CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY

1.0 Introduction

According to Hinkle and Cheever (2012), assessment is the systematic collection of data to

determine the patient’s health status and any actual or potential health problems.

Assessment is the first phase in the nurses’ process which involves a systematic and

continuous gathering of information about the patient and his/her family as well as the

community in which he/she resides. The data can be collected through observation, physical

examination, interviewing of patient and his relatives and also laboratory investigations. The

outcome of the nursing assessment is to identify nursing problems and to establish nursing

diagnosis to help in planning and implementation of care. The assessment covers patient’s

particulars, family and medical history (both past and present)

1.1 Patient’s Particulars

It is made up of patient’s name, sex, next of kin, marital status, occupation, address and

religion.

Mr. A.Y.I is a 51 year old man born on 24th February, 1967 at Kokoa in the Jaman North

District, Brong Ahafo. Mr. A.Y.I currently lives in a 3 bedroom boys quarters house

(number KKS/NE 002) in Kokoa with his family and he hails from Kokoa where he has

lived all his life. He is married to Maame S.S and both are farmers. Mr. A.Y.I has two

children, one male and one female who are all alive. Currently, he stays with his wife,

Maame S.S and his daughter. Mr. A.Y.I together with his all family members are

Christians. Mr. S.M. (son) is his next of kin. S.M does not live in the same house with the

father. According to patient, he attended school up to form four, therefore he is semi-

literate. He was born to Mr. K.F and Mrs. A.B on 24th February, 1967 who are all dead. Mr.

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A.Y.I is dark in complexion, 1.68meters tall and weighs 76 kilograms. Mr. A.Y.I has no

facial mark. Mr. A.Y.I is a Fantra (Nafana) by ethnic group and speaks Bono, Nafana and

little of English languages and has no physical impairment.

1.2 Patient’s / Family’s Medical History

According to patient, there are no known hereditary diseases such as Asthma, Diabetes

Mellitus, Mental illness, sickle cell disease or Hypertension in the family. He also said that,

there are no chronic and infectious conditions like cancer, tuberculosis, epilepsy and

leprosy in the family. Patient also was not aware of any allergy to any food or drugs to any

member of His family.

However, he said that sometimes the family members do experience minor illness like

common cold, headache and fever which they treat by using over the counter drugs and

usually go to the hospital when symptoms persist for long period. (Based on this, I

educated and advised them against the use of over the counter drugs and told them to go to

the hospital any time they fall ill). Patient told me that the only death the family has

recorded is his parents who died a natural death due to old age. According to patient, there

is one person in his family who is blind. According to him, it was caused by trauma to the

eye as the family member was beaten by some people who claimed he was a thief. Mr.

A.Y.I said he was hospitalized four years ago for upper respiratory tract infection and road

traffic accident. He was hospitalized for about 8 days and discharged. The source of their

medical treatment is the orthodox and herbal medicine.

1.3 Patient’s/Family Socio-Economic History

The patient, Mr. A.Y.I is a farmer at Kokoa and he is the bread winner of the family. He is

supported by his wife, Maame S.S. who is also a farmer but his son is a taxi driver.

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He (Mr. S.M) support Mr. A.Y.I, the wife and the daughter who reside with Mr. A.Y.I

occasionally. Because of his occupation, he is prone to occupational hazards like cuts,

animal bites or stings. Patient also claim that because of his occupation, he goes to work

very early in the morning, and normally return late in the afternoon. Their income from the

farming is used for the up keep of the family and family health needs when health

insurance does not cover such expenses. Patient and family are holders of the national

health insurance card.

Patient is a Christian who attends church at the Pentecost Church of Ghana in Kokoa. Mr.

A.Y.I said he is a leader in his church and performs important religious duties in His

church. Mr. A.Y.I said that sometimes in the absence of the Churches elders, he leads the

prayers. According to patient it is a taboo to go to the farm on certain days on the week

especially Friday. Mr. A.Y.I said he was taught to respect the elderly, promote health in the

community by not bathing or washing in streams around. He said when one goes contrary

to the set rules and regulations in the community, sanctions are applied.

