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PATIENT/FAMILY CARE STUDYON A PATIENT WITHSEVERE ANAEMIAAT TAMALE WEST HOSPITALWRITTEN BYSERWAA BERTHA ODAMEA FINAL YEAR STUDENT OF THE COLLEGE OF NURSINGAND MIDWIFERY NALERIGUSUBMITTED TO THE NURSING AND MIDWIFERY COUNCIL OF GHANA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF CERTIFICATE IN REGISTERED GENERAL NURSINGMAY, 2016TABLE OF CONTENTS TOC \o "1-3" \h \z \u PREFACE PAGEREF _Toc321944651 \h iACKNOWLEDGEMENT PAGEREF _Toc321944652 \h iiINTRODUCTION PAGEREF _Toc321944653 \h iiiCHAPTER ONE PAGEREF _Toc321944654 \h 1Assessment of Patient and Family PAGEREF _Toc321944655 \h 11.1 Patient’s Particulars PAGEREF _Toc321944656 \h 1 1.2 Patient’s Family Medical History21.3 Socio-Economic History PAGEREF _Toc321944658 \h 21.4 The Patient’s Developmental History PAGEREF _Toc321944658 \h 21.5 The Patient’s Lifestyle and Hobbies31.6 Patient’s Past Medical History PAGEREF _Toc321944660 \h 31.7 Patient’s Present Medical History41.8 Admission of the Patient PAGEREF _Toc321944662 \h 41.9 Patient’s Concept of Illness61.10 The Literature Review on Anaemia61.11 Validation of Data15CHAPTER TWO162.1 Comparison of data with standards16b. Causes of Patient’s Illness18d. Specific Medical Treatment19e. Complications212.2 The Patient / Family Strengths212.3 Patient Health Problems212.4 Nursing Diagnosis22Chapter Three23Planning for Patient/Family Care233.1 Nursing Objectives23CHAPTER FOUR30Implementation of Patient / Family Care304.1 Summary of Actual Nursing Care304.2 Preparation of Patient and Family torwards Discharge and Rehabilitation324.3 Follow-Up / Home Visit / Continuity Of Care33CHAPTER FIVE36Evaluation of care rendered to Patient/ Family365.1 Statement of Evaluation365.2 Amendment of Nursing Care Plan375.3 Termination of Care385.4Summary of care rendered to Patient/ Family385.5 Conclusiion and Recommendations39BIBLIOGRAPHY40SIGNATORIES41LIST OF TABLESTabletitlepage no.1.1Diagnostic investigations192.1Comparison of clinical features203.1Pharmacology of drugs224.14.24.34.44.5Nursing care planNursing care planNursing care planNursing care planNursing care plan2728293031PREFACEThe patient/family care study is carried out to help the student nurse build a good relationship with patient and family as well as the health team so as to meet the health needs of the patient. It affords the student nurse the opportunity to put his broad theoretical knowledge acquired from the classroom, in the clinical and community setting.Patient/family care study is aimed at addressing the physiological, psychological, physical, emotional, spiritual and the social needs of the patient and family. The patient/family care study offers the student nurse the opportunity to make follow up visit to the patient’s house or community where he can promote health by using their own resources available. It also gives an insight into research work. The patient/family care study is a requirement by The Nurses and Midwives Council of Ghana for the reward of Diploma in General Nursing. It therefore serves as an assignment to determine the theoretical as well as practical abilities of the student nurse.ACKNOWLEDGEMENTI wish to express my sincere gratitude to the most gracious everlasting Father for giving me the knowledge and wisdom, health and strength to come out with this study. My heart felt gratitude goes to my entire family especially my mother Comfort Aboagye for their moral and financial support given to me, may God bless them all.Also, my thanks goes to my patient Mr I.B. and his family for allowing me to use him for my patient/family care study. I appreciate the cooperation given me by the patient and the family throughout the period of hospitalisation.I am also grateful to the tutorial staffs of college of nursing and midwifery-Nalerigu especially Mr Hassan Sibdow who carefully guided me throughout this script, I say God is your reward.Furthermore, I am equally grateful to the nurse-in-charge as well as the entire staff of the male medical ward of Tamale West Hospital for their contribution.Finally my acknowledgement will be incomplete if I fail to express my gratitude to the Authors of the various text books from which I extracted relevant information for this studies. May God richly bless you!INTRODUCTIONThis care study is written on Mr I.B. a 35 year old man, who was diagnosed of severe anaemia and admitted to the male medical ward for observation and management at the Tamale West Hospital on the 8th October 2015. Patient and relatives were welcomed into the ward and taken through the admission process. To render total patient care, assessment was done and a number of problems identified and managed on daily basis. The patient responded promptly to the interventions and was discharged home.Following his discharge, three home visits were made to his house to assess the patient and his home environment and health education given. His care was finally handed over to a community health nurse for continuity of care. This script is presented in five chapters that are in line with the nursing process. Chapter deals with assessment of patient and family. Chapter discusses analysis of data, chapter three contains nursing care plan. Chapter four is concerned with implementation of patient/family care plan and home visit. Chapter five discusses evaluation of nursing care rendered. CHAPTER ONEAssessment of Patient and FamilyIntroductionAssessment is the first step in the nursing process. It involves systematically collecting information (data), organizing the data, validating the data and documenting the data on the personal, mental, cultural, spiritual and economic background about a particular client and family. A combination of observation, interview and measurement provides full assessment. Assessment begins as soon as the client reports at the hospital and continues after discharge. The data can be collected through review of client’s records and interviewing client, family and friends and notable sources.Patient’s ParticularsMr. I.B., a 35-year-old Junior High School Teacher at Tolon D/A primary school in the Northern region of Ghana, has a short stature, dark complexion and weighs 48 kilogram. He is a Muslim, hails from Tolon and speaks Dagbani, English and Twi. He is married with two male children. He stays at tolon in a teachers’ cottage and has a-3-bed room house (PLT 43 BLK D, Tolon). He is the 9th born child to Mr. and Mrs. Alhassan. The father is of blessed memory and his mother stays with him. Mr. I.B. was enrolled in school at the age of two (2) years where he had his primary education. He attended Tamale Secondary school. He is now a graduate teacher from university of education winneba. Patient Family Medical History