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ASSESSMENT OF PATIENT/FAMILY
1.0 Introduction
considers the symptoms and signs of the condition, the patient's verbal and
nonverbal communication, the patient's medical and social history, and any other
information available. Among the physical aspects assessed are vital signs, skin
colour and condition, motor and sensory nerve function, nutrition, rest, sleep,
activity, elimination, and consciousness. Among the social and emotional factors
health care, mood, emotional tone, and family ties and responsibilities.
The assessment of the patient and family during admission is the first step of the
nursing process. This phase deals with the collection of data from the patient,
family, friends and existing medical records. Data collection is also based on
identify patient’s health problems so that the appropriate nursing care would be
rendered. This forms the basis of nursing care, since it aids the patient-centered
care needed.
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1.1 Patient’s Particulars
Patient’s particulars are the details of information of the patient that has been
recorded which includes; name, sex, date of birth and religion, marital status, next
Miss S.A.P. is the name of my client. She is 11 years old and was born on 8th
January, 2005. She was born to Mr K.A.M and Mrs A.B. who are both alive. Miss
S.A.P is the sixth born of seven Children: three males and four females. Miss
S.A.P. comes from Drobo in the Brong Ahafo Region and stays at Krupiese. She
lives with her Parents in house number D112, Block D, Kurpiese a suburb of
Drobo. She is a Christian and attends True Christ Apostle Church to be precise.
She is chocolate in complexion and weighs 32kg. She is about 1.2m tall. She is an
Akan and speaks only Twi. She is schooling and she is in class 4. Her next of kin
is Mr K.A.M. (Father).
Patient and Family’s Medical History provides information about illness which
such as sickle cell disease, hypertension, diabetes, mental illness as well as any
chronic disease such as, chronic heart failure and chronic renal failure in her
family. She also added that there are no communicable diseases like tuberculosis
attacks of headache, chills and fever which they go for over-the-counter (OTC)
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drugs, again her mother said this is her third time of being on admission and all
these hospitalizations were as a result of malaria. The siblings of Miss S.A.P. are
all in good condition of health and also treat minor ailments with over the counter
drugs but visits a health facility with major illnesses. There are no known allergies
in her family. I educated the patient and relative about buying over-the-counter-
drugs since it was not prescribed by the medical officer and it can lead to another
health complication.
role to play and rules to respect. Members of the system are expected to respond
relationship agreements.
Upon observations made on my patient, the relationship between her and the
family was very cordial since her relatives and friends visited her when she was
on admission to give her emotional support, bringing her food and other necessary
Patient’s father, Mr. K.A.M is a trader who supplies store goods to customers at
Drobo and he is the bread winner of the house. He is supported by his wife, Mrs
A.B who is also a trader. Their income is used in settling the family’s bills such as
up keeping of the family, school fees and hospital bills. They are able to provide
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They belong to the middle socio-economic class of the society. She goes to
church on every Sunday but does not join any association at church. S.A.P and
family have registered with the National Health Insurance Scheme (NHIS) and
this enables them to get free medical treatment when they fall sick. Patient’s
mother said she believes there are family values, taboos and cultural practices but
which the body reaches its point of complete physical development (Gillian,
2005).
nine months and did not experience any major complication during that period.
She attended antenatal clinic regularly at St Mary’s hospital, Drobo and had
Spontaneous Vaginal Delivery (SVD) at St. Mary’s hospital, Drobo. The date of
S.A.P was breastfed for 6 months and her mother started introducing
supplementary feeds such as porridge with milk. She was immunized against all
the childhood diseases that are the Bacillus Calmette Guerin (BCG), Polio,
Measles and Yellow Fever. This was evidenced by the (BCG) mark on her right
shoulder.
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According to S.A.P’s mother, she went through the average normal
was able to sit at six (6) months, and at the age of nine (9) months, she started
crawling. Her milk teeth started erupting at age nine (9) months and she started
walking at the age of twelve (12) months. At about the age one and half, she could
talk and could play with other children. Her permanent teeth started replacing the
milk teeth at the age of six (6) years. She started schooling at the age of (4) years
and started developing breast and pubic hairs at the age of eleven (11) years.
are eight (8) distinct stages with each possible result, thus either success or failure
fourth stage. During this period, the school age child learns to do things on their
own. The child may either feel encouraged or discouraged in their ability to
that she falls under competency (industry) since she is able to sing in church and
at school. According to patient’s mother, she saw her developing breast four (4)
5
month ago. She is aiming at becoming a nurse.
recreation, as well as personal habits such as smoking and the use of illicit drugs,
Miss S.A.P wakes up around 6:00am daily, brushes her teeth with tooth brush
and tooth paste, empties her bowel and takes warm bath. She empties her bowel
twice daily and empties the bladder whenever necessary. Miss S.A.P normally
takes porridge with bread or beverage/tea with bread in the morning, she takes
rice and stew or any food with fruit for lunch, Since she is a child, she normally
eats in between meals and in the evening, she normally eat fufu and soup or banku
and okro stew. However, she prefers banku and okro stew to other foods and also
drinks water frequently. After supper she goes to bed usually 8:30pm. She enjoys
staying with her mother whiles cooking, watching television and learn.
According to patient’s mother, she had been detained in the St Mary’s Hospital,
Drobo on two occasions, all with malaria and was treated with anti-malarial
drugs. She mostly get access to health care in the hospitals where she goes
because she has registered with the National Health Insurance Scheme but her
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mother again said anytime she suffers slight headaches, fever and other minor
ailments she treats with drugs bought from the chemical shop. She always
observes her personal hygiene regularly and lives in a tidy home environment but
Present medical history is the history of the present medical concern. It is the
single most important factor in helping the health care term arrive at a diagnosis
or determine the patient’s needs, it entail the Chief Complains(The reason for the
visit to the hospital) and History of present illness (Smeltzer & Bare, 2010).