1.4 Patient’s Developmental History

According to Weller (2009), development is the process of growth and differentiation.

According to Weller (2009), growth is the progressive development of a living thing

especially the process by which the body reaches its point of complete physical

development. According to Weller (2009), maturation is ripening or developing.

According to patient, his mother experienced normal pregnancy for a period of nine months

and did not experience any disease during that period. She attended antenatal, and had

spontaneous vaginal delivery in the hospital in 1967. Patient has been immunized against

the childhood diseases as confirmed by marks on the deltoid muscles indicating the

injection of BCG and also patient had weighing card to confirm vaccination.

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Patient has few grey hair which he confirmed started coming when he was around 50 years.

Patient’s teeth are all intact and his skin is minimally wrinkled.

According to patient, he went through the average normal developmental milestone and

child’s developmental characteristics. He said the mother told him at about seven months

he was sitting, crawling at nine months and could walk at ten months and can eat all meals

prepared at home and as a result has being wean at two years. He started developing

secondary sexual characteristics such as growing of pubic hair, breaking of his voice, and

increase in his muscle mass at age 14.

In Erick Erickson’s psychosocial theory (1950), he suggested the eight stages that one goes

through from birth to death and failure to go through one stage successfully can result in a

reduced ability to complete further stages and therefore a more unhealthy personality and a

sense of self.

Patient falls within the 8th stage thus integrity versus despair of Erik Erikson psychosocial

theory. According to my observation and interaction with patient, he has developed an

integrity since he is able to achieved most of his life goals. He has been able to raise his

children to some level where they can cater for themselves. He always try his best to work

hard to cater for the family. Mr. A.Y.I is calm, humble, and respectful and treats all people

equally according to his wife and children.

1.5 Patient’s Lifestyle and Hobbies

Mr. A.Y.I wakes up about 4:00am, brushes his teeth and then goes to the Church for

prayers in the dawn before leaving for His farm around 6 am every week from Monday to

Thursday and also on Saturday. He usually doesn’t go to farm on Fridays because most

Fridays are believed to be a ‘’bad days’’ for going to farm and such a taboo.

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According to Mr. A.Y.I, he does almost everything for himself. He usually takes his

breakfast at 9:30am and takes his lunch around 12:00pm when listening to 12pm news

many of the times in the farm. On days that they do not go to farm, he goes to chat and play

‘dame’(graft) with the friends who are farmers also. At his leisure time, he also watches

football. His favourite team is Kumasi Asante Kotoko. Patient does not take alcohol,

tobacco and other illicit drugs because of his religious beliefs and I encouraged him to keep

on with that because medically, it can also have negative implications on his health. On

Friday evenings, he and the family go to the Church to pray. On Saturday, he goes to the

farm with the family. On some Saturday’s when they don’t go to farm, they attend funerals

or wedding or naming ceremonies. Sometimes too, he undertakes such social gathering

after church. He often takes a three square meal daily but at times takes two meals daily

with fufu and “kontomire” soup as his favourite. His wife Madam S.S also told me he likes

eating sugary things and he himself testified it. With this, I educated him on avoidance of

eating excessive sugary foods that they have harmful effects on metabolism and contribute

to all sorts of diseases such as diabetes. He then promised to reduce its intake. Mr. A.Y.I

says he moves his bowel once a day or at times none in the day. This was because he

usually leave the house very early to the farm, and He does not like to eliminate his bowel

on his farm also. Even though He sometimes have the urge to eliminate bowel on during

the day, He keeps it till he returns from the farm. Due to this he sometimes experiences

constipation. Patient was advised to make elimination of his bowel part of his daily

personal hygiene activities. He finds no difficulty in eating, grooming, dressing and

walking. He is not allergic to any food. He eats any food so far as it edible. His best food is

fufu and kontomire soup. Patient normally baths cold water and brushes His teeth with

toothbrush and tooth paste. Each person in the household have their own toothbrush,

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sponge and towel. Patient’s favourite tooth paste is Pepsodent, because it cost less and it’s

the longest in the market also.

