CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY

1.0 Introduction

Assessment is the systemic collection of data to determine the patient health status

any actual or potential health problems. [Smelter and Bare2010]. Among the It

entails collection of data from the patient/family through interviews, observations,

medical records and laboratory investigations and physical examination. The

patient/family’s problems are identified and the appropriate nursing interventions

are rendered based on the information gathered.

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 A.T is the name of my client. She is 11 years old and was born on 25th

March,2007. She was born to Mr. A.M and Mrs. A.S who are both alive. Miss

A. T is the second born of her parents of three (3) children of which two (2) are

females and one(1) male. Miss A.T comes from biadan which is a suburb of

Berekum municipality in the Brong Ahafo region of Ghana. She is in primary five

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(5) at Methodist primary and junior high school at biadan. She is an akan by tribe

but speaks both twi and english. Miss A.T is a christian and therefore attends

church of Pentecost. Miss A.T is fair in complexion, slim and she is 1.2 meters

tall and weigh 22kg.Miss A.T lives in a boys quarters with her family members

except her grandfather who has passed away about three years ago. Miss A. T

lives in house number BD 22 at biadan. Her next of kin is M.S.A, who is her

cousin.

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. According to her parents, in case of minor

ailment such as headache, general body, weakness, chills, constipation etc, they

usually resort over the counter drug for cure. According to her mother this is the

second time miss A.T had been admitted to hospital with the same disease

condition(malaria)

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
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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 including her class mate

visited her when she was on admission to give her emotional support, bringing her

food and other necessary items she needed.

According to miss A.T, her father is a teacher and her mother is trader and sells

palm oil at biadan. He is supported by his wife, Mrs. A.S 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.

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. Miss A.T 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 is

the progressive development of a living thing, especially the process by which the

body reaches its point of complete physical development. (Weller, 2009).

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Maturation is the process of becoming completely developed mentally or

emotionally. [Heacock,2013)

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 holy family hospital, Berekum and had

Spontaneous Vaginal Delivery (SVD) at holy family hospital, Berekum. The date

of delivery was on 25th march, 2007 at 3:27 pm.

Miss A.T was breastfed for 6 months and her mother started introducing

supplementary feeds such as porridge with milk. According to her parents, she

was immunized against all the childhood diseases that are the Bacillus Calmette

Guerin (BCG), Polio, Diphtheria, Pertussis, Tetanus, Hepatitis B, Haemophilus

Influenza Type 3, Measles and Yellow Fever. And upon observation at her right

upper arm(shoulder), there was mark confirmed that the bacillus calmette guerin

(BCG) was given.

According to miss A.T 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 (8) 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 (3) years

and started developing breast and pubic hairs at the age of eleven (11) years.

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 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)
 According to Erik Erikson’s theory of psychosocial development, my client falls

under industry verse inferiority (6-12) years. Erick Erickson explained industry as

period whereby the children feel good about what they have been able to achieve.

If they are encouraged and commended, for their actions done, they develop a

feeling of competence and beliefs in their abilities to achieve goals. And also

defined Inferior as children whose initiative is not encourage but restricted begins

to feel, doubts in their ability and therefore may not reach his potential. By

assessment, my client falls under industry. This is because her parent(mother) and

cousin always commend and encourage her for assisting them during cooking and

cleaning which makes her feels happy and confident.

According to patient’s mother, she saw her developing breast four (5) month ago.

She is aiming at becoming a midwife.

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 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 A.T 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 A.T 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 eats 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. Naturally Miss A.T is friendly and wants to chat with people, particularly her

equal age group. She said that, she likes helping her mother during cooking and assisting

them during washing of clothes but dislikes returning home from school without food at

home.

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 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 admitted once in holy family

hospital, Berekum, with the same malaria before and was treated with anti-

malarial drugs. She mostly gets access to health care in the hospitals where she

goes because she has registered with the National Health Insurance Scheme but

her mother again said anytime she suffers slight headaches, fever and other minor

ailments she treats with drugs bought from the chemical shop.

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 17th June, 2018 when she

realized that she was having high temperature body,headache,anorexia and general body

weakness. These clinical manifestations were experienced when she came back from

church at 1:23pm. She was therefore given analgesic and antipyretic drug (that is

paracetamol 500mg). According to her parents, it became severe at night(around

11:00am) and which made them(parents) brought her to holy family hospital,Berekum..

Miss A.T reported to out-patient department of holy family Hospital at Berekum on the

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18th June, 2018 at 8:17 am and her weight 31kg was taken in addition to her vital signs

that were checked and recorded prior to seeing a doctor were as follows,

 Temperature 38.8 degrees Celsius (oC)

 Pulse 110 beats per minute (bpm)

 Respiration 28 cycles per minute (cpm) .

She was seen and diagnosed with severe malaria by Dr. Omane base on
the clinical manifestations presented by miss A.T and the complaints from
her mother which includes,high body temperature,headache,anorexia and
general body weakness

 Blood film for malaria parasite.

 Blood for hemoglobin level estimation.