According to Mr. I.B. there is no history of any debilitating illness in both paternal and maternal families in the likeness of hypertension, diabetes mellitus, sickle cell disease, mental illness, heart disease and obesity.Socio-Economic HistoryMr. I.B. is currently a teacher and depends on his salary. He is married and blessed with two children. He takes care of his bills by himself. He has other family members who depend on him for their daily living. Among those he caters for are his wife, mother and his two children, two of his brothers and their wives. He prefers spending his spare time with his family and so does not indulge himself in any other outdoor activity.The Patient’s Developmental HistoryAccording to Mr. I.B. he was born through spontaneous vaginal delivery after full-term pregnancy at home as said by his mother. Her mother was strong throughout her conception and delivery. He was not immunized against any preventable childhood disease at infancy. He was immunized during his school going age against tetanus only. His teeth erupted at the age of 6 months and started walking without support at the age of one year. He passed through the developmental milestone with few discrepancies. His style of walking changed along the brim as a result of measles attack at childhood. He started schooling at the age of 2 years. In his teens he had normal growth of hair in the armpits and the pubis. He had his first wet-dream at the age of 22 years. He lost his father in the school going days. He had supported himself ever since his father’s death. He got marriage at the age of 26 years. He lost his first unborn child through his wife’s miscarriage. He is now blessed with two sons.The Patient Lifestyle and HobbiesMr. I.B. wakes up as early as 5:00 ‘clock in the morning to observe his dawn prayer ‘‘Fajr’’ as part of his obligations. He observes his oral hygiene twice a day with tooth brush and ‘pepsodent’ tooth paste. He takes his breakfast at 6:30 am that his wife prepares for the family. He prefers to take light diet for breakfast such as tea and bread with fried eggs or porridge and bread. By 7:00 am, he takes his children to school and as a head teacher he goes to the schools office to perform his duties. At 12:00 o’clock noon he observes his ‘’Zuhr’’ prayers. He closes from school at 2:30 pm and then takes his children home and enjoys lunch with the family. He prefers tuo-zaafi or rice and stew at lunch. After his lunch he heads back to the teachers cottage to take his rest to avoid disturbances by his children. Mr. I.B. does not take alcohol, smoke, rather he takes fruit juice. He indulges in conversation with his children and wife in the night. He assists his children in doing their homework. He takes his supper and goes to bed as early as 8:00 pm after observing his ‘’magrib’’ and ‘’Isha’’ prayers.Patient’s Past Medical HistoryMr. I.B. said during his childhood age, he suffered from measles which almost took his life. He got his cure from a mixture of herbal concoctions offered to him by a traditional herbalist. On 21st October, 2014, he became ill suddenly and lost weight beyond his understanding although he had good appetite. Upon deciding, he went to tamale west hospital to run some checkups. He was told that his blood level was too low (he was diagnosed of severe anemia). He was admitted into the male ward for five days with treatment. He responded to treatment and on his fifth day of admission he was discharged. Mr. I.B. said he has been to hospital on three different occasions.Patient Present Medical History Mr. I.B. was well until 7th October, 2015, he felt so dizzy and extremely tired. He attributed it to work load, so he took a day off from teaching to get enough rest with the notion that he will regain his strength. The next day, he woke up to see no changes in his condition. To his dismay he immediately alerted his brother to accompany him to Tamale West Hospital. He was diagnosed of severe anaemia and he was admitted into the male ward.Admission of Patient Mr. I.B. was admitted into the male medical ward of Tamale West Hospital on 8th of October, 2015 at 3:00 pm on Doctor’s advice. He came through the Out-Patient-Department where he was provisionally diagnosed of severe anemia. He was brought into the ward in wheel chair with an accompanied nurse, his brother and a friend. On arrival he was received warmly and his relatives were offered seats. Client’s particulars were taken from the accompanied nurse; his name was mentioned to confirm his identity. I introduced myself and other staff nurses on duty to client and relatives. Quick assessment was made and his particulars entered into admission and discharge book, daily ward state, and nurses’ notes, treatment sheet and report book and other documentations were later done. Client and relatives were reassured of competent health care and client’s speedy recovery. His vital signs was checked and recorded and client was put into bed made to suit his condition. His personal belongings were checked together with the accompanied nurse and relatives and were kept in the patient locker. Client was introduced to other sick patients. His relatives were oriented to the ward environs. Relatives were educated on national health insurance policy and cash and carry system of payment. They were told what to bring to client on their next visit. They were allowed to see client and bade good bye. Patient complaints were chest pain, back pain, tiredness, and he had pale conjunctiva. Care plan was made to tackle his complaints. The initial vitals were:Temperature 37.9 degrees Celsius Pulse 100 beats per minuteBlood pressure 100/60 mmHgRespiration 20 circles per minuteHe weighed 48 kilogram on admissionHis immediate prescribed medications were taken from the pharmacy and were served accordingly, he was placed on:Haemo-transfusion (3 units of whole blood)Paracetamol 1g TDS X 5/7 IV furosemide 60mg statLaboratory investigations requested were:Blood for grouping and cross matchingFull blood countClient’s consent was seek after explanation of procedure to him and blood sample was taken under strict aseptic technique, put in vacuum tube, endorsed correctly and sent to the laboratory.The Patient’s Concept of IllnessMr. I.B did not attribute his ailment to any spiritual force but said illness is inevitable and he continued that in one’s lifetime one has to fall sick in a while. Although he didn’t actually know the cause of his illness but he had a strong believe that Allah will help him to regain his health.Literature Review on AnaemiaDefinition of AnaemiaAnemia, “It is a condition in which haemoglobin concentration is lower than normal. It reflects the presence of fewer than normal number of erythrocytes