse patient relationship relationship was established.

5. Introduce patient to 5.A patient with similar

other patient who have condition who has improved

similar conditions and was introduced to patient.

have improved.

DATE/ NURSING OBJECTIVES AND NURSING ORDERS NURSING DATE/ EVALUATION SIGN
18
TIME DIAGNOSIS OUTCOME INTERVENTIONS TIME

CRITERIA

30/09/2 Knowledge Patient will have 1.Reassure patient. 1.Patient was reassured 30/09/24 Goal fully met.

4 at deficit (causes, adequate information that he will gain at Patient was able to

5:00 pm prevention and about the disease adequate knowledge on his 6:00pm answer questions

complication) condition within an hour condition with the asked on

related to lack of as evidenced by; education to be given. Gastroenteritis

exposure to a. Patient answering at 2.Assess patient knowledge 2.Patient knowledge level correctly.

information. least 70% of questions level on the disease was assessed on the disease

asked correctly. condition (Gastroenteritis). condition (Gastroenteritis).

b. Patient verbalizing an 3.Educate patient on the 3.Patient was educated on

understanding in the condition. the cause, management,

cause, treatment, prevention of complications

prevention and using clear and simple

complication of the terms.

disease condition. 4.Encourage patient to ask 4.Patient was encouraged to

questions for clarification.

19
 asked questions and

these were addressed

tactfully.

20
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT / FAMILY CARE PLAN

Implementation refers to the execution of the nursing care plan, which encompasses both

medical and nursing interventions. It involves taking action based on the care plan's findings

to achieve the desired outcomes, with the ultimate objective of promoting client

independence.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO MR. W.R. AND HIS

FAMILY

The actual care rendered to Mr. W.R. and his family commences on the day of admission,

September 27th, 2024. Thus, when I began my interaction with him, subsequent care

continued until October 2nd, 2024, when care was finally terminated. The nursing activities

undertaken to assist him in his recovery are detailed in this section. This is the summary of

the actual nursing care rendered to my patient (Mr. W.R) and family throughout his

admission on daily basis

DAY OF ADMISSION (29/10/2023)

Mr. W.R. was admitted to the Medical Ward Annex of Agogo Presbyterian Hospital on

September 27th, 2024, at 9:30am by Dr. B.E.D. through the triage unit. Accompanied by a

nurse and his wife, on account of vomiting, abdominal pain, fever, associated with anorexia

and bitter taste. Upon arrival, the patient and his wife were kindly welcomed and offered a

seat at the nurse's station. A nurse collected all the necessary documents and information to

confirm his identity. After being introduced to the patient next to him, Mr. W.R. was assured

of receiving competent medical treatment and nursing care. The medical team explained that

he was diagnosed with Gastroenteritis, an inflammation of the stomach lining that causes

symptoms like anorexia, vomiting, and abdominal pain. They reassured him that the

condition was treatable and that he would soon recover. The medical team conducted a

21
thorough assessment of the patient to determine the extent of his condition. They monitored

his vital signs, including his blood pressure, pulse, and temperature. They also conducted

physical examinations, such as listening to his heart and lungs, examining his abdomen, and

checking for tenderness and swelling. The team then developed a personalized treatment plan

for Mr. W.R. throughout the admission process, Mr. W.R. received compassionate care and

attention from the medical team and nursing staff at Agogo Presbyterian Hospital. They

ensured that he and his companions were comfortable and informed every step of the way.

The patient was well oriented to time, place, and person and could give a good account of

himself.

On observation, the patient is not in any obvious respiratory distress. His name was quickly

entered into the admission and discharge book as well as the daily ward state, monitoring

sheet such as the four hourly temperature, pulse and respiration chart, blood pressure chart,

and nurses’ notes after it had been confirmed. He was made comfortable in bed and his vital

signs checked and recorded as follow;

Temperature - 37.8 degrees Celsius

Pulse - 76 beats per minute

Respiration - 22 cycles per minute

Blood pressure - 110/70 millimeters of mercury

Random Blood Sugar - 5.6 millimoles per liter

The following laboratory investigations were requested and done;

 Hemoglobin level estimation

 Blood firm for Malaria parasite

 Stool for routine examination

Doctor B.E.D. prescribed the following medications;

 Intravenous Metoclopramide 10mg stat.