 White blood cell count (WBC)

 Blood for sickle cell test

1.8 Admission of Miss A.T

On 18th June, 2018 at 8:47am, patient by name miss A.T came into the

paediatric ward through outpatient department in a wheel chair and accompanied by her

relative (mother) and a student nurse. They were warmly welcomed and I offered them a

seat. I took the folder from the accompanied nurse and mentioned the name to be sure

that was the right patient. On arrival, patient complains of high body temperature,

headache, anorexia and general body weakness and by observation patient looks weak. I

did the introduction of myself and other staffs present. Patient and her relative (mother)

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were prepared psychologically by reassuring them and explaining all procedures to be

carried on the patient in order to build trust and also gain her cooperation. Miss A.T 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. They were therefore asked whether,

Miss A.T had taken in any drug. (This was done, to know the type of drug and also the

dosage). I took patient to bedside and made her comfortable on admission bed. Miss A.T

vital signs were checked and recorded at 9:00am in addition to her weight which was

31kg are as shown below;

Temperature 38.8 degree Celsius (oC)

Pulse 110 beats per minute(bpm)

Respiration 28 cycles per minute(cpm)

Patient medications were collected and served as prescribed by Dr. Omane

As the hospital protocol, they were introduced to other patients also on admission. I

quickly glanced through the folder with the aim of gathering more information on the

disease condition (malaria). They were also made aware of the hospital protocol such as

ward rounds, time for serving of medication, time for checking of vital signs, visiting

hours, national health insurance policy and mother was asked to bring these list items

such as tooth paste, soap, sponge,towel,plate,cup,spoon,tooth brush,clothes etc which will

be needed by the patient while on admission at holy family hospital,Berekum. I quickly

washed my hands and then entered the patient’s name in the admission and discharge

book and also on the daily ward state. Medications prescribed for the patient include the

following,
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  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 Ringers Lactate 1 liter over 24hours

 Oral Rehydration Salt 3 sachets

Patient and relative (mother) were informed about my desire to take Miss A.T as a patient

for the patient and family care study to enable me render to her individualized

comprehensive nursing care until her discharged, to study her condition and write a

patient and family care study on her and her condition. I told them that I will be assisting

the health team to take care of them whilst on admission. I informed them that it was a

requirement by the nurses and midwifery council that, I had to fulfill as a partial

fulfillment towards the award of diploma certificate in registered general nursing in

Ghana. They were very happy and agreed to my request and promised to cooperate fully

in caring for miss A.T.

With the help of her relative (mother), her valuables were arranged nicely in the bedside

locker. The patient particulars and all the care given were documented on the nurse’s

continuation sheet, admission and discharge book and the daily ward state. The nurse’s

care plan for miss A.T was drawn with the help of her relatives and miss A.T herself to

promote recovery. I thanked them for their cooperation and assured them that the

information that will be given throughout her care and the study will be confidential.

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1.9 Patient’s Concept of Her Illness

Patient had heard about the disease condition(malaria)since she had been admitted

previously with this same condition disease(malaria) before but said she does not

know much of the disease condition.

I took this as an advantage to educate patient and her mother about malaria which

includes, 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).

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).

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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

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.

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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.

Five (5) species of plasmodium parasite cause malaria;

 Plasmodium ovale

 Plasmodium malariae

 Plasmodium falciparum
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  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

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)

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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,

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
15
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

 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

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  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

(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

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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

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

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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

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.

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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.

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.

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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

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

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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.

 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).

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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

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

seeing the physician.

 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;

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  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.

 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 give

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1.11 Validation of Date

This is act of confirming/verifying data. The purpose is to keep the data as free from

error, bias and misinterpretation as possible.

Comparing the observation made and signs and symptoms presented by miss A.T as well

as information collected from mother, it was obvious that the data collected was valid and

free from error.

CHAPTER TWO

ANALYSIS OF DATA

2.1 Introduction

Analysis is the detailed study or examination of something in order to understand

more about it. (Wehmeier,Turnbull and Mclntosh)(2006)

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

25
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.

 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 A.T with that of the Standards.

Date Specimen Investigation Results Normal Ranges Interpretation Remarks

(Standards)
18/6/18 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)

were

prescribed and

served

18/6/18 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

has mild form of 30days was

anaemia given

18/6/18 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.

no presence of

27
 infection

18/6/18 Blood Red Blood Cell 4.75x 106/ μL 3.00 – 5.80x106/μL Results were within No treatment

(RBC) count normal range. given.

28
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 A.T 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 and bush area.

Table 2: Comparison of Clinical Manifestations on Miss A.T with that of the

Literature review

Manifestation On The Patient’s Manifestations

Literature Review
Headache Headache was present
Nausea Nausea not was present
Anorexia Anorexia was present
Fever Pyrexia 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 general body
weakness
Vomiting Patient experience vomiting
Diarrhoea Diarrhoea was not present
Abdominal pain Abdominal pain was absent
Anaemia Patient was not having
anaemic(mild)

29
 Bitterness in mouth Bitterness in mouth was not present
Sweating Sweating was not present
Patient did not present with fits and coma which is a late clinical manifestation

because she reported earlier for treatment.