within the circulation” (Smeltzer, Bare &Hinkle, 2010). Anaemia denotes a reduction in the oxygen carrying capacity of the blood. ‘’This occurs as a result of fewer circulation erythrocyte than is needed or is normally defined as a haemoglobin level in the blood of less than 13.5g/dl in men and 11.5g/dl in women’’ (Walsh &Crumbie, 2002). It is not a disease itself but is a symptom of another disorder.Types of AnaemiaDifferent types of anemia can be classified based on either aetiology or morphology of the red blood cells. Types of anaemia based on the aetiological classification include:Nutritional AnaemiaIron Deficiency Anaemia: This is a type of anaemia in which the iron level is lowered and therefore does not meet the demands of red blood cells formation. An average diet supplies the body with 12- 15mg/day of iron of which only 5% to 10% (0.5 – 1.5mg) is absorbed. The most common anaemia in all age group and mostly affects women 15- 45 years of age. It is a major health problem due to poor nutrition.Megaloblastic Anaemia: This is the type of anemia in which excessive large cells are formed due to absence of vitamin B12.Pernicious Anaemia (vitamin B12 deficiency)It is a type of anaemia due to lack of Vitamin B12 as a result of;Malabsorption of vitamin B12 due to the stomach or lack of intrinsic factors.Inadequate intake of vitamin B12 which is necessary for the formation of vitamin B12.Haemolytic Anaemia It occurs when the red blood cells are excessively destroyed while in circulation leading to shortening in their lifespan. The destruction done or haemolysis exceeds the erythropieotic ability of red bone marrow hence manifestation of anemia signs and symptoms. The following are types of haemolytic anaemia;Sickle Cell Anaemia: This is congenital haemolytic condition which occurs as a result of defective haemoglobin molecule that causes red blood cell to be rough and assume the shape of a sickle or crescent, because of the absence of the adequate oxygen supply.Glucose-6-Phosphate Dehydrogenase: This is an inherited disease that causes haemolysis of red blood cell when an individual is exposed to stress and certain drugs, examples of those drugs include, anti-malarial drugs, the thiazide, and many others.Thalassemia: The thalassemia type of anaemia occurs in major and minor forms. It is a group of hereditary anaemia produced by either a defective production of alpha or beta haemoglobin polypeptides.Auto-Immune Anaemia: This is an acquired disorder characterized by erythrocyte destruction from abnormalities of an individual’s own immune system. The body produces antibodies which attack the red blood cells. It is more common in new born and children with blood group AB, and B.Aplastic Anaemia It is a type of anaemia that comes as a result of depressed bone marrow activity. It involves failure to produce adequate red blood cell, white blood cell and platelets and hypo cellular bone marrow. Aplastic anaemia could be congenital or acquired through radiation therapy, non-steroidal anti-inflammatory drug (NSAID) example aspirin.Hemorrhagic Anaemia This type of anaemia is due to excessive loss of blood which could either be due to the following:Acute (large volume of blood loss over short period of time) due to injury. This type of bleeding can lead to shock.Chronic (small volume of blood loss over a long period of time) such as gastrointestinal bleeding.Heavy blood loss in menstruation in women.Classification Of Anaemia Due To Morphology Of The Cells And Haemoglobin Concentration Are As Follows:Hyperchronic Macrocytic AnaemiaIn this type of anaemia, the red blood cells are larger than normal (macrocytes) but the haemoglobin content is less than the number of red blood cells (Hyperchronic). It is caused by lack of vitamin B12 or folic acid.Hypochromic Microcytic Anaemia With this type of anaemia, the red blood cells are smaller than normal (microcytes) and there is a severe reduction of the haemoglobin content (Hypochromic) as well as reduction in the number of cells. It is caused by deficiency of iron. Normocytic AnaemiaIn this type of anaemia, the red blood cells are normal in size and the haemoglobin is in the same proportion as the red blood cells. It is caused by acute haemorrhage.Incidence of Anaemia Anaemia is extremely high in developing countries where nutrition is poor. It is also high in the tropical regions where hookworm and malaria is endemic. A community-based estimate of the anaemia prevalence of African children in areas where malaria is endemic ranges between 49% and 76% (schellemberg, 2013). The average prevalence is 56% in African preschool children; 63% in pregnant African woman (caused by malaria and malnutrition); 44% non-pregnant women and 20% of men in Africa (parry, 2004). Menorrhagia is a common cause of anaemia in females still menstruating.Aetiology of AnaemiaThe causes of anaemia are;Disease condition example: malaria, cancers, hook worm infestation.Nutritional deficiencies such as vitamin B12, folic acid, ascorbic acid and protein deficiencies.Haemorrhage (excessive bloodloss).Haemolysis (excessive destruction of erythrocyte).Chemicals or drugs with the potential to suppress bone marrow activities.Morphological abnormalities (structure, shape and size). Pathophysiology of Anaemia1. Anaemia is cause by decrease number of circulating red blood cells (RBCs), reduction in the amount of hemoglobin in the RBCs, or a combination of both.2. This causes diminished oxygen carrying capacity of the blood (maakaron, 2011) 3. This result in tissue hypoxia with marked fatigue.4. The erythropoietin in turn stimulate the bone marrow to produce more erythrocyte to compensate for those destroyed. As a result of haste production of erythrocytes, most of them are released prematurely causing recticulocytosis which worsen the condition. 