According to patient’s mother, client was well until it was around 9:30am on 8th
August, 2016 when she realized that she was having high temperature, headache
and anorexia. She tepid sponged her and gave her 500mg paracetamol tablet. She
said it started the day before but it became very severe on this day which made the
mother rush her to St Mary’s hospital, Drobo around 10:30am. They first reported
After arrival her vital signs were checked and recorded which confirmed the fever
the patient’s mother was complaining of. She was seen by Dr. Benneh at A&E
and he ordered for her to be admitted to the Children’s Medical Ward. She was
tepid sponged and given tablet paracetamol 500mg stat, which made the
temperature reduced.
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1.8 Admission of Miss S.A.P
On 8th of August, 2016 at exactly 11:00am, Miss S.A.P was brought to the ward
through the Accident and Emergency Unit in a wheel chair in the company of a
student nurse and her mother. The mother complained of fever, anorexia,
headache, diarrhoea and general body weakness. She was seen and diagnosed
On observation, she looked weak. S.A.P’s mother was offered seat to sit and I
greeted them and asked them to feel at home. A comfortable and neat admission
bed was made for Miss S.A.P and her vital signs were checked and recorded as
follows:
Her weight was also checked and recorded as 32 kilograms and height recorded
was about 1.2m and random blood sugar (RBS) level was checked and it read
6.2mmol/L Physical examination on patient was done from head to toe and no
The following laboratory investigations were ordered and samples were taken to
the laboratory.
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White blood cell count (WBC)
The drugs were collected from the pharmacy and served as ordered.
The mother was assisted to send Miss S.A.P.’s belongings to the bedside. She was
once again tepid sponged because of the high temperature. I.V Artesunate 80mg
stat was served and intravenous 5% dextrose was set up. I expressed my interest
to her mother to use her for my care study because I wanted to know more about
the condition since it is one of the frequently occurring diseases in Ghana and I
also asked permission from the ward in-charge which she granted.
I orientated the mother to the ward and hospital routines explained to them whiles
she was made comfortable in bed. Miss S.A.P and mother were reassured of being
in the hands of competent health care team who were going to assist her to
recover fully. Miss S.A.P and mother were made to understand that the hospital is
a temporal home for her now and that she will be discharged home when the
condition gets better. The nurses present and other patients in the ward were
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introduced to her and all the necessary documentations were done at the nurse’s
station. Patient’s name was written in the admissions and discharges book and
then on the daily wards state. Her mother was there to help in caring for Miss
Patient is ignorant about her disease condition since she is a child. Her mother
however, admitted that she did not also know the cause of the illness but believes
She believes that God will restore Miss S.A.P’s health to normal and hopes she
recovers soon.
I took this opportunity to educate her mother on malaria; its causes, signs and
Definition
Malaria is an infection of the red blood cell caused by plasmodium, a single cell
transmitted by the bite of an infected female Anopheles mosquito (Parry & Gill,
2004).
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Malaria is an acute febrile disease which is typically transmitted through the bite
parasite and when this mosquito bites human the parasite is released into the
people through the bites of infected female Anopheles mosquito (World Health
Organization, 2016).
Incidence
Malaria is one of the most widely prevalent diseases in the world. It is a constant
In Ghana, it is the most common disease and accounts for about 40-42% of all
out-patient attendants. It also accounts for about7-9% of all certified death and
ranks fifth among the commonest cause of death in children below four years
Aetiology
Malaria is mainly cause by the bite from the female Anopheles mosquito, which
Epidemiology
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Malaria is the leading cause of death and disease in many developing countries.
According to the world health organization, world malaria reports (2011) and the
global malaria action plan, 3.3 billion people worldwide live in areas at risk of
In 2012, malaria led to 216 million clinical episodes and 655,000 deaths. An
the south-east Asian region and 3% in the eastern Mediterranean region. 86% of
all deaths worldwide are all children (World Malaria Report, 2012).
Mode of Transmission
its life time may infect several people. The mosquito is not infective
occur and hence a relapse due to dormant hepatic forms also does not
indicated.
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Five (5) species of plasmodium parasite cause malaria;
Plasmodium ovale
Plasmodium malariae
Plasmodium falciparum
Plasmodium vivax
Plasmodium knowlesi
Plasmodium ovale is a rare parasite restricted to the tropical climate and found
Plasmodium malariae are also found in the temperate and tropical regions but it is
Plasmodium vivax is the widely distributed parasite in the temperature and the
tropical climate regions. It has a cycle of 48 hours and fever presents every
48hours.
Plasmodium falciparum is the most serious type of the genus plasmodium because
of the development of the high parasite densities in blood. Infected Red blood
cells (RBCs) tend to agglutinate and from micro emboli (Parry & Gill, 2004).
Incubation Period
The incubation period is the length of time between the infective mosquito bite
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and the first appearance of clinical signs of which fever is most common. This
period is usually not less than 10days. The duration of incubation period varies
with the species of parasite and it ranges from 12-28 days (Parry & Gill, 2004).
The parasites are passed to the bloodstream through the bite of an infected Female
Anopheles mosquito in whose body the parasite has developed. They localize in
the cells of the liver, grow and multiply. This is known as Pre-erythrocytic phase.
From there, they enter into the erythrocytic phase. During this phase, the parasites
merozoites then attacks the red blood cells, terminates with rapture of cells and
At about two weeks or at times long periods, mosquito bite from an infected
The paroxysms of chills and fever that occur in malaria are due to liberation of
metabolic by-products of the parasites in the red blood cells. During the asexual
development of the parasite in man, there is a period of gametogamy, that is, few
merozoites develop into sexual forms of the parasite known as gametocytes. Thus,
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when an anopheles mosquito ingests a human blood containing gametocytes, this
marks the commencement of the sexual cycle of the plasmodium in the mosquito.
As some of the merozoites enter the red blood cell instead of developing into
schizonts they become male and female gametocytes. These are taken up into the
blood by the mosquito during a bite. The male gametocytes fertilizer the female
gametocytes to produce a zygote. This zygote then penetrates the stomach of the
mosquito to form a cyst called an oocyst. Inside the oocyst are large number of
sporozoites which mature and rupture off the cyst and spreads to the salivary
Bodily pains
Bodily weakness
Headache
Nausea
Vomiting
Abdominal pain
Poor appetite
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Diarrhea (Parry & Gill, 2004)
Diagnosis of Malaria
White blood cells (WBC) counts to rules out other possible infections
Medical Management
1. Fluid management
Intravenous fluids such as normal saline, ringers lactate and others are useful.