Table 3: Comparison of Treatment given to Miss A.Twith that of the

Literature review

Drugs in Literature Review Drugs Given/Served to the Patient

1, Anti malaria:
(i) Artesunate Intravenous Artesunate 80mg (0hour,12hours,24hours) was given/served
(ii) Quinine Was not given/served
(iii) Artemether Lumefantrine Tablet Arthemeter Lumefantrine (20mg/120mg) 12 hourly x 3days was
given/served

2.Antipyretics and analgesics:

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

3 Management of Anaemia Tablet Fersolate 200mg daily x 30day was given

(i) Haematinics
(ii) Blood transfusion Patients was not transfused
4 Management of convulsion
(i) Diazepam Was not given
(ii) Phenobarbitone Was not given

5 The use of antibiotics Was not given

6 Fluid management
(i) Normal saline Was not given
(ii) Ringers lactate Intravenous fluid ringers lactate 1 liter over 24 hours was given/served
(iii) Dextrose water Intravenous Fluid 5% dextrose 1 liter over 24 hours was given/served

30
(iv) Oral Rehydration Salt Three (3) sachets of Oral Rehydration Salt were given/served

The treatment given is in line with the treatment in the literature review which

shows that the patient received the right treatment.

31
 Table 4: Pharmacology of Drugs

Date Drug Patient Classification Desired Actual Effect Side Effect Remarks
Dosage/Route Effects Observed
18/6/18 Tablet 200mg daily x Multivitamin To increase Miss A.T’s condition Gastro-intestinal Patient did not

Fersolate 30days. appetite and improved as the irritation, manifest any of

Orally haemoglobin haemoglobin level was nausea and these side effects.

level. within the normal range. epigastric pain

18/6/18 Tablet 500mg tds Antipyretic To reduce pain Miss A.T was relieved Skin reactions None was

Paracetamol ×5days and Analgesic and fever of fever such as itching. exhibited by the

Orally (opioid Liver and patient

analgesic) kidney damage

32
 Table 4: Pharmacology of Drugs continued

Date Drug Patient Classification Desired Effects Actual Effect Side Effect Remarks
Dosage/Route Observed
18/6/18 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.
18/6/18 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.
18/06/18 Intravenous 1 liter over 24 Intravenous To maintain Patients Oedema. Oedema not
Ringers hours electrolyte and electrolyte body electrolyte and observed on
lactate Intravenously fluid fluid balance fluid balance was the patient.
Solution replacement maintained
19/06/18 Oral 1.5 liter over Anti-vomiting Replacement of vomiting stopped Puffy eyes. It was not
rehydration 8-24 hrs fluid and completely on the observed

33
salt Orally electrolyte loss. 21/06/18

34
(E) Complications

With regards to the complications listed under the literature review, miss A.T

presented with mild form of anaemia with haemoglobin of 11.3g/dL. She was

not transfused, however she was managed with diet and haematovites

(fersolate)

2.2 Patient and Family Strengths

This involves activities the patient can perform and those that the family can

also perform in helping the patient recover (Lewis, 2012). The following were

the patient/family strengths

Miss A.T had the following strengths;

 Patient could tolerate tepid sponging

 Patient’s headache subsided with bed rest

 Patient can eat half of each meal served

 Patient could tolerate passive exercises

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

 Patient could tolerate fluid

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

35
 appropriate measures. The client had the following problems.

(Parry and Gill, 2004)

 Patient had high body temperature (38.8oC) (18/06/18)

 Patient had headache (18/06/18)

 Patient cannot eat well (18/06/18)

 Patient had general body weakness (18/06/18)

 Patient was not able to sleep well in the night (19/06/18)

 Patient was vomiting (19/06/18)

2.4 Nursing Diagnoses

It is a clinical summary of the client’s health problem and it cause.

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

toxins in blood. (18/06/18)

2. Impaired comfort related to headache. (18/06/18)

3 Imbalanced nutrition (less than body requirements) related loss of appetite

4. Risk for pressure ulcer related to prolonged stay in bed secondary to general

body weakness (18/08/18)

5. Disturbed sleeping pattern (insomnia) related to change of

environment (19/06/18)

6. Risk for deficient fluid volume related to vomiting (19/06/18)

36
 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 A.T.

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

hours

 Patient body comfort will be restored within 24hours

37
 Patient will regain her normal nutritional pattern (good appetite) within

72 hours

 Patient will not develop any bedsores within the period of

hospitalization period.

 Patient will be able to sleep at least 7 hours in a day within 48 hours.

