CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY

1.0 Introduction

Assessment is an interview with and observation of a patient by the nurse and

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

included in assessment are religion, occupation, attitude toward hospital and

health care, mood, emotional tone, and family ties and responsibilities.

Assessment is extremely important because it provides the scientific basis for a

complete nursing care plan (Mosby's Medical Dictionary, 2009).

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

observation, interviews and examination. The importance of this assessment is to

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

of kin, address, occupation.

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).

1.2 The Patient/Family’s Medical History

Patient and Family’s Medical History provides information about illness which

has a genetic of families’ tendency (Smeltzer & Bare, 2010).

According to patient’s mother, there is no known genetic or hereditary disorder

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

or leprosy existing in their family. Occasionally, members of the family suffer

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.

1.3 The Patient/Family’s Socio-Economic History

According to Bowen (1998), a family is a system in which each member had a

role to play and rules to respect. Members of the system are expected to respond

to each other in a certain way according to their role, which is determined by

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

items she needed.

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

all their basic needs.

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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

they are not known to her.

1.4 Patient’s Developmental History

Development is defined as the process of growth and differentiation. Growth as

well, is the progressive development of a living thing, especially the process by

which the body reaches its point of complete physical development (Gillian,

2005).

According to patient’s mother, she experienced normal pregnancy for a period of

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

delivery was on 8th January, 2005 at 3:30 pm.

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,

Diphtheria, Pertusis, Tetanus, Hepatitis B, Haemophilus Influenza Type 3,

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

developmental milestone and child’s developmental characteristics. She said, she

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.

According to Erik Erikson’s theory of Psychosexual Development (1959), there

are eight (8) distinct stages with each possible result, thus either success or failure

personality. These theories are.

 Trust verses Mistrust (Birth to 12 months).

 Autonomy verses Shame and Doubt (1 to 3 years).
 Initiative verses Guilt (3 to 6 years).
 Industry verses Role Inferiority (6 to 12 years).
 Identity verses Role Confusion (12 to 20 years).
 Intimacy verses Isolation (20 to 40years).
 Generatively verses Stagnation (40 to 65 years).
 Integrity verses Despair (65 to death)
Patient is at the level of industry (competency) verses role inferiority which is the

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

achieve goal. Upon various interactions with my client, I came to a conclusion

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)

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month ago. She is aiming at becoming a nurse.

1.5 Patient’s Lifestyle and Hobbies

Lifestyle section of a patient provides information about health related

behaviours. These behaviours include pattern of sleep, exercise, nutrition and

recreation, as well as personal habits such as smoking and the use of illicit drugs,

alcohol and caffeine.

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.

1.6 Patient’s Past Medical History

Patients Past Medical History is a detailed summary of a person’s past health is an

important part of the health history (Smeltzer & Bare, 2010).

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

a water prone area.

1.7 Patient’s Present Medical History

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

at the Accident and Emergency Unit (A&E).

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

with Severe Malaria by Dr. Benneh.

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:

 Temperature 39.0 degrees Celsius (oC)

 Pulse 112 beats per minute (bpm)

 Respiration 35 cycles per minute (cpm)

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

abnormalities were detected.

The following laboratory investigations were ordered and samples were taken to

the laboratory.

 Blood film for malaria parasite.

 Blood for hemoglobin level estimation.

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  White blood cell count (WBC)

 Blood for sickle cell test

S.A.P was put on the following medications;

 Intravenous Artesunate 80mg (0 hour, 12 hour, 24hour)

 Tablet Arthemeter Lumefantrine (20mg/120mg) 12 hourly x 3days

 Tablet Paracetamol 500mg tid x 5days

 Tablet Fersolate 200mg daily x 30days

 Intravenous Fluid 5% Dextrose 1 liter over 24hours

 Intravenous Fluid Ringers Lactate 1 liter over 24hours

 Oral Rehydration Salt 3 sachets

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

S.A.P and she slept around 11:45pm

1.9 Patient’s Concept of Her Illness

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

that sickness can affect any one at any time.