22
  Tablet Paracetamol 1gram every 8 hours for 3 days

 Intravenous Flagyl 500mg every 8 hours for 48 hours

 Intravenous Normal Saline 1 liters in 24hours

 Oral Rehydrated Salt 3 sachets in 72 hours

 Intravenous Ringers Lactate 1 liters in 24 hours.

 Intravenous Ciprofloxacin 40mg bd in 24 hours.

FIRST DAY OF ADMISSION 28/09/2024

I visited Mr. W.R. at 5:10 a.m., and he was already up but was in bed. An inquiry was made

about his first night, and he responded and with a frowned facial expression, he said he had

little sleep. According to the night nurses report, Mr. W.R. passed three diarrhea stools but

did not vomit. The morning medications were served and the vital signs were also checked

and recorded as follows;

Temperature 36.1˚c

Pulse 76 bpm

Respiration 22cpm

Blood pressure 120/80 mmHg

I assisted my patient in his activities of daily living including his personal hygiene. His bed

linen was changed to promote his comfort. A warm milo drink and bread was served. He was

able to drink less than half of it. At 9:30 am, Mr. W.R. was reviewed by the physician. He

complained of frequent diarrhea stools and an absence of vomiting so physician ordered to

continue current treatment.

I found out my patient has lost his appetite based on the assessment I made that morning; a

care plan was drawn to maintain his nutritional status. Patient was reassured that his

nutritional status will improve with effective management and his cooperation. Light and

easily digestible meals were served in bit but frequently. Oral hygiene was maintained before

23
and after meals. At 2:00pm his due medication of tablet Paracetamol 1g, Intravenous Flagyl,

500mg etc. were served. Mashed kenkey with milk was served as launch

At 5:30pm his personal hygiene was maintained, vital signs were checked and recorded. Very

soft-boiled rice and light soup was served as supper. Mr. W.R oral hygiene was maintained.

All other procedure was documented in the Nurse’s note. I bid my patient good night and

handed him over to the night Nurses.

SECOND DAY OF ADMISSION 29/09/2024

Mr. W.R. was seen at 5:45am on the 29th of September, 2024. I confidently greeted his and

inquired about his wellbeing, and was pleased to hear that he showed improvement in his

state. I assisted him with bathing, brushing his teeth, and dressing up in bed to ensure

maximum comfort. The prescribed medications were administered as instructed by the

doctor, and Mr. W.R.'s response to the treatment was closely monitored. The outlook was

positive, indicating that everything was progressing well. Vital signs were checked and

recorded as:

Temperature 36.3 0C

Pulse 78 beat per minute

Respiration 22cycle per minute

Blood pressure 120/70 mmHg

During the rounds, he gave no complains. The doctor ordered that, the intravenous fluid

should be discontinue and continue with Oral Rehydration Salt. After the doctors round Mr.

W.R. was anxious because he said he does not know the outcome of his hospitalization and

condition (Gastroenteritis). He was also noticed not have adequate knowledge on the

condition.

A care plan was drawn to give him education on his condition and the outcome of his

hospitalization. Patient was reassured that with effective management, his condition will

24
improve and he will be discharged home. Mr. W.R. expressed his fear and concern about his

hospitalization as he was encouraged to do so. Patient was encouraged to asked question

about her condition and questions asked were answered correctly and in simple terms for

simple clarification. A patient with similar condition who has improved was introduced to

patient.

At 2:00pm his due medication of tablet Paracetamol 1g, Intravenous Flagyl, 500mg etc. were

served. He requested for beans and fried plantain for launch which he ate more than half of

the meal served.

In the evening, patient’s personal hygiene was maintained. His vital signs were checked and

recorded. Rice balls and groundnut soup was served as supper. His oral hygiene was done

after eating. He was made comfortable in bed and handed his over to the night Nurses.