5. Further break down of the haemoglobin into haem and globin results in about 70-80% of the haem being converted to unconjugated bilirubin resulting in jaundices.General Clinical Features of AnaemiaThe clinical features of anaemia can be looked at under the following body systems:Cardiovascular systemIncreased pulse rateAngina pectorisCardiac enlargementPalpitationIntegumentary systemFeverPallor of skin and conjunctivaDiaphoresisBrittle and spoon shaped nailsNeurological systemHeadacheIrritabilityLethargyDizzinessGeneral body weaknessRespiratory systemIncreased respiratory rateDyspneaGastrointestinal system AnorexiaAbdominal painDiarrhea and constipationAngular stomatitisHepatomegaly and jaundice Complications of AnaemiaHepatomegalySplenomegalyCongestive heart failureRenal failureGrowth retardation in childrenShockInfectionBrain deathMyocardial infarctionDiagnostic InvestigationPhysical examination. Full blood count.Blood film for malaria parasite.Sickling test.Red bone marrow examinationHematocritErythrocyte sedimentation rate.A test for vitamin B12 absorption (schilling test).Medical Treatment of AnaemiaTreating the underlying cause of anaemia and restoration of haemoglobin level to normal i.e. 13-18g/dl in males and 11-16g/dl in females.Blood transfusion in severe cases.Iron preparations like ferrous sulphate orally.Give anti-malarial drug if anaemia is due to malaria.In the case of sickle cell anaemia, hydioxyuria which is effective in increasing haemoglobin level and decrease the formation of sickle cell can be given.Folic acid can be given and a dosage depends on the condition.If anaemia is due to worm infestation, tabs ibendazole can be given.Antibiotics may be given to control and treat infections.Nursing Management of Anaemia DietThe nurse should explain to the client and family to adhere to dietary requirements.The nurse must ensure that the client is served with a well-balanced diet.Give iron and folic acid supplements daily.Diet must be served in bit to enhance appetite.ExerciseThe patient should be made to undergo exercise in the form of passive and active moderately as tolerated. Some of these exercises are deep breathing, walking around the ward to prevent boredom. If possible the service of physiotherapist should be employed.Rest and SleepDress the bed to be free from creases and cramps.Limit visitors.Minimize noise and improve ventilation by opening windows and fans.Plan activities in a way that they don’t interfere with the patient’s time of rest and sleep.Assess patient sleeping pattern.Personal Hygiene The patient has to be educated on the need to bath at least twice daily and if the client is bed ridden, bed bath should be given.Ensure oral hygiene twice daily.Advice the patient on washing the hands after visiting toilet.ChemotherapyAdminister prescribed drugs and chart them.Observe for any side effect and report appropriately. Educate patient on side effect of the drugs. ObservationGeneral physical appearance of the client should be observed and examined including the color of the skin and mucus membrane, nature of hair and nails.Check and record vital signs four hourly or as directed.Observe for bed sore and treat if any.Observe and estimate the level of anxiety in client and family.Look for signs of shock including tremors, hypotension, dummy skin etc.If the patient is on transfusion monitor for reaction example sweating, restlessness.Observe and record intake and output of the client. Psychological CareReassure patient and family of competent care.Introduce patient to other patient especially those recovering from similar condition.Encourage client to ask question to express his feelings and take time to address them.Explain every procedure to be carried on the patient to the patient and family.Health Education and PreventionThe nurse should educate the client to take well-balanced diet to boost immunity.The nurse should educate the client and family on the causes, signs and symptoms, treatment and prevention of anaemia.The patient should be advised against self-medication.Encourage the client and family to undertake regular rm the client to report any abnormality to the hospital after discharge.Educate client and family to keep their surroundings clean to prevent and destroy breeding grounds for mosquitoes because they can cause malaria which result in anaemia.1.11. Validation of DataAll information was gathered from the patient and relatives, medical record, laboratory investigation and literature. It was compared with standard to determine discrepancies. There were no discrepancies found from all the sources of information and therefore the data was valid.CHAPTER TWOANALYSIS OF DATAIntroductionThis is the second stage of the nursing process and it involves categorizing and comparing the data collected during the assessment with standards in literature. This helps to identify actual or potential alteration on the health of the patient as well as patient and family strength and weaknesses.2.1 Comparison of Data with standardsa. Diagnostic investigationThe diagnostic investigations carried on Mr. I.B. were;Blood for haemoglobin level estimationBlood for grouping and crossing matchingBlood for sickling testBlood for malaria parasite testFull blood count for:Red blood cell White blood cellMCHMCHCPlatelet countTable 1.1 Comparison of diagnostic investigations with standards DateSpecimenInvestigationResultNormal ValueInterpretationRemarks8/10/2015BloodHaemoglobin level estimation4.4g/dl14-18g/dlBelow Normal indicating severe anaemiaBlood transfusion and haematinics ordered and administered8/10/2015BloodGrouping and cross matchingBlood group B, Rhesus positiveBlood group A,B,O,AB Rhesus negative and positive FactorsBlood group B Rhesus positiveBlood group O or B positive was transfused without reaction8/10/2015BloodFor malaria parasiteNo malaria parasite was seenNo malaria parasite should be seenIndicating that client is not suffering from malariaAnaemia was not due to malaria8/10/2015BloodSickling testNegativeNegativeClient does not have sickle traitAnaemia was not due to sickle cell haemolysis 8/10/2015BloodWhite blood cell count4.2uL(4-10)x10 (9)/LWBC was within normal range so no infection detectedNo antibiotics were prescribed8/10/2015Blood Red blood cell count1.45uL4.20-6.30m/oRBC was low indicating anaemiaNo antibiotics were prescribed8/10/2015Blood MCH17.7PG26.0-32.0PGMCH was low indicating hypochromiaNo antibiotics were prescribed8/10/2015BloodMCHC32.1PG32.0-36.0g/dlMCHC is low indicating hypochromiaNo antibiotics were prescribed8/10/2015BloodPlatelet count311k/uL150-400Platelet count was within normal rangeNo anticoagulant was prescribedb. Causes of Patient’s IllnessWith reference to the general causes of anaemia in the literature review and compared with the laboratory results, Mr. I.B suffered hypochromic microcytic anaemia. This may be due to low dietary intake of iron (iron deficiency anaemia). It was evidenced by low corpuscular volume of red cells. Furthermore, Iron deficiency anaemia is mostly common in old age, young growing and especially in pregnant women.Table 2.1 Comparison of clinical features Number Clinical Features In LiteratureFeatures exhibited by client1Dyspnea Was present2Fever Fever was not present (36.0c)3Loss of appetite Present4Headache Present5Dizziness Present6Tachycardia Was not present7VomitingWas not present8PalpitationWas not present9Angina pectorisWas not present10HepatomegalyWas not present11Angular stomatitis Was not present12CoughMild cough13Weight lossIt was indicated14Spleen enlargementWas not present15PolyuriaWas not present16Pallor of skinWas present17Fatigability Was present18Muscle