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

symptoms, treatment, prevention and the need for the admission.

1.10 Literature Review on Malaria

Definition

Malaria is an infection of the red blood cell caused by plasmodium, a single cell

organism. The disease is however characterized by periodic chills, fever, sweating

and splenomegaly (Medical News Today, 2014).

Malaria is a febrile disease caused by parasite of the genus plasmodium and

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

of Female Anopheles mosquito. Infected mosquitoes carry the plasmodium

parasite and when this mosquito bites human the parasite is released into the

blood stream (Health line Media, 2015).

Malaria is a life-threatening disease caused by parasites that are transmitted to

people through the bites of infected female Anopheles mosquito (World Health

Organization, 2016).

Malaria is a mosquito-borne infectious disease affecting humans and other

animals caused by parasitic protozoan’s (a group of single-celled

microorganisms) belonging to the plasmodium (Caraballo, 2014).

Incidence

Malaria is one of the most widely prevalent diseases in the world. It is a constant

threat and kills about billion humans in the world.

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

(World Health Organization, 2014).

Aetiology

Malaria is mainly cause by the bite from the female Anopheles mosquito, which

then infects the body with the parasite, Plasmodium.

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

malaria transmission in 106 countries and territories.

In 2012, malaria led to 216 million clinical episodes and 655,000 deaths. An

estimated 91% of deaths in 2010 were in the African region followed by 6% in

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

There are three modes of transmission:

 Vector transmission: Malaria is transmitted by the bite of certain species

of infected female anopheline mosquitoes. A single infected vector during

its life time may infect several people. The mosquito is not infective

unless sporozoites are present in its salivary gland.

 Direct Transmission: Malaria may be induced accidentally by hypodermic,

intramuscular and intravenous infections of blood or plasma e.g. blood

transfusion. In transfusion malaria, pre-erythocytic schizogony does not

occur and hence a relapse due to dormant hepatic forms also does not

occur. Therefore treatment with primaquine for 5 or 14 days is not

indicated.

 Congenital Malaria: Congenital infection of the newborn from an infected

mother may also occur but this is very rare.

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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

primarily in eastern Asia.

Plasmodium malariae are also found in the temperate and tropical regions but it is

less common than the plasmodium vivax.

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 knowlesi is found throughout Southeast Asia as a natural pathogen

of long-tailed and pig-tailed macaques.

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).

Pathophysiology (Life Cycle)

The pathophysiology of malaria has two aspects;

 Asexual development in man

 Sexual development in mosquito

Asexual Development in Man

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

undergo further development such as trophozoids, schizoites and merozoites. The

merozoites then attacks the red blood cells, terminates with rapture of cells and

release of merozoites into circulation.

At about two weeks or at times long periods, mosquito bite from an infected

person can take place and continue with the process.

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.

Sexual Development in 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

glands of the mosquito (Parry & Gill, 2004).

Signs and Symptoms

 High intermittent fever

 Cold, sweating and rigors

 Bodily pains

 Bodily weakness

 Headache

 Nausea

 Vomiting

 Abdominal pain

 Poor appetite

 May progress to fits and coma

 Anaemia in severe cases

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  Diarrhea (Parry & Gill, 2004)

Diagnosis of Malaria

 Clinical manifestation (Signs & Symptoms)

 Blood film for malaria parasite (mps)

 White blood cells (WBC) counts to rules out other possible infections

 Hemoglobin estimation to rules out anaemia

 Rapid Diagnostic Testing (RDT) (Parry & Gill,2004)

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

decrease intake of fluid and increase in micturition

2. Anti-malaria treatment

Example are, Artemether Lumefantrine, I.V Artesunate, Quinine I.V Artesunate

remains the parenteral drug of choice in Africa, as the first line drug for malaria

treatment.