According to family, Mr. A.Y.I is very friendly and likes hardworking people. He likes

talking to his family and also listening to the radio whenever it is time for news especially

6am, 12pm and 6pm news. He said he always takes the radio to the farm to listen to news

Their farm is far from the house so they built a hut in the farm where they rest for

sometimes before they return home. Mr. A.Y.I is the head of the family and that, he

associates well with neighbors. He also encourages them but really hates lazy people.

According to Mr. S.M (patient’s son), whenever he is doing something bad, the father is

able to use gestures to communicate for him to stop it. According to Mr. A.Y.I he is able to

express his feeling and does not harbor any bad intention towards any one. My personal

impression of Mr. A.Y.I is he an extrovert, a good Christian and a hardworking person

1.6 Patient’s Past Medical History

According to Mr. A.Y.I he had his first admission four years ago at the Sampa Government

Hospital for treatment of chest infection and on another occasion when he was involved in

a road traffic accident. There was no complication because of the competence work of

staffs and medical doctors. He spent eight days at the hospital .He said that, he occasionally

experiences minor ailments such as headache, body weakness, fever and but are treated

with drugs purchased from the chemical shops. He has never had surgery and through my

observation has no physical deformity. He also said that his mother did not tell him that, he

had any childhood diseases like whooping cough, measles, poliomyelitis or any other

disease. Patient said he suffered chicken pox when he was 15 years old and has never had it

again. Patient is not allergic to any drug, animal, any insect or a specific object. Patient said

he sometimes experience constipation. Patient said he does not go for medical checkup

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unless he is sick or is involved in an accident. He is registered with the National health

insurance scheme and has easy access to health care. Patient said there is a health Centre at

Kokoa which he can access anytime he wants.

1.7 Patient’s Present Medical History

According to patient, he was doing well until two week ago when he started having severe

constipation and also started observing that there was blood in his stools anytime He

eliminated His bowel. Initially He took herbal medicine and the bleeding and constipation

subsided. Then it all started again about three days ago, this time the bleeding was profuse.

He started again taking herbal medication. Patient said the bleeding didn’t not stop and he

started feeling dizzy, palpitations and waist pain also. When the bleeding did not subside,

he then went to the Kokoa Health Centre. He was managed on Suppository diclofenac and

then referred to the Sampa Government Hospital for management of the disease condition

on the 1/10/2018. His vital signs was checked and recorded at the outpatient department as:

Temperature -36.8oc.

Pulse -99 bpm.

Respiration -22cpm.

Blood pressure -100/60mmHg.

Weight -76kgkg

Patient was seen by Dr. Arthur and then was admitted to the ward for further care.

1.8 Admission of Patient.

On 1/10/2018 at 1pm, Mr. A.Y.I was admitted at the general ward of Sampa Government

Hospital, Sampa per ambulatory from out- patient department accompanied by an OPD

nurse and his wife. Patient’s folder was collected from the OPD nurse and his name was

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mentioned to ascertain and confirm the identity of the patient. Mr. A.Y.I was immediately

made comfortable in an already prepared simple bed in male’s ward with bed number M-2

because he looked weak. And I introduced myself and other staff on duty to Mr. A.Y.I and

his wife. Mr. A.Y.I ’s. particulars were documented into the admission and discharge book

and daily ward state. Upon assessment patient looked very pale, weak and generally looked

ill. He complained of bleeding per anus any time he eliminated his bowel, waist pains,

palpitations, dizziness, easy fatiquability and burning sensation in the anus. Patient and

family were observed to be anxious also. Vital signs was checked and recorded as follows

Temperature - 36.9oc

Pulse - 84bpm

Respiration - 21cbm

Blood Pressure - 120/60mmHg

SPO2 - 97%

Laboratory investigations requested on admission were

Blood for Full blood count

Blood for malaria parasite

Widal test

Stool for Routine examination

Blood sample was taken, sample bottle labelled and sent to the laboratory for the

investigations to be carried out.

Patient was placed on the following medications;

Capsule Flucloxacillin 500mg qid for 7 days

Tablet Pilex II tid for 30 days

Ointment Pilex tid for 30 days (apply after each stool)

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Tablet Zincovit I daily for 15 days

Table Folic Acid 5mg daily for 15 days.