weaknessWas present19Joint painWas present20Difficulty in breathingWas present21NauseaWas presentd. Specific Medical TreatmentIn view of the medical treatment under the literature review, the specific treatment ordered for Mr. I.B includes:Tablet Paracetamol TID x 5/7 daysI.V Furosemide 60 mg statTablet Folic Acid 1 daily x30Three Units of Whole blood for transfusion Table 3.1 Pharmacology of drugsDate Drug`Standard DosageDosage And Route of AdministrationClassificationDesired effectActual action observedSide effectsAnd remedies8/10/2015BloodTo correct acute severe anaemia(Hb?6g/dl): 30ml/kg of whole blood transfusion over four hours Standard care recommended by WHOThree Units of whole blood IntravenouslyBloodIncreased blood volume and Haemoglobin levelHaemoglobin level increasedPyrexia, rigor, circulatory over load, haemolysis, rashes. These were not observed8/10/2015Tablet ParacetamolAdults: weighing 50kg and over: 1g every 6 hours (oral)1g TID x 5/7 daysAnalgesic/antipyreticRelieves painClient says bodilypains have subsidedLiver damage, drowsiness, tinnitus. None was observed8/10/2015Tab folic AcidAdults: 400mcg daily (oral)5mg daily x 30 days orallyHemaetinicIncrease red blood cell formationHaemoglobin level of client improvedFlushing, bronchospasm. These are not observed 8/10/2015FurosemideAdults: 20- 80mg I.V over 1-2minutesI.V 60mg statLoop diureticPrevent transfusion reactionTrans-fusion reaction was not observedEdema was not observede. ComplicationsIn view of the complications of anaemia stated in the literature review, Mr. I.B. did not develop any complication. This was due to quality nursing and medical care rendered to him.2.2 The Patient/Family StrengthsSpecific strengthsPatient could sit up to reduce the pressure on the chestPatient can describe the location of pain (back pain)Patient could walk for a short distancePatient could perform minimal activitiesPatient could eat bits of food at a timeGeneral strengthsPatient cooperates during serving of medication.Patient and relatives cooperated and asked questions during health education.2.3Patient Health ProblemsSpecific health problemsPatient had ineffective breathing Patient had bodily discomfort (back pain)Patient was dizzyActivity intolerance ( fatigue)Risk of altered nutrition less than body requirements (anorexia)General health problemsPatient appears anxiousPatient lacks knowledge on condition (severe anaemia)2.4 Nursing DiagnosisImpaired gaseous exchange related to decreased haemoglobin level (4.4g/dl)Alteration in bodily comfort related to back painRisk for injury related to dizzinessActivity intolerance related to fatigueAlteration in nutrition less than body requirements related to loss of appetite (anorexia)CHAPTER THREEPLANNING FOR PATIENT/FAMILY CAREIntroductionThis the third component of the nursing process and it entails setting up nursing objectives, nursing orders and instituting the appropriate nursing intervention to achieved the set goals and objectives within a time frame. The objectives are formulated based on the nursing diagnosis made. The objectives could either be a short term or long term ones but must have a specific time period within which they can be achieved.3.1 Nursing ObjectivesShort term objectives1. To assist patient maintain normal breathing within 12hours evidenced by;I. Client having a normal breathing rateII. Client’s hemoglobin level increasing to 10.2g/dl 2. To restore comfort to patient by relieving back pain within 24hours, evidenced by;I. Client verbalizing relieve of back painII. Client being seen comfortable in bed3. Client will experience no falls within 24 hours: evidenced byClient verbalizing the absence of dizziness Client walking for long distance unassisted 4. To assist client overcome fatigue within 48hours, evidenced by;I. Client performing activities such as bathing, waking, eating etc.II. Client verbalizing absence of fatigueLong term objectives5. To assist client to maintain an optimal nutrition status throughout his stay in the ward, evidenced by;I. Client eating more than half of a plate of food servedII. Client verbalizing improvement of appetite Table 4.1 Nursing Care Plan of AnaemiaDate/TimeNursing DiagnosisObjective/Outcome CriteriaNursing OrdersNursing InterventionDate/TimeEvaluationSign8/10/20153:00 P.MImpaired gaseous exchange related to decreased hemoglobin level(4.4g/dl) Client’s will regain normal breathing pattern within 12hours, evidenced by:1. Client having a normal breathing rate (16-20 CPM)2. Client’s hemoglobin level increasing to 10.2g/dl.1. Assess respiratory rate and depth 2hourly2. Prop up client in bed and support with pillows.3. Loosen tight clothes around neck.4. Instruct client to do effective coughing and deep breathing5. Administer prescribed diuretics and transfuse client with 3 units of whole blood x72hours.1. Respiratory rate and depth were assessed.2. Client was propped up in bed.3. Tight clothes were removed.4. Client was instructed in effective coughing and deep breathing. 5. Furosemide 60mg was administered and client was transfused with the 1st unit of whole blood.09/10/20153:00 A.MGoal fully met; client had normal breathing rate (16 CPM) and respiratory depth and haemoglobin level was 10.2g/dl.Table 4.2 Nursing Care Plan of AnaemiaDate/TimeNursingDiagnosisObjective/OutcomeCriteriaNursing OrdersNursing Intervention Date/TimeEvaluationSign 09/10/20153: 00 P.MAlteration in body comfort related to back pain.Client will regain body comfort within 24 hours, evidenced by:1.Client verbalizing the absence of back pain2.Client being seen comfortable in bed and chatting with other patient1. Assess the location and severity of the pain.2. Assess and document client response and effects to medication3. Massage client every 2hourly4. Ensure adequate bed rest.5. Serve prescribed analgesics example Tab. Paracetamol 1. Client had pain in the lumbo-sacral region and graded 7on pain scale.2. Assessment and documentation on client’s response and effects to medication was done.3. Client was massaged in 2 hour intervals4. Client was put on comfortable bed and nursing activities were carried together.5. Tab. Paracetamol 1g was served twice daily.10/10/20153:00 P.MGoal fully met;Client verbalized the absence of back pain and was seen comfortable in bed.Date/TimeNursing diagnosisObjective/outcome criteriaNursing ordersNursing interventionDate/TimeEvaluationSignature9/10/2015Risk for fall related to dizziness.Client will experience no fall within 24hours evidenced by:1. Client verbalizing the absence of dizziness2.Client walking long distance unassisted1. Assess client level of dizziness.2. Ensure adequate bed rest3. Nurse client on a low bed and side rails raise4.Keep the floor of the ward dry5.Provide good