Artesunate for Injection (60 mg/vial): It should be administered in a dose of 2.4

mg/kg via intra-muscular or intravenous injection and administered as 0 hours, 12

hours and 24 hours. Total doses are 360-480 mg for adults. The vial of Artesunate

powder should be mixed with 1 ml of 5% sodium bicarbonate. Solution

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(provided) and shaken 2-3 minutes for better dissolution. Add 5 ml of 5% glucose

or normal saline to make the concentration of Artesunate in 10 mg/ml

For slow intravenous infusion

Add 2 ml of 5% glucose or normal saline to make the concentration of Artesunate

in 20 mg/ml

For intra-muscular injection

Doses for Children: 1.2mg/kg

Adverse Reactions

No adverse reaction has been observed with recommended dose up to now.

Transient

Reticulocytopenia may occur when overdose of Artesunate injection (more than

3.75 mg/kg) is given.

Note:
The solution should be used immediately after the powder is dissolved. It should

not be used (World Malaria Report, 2012).

3. If treatment failure is confirmed, treat with quinine

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

heamoglobin concentration between 4 and 6g/dl, without signs of severe malaria

do well with oral anti malaria and haematinics. In severe cases blood transfusion

is recommended.

6. Management of Convulsion

Convulsion is a feature of malaria in children. Diazepam is given in dose of

0.3mg per kg (up to a maximum of 10mg in both older children and adults-rectal

route is preferred in children). Paraldehyde is an anti convulsant with less risk of

respiratory distress, but its use has declined and not available in many settings.

Others include; phenobarbitone, phenytoin, etc.

7. The use of antibiotics

Pathological bacteria are isolated in significant minority of patient with severe

malaria

A reasonable compromise is to target anti biotic to those at high risk. (Parry and

Gill, 2004)

Nursing Interventions (Management)

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

should be explained to help gain his confidence. Client should be introduced to

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.

Rest and Sleep

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

windows can be opened to maintain proper ventilation.

Position

Ensure comfortable position which is not contraindicated to patient’s condition.

This is done to ensure his safety.

Observation

Vital signs, that is temperature, pulse, respiration and blood pressure are

monitored and recorded on the nurses’ note depending on patient’s condition to

know if patient’s condition is improving or deteriorating.

Infusion site is observed for patency and fluid intake and output chart is

monitored. Possible complication like respiratory distress is observed. Moreover,

the mental orientation of the patient to time, place and persons are observed as

well as desired and side effect of the drugs patient is given.

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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

dirt and microbes.

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

massaging in a circular motion to improve circulation. Patient’s bed linens are

changed frequently when soiled or dirty to make patient comfortable.

Nutrition

Patient is given a well-balanced diet. The food should be rich in carbohydrates to

provide energy, vitamins to aid to improve the immune system and protein to

build worn-out tissues.

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

into consideration her cultural background, her dislike, etc.

Exercise

Patient is encouraged to do active and passive exercises such as range of motion

exercises. It is to improve circulation, prevent muscle wasting and relief

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

encouraged depending on patient’s condition. If urination fails, a nearby tap is

turned on to psyche-up the patient to urinate. Warm compresses can be applied on

the lower abdomen to relax the muscle and aid urination. If all these nursing

measures fail, catheter is finally passed.

Education

 Patient with malaria should be educated to complete the prescribed dosage

even if the signs and symptoms of the condition have subsided.

 People infected with plasmodium, especially that of ovale and vivax type

may harbor the parasite (plasmodium) in their liver cells after treatment

and the risk of frequent remissions are possible.

 They should also be educated on the predisposing causes such as stagnant

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-

treated bed net (Smeltzer & Bare, 2010).

Prevention

According to Parry and Gill (2004), people travelling to malaria endemic regions

or countries should follow preventive measures such as:

 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.

 Wearing white dresses at night to minimize mosquito contact and

attraction

 Regular spraying of breeding sites with chemicals

 Drainage of all stagnant waters and providing proper refuse disposal

methods

 People in endemic areas should take chemoprophylaxis. That is a chemical

measures to prevent the occurrence of the disease and this can be done by

seeing the physician.

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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;

 Cerebral malaria- this occurs when parasite-filled blood cells (plasmodium

parasite) block small vessels in the brain and this mostly occurs when

malaria is not treated early.