THIRD DAY OF ADMISSION 30/09/2024

At 5:30 am, I visited Mr. W.R., who appeared cheerful and eager to know when he would be

discharged from the hospital. He asked me for an update, and I confidently reassured him that

it would be sooner rather than later, as he was making significant progress. Nevertheless, the

ultimate decision rested with the doctor. Mr. W.R. took care of his hygiene himself, and we

administered the prescribed medications as per the doctor's instructions. We diligently

monitored his response to the treatment, and the outlook was positive. Mr. W.R had a hearty

breakfast consisting of porridge and bread, followed by rice and stew for lunch, and fufu and

light soup in the evening. Despite his initial lack of appetite during the first and second days

of admission, he ate well this time around. Before checking and recording his vital signs, we

allowed him to assume a comfortable position. The vital signs were as follows;

Temperature 36.6 degree celsius

Pulse 76 beat per minute (bpm)

Respiration 20 cycle per minute (cpm)

25
Blood pressure 120/80 mmHg

His oral hygiene was maintained. I had a little chart with him after which he returns to bed.

All procedures were documented in the Nurses note and patient was handed over to the night

nurse

FOURTH DAY OF ADMISSION (01/10/2024)

Mr. W.R. was visited at 6:30 am. As I got there, he had already taken his bath. Mr. W.R. still

insisted on knowing when he would be discharged home. I continued to assure him that it

would be a bit sooner since he was doing much better. The usual nursing care for the other

days continued. Vital signs were checked and recorded as; temperature - 36.7 degree Celsius,

pulse - 100 beat per minute, respiration - 25cycles per minute, and blood pressure – 100/90

millimeters of mercury. Prescribed medications were served to meet his nutritional needs, and

rest and comfort were cared for. At 8:30 am, the doctor came on rounds and informed him

about a possible discharge the following day. Mr. W.R. was excited to hear that. Education

on personal hygiene, diet, and lifestyle modification was given. After which I paid my

client’s family and relatives a visit in his respective home.

My patient took his bath and supper, was bid good night, and was handed over to the

night nurse.

DAY OF DISCHARGE 02/10/2024

Mr. W.R. was seen that day looking very cheerful and conversing with one of the patients in

the ward. He had already attended to his hygiene. His vital signs were checked and recorded.

During the ward rounds, upon the doctor seeing that Mr. W.R.'s health condition was now

better, he was discharged home to come for a review on October 10, 2024 later. He was

discharged on the following drugs:

1. Tablet Zinc 8 mg daily x 7 days.

2. Tablet Paracetamol 1g 8 hours daily x5 days.

26
He was informed as to when to come for review, which was on October 10, 2024. An

explanation of how to take the drugs was given, as well as their action and side effects. He

was advised to report any signs of recurrence or complications to the hospital for necessary

treatment. Advice on dietary modification, reduction of stress, maintenance of good personal

hygiene, reducing the intake of mucosal irritants such as spices, and pepper, avoiding alcohol

intake, etc. They were made aware of the home visit that would be paid to them, which they

agreed to and were very pleased with. The family members expressed their sincere gratitude

to all the nursing staff for the care and attention rendered to him during the period of

admission to the ward. Afterward, I helped him pack his belongings, escorted them to the

hospital gate, and returned to the ward to remove the bed linen. The pillow, mattress, and

bedside locker were disinfected, making them ready for use once again.

27
 PREPARATION OF PATIENT AND FAMILY FOR DISCHARGE AND

REHABILITATION

The preparation for a patient's discharge begins from the day of admission and continues until

the day they leave the hospital. To ensure that my patient and their family were prepared for

discharge, I educated them about the patient's condition and how to maintain their health

status to prevent further illness once they returned home. We discussed the possible duration

of hospitalization, and I encouraged them to ask questions and express any concerns they had.