Patient with severe malaria are often relatively dehydrated due to combination of
2. Anti-malaria treatment
remains the parenteral drug of choice in Africa, as the first line drug for malaria
treatment.
hours and 24 hours. Total doses are 360-480 mg for adults. The vial of Artesunate
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(provided) and shaken 2-3 minutes for better dissolution. Add 5 ml of 5% glucose
in 20 mg/ml
Adverse Reactions
Transient
Note:
The solution should be used immediately after the powder is dissolved. It should
4. Analgesics and Antipyretics should be given for pain and fever e.g.
paracetamol.
5. Management of Anaemia
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Many people develop anaemia from severe malaria. Many people with
do well with oral anti malaria and haematinics. In severe cases blood transfusion
is recommended.
6. Management of Convulsion
0.3mg per kg (up to a maximum of 10mg in both older children and adults-rectal
respiratory distress, but its use has declined and not available in many settings.
malaria
A reasonable compromise is to target anti biotic to those at high risk. (Parry and
Gill, 2004)
Reassurance (Psychotherapy)
Patient and relatives are reassured that, they are in the hands of competent health
personnel who are ready to help patient to recover. Rapport with client and
relatives should be established to help gain their trust and support in the care
given and also involve client and relatives in the care and treatment been
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provided. Client and relatives should be encouraged to ask questions and answer
them in straight and simple terms. Each procedure to be performed on the client
other clients on the ward who have successfully recovered from malaria. This will
help relax client, allay fears and anxiety and to gain client’s cooperation.
This is ensured to conserve energy, promote relaxation and healing process. Rest
and sleep could be achieved by making bed free from creases, giving warm bath
to relax the muscles of the patient, minimizing the noise on the ward by reducing
the volume of the radio and television sets and restricting visitors. Also, nearby
Position
Observation
Vital signs, that is temperature, pulse, respiration and blood pressure are
Infusion site is observed for patency and fluid intake and output chart is
the mental orientation of the patient to time, place and persons are observed as
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In patients with fever, if there is chills, more clothing are added to keep him or her
warm, nearby windows are closed and fans are put off.
In hot stage, extra blankets or clothing are removed, patient is tepid sponged to
reduce temperature. Nearby windows are opened and cold nourishing drinks are
served. Vital signs are checked and compared with baseline vital signs.
Personal Hygiene
Good personal hygiene is ensured from hair to toe by washing patient’s hair with
shampoo and water, and cutting of fingernails and toenails to prevent harboring of
Patient’s mouth is cared for with toothbrush at least twice daily to prevent
infection and stimulate appetite. Patient could be given bed bath or assisted bed
bath to remove dirt and microbes from the skin, to improve circulation and also
patient’s comfort. At least, the bath should be twice daily and pressure areas like
the occiput, sacrum and shoulder are treated by applying soap into the palm and
Nutrition
provide energy, vitamins to aid to improve the immune system and protein to
Food should be served in bits and dirty rags and bedpans should be removed from
the scene. Patient’s food of choices should be served and should be attractive
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enough to increase his appetite. Patient’s diet should be planned with her taking
Exercise
boredomness. Exercises also help peristalsis and help remove toxins from the
body.
Elimination
Patient is served with bedpan and urinal on demand. Fluid and roughage intake is
the lower abdomen to relax the muscle and aid urination. If all these nursing
Education
People infected with plasmodium, especially that of ovale and vivax type
may harbor the parasite (plasmodium) in their liver cells after treatment
chocked gutters.
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The signs and symptoms such as high body temperature, nausea and
vomiting should be made known to people to enable them seek for early
treatment.
All patients should be told to return to the hospital for blood examination
after 4-5 days completion of treatment to assess whether the parasite has
been completely eliminated from the body and to sleep under a well-
Prevention
According to Parry and Gill (2004), people travelling to malaria endemic regions
The use of mosquito repellents may help reduce the number of mosquito
attacks
The use of insecticide treated bed nets prevents the mosquito from biting.
attraction
methods
measures to prevent the occurrence of the disease and this can be done by
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All patients should be encouraged to complete their courses of malaria
treatment.
Complications of Malaria
According to Parry and Gill, 2004, client with severe malaria may suffer the
following complications;
parasite) block small vessels in the brain and this mostly occurs when
tissues.
hepatic failure.
erythrocytes causes failure of blood flow to the vital organs of the body
(circulatory collapse).
Severe anemia- malaria damages many red blood cells, which causes
severe anemia.
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Bleeding abnormalities- there is low platelet count in severe malaria that
These complications mostly come about when early treatment is not given.
This information obtained from Miss S.A.P and her family, medical records,
health professionals and references from books is considered valid for the purpose
they have served because there was congruity between these data sources.
Findings of the home visits also authenticate the data, making it valid to serve its
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CHAPTER TWO
ANALYSIS OF DATA
2.0 Introduction
data with the goal of discovering useful information and suggesting decision
making. Data analysis has multiple facets and approaches, encompassing diverse
This aspect of the care study deals with the critical examination and interpretation
of the data collected during the assessment of the patient. Here, there is a
comparison between the results of the investigations carried out and the normal
literature review to that of the client. This chapter also deals with the patient and
family strengths, their health problems and their corresponding nursing diagnosis.
A. Diagnostic Investigations
The following investigations were carried out on my client to aid in the diagnosis
and treatment;
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White blood cell count (WBC)
The table below displays the results of the above mentioned investigations
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Table 1: Comparison of Diagnostic Investigations carried on Miss S.A.P with that of the Standards.
(MPs) (0hr,12hr,24hr)
anaemia given.
8/8/16 Blood White blood cells 8.26 x 103/μL 4 x 103/ μL – 11 x 103/μL Result was within No treatment
the presence
ofinfection
8/8/16 Blood Red Blood Cell 4.75x 106/ μL 3.00 – 5.80x106/μL Results were within No treatment
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Based on the test done, it was confirmed that the patient had malaria.