 Coma- this occurs after cerebral malaria has developed.

 Convulsion- the presence of the parasite-filled blood cells as well as

untreated fever may lead to convulsions.

 Renal failure- this occurs as a result of mechanical obstruction of infected

erythrocytes in the afferent arterioles leading to necrosis of the kidney

tissues.

 Hepatic failure (hepatic dysfunction) - mechanical obstruction of blood

vessels with infected erythrocytes causes multiple organ failure including

hepatic failure.

 Shock (circulatory collapse) - obstruction of blood vessels with infected

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

leads to the bleeding problems.

These complications mostly come about when early treatment is not given.

1.11 Validation of Data

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

usefulness in the care study.

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 CHAPTER TWO

ANALYSIS OF DATA

2.0 Introduction

Analysis of data is a process of inspecting, cleaning, transforming, and modelling

data with the goal of discovering useful information and suggesting decision

making. Data analysis has multiple facets and approaches, encompassing diverse

techniques under a variety of names in different business, science, and social

domains (Nilep, 2010).

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

values to detect any abnormality from normal. Again there is a comparison

between the causes, clinical manifestations, treatment and complications in the

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.

2.1 Comparison of data with standards

A. Diagnostic Investigations

The following investigations were carried out on my client to aid in the diagnosis

and treatment;

 Blood film for malaria parasite (MPs)

 Blood for haemoglobin level estimation.

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  White blood cell count (WBC)

 Blood for sickle cell test.

The table below displays the results of the above mentioned investigations

compared to that of the literature review

26
Table 1: Comparison of Diagnostic Investigations carried on Miss S.A.P with that of the Standards.

Date Specimen Investigation Results Normal Ranges Interpretation Remarks

(Standards)
8/8/16 Blood Blood film for Positive No malarial parasites Positive means I.V Artesunate

malarial parasites should be present. presence of malaria. 80mg

(MPs) (0hr,12hr,24hr)

8/8/16 Blood Hemoglobin level 11.3g/dl Female;11.5-16.0g/dl Haemoglobin is Tablet

estimation. Male;13.5-18.0g/dl slightly below normal Fersolate

Children;11.5-15.5g/dl values. Meaning client 200mg daily x

has mild form of 30 days was

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

count normal range. Meaning given.

the presence

ofinfection

8/8/16 Blood Red Blood Cell 4.75x 106/ μL 3.00 – 5.80x106/μL Results were within No treatment

(RBC) count normal range. given.

27
Based on the test done, it was confirmed that the patient had malaria.

(B) Causes of Client’s Condition

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

nearby stagnant water.

Table 2: Comparison of Clinical Manifestations on Miss S.A.P with that of

the Literature review

Manifestation On The Patient’s Manifestations

Literature Review
Headache Headache was present
Nausea Nausea was present
Anorexia Anorexia was present
Fever Fever was presented by patient
Rigor Patient did not present with rigor
Fits and Coma Fits and Coma were not presented
by patient
General body weakness Patient presented with weakness
Vomiting Patient did not experience
vomiting
Diarrhoea Diarrhoea was present
Abdominal pain Abdominal pain was absent
Anaemia Patient was anaemic(mild)
Patient did not present with fits and coma which is a late clinical manifestation

because she reported earlier for treatment.

28
 Table 3: Comparison of Treatment given to Miss S.A.P. with that of the

Literature review

Drugs in Literature Review Drugs Given to the Patient

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

2.Antipyretics and analgesics:

(i) Paracetamol Tablet Paracetamol 500mg tid x 5days was given

3 Management of Anaemia
(i) Haematinics
(ii) Blood transfusion
4 Management of convulsion
(i) Diazepam
(ii) Phenobarbitone
Tablet Fersolate 200mg daily x 30day was given
Patients was not transfused
Was not given
Was not given

5 The use of antibiotics Was not given

6 Fluid management
(i) Normal saline
(ii) Ringers lactate
(iii) Dextrose water
(iv) Oral Rehydration Salt
Was not given
Intravenous Fluid Ringers Lactate 1 liter over 24 hours was given
Intravenous Fluid 5% Dextrose 1 liter over 24 hours was given
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

shows that the patient received the right treatment.