 Patient will no more vomit throughout hospitalization period

38
 Table 4: Nursing Care Plan for Miss A.T and Family

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/Time Evaluation Sign
Time Diagnosis Criteria
18/06/18 Ineffective Patient will have normal (1) Monitor patient’s vital (1) Patients vital signs were 19/06/18 Goal fully met

9:00am thermoregula- body temperature(36.2- signs and record monitored particularly 9:00am as nurse
37.2oC) within 24 hours particularly body temperature.
tion (fever) recorded
as evidenced by: temperature. (2) Patient was tepid
related to patient’s body
(1) The nurse recording (2) Tepid sponge patient sponged to bring
presence of temperature
patient’s body temperature down by 1 C 0

plasmodium within normal

temperature within (3) Ensure (3) Adequate room
toxins in range(36.0oC)
normal range(36.2- adequate room ventilation ventilation was ensured by
blood and Patient
37.2oC) opening windows and
verbalized
(2) The Patient (4) Serve cold drinks switching on fan

verbalizing that her (5). Encourage client to (4) Cold drinks were served that body not

body not warm when practice cold bath (5). Patient was encouraged warm when

touched (6)Administration of to practice cold bath touched

antipyretic drug as (6)Antipyretic drug(tablet

39
 Prescribed. Paracetamol) was served as

prescribed.

Table 4: Nursing Care Plan for Miss A.T and Family Continued

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

Time Diagnosis Criteria

40
 18/06/18 Impaired Patient’s body comfort (1) Ensure adequate oral (1) Fluid was served 19/06/18 Goal was

9:00am comfort will be restored within fluid intake to maintain adequately in maintaining 9:00am met fully as

related to 24 hours as evidenced circulatory volume and circulatory volume patient

by: restore comfort (2) Client was involved in
headache verbalized
(1) Patient verbalizing (2) Provide diversional conversations with relatives
that she no
that she no longer has therapy (3) Patient’s bed was neatly
longer has
headache (3) Well prepare patient’s laid to promote comfort
headache and
(2) Nurse observing bed to promote rest (4) Adequate room ensured
nurse
patient with relax facial (4) Ensure adequate room by opening windows
observed
expression. ventilation (5) Enough rest and sleep

(5) Ensure enough rest and was ensured. patient with

sleep (6) Warm bath was given relax facial

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

every meal to promote comfort

comfort

Table 4: Nursing Care Plan for Miss A.T and Family Continued

41
Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time

18/08/18 Imbalanced Patient will regain her (1) Ensure oral hygiene (1) Oral hygiene was ensured 21/08/18 Goal fully

9:05am nutrition normal nutritional (mouth care) 9:05am met as nurse

(less than pattern (good appetite) (2) Plan meal with patient (2) Patient meal was plan observed
within 72 hours as accordingly to her choice
body patient eating
evidenced by; (3) Patient’s favorite meals like
requirement) (3) Prepare and serve more than
(1) The nurse observing banku with okro soup were
related to patient’s favorite meal half of each
that patient eating more prepared and served attractively.
attractively
loss of meal served
than half of each meal (4) Food was served in bits and
(4) Serve food in bits and at
appetite and patient
served. at regular intervals.
regular interval.
verbalized
(2)Patient verbalizing (5) Fruits such as oranges were
(5) Serve fruits after meals.
that her appetite had served after each meal. that her
(6)Eliminated unpleasant
been restored (6)Unpleasant sights example appetite had
and nauseating articles from
bed pan, bins were eliminated been
sight of the patient before
before meal. restored.
meal

42
Date/Time Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Diagnosis Criteria Time

19/06/18 Disturbed Patient will be able to 1. Perform all nursing 1. Nursing activities were performed 20/06/18 Goal fully met
when necessary to promote sleep
8:15am sleeping sleep for at least 7 hours procedures at a goal 8:15am as nurse

pattern in the night within 24 2. Give patient warm bath observed

2. Patient was given a warm bath to relax
hours as evidenced by: before she goes to bed at and induce sleep.
(insomnia) patient having
(1) Nurse observing that night
related to 3. Patient’s bed was made free from an
patient was able to 3. Make bed comfortable.
particles, creases and cramps.
change of uninterrupted
sleeps for at least 7 4. Ensure quiet 4. A quiet environment was ensured by
environment restricting visitors and reducing the sleep for a
hours uninterrupted. environment.
volume of radio and television sets. least 7 hours
(2) Patient’ mother
and patient’s
verbalizing that she was 5. Provide dim lights. 5. Lights on the ward were dimmed in the
evening to enable patient to sleep. mother
able to sleep throughout

the night. verbalized that

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

43
 throughout the

night

Table 4: Nursing Care Plan for Miss A.T and Family Continued

Table 4: Nursing Care Plan for Miss A.T and Family Continued

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

Time Diagnosis Outcome Time

Criteria

18/06/18 Risk for Patient will not 1. Asses and monitor for patient’s 1. Clients pressure area was assessed and 22/06/18 Goal fully met

9:10am pressure ulcers develop any pressure area monitored on daily bases 9:10am as nurse

44
 related to bedsores within the 2. Change position of patient every 2. Patient’s position was changed every 2 observed

prolong stay in period of 2 hours hours to prevent bedsores. patient with

bed secondary hospitalization 3. Treat pressure areas 3. Pressure areas were treated with soap good skin
to body as evidenced by; and talcum powder after bathing.
integrity and
weakness (1) Nurse observing 4.Engage patient in passive 4.Patient was assisted to sit up and to
patient
patient with good exercises walk around
verbalized that
skin integrity 5. Change soiled linen frequently 5. Soiled linens were changed frequently
she has intact
(2) Patient 6. Straighten bed linens regularly to 6. Bed linens were straightened regularly
skin on the day
make patient comfortable. to make patient comfortable.
verbalizing that
of discharge
she has intact skin