Syrup Iron III Polymaltose 10mls tid for 10 days.

All drugs were procured from the pharmacy and administered to the patient immediately.

Patient and relative were then orientated to ward and its environs such as the toilet, bath

room and the nurses station. They were also introduced to the other patients on the ward.

The wife of Mr. A.Y.I was encouraged to bring patient’s personal that He may need at the

ward such as towel, sponge, tooth brush, toothpaste and bucket from the house. They were

asked to talk to any of the nurses around if they needed anything or help.

After these interventions, I told the ward in-charge of my intention of using the patient and

the family for a case study and I was given the permission. I introduced myself to the

patient/family that, I am a student nurse of Nurses’ Training College, conducting a study at

the hospital. I then made it known to them my desire to give Mr. A.Y.I a special nursing

care for his speedy recovery. I told them that, as part of my training, final year students are

to take a patient each, nurse him or her from the time of admission till time of discharge

and home visits. The patient and family accepted and promised their cooperation and

readiness to give me any information needed for my study. They were told that, they would

be discharged home once the patient’s condition is stable and that they were not going to be

on the ward forever. They were also informed that, as part of my care, I would visit their

home whiles he was on admission and after he has been discharged. I choose to write my

care study on bleeding hemorrhoid because even though hemorrhoid it’s very common in

most people, there are a lot of misconception about it and people usually treat it at home

and come to the hospital only after complications. I wanted to know more about this

condition and to holistically nurse a patient who was suffering from this ailment.

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1.9 The Patient/Family Concept about his Illness.

During my interaction with Mr. A.Y.I he does not know the cause of the illness but he had

heard that eaten a lot of starchy food i.e “Mankani”(cocoyam), Cassava, yam may cause it.

He also said he believed was not spiritual and that sickness can affect any other person at

any time. He said that, he was afraid but believes that with God and prayers, all things are

possible.

He also knows that so far as medical interventions have begun, he would gain his normal

health.

1.10 Literature review of haemorrhoids

Review Anatomy and Physiology of the Anal canal( anus)

The Anal canal

Diagram of the anal canal. Waugh &Grant, 2014

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According to Waugh & Grant (2014), this is a short passage about 3.8 cm long in the adult

and leads from the rectum to the exterior. Two sphincter muscles control the anus; the

internal sphincter, consisting of smooth muscle, is under the control of the autonomic

nervous system and the external sphincter, formed by skeletal muscle, is under voluntary

control

Structure

The four layers of tissue described in the basic structure of the gastrointestinal tract (are

present in the caecum, colon, the rectum and the anal canal. The arrangement of the

longitudinal muscle fibres is modified in the caecum and colon. They do not form a

continuous layer of tissue but are instead collected into three bands, called taeniae coli,

which run lengthways along the caecum and colon. They stop at the junction of the sigmoid

colon and the rectum. As these bands of muscle tissue are slightly shorter than the total

length of the caecum and colon they give it a sacculated or puckered appearance In the

rectum the longitudinal muscle fibres spread out as in the basic structure and this layer

therefore completely surrounds the rectum and anal canal. The anal sphincters are formed by

thickening of the circular muscle layer.

In the sub mucosal layer there is more lymphoid tissue than in any other part of the

alimentary tract, providing non-specific defense against invasion by resident and other

potentially harmful microbes.

In the mucosal lining of the colon and the upper region of the rectum are large numbers of

mucus-secreting goblet cells within simple tubular glands.

They are not present beyond the junction between the rectum and the anal canal.

The lining membrane of the anal canal consists of stratified squamous epithelium continuous

with the mucous membrane lining of the rectum above and which merges with the skin

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beyond the external anal sphincter. In the upper section of the anal canal the mucous

membrane is arranged in 6–10 vertical folds, the anal columns. Each column contains a

terminal branch of the superior rectal artery and vein.