29
 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.

level. within the normal range. pain

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

mol Orally (opioid Liver and kidney patient

analgesic) damage

30
 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

31
(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).

2.2 Patient/Family Strengths

The strength of the patients and the family involves what can be done on their

part to facilitate the work of healthcare providers in providing holistic care to

promote recovery (Gulanick Myers, J.L., 2006).

The patient/family strengths are the coping strategies that can enable them

cope with stressful situations thereby promoting speedy recovery to the

patient.

Miss S.A.P. had the following strengths;

 Patient could tolerate tepid sponging

 Patient’s headache subsided with bed rest

 Patient could tolerate fruits and half of served meals

 Patient was able to take 2 hours naps in the afternoon

 Patient could tolerate passive exercises

 Patient was able to tolerate oral fluids. (about 1.5 liters in a day)

2.3 Patient/Family Health Problems

A health problem is any stressful situation whether physical, social or

psychological on the patient/family that requires nursing intervention and

32
appropriate measures. The client had the following problems.

(Parry and Gill, 2004)

 Patient had high body temperature (39.0oC) (8/08/16)

 Patient had headache (8/08/16)

 Patient had loss of appetite (8/08/16)

 Patient was not able to sleep in the night (9/08/16)

 Patient was feeling weak and was bedridden (9/08/16)

 Patient had diarrhoea. (10/08/16)

2.4 Nursing Diagnoses

It is a clinical summary of the clients health problem and it cause.

1. Ineffective thermoregulation (fever) related to presence of plasmodium

toxins in blood. (8/08/16)

2. Impaired comfort (headache) related to disease process. (8/08/16)

3. Imbalanced nutrition (less than body requirements) related to nausea.

(8/08/16)

4. Disturbed sleeping pattern (insomnia) related to change of environment.

(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).

33
 CHAPTER THREE

PLANNING FOR THE PATIENT /FAMILY CARE

3.0 Introduction

Planning is the process of setting goals, developing strategies and outlining

tasks and schedules to accomplish the goals (Murcko, 2013).

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

health problems identified during the phase of analysis. In order to achieve

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

patient and family in the hospital and at home.

3.1 Patient/Family Care Objectives and Outcome Criteria

Patient and family care, it is the process of a plan, based on a nursing

assessment and nursing diagnosis, carried out by a nurse (Mosby’s medical

dictionary 9th edition)

The under listed objectives were set to solve the health problems of Miss

S.A.P.

 Client will have normal body temperature (36.2-37.2oC) within 24

hours

 Client’s body comfort will be restored within 24hours

34
 Client will regain her normal nutritional pattern(good appetite) within

72 hours

 Client will be able to sleep at least 6 -8 hours in a day within 48 hours.

 Client will not develop any bedsores within the period of

hospitalization.

 Client will maintain normal fluid volume within the period of

hospitalization.

35
 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

-tion (fever) temperature(36.2- temperature. temperature. patient’s

37.2oC) within 24 (2) Tepid sponge patient (2) ) Patient was tepid
related to temperature
hours as evidenced by: sponged to bring
presence of reduced to
(1)The nurse recording temperature down by 10C
plasmodium 36.0oC
patient’s temperature (3)Adequate room
(3) Ensure adequate room
toxins in
which is consistently ventilation was ensured by
ventilation
blood
normal(36.2-37.2oC) opening windows

(2) The mother (4) Cold drinks were served

(4)Serve cold drinks
verbalizing patient’s (5).Patient was supported
(5).Encourage client to
body not warm to and engages in cold bath
practice cold bath
touch (6)Tablet Paracetamol was
(6)Administration of
served as ordered
antipyretic drug as ordered

36
 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

Time Diagnosis Criteria

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

(2) Nurse visualizing bed to promote rest (4)Adequate room ensured

that client is relieved of (4)Ensure adequate room by opening windows

headache through her ventilation (5) Enough rest and sleep

relaxed facial (5) Ensure enough rest and was ensured.

expressions. sleep (6)Warm bath was given

(6)Give warm bath after after every meal to promote

every meal to promote comfort

comfort

37
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

12:30pm nutrition normal nutritional (mouth care) 12:30pm met as client

(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

38
 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

able to sleep throughout

6. Encourage patient to 6. Bed time rituals were done to induce
the night. sleep example listening to music, reading
perform bed time rituals.
the bible.