With reference to the literature review, Miss S.A.P’s condition was due to the
presence of malaria parasites in the blood. The malaria parasites were introduced
into the blood through the bite of an infected female anopheles mosquito. On
observation during my home visit, I realized that the mosquitoes were from
Literature review
1, Anti malaria:
(i) Artesunate Intra Venous Artesunate 80mg (0hour,12hours,24hours) was given
(ii) Quinine was not given
(iii) Artemether Lumefantrine Tablet Arthemeter Lumefantrine (20mg/120mg) 12 hourly x 3days was
given
3 Management of Anaemia
(i) Haematinics Tablet Fersolate 200mg daily x 30day was given
(ii) Blood transfusion Patients was not transfused
4 Management of convulsion
(i) Diazepam Was not given
(ii) Phenobarbitone Was not given
6 Fluid management
(i) Normal saline Was not given
(ii) Ringers lactate Intravenous Fluid Ringers Lactate 1 liter over 24 hours was given
(iii) Dextrose water Intravenous Fluid 5% Dextrose 1 liter over 24 hours was given
(iv) Oral Rehydration Salt Three (3) sachets of Oral Rehydration Salt were given was given
The treatment given is in line with the treatment in the literature review which
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Table 4: Pharmacology of Drugs
Date Drug Patient Classification Desired Actual Effect Observed Side Effect Remarks
Dosage/Route Effects
8/8/16 Tablet 200mg daily x Multivitamin To increase Miss S.A.P’s condition Gastro-intestinal Patient did not
Fersolate 30days. appetite and improved as the irritation, nausea manifest any of
Orally haemoglobin haemoglobin level was and epigastric these side effects.
8/8/16 Tablet 500mg tds Antipyretic To reduce pain Miss S.A.P was relieved Skin reactions None was
Paraceta ×5days and Analgesic and fever of fever such as itching. exhibited by the
analgesic) damage
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Table 4: Pharmacology of Drugs continued
Date Drug Patient Classification Desired Effects Actual Effect Side Effect Remarks
Dosage/Route Observed
8/8/16 Artesunate (0hours, Anti-malarial To eradicate the Patient was Abdominal pain, None was
80mg 12hours, causative organism relieved of the headaches, exhibited
24hours) per (plasmodium signs and dizziness,
Intravenous falciparum) in the symptoms like palpitations, hot
blood chills and fever. and flushed skin.
8/8/16 5% 1 liter over 24 Caloric agent, To supplement Client was Confusion, None was
Dextrose hours plasma volume caloric needs of the hydrated and her pulmonary observed.
Solution Intravenously expander and client and to energy restored. embolism, fluid
replacement maintain electrolyte overload,
fluid (glucose balance. Glucosuria and
solution). osmotic diuresis.
10/08/16 Intravenou 1 liter over 24 Intravenous To maintain Patients electrolyte Oedema. Oedema not
s Ringers hours electrolyte and electrolyte body and fluid balance observed on
lactate Intravenously fluid fluid balance was maintained the patient.
Solution replacement
10/08/16 Oral 1.5 liter over 8- Anti-diarrhoea Replacement of Diarrhoea stopped Puffy eyes. It was not
rehydratio 24 hrs fluid and electrolyte completely on the observed
n salt Orally loss. 12/08/16
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(E) Complications
With regards to the complications listed under the literature review, Miss
S.A.P presented with mild form of anaemia with Hb of 11.3g/dL. She was not
transfused, however she was managed with diet and haematovites (fersolate).
The strength of the patients and the family involves what can be done on their
The patient/family strengths are the coping strategies that can enable them
patient.
Patient was able to tolerate oral fluids. (about 1.5 liters in a day)
32
appropriate measures. The client had the following problems.
(8/08/16)
(9/08/16)
5. Risk for pressure ulcer related to prolong stay in bed secondary to body
weakness. (9/08/16)
6. Risk for deficient fluid volume related to frequent passing of loose stools.
(10/08/16)
(Nanda 2015).
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CHAPTER THREE
3.0 Introduction
Planning for the patient/family care is the third stage of the nursing process. It
involves the developing of plans designed to reduce, correct and prevent the
and implement an effective nursing care plan, the nurse has to draw a care
plan with the patient and his family on the various nursing problems
identified. This will serve as the tool for the nurse to keep record of the
patient’s health needs and provide the basis for continuity of care for the
The under listed objectives were set to solve the health problems of Miss
S.A.P.
hours
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Client will regain her normal nutritional pattern(good appetite) within
72 hours
hospitalization.
hospitalization.
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Table 4: Nursing Care Plan for Miss S.A.P and Family
Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/Time Evaluation Sign
Time Diagnosis Outcome Criteria
8/08/16 Ineffective Patient will have (1) Monitor patients vital (1) Patients vital signs were 9/08/16 Goal was
12:30pm thermoregula normal body signs and record especially monitored especially 12:30pm fully met as
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Table 4: Nursing Care Plan for Miss S.A.P and Family Continued
Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/Time Evaluation Sign
8/08/16 Impaired Client’s body comfort (1) Ensure adequate oral (1) Fluid was served 09/08/16 Goal was
12:30pm comfort will be restored within fluid intake to maintain adequately in maintaining 12:30pm met fully as
(headache) 24 hours as evidenced circulatory volume and circulatory volume patient said
by: restore comfort (2) Client was involved in
related to she no longer
(1) Client verbalizing (2) Provide diversional conversations with relatives
disease has headache
that she no longer has therapy (3) Patient’s bed was neatly
process.
headache (3) Well prepare patient’s laid to promote comfort
comfort
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Table 4: Nursing Care Plan for Miss S.A.P and Family Continued
Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
8/08/16 Imbalanced Patient will regain her (1) Ensure oral hygiene (1) Oral hygiene was ensured 11/08/16 Goal fully
(less than pattern(good appetite) (2) Plan meal with patient (2) Client meal was plan could eat
within 72 hours as accordingly to her choice
body more than
evidenced by; (3) Patient’s favorite meals like
requirement) (3) Prepare and serve half of the
(1)The nurse observing banku with okro soup were
related to patient’s favorite meal food served.
that patient eats more prepared and served attractively.
attractively
anorexia
than half of her meals (4) Food was served in bits and
(4) Serve food in bits and at
served. at regular intervals.
regular interval.