Blood supply

Arterial supply is mainly by the superior and inferior mesenteric arteries

The superior mesenteric artery supplies the caecum, ascending and most of the transverse

colon. The inferior mesenteric artery supplies the remainder of the colon and the proximal

part of the rectum. The middle and inferior rectal arteries, branches of the internal iliac

arteries, supply the distal section of the rectum and the anus.

Venous drainage is mainly by the superior and inferior mesenteric veins which drain blood

from the parts supplied by arteries of the same names. These veins join the splenic and

gastric veins to form the portal vein.

Veins draining the distal part of the rectum and the anus join the internal iliac veins, meaning

that blood from this region returns directly to the inferior cava, bypassing the portal

circulation.

Functions of the large intestine, rectum and anal canal

Absorption

The contents of the ileum which pass through the ileo-caecal valve into the caecum are fluid,

even though a large amount of water has been absorbed in the small intestine.

In the large intestine absorption of water, by osmosis, continues until the familiar semisolid

consistency of faeces is achieved. Mineral salts, vitamins and some drugsare also absorbed

into blood capillaries from the large intestine.

Microbial activity

The large intestine is heavily colonised by certain types of bacteria, which synthesise vitamin

K and folic acid.

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They include Escherichia coli, Enterobacter aerogenes, Streptococcus faecalis and

Clostridium perfringens. These microbes are commensals, i.e. normally harmless, in humans.

However, they may become pathogenic if transferred to another part of the body, e.g. E. coli

may cause cystitis if it gains access to the urinary bladder.

Gases in the bowel consist of some of the constituents of air, mainly nitrogen, swallowed

with food and drink. Hydrogen, carbon dioxide and methane are produced by bacterial

fermentation of unabsorbed nutrients, especially carbohydrate. Gases pass out of the bowel as

flatus (wind).

Mass movement

The large intestine does not exhibit peristaltic movement as in other parts of the digestive

tract. Only at fairly long intervals (about twice an hour) does a wave of strong peristalsis

sweep along the transverse colon forcing its contents into the descending and sigmoid colons.

This is known as mass movement and it is often precipitated by the entry of food into the

stomach. This combination of stimulus and response is called the gastrocolic reflex.

Defaecation

Usually the rectum is empty, but when a mass movement forces the contents of the sigmoid

colon into the rectum the nerve endings in its walls are stimulated by stretch.

In infants, defaecation occurs by reflex (involuntary) action. However, during the second or

third year of life children develop voluntary control of bowel function. In practical terms this

acquired voluntary control means that the brain can inhibit the reflex until it is convenient to

defaecate. The external anal sphincter is under conscious control through the pudendal nerve.

Thus, defaecation involves involuntary contraction of the muscle of the rectum and

relaxation of the internal anal sphincter. Contraction of the abdominal muscles and lowering

of the diaphragm increase the intra-abdominal pressure (Valsalva’s manoeuvre) and so assist

defaecation. When the need to pass faeces is voluntarily postponed, it tends to fade until the

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 next mass movement occurs and the reflex is initiated again. Repeated suppression of the

reflex may lead to constipation (hard faeces) as more water is absorbed.

Heamorrhoid

Hemorrhoids are dilated portions of veins in the anal canal (Hinkle & Chever, 2014)

The term hemorrhoids also refers to a condition in which the veins around the anus or lower

rectum are swollen and inflamed (Scalon & Sanders, 2014)

Sustained pressure on distended veins at the junction of the rectum and anus leads to

increased venous pressure valvular incompetence and the development of haemorrhoids.

(Waugh & Grant,2014).

A B

Source: Scalon&Sanders(2010) and Hinle and Cheever (2014)

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Incidence of Hemorrhoid

According to Hinkle and Cheever (2014) they are very common. By the age of 50, about 50%

of people have hemorrhoids to some extent. The incidence is the same in both males and

females and common in pregnant women.

Types of Hemorrhoid

According to Hinkle and Cheever (2014), there are two types of hemorrhoids:

External hemorrhoids

Hemorrhoids located outside of the anus are called external hemorrhoids. Here, swollen veins

cause a soft lump around the anal opening. These lumps can turn hard if blood clot develops,

and become painful thrombosed hemorrhoids. Since the anus has many nerve endings, external

hemorrhoids can be very painful or itchy. Sometimes, the clot may even break out of the

hemorrhoid by itself or dissolve back into normal blood circulation.