I explained the causes, signs and symptoms, treatment, and prevention methods related to

their condition. I also emphasized the importance of personal and environmental hygiene and

the need to report to a health facility early if they noticed any abnormality about their

condition or any other condition in the family. Additionally, I outlined the need to take their

medication as prescribed, attend follow-up appointments, and come for periodic reviews after

discharge

HOME VISIT AND CONTINUITY OF CARE

Home visits are paid to patients/clients in their homes to assist them home visits are

conducted by healthcare professionals to assist patients in their homes with leading a healthy

life, preventing illness or disabilities, and ensuring continuity of care. This method of care

allows for a more accurate assessment of the patient's condition in a familiar environment

using their items and surroundings. This approach puts the patient at ease and encourages

cooperation with the healthcare provider. Additionally, early detection and prevention of

certain conditions can be achieved through regular home visits.

THE FIRST HOME VISIT

This was done on the 28th September, 2016 whiles patient was still on admission. The

essence of this visit was to survey the home environment of my patient in order to identify

possible health hazards so that the needed education will be given. He stays at Agogo

28
Bontoduase. I reached the house at around 2:30pm greeted other members of the house after

which I was offered a seat and water. They live in a compound house constructed with

cement blocks and roofed with aluminum sheets. I found their homes to be clean and tidy but

the backyard was bushy with a refuse damp. The toilet and bath were clean but behind the

bathroom was a pit constructed to collect water after bath. I noticed that it was not drained. I

also observed that the water tank which they store water in was not clean and uncovered. I

took the opportunity to educate them on the need to keep their refuse damp tidy and away

from the house, and also keep the water tank neat and cover it. Also, I educated them on the

need to avoiding stagnant water to prevent flies settling on them and later settle on their

uncovered water tank to contaminate it making it unsafe for drinking. She accepted my

advice and agreed to comply with it. I thanked her and other relatives in the house for their

cooperation and hospitality and ask permission to take my leave and promised another visit. I

bid them goodbye and returned to school with one of his relative.

SECOND HOME VISIT (03/|10/2024)

On October, 3rd, 2024, I visited my client's house for the second time. I arrived at 3:00 pm

and was greeted warmly by everyone. After exchanging pleasantries, I inquired about my

client's health status. His daughter informed me that he was doing well. I reminded them of

the education that I had provided during my previous visit and informed them of the

upcoming review on October, 10th, 2024. After discussing everything, I said goodbye and

departed.

REVIEW (10/10/2024)

Mr. W.R. underwent a medical review on October 10th, 2023, and she appeared to be in

excellent health and robust. He did not report any health issues during the visit, and his

overall condition was deemed stable. Doctor B.E.D. advised her to maintain a consistent diet

while avoiding highly-seasoned foods, coffee, and tea. he was also advised to avoid stressful

29
activities. Dr. B.E.D. declared him fit, and no new medication was prescribed. Mr. W.R. was

cautioned against self-medication and instructed to report any health issues to the hospital. I

informed him of my last visit to them.

THIRD HOME VISIT (12/10/2024)

On October, 12th, 2024, I visited Mr. W.R. for the third time to terminate my care for him

and his family. I arrived at 1:00 pm, and after exchanging greetings, I explained my

objectives to them, which were to end my care as previously discussed during his admission.

I inquired about his health status, and he responded positively. Though it was a sad event to

terminate my care, they expressed their gratitude and appreciated the care I provided.

Without any further questions, I asked for permission to leave, and they granted it.

30
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO THE PATIENT AND FAMILY.

Evaluation is defined as an ongoing comparison or appraisal of the degree to which the

outcomes have been accomplished. It provides important feedback for changing priorities and

revising the care plan.

STATEMENT OF EVALUATION

This is a report on the outcome of care given to the patient during assessment. It is summary

statement. All the pre-established objectives and outcome criteria in the care of Mr. W.R was

fully met during the period of hospitalization. Six health problems were identified:

1. On the 28th of September, 2024 at 3:00pm, the first problem identified on my

patient was abdominal pain due the inflammatory process. The objective set was pain will

reduce within 2 hours and relieved completely within 24 hours. Nursing intervention put in

place were; patient was reassured that he will be relieved of pain; the cause of pain was

explained to patient. Patient was made to assume the most comfortable position. I engaged

patient in a diversional therapy by asking him to watch his most favorite television

programme and prescribe analgesics of tablet Paracetamol 1g was served. Objective set was

fully met on 28th September, 2016, at 3:00pm as patient verbalized an absence of pain.