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

45
 Diagnosis Criteria Time

19/06/18 Risk for Patient will maintain 1. Reassure client and relatives 1. Client was reassured that the diarrhea 21/06/18 Goal was
deficient normal fluid volume that vomiting will stop will subside with time. fully met as
9:20am 9:20am
fluid during the period of nurse
2.Assess patient ‘s skin turgor 2.Patient skin turgor was assessed for
volume hospitalization as observed
signs of dehydration
related to evidenced by; patient with
frequent 1.nurse observing 3.Weigh patient daily 3.Patient was weighed daily to prevent good skin
vomiting patient with good cardiac overload turgor and no
skin turgor and no 4. Administer intravenous fluid 4.Intravenous fluids were administered as
sign of
sign of dehydration dehydration
as ordered ordered to maintain normal fluid balance
2. Patient verbalizing And patient
that vomiting has 5.Give oral rehydrated salt(ORS) 5.Oral rehydrated salt was given as
verbalizing
stopped. 6. Prescribed medication was ordered
that vomiting
served 6. Prescribed medication was served
has stopped

46
 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:18/6/18

On 18th June, 2018 at 8:40am, patient by name Miss A.T came into the pediatric ward

through outpatient department in a wheel chair and accompanied by her relative (mother)

and a student nurse. They were warmly welcomed and I offered them a seat. I took the

folder from the accompanied nurse and mentioned the name to be sure that was the right

patient. On arrival, patient complains of high body temperature, headache, anorexia and

general body weakness and by observation patient looks weak. I did the introduction of

myself and other staffs present. Patient and her relative (mother) were prepared

psychologically by reassuring them and explaining all procedures to be carried on the

47
patient in order to build trust and also gain her cooperation. Miss A.T 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. They were therefore asked whether, Miss

A.T had taken in any drug. {This was done, to know the type of drug and also the

dosage}. I took patient to bedside and made her comfortable on admission bed. Miss A.T

vital signs were checked and recorded at 9:00 am in addition to her weight which was

31kg are as shown below;

Temperature 38.8 degree Celsius (oC)

Pulse 110 beats per minute(bpm)

Respiration 27 cycles per minute(cpm)

Patient medications were collected and served as prescribed by Dr.Omane

As the hospital protocol, they were introduced to other patients also on admission. I

quickly glanced through the folder with the aim of gathering more information on the

disease condition (malaria). They were also made aware of the hospital protocol such as

ward rounds, time for serving of medication, time for checking of vital signs, visiting

hours, national health insurance policy and mother was asked to bring these list items

such as tooth paste, soap, sponge,towel,plate,cup,spoon,tooth brush, clothes etc which

will be needed by the patient while on admission at holy family hospital,Berekum. I

quickly washed my hands and then entered the patient’s name in the admission and

discharge book and also on the daily ward state. Medication and prescribed for the patient

include the following,

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

48
  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)

 Oral Rehydration Salt 3 sachets

Patient and relative (mother) were informed about my desire to take miss A.T as a patient

for the patient and family care study to enable me render to her individualized

comprehensive nursing care until her discharged, to study her condition and write a

patient and family care study on her and her condition. I told them that I will be assisting

the health team to take care of them whilst on admission. I informed them that it was a

requirement by the nurses and midwifery council that, I had to fulfill as a partial

fulfillment towards the award of diploma certificate in registered general nursing in

Ghana. They were very happy and agreed to my request and promised to cooperate fully

in caring for miss A.T.

With the help of her relative(mother) valuables were arranged nicely in the bedside

locker. The patient particulars and all the care given were documented on the nurse’s

continuation sheet, admission and discharge book and the daily ward state. The nurse’s

care plan for miss A.T was drawn with the help of her relatives and miss A.T herself to

promote recovery. I thanked them for their cooperation and assured them that the

information that will be given throughout her care and the study will be confidential.

Objective was set for miss A.T within 24 hours and nursing care plan was drawn for her

high body temperature(pyrexia) (38.8) which was checked and recorded on admission at

the pediatric ward. In order to achieve the set objective, interventions for her includes;
49
patient’s vital signs were monitored particularly temperature, patient was tepid sponged to bring

temperature down, adequate room ventilation was ensured by opening windows and switching on

fan, cold drinks were served, patient was encouraged to practice cold bath and antipyretic drug