Internal hemorrhoids

Internal hemorrhoids are located inside the rectum or anal canal, and are usually not painful.

This is because the anal canal does not have many nerve endings. Indeed, most people are not

aware that they have internal hemorrhoids until a hard stool rubbing against them cause these

hemorrhoids to rupture and bleed.

Left untreated, some internal hemorrhoids can "prolapse" or be pushed out of the anal opening.

Sometimes, the sphincter muscle can close shut in a spasm and trap this prolapsed hemorrhoid

outside the anus. This cuts off the blood circulation, and creates a strangulated hemorrhoid.

Some prolapsed hemorrhoids can be manually "pushed" back inside the anus. Advanced cases

of prolapsed hemorrhoids, however, must be surgically treated.

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Prolapsed and strangulated hemorrhoid are a serious medical condition that requires immediate

attention. Also, bleeding of any amount should be checked by a doctor since it may be an

indication of more serious conditions, such as colorectal cancer.

Etiology and Pathophysiology Of Hemorrhoid

According to Hinkle & Cheever (2014); there are hemorrhoidal veins in the anus, anal canal,

and rectum. These veins do not have valves, which would normally help support and distribute

the weight of the blood. Many factors can cause undue pressures on these veins, which can

then cause these veins to become distended and swollen hemorrhoids.

Below are the factors that can cause hemorrhoids:

Straining during bowel movement

One of the most frequent causes of hemorrhoids is straining during bowel movements. Forcing

for too long or too hard, because of diarrhea, constipation, or bad bathroom habits (such as

reading on the toilet) is actually attributed to the majority of hemorrhoids cases.

Genetics

Inherited characteristics such as weak vein walls can result in tendencies to develop

hemorrhoids. Heredity alone, however, does not usually lead to a hemorrhoid without

additional factor(s), such as a bad bathroom habit or a job that requires standing or sitting for

prolonged periods.

Diet

Foods that are lacking in fibers actually create stool that is harder to pass. This results in

straining during a bowel movement, and thus hemorrhoids.

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Pregnancy

Another of the most common causes of hemorrhoids in women is pregnancy: the extra weight

of the uterus adds great pressure on the rectal veins. For women who already have

hemorrhoids, pregnancy can definitely make their hemorrhoid condition worse.

Even women who do not develop hemorrhoids during pregnancy can still get them because of

long and arduous labor and delivery, or because of constipation that arise after childbirth. For

example, in the days and weeks after vaginal delivery, some women regularly postpone bowel

movements because of tenderness in the anus and perianal area.

Postponing bowel movement

Sometimes when "nature calls", there is no toilet nearby. While occasionally postponing bowel

movement does no harm, doing it regularly can contribute to hemorrhoids.

The longer fecal matter remains in the colon, the drier it becomes and therefore the harder it is

to pass without straining. Repeated inhibition of the urge to defecate can also result in weaker

signals to the rectal muscles to pass stool. Eventually, it may be difficult to pass stool naturally

without some straining.

Also, a colon filled with fecal matters is heavy and exerts pressure on the blood vessels and

veins of the anus and rectum. This can cause these veins to swell and become hemorrhoids.

Diseases

There are several diseases that can actually lead to the development of hemorrhoids. Of these,

the most serious is rectal cancer, which causes a false "call of nature", thus encouraging the

patient to go to the bathroom and strain unnecessarily.

Enlargement of the liver, often found in people who abuse alcohol, can create extra pressure on

the hemorrhoidal veins. Other digestive diseases, such as intestinal tumor and irritable bowel

syndrome, can interfere with normal elimination or cause constipation.

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Lastly, although heart attack does not cause hemorrhoids, it does increase venous pressure and

therefore can make an existing hemorrhoid worse.