(2)Patient’s mother (5) Fruits such as oranges were
(5)Serve fruits after meals.
verbalizing that her served after each meal.
(6)Eliminated unpleasant
daughter appetite has (6)Unpleasant sights example
and nauseating articles from
been restored bed pan, bins and odors were
sight of the patient before
eliminated before meal.
meal
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Table 4: Nursing Care Plan for Miss S.A.P and Family Continued
Date/Time Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Diagnosis Criteria Time
9/08/16 Disturbed Patient will be able to 1. Perform all nursing 1. Nursing activities were perform when 11/08/16 Goal fully met
necessary to promote sleep
9:00am sleeping sleep for at least 6 -8 procedures at a goal 9:00am as patient had
hours in the night within 2. Give patient warm bath
pattern 2. Patient was given a warm bath to relax uninterrupted
48 hours as evidenced before she goes to bed at and induce sleep.
(insomnia) sleep for 6
by: night
related to 3. Patient’s bed was made free from hours
1) Nurse observing that 3. Make bed comfortable.
particles, creases and cramps.
change of
patient was able to 4. Ensure quiet 4. A quiet environment was ensured by
environment restricting visitors and reducing the
sleeps for at least 6 environment.
volume of radio and television sets.
hours uninterrupted.
2) Patient’ mother 5. Provide dim lights. 5. Lights on the ward were dimmed in the
evening to enable patient to sleep.
verbalizing that she was
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Table 4: Nursing Care Plan for Madam A.A. and Family Continued
Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Criteria
9/08/16 Risk for Patient will not 1. Asses and monitor for patient’s 1. Clients pressure area was assessed and 13/08/16 Goal fully met
6:00pm pressure ulcers develop any pressure area monitored on daily bases 9:00am as patient did
related to bedsores within the 2. Change position of patient every 2. Patient’s position was changed every 2 not have any
prolong stay in period of 2 hours hours to prevent bedsores.
bedsores on the
bed secondary hospitalization 3. Treat pressure areas 3. Pressure areas were treated with soap
day of
to body as evidenced by; and talcum powder after bathing.
discharge
weakness Nurse observing 4.Engage patient in passive 4.Patient was assisted to sit up and to
good skin integrity 5. Change soiled linen frequently 5. Soiled linens were changed frequently
with no ulcers after 6. Straighten bed linens regularly to 6. Bed linens were straightened regularly
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Table 4: Nursing Care Plan for Miss S.A.P and Family Continued
Date/Time Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
10/08/16 Risk for Patient will maintain 1. Reassure client and relatives 1. Client was reassured that the diarrhoea 12/08/16 Goal was
deficient normal fluid volume that diarrhoea will stop will subside with time.
6:00am 6:00am fully met
fluid during the period of
2.Assess patient ‘s skin turgor 2.Patient skin turgor was assessed for
volume hospitalization as
signs of dehydration
related to evidenced by;
frequent 1.nurse observing the 3.Weigh patient daily 3.Patient was weighed daily to prevent
ordered
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CHAPTER FOUR
4.0 Introduction
any design for doing something. As such, implementation is the action that must
follow any preliminary thinking in order for something to actually happen (Rouse,
2007).
This chapter forms part of the patient and family care study. It gives a vivid
account of the actual nursing care that was rendered to the patient and family from
the day of admission until discharge based on the health problems identified. It
also deals with follow up visits and home visits to ensure continuity of care.
Miss S.A.P was admitted to the children medical ward of the St Mary’s Hospital,
Drobo through the Accident and Emergency Unit (A&E) at 11:00 am, where she
was diagnosed with malaria. The patient and relative were given a warm reception
and offered seats on arrival at the ward. The patient’s particulars were handed to
the ward nurse by the accompanying nurse. Miss S.A.P was brought to the ward
with the complaints of fever, anorexia, general body weakness and headache. On
examination, patient looked weak and a bit pale. The patient and relative were
reassured of the readiness of the health team to do their best to help the patient
42
recover. Miss S.A.P was made comfortable into an already prepared admission
Miss S.A.P’s relatives were assisted to send her belongings to the bedside. She
was tepid sponged to reduce the pyrexia. I introduced myself to patient and family
and sought for her consent to take her for my care study. She accepted and I
orientated the relatives to the ward and hospital routines were explained to them.
Miss S.A.P and relatives were reassured of being in the hands of competent health
care team who were going to assist her to recover. The nurses and other patients
in the ward were introduced to her and all the necessary documentations were
done at the nurses’ station. Patient’s name was written in the admissions and
discharges book and then on the daily wards state. Miss S.A.P and relatives were
also encouraged to contact any nurse on duty any time they needed help. Ordered
medications were taken from the pharmacy and treatment started immediately.
43
Oral Rehydration Salt 3 sachets
Blood film for malaria parasite, Full blood count, White blood cell count and
Blood for sickle cell test were ordered and carried out.
8/8/16 and an objective was set to relieve the fever within 24 hours. The nursing
ventilation, tepid sponging patient, serving cold drinks and serving prescribed
analgesics to help relieve headache. On the same day, patient was having loss of
appetite at 12:30pm and ensuring oral hygiene (mouth care), preparing and
serving patient’s favorite meals attractively, serving food in bits and at regular
interval were some of the nursing interventions carried out to help achieve the
She was tepid sponged and the temperature was checked again at 8:00pm and
recorded as 37.2oC. She was handed over to the night nurses at 8:00pm. After the
44
Second Day of Admission: 09/8/2016
The following day Miss S.A.P. woke up at about 2:30am and was not able to
sleep again. Around 5:30am, she had her teeth brushed and had her bath. Her bed
was laid and the locker and bed side table cleaned. The night nurse reported that
the client was unable to sleep well which was as a result of change in
objective was set to enable patient sleep for at least 6-8 hours in the night within
48 hours. She was made aware that nursing interventions such as giving a warm
bath to relax and induce sleep, ensuring quiet environment by restricting visitors
and reducing the volume of radio and television sets and dimming of lights on the
ward in the evening would help her sleep in the night. She was made to
understand that all these measures together with her cooperation will enable her
gain her normal sleep pattern. She was fed with porridge and bread as breakfast.