lightening system1. Client’s level of dizziness was assessed2. Adequate rest was ensured3. Client was nursed on a low bed and side rails raised4. The floor of the ward was kept dry 5. A good lightening system was provided10/10/20153:00pmGoal fully met ;Client verbalized the absence of dizziness andClient walked for long distance unassistedTable 4.3 Nursing Care Plan of AnaemiaTable 4.4 Nursing Care Plan of AnaemiaDate/TimeNursingDiagnosisObjective/Outcome CriteriaNursing OrdersNursing InterventionDate/TimeEvaluationSign10/10/20152:00 P.MActivities (ADLs) intolerance related to fatigueClient will overcome fatigue within 24 hours, evidenced by:1. Client performing activities like bathing, walking, eating.2.Client verbalizing absence offatigue1. Assess client’s level of activity2. Instruct client to avoid actions that raise abdominal pressure3. Serve foods rich in calories and proteins.4. Encourage client to rest5. Encourage client perform minimal activities and ensure rest after each exercise1. Client’s level of activity was assessed.2. Client was instructed against actions that raise abdominal pressure like straining during defecation.3. Client was served with foods such as soup, ‘tuozafi and ayoo’ and porridge.4. Client was encouraged to rest to conserve energy5. Client performed limited exercises like sit ups in bed, flexion and extension of arms and limbs and he rested after each exercise.11/10/20152:00 P.MGoal fully met;Client walked, bathed and ate by himself without assistance. And Client verbalized the absence of fatigueTable 4.5 Nursing Care Plan of AnaemiaDate/TimeDiagnosisObjective/Outcome CriteriaNursing OrdersNursing InterventionDate/TimeEvaluationSign10/10/158: 00A.MAlteration in nutrition less than body requirements related loss of appetite (Anorexia)Client will maintain an optimal nutrition status throughout his stay in the ward, evidenced by:1. Client eating more than half of food served2. Client regaining his normal body weight (50kg)1.Assess client’s nutritional status2. Estimate and record amount of food consumed by client3. Provide frequent but small meals in attractive way4. Encourage a rest period of 1 hour before and after meals5. Ensure oral care at least twice daily.1. Client was assessed on previous food intake2.Daily food intake by client was recorded3. Soup, porridge and ‘tuo’ at frequent intervals were provided.4. Client was encouraged to rest an hour before and after meals5. Client’s mouth was washed with pepsodent toothbrush and toothpaste twice daily.12/10/1511: 00A.MGoal fully met:Client ate more than half of the food served and client regained his normal body weightCHAPTER FOURIMPLEMENTING PATIENT/FAMILY CAREIntroductionImplementation of client/family care is the fourth phase of the nursing process. This is a narrative for of the actual care rendered to the patient and family throughout the period of admission. This may be categorize into summary of actual nursing care rendered, preparations towards patient and family discharge, rehabilitation and follow up visits or continuity of care.4.1 Summary of Actual Nursing Care First Day of Admission (08/10/2015)On the 8th day of October, 2015, Mr. I.B was admitted in the male medical ward through the OPD with severe anemia at Tamale West Hospital, he was accompanied by a staff nurse and a relative, and he was brought into the ward on a wheel chair. On arrival a bed was prepared and patient was made comfortable on bed while his relative was offered a seat. Folders with all the necessary papers were assembled. His vital signs were taken and recorded as: Temperature 35.6oc, Pulse89 beats per minute, Respiration 20 cycles per minute, Blood pressure96/60mmHg, and Weight 48 kg. All his medications were collected and started as ordered including Tablet paracetamol 1gm TDS, Furosemide 60mg.Some of the laboratory investigations were requested for were; Hemoglobin level estimation, blood for grouping and cross matching, blood for malaria test. The specimens were quickly taken and sent to the laboratory. Patient and his relative were also taken round the ward on orientation. The relative was also advised on the items he should bring especially things that were necessary for her use while on admissionFollowing the baseline nursing assessment conducted on this day, the problem identified was, impaired gaseous exchange related to decreased hemoglobin level (4.4g/dl). Patient respiratory rate and depth were assessed and patient was also instructed to do effective coughing and deep breathing exercise. Due to the decrease hemoglobin level, he was scheduled for transfusion with a unit of whole blood daily for three days. The patient was given 60mg of furosemide prior to the blood transfusion. First blood transfusion started at 3: 57pm with blood group of B+ and completed at 6:25 without any reaction. Vital signs were monitored and recorded.Second Day of Admission (09/10/2015)On 9th of October 2015, as early as 6.00, a critical observation made on the patient revealed that he had alteration in body comfort related to back pain. Nursing interventions instituted to resolve this problem included assessment of client’s location of pain (lumbosacral region) and severity of the pain, assessment and documentation on patient response and effects to medication was done and the patient was also massaged on 2 hour intervals. Second blood transfusion was setup at 10.13am and was completed at 12.30pm without any transfusion reaction.Another problem identified was risk for fall related to dizziness. In response to this problem, patient level of dizziness was assessed, adequate bed rest was ensured and patient was nursed on a low bed and side rails raised.Third Day of Admission (10/10/2015)Patient was assisted to bath and had his mouth cleaned in the morning. He was served with tea and bread. Other usually routine ward activities were carried out after ward rounds. Upon continuous assessment, it was found out that patient had activities intolerance related to fatigue. Client’s level of activities was assessed, patient was instructed against actions that raise abdominal pressure like straining during defecation and he was also assisted to perform activities of daily living like bathing, oral care. His vital signs taken and recorded after which 60mg of furosemide was administered. Third unit of blood was ordered and setup at 9:03am which completed successfully without any reaction.Fourth Day of Admission (11/10/2015)On the 11th of October 2015, Mr. I.B woke up looking hopeful and said he was happy about the way he was responding to treatment. It was obvious and convincing when the patient said he was generally better. His vital signs were taken and recorded. Porridge and bread was served as his breakfast