Bouts of diarrhea

Diarrhea is the body's way of getting rid of bacteria from its digestive system. It is commonly

caused by contaminated food. However, diarrhea can also be caused by an allergic reaction to

food and milk, by stress and anxiety, as well as by an adverse reaction to medication and

laxatives. In the case of diarrhea, the expulsive force of the watery stool can damage rectal

veins and lead to hemorrhoids.

Constipation

Paradoxically, the opposite of diarrhea can also lead to hemorrhoids. Constipation is defined as

infrequent bowel movements or the difficulty in passing stool. The longer the stool remains in

the colon, the drier it gets. After a certain point, usually a fair amount of straining is required to

pass the dry and hard stool. A common condition in the elderly, constipation is one of the

major causes of hemorrhoids in this segment of the population.

Extreme physical exertion

Laborers and weightlifters often hold their breath or grunt while lifting heavy objects. This

forces air downward in the lungs and exerts pressure on the diaphragm, which in turn exerts

pressure on the abdominal organs and rectal veins. Note that weightlifters can also get

hemorrhoids because they eat a lot of animal proteins in order to gain bulk and mass.

Prolonged sitting or standing and lack of exercise

Sedentary lifestyle, lack of exercise, as well as jobs which require prolonged periods of sitting

and standing can lead to, or exacerbate, existing hemorrhoids.

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Signs and Symptoms of Heamorrhoid

According to Ministry Of health (2010), the following are the signs and symptoms of

haemorrhoids

Symptoms

 Passage of bright red blood at defecation

 Mucoid discharge

 Swelling at anus

 Perianal irritation or itch (pruritus ani)

 Discomfort after opening bowels

 Pain occurs only during an acute attack of prolapse with thrombosis, congestion and

oedema

Signs

 Inspection of the anus may be normal

 Redundant folds of skin (skin tags) may be seen in the position of the haemorrhoids and

straining may show the haemorrhoids.

 In third degree haemorrhoids, there is a swelling at the anus

 Internal haemorrhoids are not palpable inside the rectum unless thrombosed

 The patient may present with a complication of the haemorrhoids e.g. profuse bleeding,

prolapse, strangulation, thrombosis, infection or ulceration or severe anaemia.

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Diagnostic Investigations

According to Hinkle & Cheever (2014) and Ministry of Health,(2010), the diagnostic

investigations of haemorrhoids includes;

 Full blood count especially value of haemoglobin and Hematocrit testing is suggested if

excessive bleeding with concomitant anemia is suspected.

 Proctoscopy (the gold standard for diagnosis): A protoscope is used to examine the

anal cavity to detect any inflammation or swelling of the on anal veins and artery.

 Sigmoidoscopy (to exclude carcinoma of rectum): this is a minimally invasive medical

examination procedure of the large intestines from the rectum through the nearest part

of the colon, the sigmoid colon. A small fiber optic camera is inserted into the rectum

in order to help examine haemorrhoids.

 Digital rectal examination: this is especially helpful when diagnosing internal

haemorrhoids.

 Barium enema study or virtual colonoscopy is suggested if proximal colonic and

intestinal diseases must be excluded and if endoscopy is not helpful

 Signs and symptoms of the disease and physical examination of the patient

 Stool R/E may be tested periodically until they are negative for occult blood

Medical and Surgical Management of Heamorrhoid.

According to Ministry of Health (2010) and Hinkle and Cheever, Heamorrhoid can be treated

both medically and surgically.

The aims of treatment include;

 To correct anaemia, if present

 To relieve symptoms (pain)

 To prevent complications

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Surgical management of haemorrhoids

Rubber-band ligation procedure.

The hemorrhoid is visualized through the anoscope, and its proximal portion above the

mucocutaneous lines is grasped with an instrument. A small rubber band is then slipped over

the hemorrhoid. Tissue distal to the rubber band becomes necrotic after several days and

sloughs off. Although this treatment has been satisfactory for some patients, it has proven

painful for others and may cause secondary hemorrhage. It has been known to cause perianal

infection.

Cryosurgical hemorrhoidectomy:

Another method for removing hemorrhoids, involves freezing the hemorrhoid for a sufficient

time to cause necrosis. Although it is relatively painless, this procedure is not widely used

because the discharge is very foul smelling and wound healing is prolonged.