39
 Table 4: Nursing Care Plan for Madam A.A. and Family Continued

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

Time Diagnosis Outcome Time

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

that patient has exercises walk around

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

discharge make patient comfortable. to make patient comfortable.

40
 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

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

passing of patient has good skin cardiac overload

loose stool turgor 4.Assess for signs and symptoms 4.Patient was observed for signs and
2. Patient’s mother
of electrolyte imbalance symptoms of electrolyte imbalance such
verbalizing that
as muscle weakness
diarrhoea stools have
stopped. 5. Administer intravenous fluid 5.Intravenous fluids were administered as

as ordered. ordered to maintain normal fluid balance

6.Give oral rehydrated salt(ORS) 6.Oral rehydrated salt was given as

ordered

41
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT / FAMILY CARE PLAN

4.0 Introduction

Implementation is the carrying out, execution, or practice of a plan, a method, or

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.

4.1 Summary of Actual Nursing Care Rendered

First day of Admission: 8/08/16

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

bed. The vital signs checked and recorded on admission were:

 Temperature 39.0 degrees Celsius (oC)

 Pulse 112 beats per minute (bpm)

 Respiration 35 cycles per minute (cpm)

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.

She was served with the following medications;

 Tablet Arthemeter Lumefantrine (20mg/120mg) 4 tablets bid x 3days

 Tablet Paracetamol 500mg tid x 5days

 Tablet Fersolate 200mg daily x 30days

 Intravenous Fluid 5% Dextrose 1 liter over 24hours

 Intravenous Artesunate 80mg (0 hourly, 12 hourly, 24hourly)

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.

The problem of high body temperature (fever) was identified at 12:30pm on

8/8/16 and an objective was set to relieve the fever within 24 hours. The nursing

interventions given including checking of vital sign, ensuring adequate room

ventilation, tepid sponging patient, serving cold drinks and serving prescribed

antipyretics. Again patient’s body comfort was impaired (headache) so an

objective was set to relieve the discomfort within 24hours.The nursing

interventions carried out included reassuring client, providing diversional therapy,

neatly laying patient’s bed to promote sleep and administering 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

objective set to restore patient’s nutritional status to normal within 72 hours.

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

routine medication at 10:00pm, patient was made comfortable in bed to sleep.

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

environment. She gave no other complaint. As a means of helping her to sleep an

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.

Vital signs checked and recorded at 6:00am read;

 Temperature 36.4 degrees Celsius (oC)

 Pulse 82 beats per minute (bpm)

 Respiration 20 cycles per minute (cpm)

Client was given Artesunate 80mg (0hr, 12hr,24hr) Intravenously, Tablet

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

conversations with relatives to serve as a form of diversion therapy. On this day

45
the patient was informed of my intentions to visit her home the next day. She

agreed and offered to allow one of her sister’s to take me there.

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

energy as an intervention to the weakness. At 7:30pm an evaluation was made on

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.

Third Day of Admission: 10/8/2016

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)

 Pulse 78 beats per minute (bpm)

 Respiration 19 cycles per minute (cpm)

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

an orange. All prescribed medications were served. I sought permission from my

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

meals and also before bedtime. She slept around 11:00pm.

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

signs checked and recorded at 6:00am was

 Temperature 36.2 degrees Celsius (oC)

 Pulse 70 beats per minute (bpm)

 Respiration 16 cycles per minute (cpm)

Due medications were given as prescribed and documented appropriately. I

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

made on disturbed sleeping pattern(insomnia) related to change of environment

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

bedsores. At 7:30pm an evaluation was made on the diagnosis imbalanced

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.