Paracetamol 500mg tid, Tablet Fersolate 200mg. At 9:00 am, the ward doctors
came to review her condition. The doctors ordered for continuity of treatment.
She was reassured that her body comfort will be restored. Client was involved in
45
the patient was informed of my intentions to visit her home the next day. She
Client was found always lying in bed due to weakness. There was the possibility
for her to develop pressure ulcer when it continues for long time and an objective
was set to prevent patient from developing pressure ulcer throughout the period of
hospitalization. Client was made to understand this and was encouraged to sit in
bed and walk around. She was reassured that there are other nursing interventions
that were going to be ensured to help prevent her from developing bed sore.
Patient was served with cold fruit juice to refreshes her and provides her with
the objective set to help reduce patient’s temperature. The goal was met as
temperature reduced to 36.0oC. Client was given a warm bath and she slept
around 10:30pm.
On the third day, Miss S.A.P woke up around 5:30am and had her personal
hygiene maintained. Patient gave complaints of passing diarrhea stools for four
times throughout the night. The nursing diagnosis risk of deficient fluid volume
related to frequent passing of losing stool was made and an objective of patient
maintaining her normal fluid volume within period of hospitalization was set and
she was given coconut water to reduce the diarrhoea. She was reassured that the
medical officer would be informed during ward rounds and was encouraged to
take in more fluids. As usual all her drugs were given to her according to
prescription and documented. Vital signs checked and recorded at 6:00am were;
46
Temperature 35.5 degrees Celsius (oC)
She was served with “hausa porridge and koose” and she was able to take half.
During ward rounds, client lodged the complaint of passing four diarrhoea stools
in the night and Intravenous Fluid Ringers Lactate 1 liter over 24hours and Oral
Rehydration Salt 3 sachets were ordered for her. Miss S.A.P was educated on diet
and the need to take in foods rich in vitamins, minerals and proteins to help boost
the immune system. She was also educated on her disease condition, which
included the causes, signs and symptoms, management, and its associated
complications. All other nursing interventions were carried out. She was reassured
that the passing of the diarrhoea stools will subside with the start of treatment.
Miss S.A.P’s pressure areas were treated after bathing. Her position was changed
every 2 hours, and soiled linens were changed to prevent pressure ulcers. Her bed
was neatly laid to promote sleep and body comfort. In the afternoon, her relatives
prepared banku and okro stew. She was served in bits, after which she was given
client to visit her home as previously discussed. She gave me the permission and I
went with one of her sister’s which paved way for the other family members to
have enough knowledge on malaria. She complained that she was still having
headache which was making her uncomfortable. Her mouth was rinsed after
47
Fourth day of Admission: 11/8/2016
This morning, Miss S.A.P woke up around 5:30am. She lodged no new
complains. She verbalized it herself that she is doing well with treatment. Vital
informed her about my findings during the home visit and it was mainly about
them weeding behind their house since that place was conducive for breeding of
mosquitoes and draining of the choked gutters. Again I told her I will make other
visits to her after she is discharged. Miss S.A.P was found still weak in bed so she
was assisted in sitting up in bed and to walk around in form of passive exercises.
Her personal hygiene was maintained and her pressure areas were treated. She
was able to consume more than half of her meals. At 9:00am evaluation was
and patient’s mother verbalized that she was able to sleep throughout the night.
She was reviewed by the doctors during ward rounds and the plan was to continue
the treatment. She verbalized that the passage of the diarrhea stools had subsided
as she passed her normal stools this day. Miss S.A.P was served with lunch and
she was able to eat all the food. Her bed linen was straightened to prevent
nutrition (less than body’s requirement) related to anorexia and it was found out
48
that client could eat more than half of the food served so goal was fully achieved.
Miss S.A.P woke up around 5:00am. She was very strong and looked healthy as
she verbalized that she was able to sit and walk without support. Patient’s
personal hygiene was maintained. Vital signs were checked and recorded as
Temperature 35.8oC
Pulse 68bpm
Respiration 16cpm
Her drugs were given and made comfortable in bed waiting for ward rounds. At
exactly 6:00am an evaluation was made on the diagnosis risk of deficient fluid
volume related to frequent passing of loose stool and patient mother verbalized
that the diarrhoea stools have stopped. Again she was observed to have good skin
turgor with no sign of dehydration. During ward rounds that morning, Miss S.A.P
and the family were informed of a possible discharge the following day. The
review and discharge news were explained to my client and family members who
were around. They were so happy at the news. The various routine nursing
activities on the patient were carried out and the patient was able to eat all the
food given to her. Education on malaria was given to them again and the need for
49
Sixth Day (Day of Discharge): 13/8/2016
I arrived at the ward at 7:00am on this day to find Miss S.A.P looking cheerful.
The night nurse told me how well client slept throughout the night. I was told she
had already observed her personal hygiene. Vital signs were checked and
recorded as:
Temperature 36.0oC
Pulse 64bpm
Respiration 15cpm
discharged home and to report for review on 19th August,2016. The doctor
ordered tablet Paracetamol 500mg tid x 5days and to continue with the tablet
Fersolate 200mg daily. An evaluation on risk for bedsore was done and Miss
S.A.P. did not have any bedsores upon discharge. Education was given to her on
the need to complete the medication given, diet and proper sanitation and the need
to report any observed sickness on time to prevent future complications was also
stressed. The date for review was on the 19th, August 2016 was communicated to
them. I informed her that the care will be terminated sometime to come and she
was grateful to me for what I had done for her so far. The folder was sent to the
accounts office for billing. Her particulars were entered on the admissions and
discharges book and daily ward bed state. The folder was later taken to the
pharmacy for the medications ordered. Around 11:30am, Miss S.A.P was ready to
50
go home. I later escorted them out of the ward where one of her sisters had
Terminal disinfection of the bed and the linen was done to prevent cross infection
to other patients and the bed was made ready for another patient.