2. On the 29th September, 2024 at 3:30pm, Patient had a risk for dehydration because of

vomiting and diarrhea stool. An objective was set to help him maintain normal fluid and

electrolyte balance within 24 hours. Nursing interventions carried out to achieve the set goal

included; Fluid diet was served to patient, fluid (water) was served in bit but in frequent

intervals, prescribed Oral Rehydration Salt was served and prescribed intravenous fluid

Normal Saline was administered and flow rate was monitored. Objective were fully met on

the 30th September, 2024 at 3:30pm as patient did not present with any sign and symptom of

fluid volume deficit such as sunken eyes. Also, on the same 29th September 2024 at 4:00pm

31
patient was having general body weakness and objectives were set to help patient gain his

normal strength within 24 hours. Interventions for these objectives were; patient was

reassured that he will be active again, conducive environment was ensured to enhance rest

and sleep. Patient was served with more carbohydrate foods; patient was assessed in activities

he can tolerate and those he cannot and he was made to rest in between activities. Objective

was fully met on 30th September, 2024 at 4:00pm as patient gain his strength back.

3. On the 30th September, 2024 at 12:00pm patient could not eat well and objective was set

to help patient to gain his normal eating habit. Nursing interventions put in place were; Rice

and stew was served in bit but frequently, Oral hygiene was maintained before and after

meals. Goal was fully met on the 1st October, 2024 at 12pm as patient verbalizing a return of

his appetite.

5. On the 1st October, 2024 patient was anxious due to unknown outcome of

hospitalization. An objective was set to allay patient's anxiety. Nursing interventions carried

out include patient was reassured that with effective management, his condition will improve

and he will be discharged home, patient expressed his fear and concern about his

hospitalization as he was encouraged to do so and also encouraged to asked question about

his condition for clarification. Patient questions were answered correctly and in simple terms

for simple clarification and patient with similar condition who has improved were introduced

to patient. Goal was fully met on the 1st of October, 2024 at 4pm as nurse observing patient

being calm and having cheerful facial expression.

6. On the 2nd October, 2024 patient had inadequate knowledge about his disease condition.

Objective set was that patient will have adequate information about the disease condition.

Nursing interventions were; patient was reassured that she will gain adequate knowledge on

her condition, patient knowledge level was assessed on the disease condition. Patient was

educated on the cause, management and prevention of complicated in clear and simple terms,

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patient was encouraged to asked questions for clarifications and questions were answered

tactfully in simple terms. Goal was fully met on 2nd October, 2024 at 6pm as patient

answered at least 70% of questions asked correctly.

AMENDMENT OF NURSING CARE FOR PARTIALLY MET OR UNMET GOALS

This is usually done in cases of partially met or unmet goals. In this case, all objectives were

met, and as such no amendment of the care plan was carried out.

TERMINATION OF CARE

During my interaction with my patient in the admission process, I informed him that, a time

will come when my care for him will be terminated. After he had been declared fit on

October, 10th 2024 by the doctor, I informed him of my last visit on 11th October, 2024.

When I visited them, I made him and the family aware that my care for him had ended since

he had been declared fit. They expressed their gratitude and I left.

SUMMARY

This patient and family care study gives an account of the holistic care rendered to Mr. W.R,

from 27th October, 2024 to 2nd October, 2024. He was admitted to the Triage Unit of the

Agogo Presbyterian Hospital after he was diagnosed with Gastroenteritis. Through the use of

the nursing care plan, his problems were identified, goals were set and all his needs were met.

This contributed to his speedy recovery and he was discharged happily on 2nd October 2024

without any complications. Follow-up care continued until he was declared fit.

CONCLUSION

I would like to conclude that, the nursing process is the best approach that should be adopted

in the rendering of individualized care to patients and their families. Based on this approach,

comprehensive nursing care was rendered to Mr. W.R. and his family. This made it possible

for him to go through the care safely. This study has helped me to gain much knowledge on

how to nurse patients with this condition and other ones using the nursing process.