(500mg Paracetamol) was served as prescribed. At 9:00am, patient complaints of headache which

makes her body uncomfortable, objective was set within 24 hours and interventions includes;

fluid was served adequately in maintaining circulatory volume, client was involved in

conversations with relatives, Patient’s bed was neatly laid to promote comfort, Adequate room

ensured by opening windows, enough rest and sleep was ensured. Warm bath was given after

every meal to promote comfort. During the ward rounds, patient was asked to continue her

medications. Patient complaints of not able to eat well at 9:05am and objective was set within 72

hours and the nursing interventions were; oral hygiene was ensured, client meal was plan

accordingly to her choice, Patient’s favorite meals like banku with okro soup were prepared and

served attractively, food was served in bits and at regular intervals, fruits such as oranges were

served after each meal and unpleasant sights example bed pan, bins and odors were eliminated

before meal. At 9:10am, miss A.T complaints of general body weakness and therefore has being

lying in bed for several minutes. There is possibility of pressures sores.so objective was set

throughout hospitalization period and the interventions were; . clients pressure area was assessed

and monitored on daily bases,Patient’s position was changed every 2 hours to prevent bedsores,

Pressure areas were treated with soap and talcum powder after bathing patient was assisted to sit

up and to walk around, soiled linens were changed frequently and Bed linens were straightened

regularly to make patient comfortable. In the afternoon, patient vital signs were checked and

recorded and due medication was served. She took in cool drink(malta) for lunch. She therefore

retires to bed but did not sleep. In the evening, she took in 2 sliced of yam out of 7 sliced yam

with tomato stew. She brushed her teeth and took her bath. Her medication was served.AT

10:00pm, her vital signs were checked and recorded. She retires to bed but did not sleep and

therefore was hand over to the night nurses and l left the ward.
50
Second Day of Admission: 19/6/2018

On the following morning, I was told that, miss A.T couldn’t sleep well she woke up at

2:00pm and did not sleep again but decided to watch television. She took her bath and

then brush her teeth. Her vital signs were checked in the morning as shown below;

 Temperature 36.4 degrees Celsius (oC)

 Pulse 82 beats per minute (bpm)

 Respiration 20 cycles per minute (cpm)

51
After patient had taken in one-third of a cup of porridge served her due medication was

also given. I then interact with client at 8:15am and she complaints of not able to sleep

well during the night relating it to change of the environment as said by the night nurses.

Objective was served within 24 hours and the nursing interventions were; perform all

nursing procedures at a goal, give patient warm bath before she goes to bed at night, make

bed comfortable, ensure quiet environment, provide dim lights and encourage patient to

perform bed time rituals such as listening to radio to induce sleep.

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. At 9:00am in the morning,

evaluation was done on the objective set on 18/06/18, and goal fully met as nurse recorded

patient’s body temperature within normal range(36.0oC) and Patient verbalized that body

not warm when touched.

Again evaluation was also done on the objective set for headache which makes her

uncomfortable on 18/06/18 at 9:00am and goal was fully met as patient verbalized that she no

longer has headache and nurse observed patient with relax facial expression. On this day

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. During the word rounds at 9:20am, miss

A. T complaints of frequent vomiting early this morning (around 6:00pm) metoclopramide 1mls

tidx1 was prescribe for patient by Dr omane. She was also encouraged to take in oral fluid.

Objective was set throughout hospitalization period and nursing interventions includes; client
52
was reassured that the vomiting will subside with time, patient skin turgor was assessed for signs

of dehydration,. Patient was weighed daily to prevent cardiac overload, intravenous fluids were

administered as ordered to maintain normal fluid balance, oral rehydrated salt was given as

ordered, prescribed medication was served. Patient therefore sat at her bed to watch television and

at 2:00pm, her vital signs were checked and due medication was served. Miss A.T served with tea

and pie for lunch and in the evening, she ate one third of one boll of kenkey served with fish and

okro stew. She then performs her personal hygiene, she retires to bed and at her vital signs were

checked and recorded. She was again handed over to the night nurses to continuing care.

Third Day of Admission: 20/6/2018

 On the third day, miss.A.T woke up around 5:40am and had her personal

hygiene maintained.She her vital signs were checked and recorded at

6:00am includes;

 Temperature 35.5 degrees Celsius (oC)

 Pulse 78 beats per minute (bpm)

 Respiration 19 cycles per minute (cpm)

As usual all her due medications were served in the morning and then

documented.

She was served with “hausa porridge and koose” and she was able to take half.
Evaluation was done on objective set on 19/06/18 and at 8:15am and goal was fully met
as nurse observed patient having an uninterrupted sleep for a least 7 hours and patient’s
mother verbalized that she was able to sleep throughout the night. During ward rounds,
miss AT was asked of any complaint(s) by Dr omane and she responded no.She was
therefore asked to continue the rest of her medications..Miss A.T then picked to read. Her
vital signs were checked and recorded in the afternoon and her medication was also
served. She ate more than half of the rice and stew with fish served for lunch and at 4:14

53
am,she took a nap for one hour fifteen minutes. In the evening, she was served with one
boll of kenkey and fish which she ate all. Miss A.T due medications were served and she
took her bath and gently brush her teeth with the help of her mother. She then sat to
watch television and her vital were checked and recorded. Miss A.T was handed over to
the night nurses and I left the ward around 10:05pm.