Client slept around 11:00pm.

Fifth day of admission: 12/8/2016

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

review was also stressed on.

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

During morning rounds at 9:00am, she lodged no complaints hence was

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

brought a car to pick her home.

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.

4.2 Preparation of Patient/Family for Discharge and Rehabilitation

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

transmission, signs and symptoms, complications and the preventive measures.

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

also ensure personal hygiene and environmental cleanliness was emphasized.

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.

4.3 Follow-Up/ Home Visits and Continuity of Care

First Home Visit (10/08/2016)

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

College, Berekum who was rendering care to their mother as a fulfilment of my

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

made up of four bed rooms.

In front of the house, there is a kitchen and a bathroom whiles they had their toilet

at the back of the house.

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

the community toilet.

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.

Second Home Visit (14/08/2016)

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

to see Miss S.A.P active and healthy.

53
I was offered a seat in front of their room and whilst sitting, I looked through the

window to see if they were now sleeping in an Insecticide Treated Net (ITN)

which actually confirmed what one of her brother’s told me on phone. To my

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

answers they gave to my questions on malaria especially Miss S.A.P herself. I

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

bushy. I also stressed on good ventilation, nutrition and drainage of choked

gutters

During the visit, I reminded them of the date of review which was August 19,

2016. At around 10:00am, I asked permission to leave. I gave oranges, water

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

accompanied me to the road side and I returned to Drobo town.

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

the hospital entrance home. I assured her of my next home visit.

Third Home Visit (01/09/2016)

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

health nurse in the area to continue with the care.

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

EVALUATION OF CARE RENDERED TO PATIENT/FAMILY

5.0 Introduction

Evaluation is a systematic determination of a subject’s merits, worth and

significance, using criteria governed by a set of standards. The primary purpose of

evaluation is to gain insight into prior or existing initiatives and to enable

reflection and assist in the identification of future change (Tufo, 2002).

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

chapter comprises of the following;

 Statement of evaluation

 Amendment of the patient/family care plan for partially met and unmet

objectives

 Termination of care

5.1 Statement of Evaluation

1. Patient Regained and Maintained Normal Body Temperature. 9/08/2016

On 8th of August, 2016 at 7:30pm, the problem of fever was identified and

numerous nursing interventions employed as a goal was set to return clients

temperature to normal (36.20C-37.20C) within 24 hour. The patient and family

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

ventilation and administration of prescribed antipyretics and other nursing

interventions were carried out to control the pyrexia. The set objective was fully

met as patient’s temperature reduced to 36.0oC on 9/08/16 at 12:30pm.

2. Patient’s body comfort was restored on 9/08/2016

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

comfort. Miss S.A.P. was engaged in conversations with family members as a

form of diversion therapy. Tablet Paracetamol was administered as prescribed 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.

3. Miss S.A.P regained her normal nutritional pattern (good appetite) on

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

Miss S.A.P complained of sleep disturbances related to change of environment on

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

procedures were combined to avoid interference with patient’s sleeping hours.

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

able to sleep 6 to 8 hours continuously without interruption as evidenced and

verbalised by the night nurses and patient respectively.

5. Patient had no Pressure ulcers on 13/08/2016

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.

6. Patient Maintained her Normal Fluid Volume on 13/08/2016

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

diarrhoea had stopped.

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

health care team.

5.3 Termination of Care

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

were given to take home to prevent relapse. Education on environmental and

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

community or report back to the hospital whenever any ailment or disorder

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

relationship will definitely come to an end once they are well.

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 CHAPTER SIX

SUMMARY AND CONCLUSION

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

use of the nursing process.

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

relative(mother)with a diagnosis of Severe Malaria. Blood film for malaria

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

nursing interventions were given. The medical treatment given include

Intravenous Artesunate 80mg course, Tablet Arthemeter Lumefantrine

(20mg/120mg) 12 hourly x 3days, Tablet Paracetamol 500mg tid x 5days, Tablet

Fersolate 200mg daily x 30days, Intravenous Fluid 5% Dextrose 1 liter over

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

since she was healthy and well looking at that time.