and it was observed that patient could not eat half of his food. Patient had altered nutrition less than body requirement related to loss of appetite. Patient nutritional status was assessed, patient was encouraged to practice oral care before and after meals. Daily food intake by patient was recorded.Fifth Day of Admission (12/10/2015)The patient was cheerful and hopeful to be discharged soon. Patient was served tea and bread for breakfast and followed by medication, he had a sound sleep the previous night. Patient had knowledge deficit about condition related to lack of information. Patient knowledge on anemia was assessed. Time was scheduled with the patient and family and educated them on causes, signs and symptoms, treatment and prevention of anemia. Patient was encouraged to report to the nearest health facility anytime they experience unusual symptoms. The patient had no complaint this day and was therefore discharged home.4.2 Preparation of patient/ family for discharge and rehabilitationThe preparation of Mr.I.B and the family towards discharge started in the day of his admission into the ward. The patient and the family were educated on the causes, signs and symptoms, prevention and treatment of anemia. The early signs and symptoms were explained to the patient and his family and were encouraged to report to the nearest health facility as soon as he feels unusual. He was advised to continue the treatment at home but discouraged him from self-medication. The side effect of the drugs were explained to the patient and family. They were educated also on personal and environmental hygiene. The health hazards of alcohol, smoking cigarette and chewing cola were explained to the patient and family and were advised not to take them. The need to eat a balanced diet was emphasized by taking foods rich in calories, proteins and vitamins e.g. of calories include cassava, yam, rice etc. meat, fish, eggs, beans and snails are good examples of protein. Green leafy vegetables and fruit are sources of vitamin and minerals. He was told to take adequate rest and sleep and also to engage in regular exercise. He was told to honor follow up visit which was 21st, October 2015. We parted company after they packed their belongings and left home. 4.3Follow-up/Home Visit/continuity of CareFirst home visit (10/10/2015)Patient was visited home for the first time on 10th October, 2015 when he was still on admission.The main objective was to assess the living standard of patient and family in other to gather information for health education on actual and potential problems seen. It was also meant to prepare the home for continuity of care after discharge. The house is located at Tolon with house number B-13. On my arrival, members of the house welcomed me and we exchanged pleasantries. An introduction was made to patient’s wife and children and other relatives that their relative was in the care of competent hospital staffs. They were all happy and grateful to hear that. With granted permission, an inspection and observation revealed that the house contained three bed rooms of which one was occupied by patient and his wife. There was one bathroom and a toilet that all the inhabitants use. Their water system was fairly good, the taps flow at least twice a week. Members in the house were educated on the need to practice good personal and environmental hygiene in order to prevent them from falling sick. Education was also given on the risk factors, causes and prevention of some common diseases including patient’s condition (Anemia). Before my departure, I assured them of proper care of their relative back at the hospital.Second home visit (19/10/2015)The second home visit was done at the time the patient had been discharged. The aim of the follow up was to assess the health status of patient after discharge from the hospital and to know From observation, it was found that patient was healthy, cheerful and neat. He took his medications accordingly. There was also an improvement in the environmental hygiene. The education given to them on the first visit was re-enforced. Patient was also advised to take balanced and nutritious diet. Patient was reminded on review date and was encouraged to come to the hospital whenever he feels sick. I thanked them for their warm reception and they accompanied me to the road side to board a ‘’trotro’’ to my destination.Third home visit (26/10/2015)On 26th October, 2015 another follow up visit was made to see how patient and family were doing. This time, I went with a community health nurse whom the patient will be handed to. We met patient at the school where he teaches before we left for his house, where we met other family members. We were given warm reception and we interacted with them. It was observed that, there was a tremendous improvement in the education given to them, since the environment was tidy including bathroom and cooking utensils. Water pots were also cleaned and neatly covered. Patient was introduced to the community health nurse. Patient was told that he would be handed over to the community health nurse for the continuity of care. Patient and family accepted the handing over and were glad for getting another nurse to help them in matters related to their health. Together with the community health nurse, we stressed on topics of health promotion. After the health talk and necessary arrangements we took a taxi back to town and parted ways.CHAPTER FIVEEVALUATION OF CAREIntroductionEvaluation is the final step in the nursing process which is meant to make a final judgement as to whether or not the various objective and goals have been met within the time frame. It identifies factors that influenced goal achievement and terminate or amend the nursing care plan drawn for care of patient.5.1 Statement of EvaluationThe nursing care rendered to the patient was effective and comprehensive since he recovered quickly without any complication. Within a specific period of time, the goals set were all met which includes:Goal set at 3:00pm on 08/10/15 was to maintain normal breathing pattern within 12hours. Patient had impaired gaseous exchange related to decreased hemoglobin level (4.4g/dl). Some nursing interventions given were as follows; patient respiratory rate and depth were assessed and patient was also instructed to do effective coughing and deep breathing exercise, vital signs were monitored and documented, blood transfusions were given. Goal was fully met at 3:00am on 09/10/15 as Patient had a normal breathing rate (16-20cpm), increased hemoglobin level to 10.2g/dl.Goal set at 3:00pm on 9/10/15 to restore comfort to patient by relieving pain within 24hours. Patient had alteration in bodily comfort related to back pain. Some