Fourth day of Admission: 21/6/2018

This morning, Miss A.T 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 were;

 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. Miss A.T 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. Rice water and bread buttered with margarine was served for breakfast and Miss
A.T ate all. Evaluation was done on the objective set on 18/06/18 and at 9:20am and goal
was met fully as met as nurse observed patient with good skin turgor and no sign of
dehydration and patient verbalizing that vomiting has stopped and nurse observed patient
with good skin turgor. Again, evaluation was made on the objective set on 18/06/18 and
at 9;05am and goal fully met as nurse observed patient eating more than half of each meals
served and patient verbalized that her appetite had been restored. During the ward rounds,
patient did not present any complaint and therefore Dr Omane ordered for continues
treatment and patient should be observed or monitored for possible discharge tomorrow.
Miss A.T sat on a chair near her bed side to watch television programme.She then slept
and wake up in the afternoon and her vital signs were checked and recorded and also her
54
due medication was served. She took in banku and groundnut soup with fish as lunch.
Miss A.T picked her book to read. In the evening her vital signs were checked and
recorded and her due medication was given. She took in sliced yam with’ kontomire’
stew as supper. Miss went and performed her personal hygiene. She then went and sat to
watch television programme. Client slept around 11:00pm.

Fifth day of admission: 22/6/2018

I arrived at the ward at 6:56am on this day to find miss A.T 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

Her due medication was also served and patient cooperated well. Evaluation was

made on the objective set on 18/06/18 and at 9:10am and goal fully met as nurse

observed patient with good skin integrity and patient verbalized that she has intact skin

on the day of discharge.

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

discharged home and to report for review on 29th June,2018. The doctor ordered

tablet Paracetamol 500mg tid x 5days and to continue with the tablet Fersolate

200mg daily. 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 29th, June 2018 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
55
done for her so far.Her out patient department card was sent to the accounts office

for billing. Her particulars were entered on the admissions and discharges book

and daily ward bed state. The outpatient department card was later taken to the

pharmacy for the medications ordered. Around 11:30am, miss A.T was ready to

go home. I later escorted them out of the ward where father 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 ofm miss A.T 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
56
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

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 (20/6/2018)

On Wednesday, 20th June 2018, 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 to biadan and in

2:20pm, I was at the entrance of their house with the help of the information given

me by her mother. 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.

Biadan is a suburb of Berekum, and is about 1 kilometer from Berekum. Their

house is behind biadan car station. I was warmly welcome by one her relatives

present at their house. Miss A.T and a seat was offered me as well as a glass of

water. I introduced myself as a second year student of Nursing and Midwifery

57
Training College, Tepa who was rendering care to miss A.T 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.

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 (28/6/2018)

58
My second home visit was on Sunday, 28th June, 2018. 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 A.T 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 A.T family for heeding to my advice. I was very happy to

see miss. A.T active and healthy.

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 A.T and the family. I was very happy to hear the answers

they gave to my questions on malaria especially miss A.T 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 June 29, 2018.

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

pineapples to the family to give to miss A.T. 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 Berekum town.

59
Review (29/6/2018)

On 29th June, 2018, miss A.T 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

with patient to the records department to ensure that service request is

recommended for her. I escorted them to the outpatient department and checked

her vital signs and it was recorded as;

 Temperature 36.5oC

 Pulse 70bpm

 Respiration 18cpm

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 to home. I assured her of my next

home visit.

Third Home Visit (2/7/2018)

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

60
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.

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
61
  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.

On 18th of June, 2018 and at 9:00am, miss A.T was having high body

temperature(pyrexia) due to presence of plasmodium toxins in the blood. Objective was

set for miss A.T within 24 hours and nursing care plan was drawn for her high body

temperature(pyrexia) {38.8}. In order to achieve the set objective, interventions for her

includes; patients vital signs were monitored particularly temperature, patient was tepid sponged

to bring temperature down, adequate room ventilation was ensured by opening windows and

switching on fan, cold drinks were served, patient was encouraged to practice cold bath and

antipyretic drug (500mg Paracetamol) was served as prescribed. Goal fully met as nurse

recorded patient’s body temperature within normal range(36.0oC) and Patient verbalized

that body not warm when touched.

2. Patient’s body comfort was restored

On 18/06/18 and at 9:00am, patient complaints of headache which makes her body

uncomfortable, objective was set within 24 hours and interventions includes; fluid was served

adequately in maintaining circulatory volume, client was involved in conversations with relatives,

Patient’s bed was neatly laid to promote comfort, Adequate room ensured by opening windows,

62
enough rest and sleep was ensured. Warm bath was given after every meal to promote

comfort..Goal was fully met as patient verbalized that she no longer has headache and nurse

observed patient with relax facial expression

3. Miss A.T regained her normal nutritional pattern (good appetite)

On the 18th June 2018, and at 9:05am she complaints of not able to sleep well during the

night relating it to change of the environment as said by the night nurses. Objective was

served within 24 hours and the nursing interventions were; perform all nursing procedures at

a goal, give patient warm bath before she goes to bed at night, make bed comfortable,

ensure quiet environment, provide dim lights and encourage patient to perform bed time

rituals such as listening to radio to induce sleep. Goal fully met as nurse observed patient

eating more than half of each meals served and patient verbalized that her appetite had

been restored.