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

given community as a whole. The study gave me the opportunity to render

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

the necessary intervention is given mainly through health education.

In brief, I really enjoyed writing this script despite the challenges involved

including financial constraints and getting the needed information from patient

and family.

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 BIBLIOGRAPHY

Berman, A., Snyder, S. J., Kozier, B. and Erb, G. (2008). Kozier & Erbs

Fundamentals of Nursing (8thed.). New Jersey: Pearson Education,

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British Medical Association/Royal Pharmaceutical Society of Great Britain.

(2007). British National Formulatory (BNF) (54thed.). London.

Bowen, M. (1998). Family Systems Theory-Genopro. Retrieved on

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www.genopro.com/genogram/family-Systems-theory/.

Caraballo, H. (2014). Definition of Malaria. Retrieved from

www.medicalnews today.com>articles

Ellis, R. J. and Bentz, M. P. (2007). Modules for Basic Nursing Skills (7th ed).

Philadelphia: Lippincott Williams and Wilkins. Health line Media, (2015).

Definition of Malaria. Retrieved from:

www.healthnettpo.org/malariaafghanistan.com on 5/10/2016

Katzung, B. G., Masters, S. B. and Trevor, J. A. (2009). Basic and Clinical

Pharmacology, (11thed.) (International ed.). San Francisco:

McGraw-Hill Company, Inc.

Mensah, A.E. (2012). Pharmacology and Therapeutics. (2nd Ed) Excel Print,

Sunyani Medical News Today. (2014). Definition of Malaria. Retrieved from:

www.malarianomore.org.uk/the -disease on 05/10/2016

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 Ministry of Health. (2004). Standard Treatment Guidelines. (5th Ed.). Justice

Press Limited Accra-Ghana

Monahan, D. F., Sands, J.K., Neighors, M. and Green, C.J. (2007).

Phipps’Medical-Surgical Nursing; Health and Illness Perspective

(8thed.). St Louis: Mosby Elsevier.

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www.m.investorword.com/planning. on. 06/9/ 2016

Nilep, C. (2010). “Data Analysis”. Retrieved from:

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Parry, E., and Gill, B. (2004). Principles of Medicine in Africa. Teins Wa

(Pte) Ltd, Singapore.

Rouse, M. (2007). “Definition of Implementation”. Retrieved from:

www.searchcrm.techtarget.com/definition/implementation on

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Smeltzer, C. S. & Bare, B. (2010). Brunner and Saddarth’s Textbook for

Medical-Surgical Nursing. (12th Ed.), Philadelphia; PA: J.B
Lippincott Williams & Wilkins.

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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)

8/08/2016 11:00am 22 88 39.0

12:30pm 21 88 38.2
02:00pm 21 86 37.2
10:00pm 21 85 38.0
9/08/2016 06:00am 20 82 36.4
10:00am 20 80 36.1
02:00pm 18 81 35.9
06:00pm 17 76 35.8
07:30pm 17 77 36.0
10:00pm 18 78 36.0
10/08/2016 06:00am 19 78 35.5
10:00am 18 77 35.9
02:00pm 19 80 35.4
06:00pm 17 76 36.0
10:00pm 16 76 36.9
11/08/2016 06:00am 16 70 36.2
10:00am 17 74 36.8
02:00pm 18 76 35.0
06:00pm 17 75 35.3
10:00pm 16 74 37.0
12/08/2016 06:00am 16 68 35.8
10:00am 16 70 36.2
02:00pm 18 74 36.5
06:00pm 17 72 36.4
10:00pm 16 73 36.0
13/08/2016 06:00am 15 64 36.0

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 SIGNATORIES

The Principal, Holy Family Nursing And Midwifery Training College,

Berekum
Name: Ms. Monica Nkrumah
Signature:……………………………………………………………………
Date:………………………………………………………………………………

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:………………………………………………………………………………

The Student Nurse

Name: Kyereh Kwabena Fred
Signature:……………………………………………………………………
Date:………………………………………………………………………………

67