Preparation of Miss S.A.P and her family towards discharge and rehabilitation
started on the first day of admission. The fundamental aim was to enable her and
the family to take active role on her speedy recovery and also stress the need to
visit the hospital any time she is sick for prompt treatment to avoid complications.
The client and family were educated on the main cause of malaria, the mode of
They were advised to sleep in insecticide treated bed net, use mosquito repellent
creams and to wear long dresses and socks at night. They were also advised to
drain all stagnant waters and to clear all bushes around the house. The client and
family were advised to avoid self-medication and the need to report to hospital for
proper treatment when they fall sick. I also educated them on the importance of a
well balance diet and proper room ventilation. The need to drink clean water and
They were made to understand the essence to know the disease condition of the
client any time she visit the hospital and seek advice on the condition and
preventive measures about malaria. They were made to understand that abiding by
51
all these will prevent them from illnesses like malaria, cholera, diarrhoea and
anaemia.
On Wednesday, 10th August, 2016, I made my first visit to client’s home while
she was still on admission. I took off at 2:00pm. I boarded a taxi together with one
of her sisters. Within the next 5 minutes, we arrived at Krupiese. The aim of the
visit was basically to find out about the environment in which the family live, to
help identify possible health problems in the area and establish a link between the
problems and my client condition and then help remedy the situation through
health education.
Krupiese is a suburb of Drobo, and is about 1 kilometers from Drobo. Their house
is behind St Mary’s Hospital Drobo. I was warmly welcome by one of the sisters
of Miss S.A.P and a seat was offered me as well as a glass of water. I introduced
myself as a second year student of Holy Family Nursing and Midwifery Training
care study project and they were glad to see me. I made various observations
whiles I was in the compound. They live in a completed boys quarters’ which is
In front of the house, there is a kitchen and a bathroom whiles they had their toilet
52
The house was plastered but not painted. It is roofed with iron sheet. The
windows were made of wooden louver with net in the windows. They obtain their
water from borehole that was beside their house but they dispose their refuse near
There were also weeds at the back of the house. I then took my time to educate
them on the need for them to clear around the house to prevent mosquitoes from
breeding and also sleep in insecticide treated nets. I sought for permission to enter
their kitchen and there I saw some utensils that were not washed after they were
used and also their rubbish bin to have a lid. I educated them on the health
problems that these things can bring about including cholera and diarrhoea.
Lastly, I encouraged them to drain all stagnant waters on the compound to help
prevent breeding of mosquitoes. They were much grateful and thanked me a lot. I
also thanked them and asked permission to leave and informed client’s sister that
there will be another visit to Miss S.A.P and her family after discharge.
My second home visit was on Sunday, 14th August, 2016. The purpose of the visit
was to find out how they were coping with the treatment regimen after discharge,
ensure continuity of care, and remind them on the review date and re-enforce the
education that had been given earlier during Miss S.A.P’s hospitalization. I set off
around 10:20am in the morning, and arrived at the house at exactly 10:35am.
Before I entered the compound, I saw that the weeds around the house had been
cleared. I thanked Miss S.A.P family for heeding to my advice. I was very happy
window to see if they were now sleeping in an Insecticide Treated Net (ITN)
surprise, they had opened their windows for proper ventilation. I had a
conversation with Miss S.A.P and the family. I was very happy to hear the
also stressed on the preventive measures especially the use of treated mosquito
nets, draining of stagnant water and weeding around their house whenever it is
gutters
During the visit, I reminded them of the date of review which was August 19,
melon and pineapples to the family to give to Miss S.A.P. I asked permission and
they really thanked me for my support and care rendered to the family. They
Review (19/08/2016)
On 19th August, 2016, Miss S.A.P arrived at the hospital premises around 8:30am
in a very cheerful and healthy state accompanied by her mother, A.B. They were
very excited to see me and we exchanged greetings, had a little interaction and I
went for her folder at the records department. I escorted them to the outpatient
department and checked her vital signs and it was recorded as;
Temperature 36.5oC
54
Pulse 70bpm
Respiration 18cpm
She was scheduled to meet doctor at clinic two (2). At the consulting room,
patient gave no new complaints and she was asked to continue her already
prescribed haematovite. We left the consulting room and they boarded a taxi at
On the said date, I went for my third home visit. This was to see how she was
doing after her review. I set off at around 10:15am and arrived at around 10:30am.
Everybody was doing well. Since this was my last visit, I took my time and
highlighted on the various health education that I had previously given. I also re-
enforced that they should always report to the nearby clinic or hospital whenever
they fell sick and they should not practice self-medication. They were grateful and
promised to adhere to the education. She was handed over to the community
I thanked them for the opportunity offered me to take her and the family for the
care study. With this I told them that I may not be able to visit them frequently as
before, because the care has been terminated but assured them of friendly visits.
55
CHAPTER FIVE
5.0 Introduction
This chapter examines the benefit of the nursing care that was rendered to the
patient and her family. It also talks about assessment of the nursing interventions
rendered to the patient and her family and their response to the interventions. The
Statement of evaluation
Amendment of the patient/family care plan for partially met and unmet
objectives
Termination of care
On 8th of August, 2016 at 7:30pm, the problem of fever was identified and
were reassured of the readiness of the health team to help her recover. Tepid
56
sponging was done whenever necessary to reduce the fever, ensuring adequate
interventions were carried out to control the pyrexia. The set objective was fully
On the 8th of August, 2016, at 12:30pm, client complained that she was having
headache which made her uncomfortable. She was reassured that her comfort will
be restored within 24 hours. Patient’s bed was neatly laid to promote rest and
client was encouraged to take in much oral fluids. Goal was fully met on 9th
August, 2016 at 12:30pm as patient verbalized that she no longer had headache.
11/08/2016
On the 8th of August, 2016, the problem of loss of appetite (anorexia) was
identified when patient complained that she was not able to eat well at 12:30pm.
Goal was set for patient to regain good appetite within 24 hours. The following
are some of the interventions carried out to help achieve the set objective; client’s
mouth was cleaned twice daily before and after meals, client’s favourite meal was
prepared and served, food was served in small quantities at regular intervals and
fruits such as oranges were given after meals. On the 11th August, 2016, within 72
57
hours the goal was fully met as patient could eat more than half of the food
served.