4. Patient had no Pressure ulcers

On 18/06/18 and at 9:10am, miss A.T complaints of general body weakness and therefore has

being lying in bed for several minutes. There is possibility of pressures sores.so objective was set

throughout hospitalization period and the interventions were; .plients pressure area was assessed

and monitored on daily bases.patient’s position was changed every 2 hours to prevent bedsores,

pressure areas were treated with soap and talcum powder after bathing patient was assisted to sit

up and to walk around, soiled linens were changed frequently and Bed linens were straightened

regularly to make patient comfortable.Goal fully met as nurse observed patient with good

skin integrity and patient verbalized that she has intact skin on the day of discharge

63
 5. Miss A.T was able to sleep for at least 7 hours in the night

. At 19/06/18 am and on 8:15am, she complaints of not able to sleep well during the night

relating it to change of the environment as said by the night nurses. Objective was served

within 24 hours and the nursing interventions were; perform all nursing procedures at a goal,

give patient warm bath before she goes to bed at night, make bed comfortable, ensure

quiet environment, provide dim lights and encourage patient to perform bed time rituals

such as listening to radio to induce sleep. Goal. was fully met as nurse observed patient

having an uninterrupted sleep for a least 7 hours and patient’s mother verbalized that she

was able to sleep throughout the night

6. Patient Maintained her Normal Fluid Volume

at 9:20am, miss A. T complaints of frequent vomiting early this morning (around

6:00pm) metoclopramide 1mls tidx1 was prescribe for patient by Dr omane. She was also

encouraged to take in moral fluid. Objective was set throughout hospitalization period

and nursing interventions includes; client was reassured that the vomiting will subside

with time, patient skin turgor was assessed for signs of dehydration, Patient was weighed

daily to prevent cardiac overload, intravenous fluids were administered as ordered to

maintain normal fluid balance, oral rehydrated salt was given as ordered, prescribed

medication was served. Goal was met fully as met as nurse observed patient with good

skin turgor and no sign of dehydration and patient verbalizing that vomiting has stopped

and nurse observed patient with good skin turgor

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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 A.T 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 2nd June,

2018. The causes, signs, symptoms, and prevention of malaria were explained to

the patient’s family. They were also educated on the importance of good nutrition.

I educated them on the need for miss A.T 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 A.T 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.

65
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.

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 A.T 11 years old girl was admitted on the 18th June, 2018 at the paediatric

ward of holy family hospital,Berekum through the outpatient department. She was

brought into the ward in a wheel chair in the company of a student nurse and

66
relative 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 A.T spent five ((5) 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 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. Miss A.T was discharged on 22nd June, 2018 without any

complications. Care for miss A.T was terminated on the 2nd July, 2018 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.
67
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 A.T 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.

BIBLIOGRAPHY

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

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

Inc.

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

18/06/2018

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

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

www.medicalnews today.com>articles

68
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 16/06/2018

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.

Murcko, T. (2013). “InvestorWord”. Retrieved from:

www.m.investorword.com/planning. on. 19/6/ 2018

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

www.en.m.wikipedia.org/org/wiki/Data_analysis on 03/10/2016

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

(Pte) Ltd, Singapore.

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

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

02/9/2016

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

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

Tufo, S. (2002). Definition of Evaluation. Retrieved from:

www.wikipedia.org/wiki/Evaluation on 17/6/2018 at 6:14pm

Assessment. (2009). Weller, F.B. Mosby's Medical Dictionary, (9th ed.Page

34), China, Elsevier Science Ltd.

WHO, World malaria report 2014 summary. Retrieved from:

www.who.org.edu/user_summary/2014-15/ on 19/06/2018

Patient Folder Number - 11411/16

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 APPENDIX
Table 6: Vital Signs Chart of Miss A.T
Date Time Respiration(cpm) Pulse (bpm) Temperature (OC)

18/06/2018 11:00am 22 88 39.0

12:30pm 21 88 38.2
02:00pm 21 86 37.2
10:00pm 21 85 38.0
19/06/2018 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
20/06/2018 06:00am 19 78 35.5
10:00am 18 77 35.9

71
 02:00pm 19 80 35.4
06:00pm 17 76 36.0
10:00pm 16 76 36.9
21/06/2018 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
22/06/2018 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

SIGNATORIES

The Principal, Holy Family Nursing And Midwifery Training College, Tepa
Name:
Signature:……………………………………………………………………
Date:………………………………………………………………………………

The Supervisor
Name: Mr.
Signature:……………………………………………………………………
Date:………………………………………………………………………………

The Nurse In-Charge of The Children’s Ward (Holy Family Hospital,

Berekum)

72
Name:……………………………………………………………………………
Signature:……………………………………………………………………
Date:………………………………………………………………………………

The Student Nurse

Name: Asomea Florence
Signature:……………………………………………………………………
Date:………………………………………………………………………………

73