nursing interventions instituted were; patient was assessed for pain location and severity and tablet Paracetamol 1gm was served, patient was also massaged on 2 hour intervals. Goal was fully met at 3:00pm on 10/10/15 as Patient verbalized the absence of back pain, patient seen comfortable in bed.Goal set at 3:00pm on 09/10/15 to help patient experience no fall within 24 hours. Patient had risk for injury related to dizziness. Some nursing interventions instituted were; patient was assessed for level of dizziness and he was nursed on a low bed with side rails raised. Goal was fully met at 3:00pm on 10/10/15 as Patient verbalized the absence of dizziness, patient walked longer distance unassisted. Goal set at 2:00pm on 10/10/15 to help Patient overcome fatigue within 24hours. Patient had Activity intolerance related to fatigue. Some nursing interventions instituted were; patient level of activity tolerance was assessed and he was advised not to do perform actions that might raise abdominal pressure. Goal was fully met at 2:00pm on 11/10/15 as patient walked, ate, bathed without complains of fatigue.Goal set at 8:00am on 10/10/15 to maintain an optimal nutrition status of patient throughout his stay in the ward. Patient had alteration in nutrition less than body requirements related to loss of appetite (anorexia). Some nursing interventions employed were; patient was assessed on previous food intake, he was served with food according to his preference. Goal was fully met at 11:00am on 12/10/15 as patient ate all food served, patient verbalized improvement of appetite.5.2 Amendment of CareHaving carried out the evaluation, it was realized that all the goals were fully met. This success could be attributed to the quality and effective nursing interventions rendered to the patient. There was therefore no need for any amendment in the nursing care plan.5.3 Termination of CareThe process of termination of care began on the day of admission. A therapeutic and a patient centered nursing care plan was drawn and implemented which facilitated the speedy recovery and discharge of the patient without any complication. The patient and family were made to understand their stay in the hospital was temporal, hence patient would be discharged as the condition improved.Patient was educated on the causes, prevention and treatment of anemia. Patient and family education involved assisting patient to gain absolute self-care while at home through preparing the patient physically, psychologically and socially. Patient was educated on the need to complete the course of his drugs at home and entreated to come back for review on 22nd October, 2015. The side effects of the drugs were explained to the patient and he was advised to report any complication to the nearest health facility. They were educated on the need for regular check-up, exercises, personal and environmental hygiene as well as eating a balanced diet.During the doctor’s ward round on the 12th of October, 2015, the patient was declared fit for discharge and was subsequently discharged home. One pre-visit and two follow-up visits were made to the patient and family at home. The aim was to find out how the patient was faring after discharged and to give the necessary support. His care was finally handed over to a community health nurse in charge of the area on my last visit for continuity of care.5.4 Summary of Care Rendered to Patient and FamilyMr. I.B was admitted in the male medical ward of Tamale West Hospital through the OPD with the diagnosis of severe anemia on the 8th day of October, 2015 at 3:00pm. Following a good assessment, the following problems were identified; impaired gaseous exchange, dizziness, back pain, fatigue and loss of appetite. For effective and efficient nursing care to be rendered to the client, a care plan was drawn and implemented and this led his speedy recovery. Hence he was discharge to continue treatment at home on the 12th October 2015 without any complications.Following client’s discharge, a home visit was made to evaluate how patient was coping and to offer advice for his care and general health education. Patient care was finally handed over to a community health nurse for continuity of care.5.5 Conclusion and RecommendationsFamily and patient care study is very educative and beneficial to the student nurse. It helps the student nurse to have an insight into the nursing research.It also offers the student nurse the opportunity to translate the theoretical knowledge acquired into practice. I therefore recommend that such academic exercise should be maintained.BIBLIOGRAPHYBoon N.A, Colledge N. R, Hunter J.A.A. &Walker B.R., (2006). Davidson’s Principles and Practice of Medicine, Twentieth Edition, Churchill Livingstone Elsevier, 1023-1038.Guyton C.A. & Hall J.E. (2011). Guyton and Hall Textbook of Medical Physiology, Twelfth Edition, Saunders Elsevier, 420-421Braunwald E., Fauci A., Hauser S.L., Longo D.L., Jameson J.L.& Kasper D.L. (2005). Harrison’s Principles of Internal Medicine, Sixteenth Edition, McGraw-Hill Companies, 334-335.Albers G, Baker D. L., & Kelly R.B. (2010). Family Health and Medical Guide, Revised Edition, World Publishing United States of America, 133-135.Berman, Erb, Harvey, Kozier, Lake, Snyder (2008). Fundamentals of Nursing, First Edition, Pearson Education Company, 144-179.Clark M., &Kumar P. (2009). Kumar and Clark’s Clinical Medicine, Seventh Edition, Saunders Elsevier, 392-393.Alice C.M., Doenges E.M. &Moorhouse M.F. (2010). Nursing Care Plans, Ninth edition, F.A Davis Company, 459-468.Bare B.G., Hinkle J.L., Smeltzer S.C. (2010). Brunner and Suddarth Textbook of Medical-Surgical Nursing, Twelve edition, Lippincott Williams and Wilkins, a Walters Kluwer bisin, 1045-1065. Glynn, Swash (2009). Hutchison’s Clinical Methods, Twenty-Second Edition, Saunders Elsevier, 469-473.Weller F.B (2009). Bailliere Nurses Dictionary, twenty-third Edition, London; Bailliere Tindall Elsevier.Neal M.J. (2002). Medical Pharmacology at a Glance, Fourth Edition, Blackwell Publishing Company, 48-49.SIGNATORIESNAME OF CANDIDATE: ..........................................................................................................SIGNATURE: …………………………………………………………………………………DATE: …………………………………………………………………………………………NAME OF CLINICAL SUPERVISOR: ………………………………………………………SIGNATURE: ………………………………………………………………………………….DATE: ………………………………………………………………………………………….NAME OF SUPERVISORY TUTOR: ………………………………………………………SIGNATURE: …………………………………………………………………………………DATE: …………………………………………………………………………………………NAME OF PRINCIPAL: …………………………………………………………………….SIGNATURE: ………………………………………………………………………………DATE: …………………………………………………………………………………….. ................
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