4. Miss S.A.P was able to sleep for at least 6-8 hours in the night on
11/08/2016
9th August, 2016 at 9:00am. Objective was set that she will be able to sleep for at
least 6-8 hours in the night within 48 hours. Patient was reassured that she will
have her normal sleep within 48 hours. Serene Environment such as good
ventilation and noise free environment was created for patient to sleep. Visitors
were controlled from disturbing the patient when she was asleep. Nursing
Comfortable bed was provided. Lights on the ward were dimmed in the evening
to enable patient to sleep. Goal was fully met on 11th August, 2016 as patient was
On the 9th August, 2016 at 6:00pm, it was realized that client was at risk of having
bedsores due to prolong stay in bed secondary to weakness. A goal was set to
prevent pressure ulcers within the period of hospitalization. Patient was reassured
that she will not develop any pressure ulcers. Miss S.A.P’s position was changed
every 2 hours to prevent pressure ulcers. Her pressure areas were treated with
powder after bathing, soiled linens were changed, and bed linens were
58
straightened regularly. Patient was assisted to sit up and to walk around as a form
of passive exercise. On the day of discharge, 13th August, goal was fully met as
client had no pressure ulcers as evidenced by good skin integrity upon discharge.
On the 10th August, 2016 at 6:00am, patient complained of passing four diarrhoea
stools in the night which could make her have potential fluid volume deficit. An
objective was set that patient will maintain normal fluid volume within the period
of hospitalization. Patient was encouraged to take in more oral fluids. Patient was
also given O.R.S and Ringers Lactate as ordered by the physician and at the end
of the intervention goal was fully met on the 13th August, 2016 as patient showed
no signs of dehydration and had good skin turgor and also verbalized that the
5.2 Amendment of Nursing Care Plan for Partially Met and Unmet Outcome
Criteria.
No amendments were made in the care plan written for Miss S.A.P. and her
family. All goals set were achieved on the allocated time due to necessary support
and co-operation received from the patient’s family and other members of the
The nursing care rendered to the patient and family was terminated on 1st
September, 2016. The causes, signs, symptoms, and prevention of malaria were
59
explained to the patient’s family. They were also educated on the importance of
good nutrition.
I educated them on the need for S.A.P to complete the rest of the treatment they
personal hygiene and its importance was given to the patient and family. Finally, I
thanked the patient and her family members for their support and co-operation
throughout the care and having allowed me to use them for the care study. I
informed them about the need to terminate the care since Miss S.A.P. was very
strong and healthy. I entreated them to report to the nearest health facility in their
occurs. I assured them that friendly visit would be made anytime I come to their
area.
Due to the prior preparation of patient and family for termination of care, they did
not experience any separation anxiety since they were already aware that our
60
CHAPTER SIX
6.0 Introduction
This is the last step of the patient and family care study which entails the student’s
personal appreciation of the therapeutic relationship with the patient as well as the
6.1 Summary
Miss S.A.P, 11 years old girl was admitted on the 18th June, 2018 at the paediatric
ward of Holy family Hospital,Berekum through out patient derpartment. She was
brought into the ward in a wheel chair in the company of a student nurse and a
parasite; full blood count and blood for sickle cell test were requested and
specimens were sent to the laboratory for investigations to be carried out. Miss
S.A.P. spent six (6) days on the ward and during her stay six (6) nursing problems
were identified. Objectives were set for these problems and both medical and
24hours, Intravenous Fluid Ringers Lactate 1 liter over 24hours and Oral
Rehydration Salt 3 sachets. Patient was nursed on a well prepared bed which
made her comfortable; explanation of every procedure was done to the patient and
61
relatives. Before discharge, education on diet, sanitation, review and continuity of
drugs were given. Three home visits were made, one during admission and the
other two after discharge. S.A.P was discharged on 13th August, 2016 without any
complications. Care for Miss S.A.P. was terminated on the 1st September, 2016
6.2 Conclusion
In conclusion, the study has given me the insight into the condition, Malaria.
This study has actually helped me to put theoretical studies in the lecture hall into
practice using the nursing process and with this I am sure it will be of much help
to me anytime I come in contact with a patient with Malaria and other disease
conditions.
The study has deepened my relationship with patients, families and the people in a
individualized and holistic care to Miss S.A.P and family which helped with her
early recovery.
The study is very essential because it is a form of research which helps identify
certain health problems relating to individuals, their families and community and
In brief, I really enjoyed writing this script despite the challenges involved
including financial constraints and getting the needed information from patient
and family.
62
BIBLIOGRAPHY
Berman, A., Snyder, S. J., Kozier, B. and Erb, G. (2008). Kozier & Erbs
Inc.
22/08/2016
www.genopro.com/genogram/family-Systems-theory/.
www.medicalnews today.com>articles
Ellis, R. J. and Bentz, M. P. (2007). Modules for Basic Nursing Skills (7th ed).
www.healthnettpo.org/malariaafghanistan.com on 5/10/2016
Mensah, A.E. (2012). Pharmacology and Therapeutics. (2nd Ed) Excel Print,
63
Ministry of Health. (2004). Standard Treatment Guidelines. (5th Ed.). Justice
www.en.m.wikipedia.org/org/wiki/Data_analysis on 03/10/2016
www.searchcrm.techtarget.com/definition/implementation on
02/9/2016
www.who.org.edu/user_summary/2014-15/ on 03/09/2016
64
Patient Folder Number - 1992/16
65
APPENDIX
Table 6: Vital Signs Chart of Miss S.A.P
Date Time Respiration(cpm) Pulse (bpm) Temperature (OC)
66
SIGNATORIES
The Supervisor
Name: Mr. Isaac Asante
Signature:……………………………………………………………………
Date:………………………………………………………………………………
The Nurse In-Charge of The Children’s Ward (St. Mary’s Hospital, Drobo)
Name:……………………………………………………………………………
Signature:……………………………………………………………………
Date:………………………………………………………………………………
67