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Table 1
DATE TIME TYPE OF INTAKE AMOUNT TYPE OF FLUID OUTPUT AMOUNT IN BALANCE

FLUID IN MILLILITERS MILLILITERS

28/09/2024 2pm Normal saline 500mls Vomitus 250mls

4pm Soup and water 350mls

6:30pm Urine 330mls

7:30pm Vomitus 150mls

8pm Water 120mls

10pm Ringers Lactate 500mls Urine 350mls

29/09/2024 4am ORS 500mls Urine 400mls

6am TOTAL INPUT= 1970mls TOTAL OUTPUT = 1480mls 490mls

7:30am Porridge 450mls

8:10am Water 100mls Urine 350mls

10am Normal Saline 500mls Urine 250mls

1pm Water 120mls Urine 300mls

3pm Urine 150mls

34
 4pm Ringers Lactate 500mls

6pm Urine 210mls

6:50pm Soup and water 300mls

9pm Urine 200mls

30/09/2024 7am porridge 300mls

10am Urine 300mls

10:30am TOTAL INTAKE=2,270 TOTAL OUTPUT=1,760 510mls

35
 BIBLIOGRAPHY

1.Bloom, A.& Bloom, S. (1996). Tooheys Medicine for nurses.4th Edition, Churchill living

Stone, London Longman Group limited.

2. Kelham. (2009). Pharmacology a Nursing Process Approach.6th Edition, Canada

Saunders Elsevier International.

3.Waugh, A. and Grant, A. (2010) Ross and Wilson Anatomy and Physiology in health and

illness (11th ed). Elsevier, London: Church Hill Livingstone

4 Suzanne, C.S. et. al (2008) Brunner and Saddarth’s Textbook (Medical and Surgical

Nursing (11th Edition) Philadelphia. Lippincott William and Wilkin.

36
 APPENDIX
Table 2 Vital Signs
DATE TIME TEMPERATURE IN DEGREE PULSE IN BEATS RESPIRATION IN BLOOD PRESSURE IN

CELSIUS PER MINUTES (BPM) CYCLES PER MINUTE MILLIMETERS OF

(CPM) MERCURY (mmHg)

27/09/24 9:30am 37.8 76 22 110/70

10:00pm 37.2 72 20 100/75

28/09/24 6:00am 36.1 76 22 120/80

10:00am 36.5 80 22 110/80

2:00pm 36.3 66 20 110/75

6:00pm 36.0 68 19 120/67

10:00pm 36.7 70 21 120/75

29/09/24 6:00am 36.3 78 22 120/70

10:00am 36.5 74 22 100/75

2:00pm 36.5 65 20 100/80

6:00pm 36.2 64 20 110/80

37
 10:00pm 36.4 70 21 110/80

30/09/24 6:00am 36.6 76 20 120/80

10:00am 362 66 22 110/75

2:00pm 36.9 66 21 120/70

6:00pm 37.0 68 19 120/75

10:00pm 36.2 70 20 110/67

01/10/24 6:00am 36.7 100 25 100/90

10:00am 36.0 70 20 120/80

2:00pm 37.1 65 20 120/75

6:00pm 36.5 68 20 110/80

10:00pm 36.6 68 20 100/80

02/10/24 6:00am 36.1 64 19 110/80

10:00am 36.5 74 20 100/80

38
 SIGNATORIES
NAME OF STUDENT: GLORIA

SIGNATURE…………………………………………………………………….

RANK…………………………………………………………………………….

DATE………………………………………………………………………………

NAME OF SUPERVISING TUTOR: MISS NIMATU

SIGNATURE……………………………………………………………………...

RANK……………………………………………………………………………...

DATE…………………………………………………………………………….

NAME OF CLINICAL SUPERVISOR…………………………………………

SIGNATURE……………………………………………………………………

RANK……………………………………………………………………………

DATE…………………………………………………………………………….

NAME OF COLLEGE PRINCIPAL: MRS. CAROL BOATENG

SIGNATURE……………………………………………………………………...

RANK……………………………………………………………………………...

DATE……………………………………………………………………………

39