The Nd:YAG laser

This is useful in excising hemorrhoids, particularly external hemorrhoidal tags. The treatment

is quick and relatively painless. Hemorrhage and abscess are rare postoperative complications.

Anal Dilation

Although this technique is no longer commonly used, when properly used, anal dilation can

help relieve the pain and promote healing of hemorrhoids. In this anal dilation procedure, the

anal sphincter muscle is stretched or dilated to prevent hemorrhoids from increasing rectal

pressure, as well as to reduce the need of straining to pass stool.

Because of its potential side effect of fecal incontinence or anal leakage, this procedure not be

used for eldery patients or those with weak sphincter muscle.

21
Stapled Hemorrhoidectomy

Stapled hemorrhoidectomy is the newest surgical technique for treating hemorrhoids. Stapled

hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but,

rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the

hemorrhoids to prolapse downward. For stapled hemorrhoidectomy, a circular, hollow tube is

inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually

woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the

suture are brought out of the anus through the hollow tube. The stapler (a disposable

instrument with a circular stapling device at the end) is placed through the first hollow tube and

the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting

tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their

normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts

off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at

the same time staples together the upper and lower edges of the cut tissue.

Medical Management of Haemorrhoids

1. Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and

by avoiding excessive straining during defecation.

2. A high-residue diet that contains fruit and bran along with an increased fluid intake

may be all the treatment that is necessary to promote the passage of soft, bulky stools to

prevent straining.

3. If this treatment is not successful, the addition of hydrophilic bulk-forming agents such

as psyllium and mucilloid may help.

4. Warm compresses, sitz baths, analgesic ointments and suppositories, astringents (eg,

witch hazel), and bed rest allow the engorgement to subside.

22
 5. For prolapsed haemorrhoids, lie patient down and elevate the foot end of the bed. Try

gentle digital reduction after application of local anaesthetic cream. If this fails, apply

cold compresses.

6. Exercising

7. Use a moist wipe: Instead of toilet paper, patient is encouraged to use moistened wipe

to clean himself after going to the bathroom. Some commercially available wipes are

medicated with witch hazel, a natural astringent that can reduce the swelling and ease

the pain of hemorrhoids.

Pharmacological management

According to Ministry of health (2010), the following classification of drugs may be used to

alleviate the signs and symptoms of the condition and to alleviate patient’s discomfort

When associated with constipation:

1. Stool Softeners or laxatives such as Liquid paraffin, Senna granules, Syrup lactulose.

This drugs will help to prevent constipation and to prevent further exertion on the rectal

veins.

When associated with local itching or discomfort:

1. Lubricants in the form of Ointments or suppositories (with or without steroids) such as

cocoa butter, lanolin, glycerin, cod-liver oil, and vegetable oil. These drugs work

reduce friction and ease the irritation of hemorrhoids

When it is associated with pain

1. Analgesics such as paracetamol, diclofenac, Suppository Anusol, Suppository

hydrocortisone

23
 2. Anesthetic agents such as benzocaine, lidocaine. This may be in the form of

suppository or cream and it helps to give temporal relief from pain.

If haemorrhoids infected:

1. Antibiotics such as Gentamicin, Metronidazole, Ciprofloxacin, Amoxicillin,

Flucloxacillin,

2. Antimicrobial such as oral or Suppository Pilex, metronidazole

When associated with anaemia:

1. Iron preparation such as ferrous sulphate/fumarate, Iron III Polymaltose,

2. Multivitamin such as Zincofer, Zincivit, Folic acid.

3. Blood transfusion as indicated.

Nursing Management

Reducing Pain

1. Asses level of pain according to pain scale level by asking the patient for further

management.

2. Monitor vital sign to detect any abnormality such as blood pressure more than

140/90mmhg and tachycardia

3. Position patient on side lying position to reduce the pressure on the buttocks so that it’s

can help to reduce the pain.

4. Teach patient how to do breathing exercise to reduce the pain

5. Give diversional therapy such as watching television, reading magazine so that patient

do not focus on the pain.

6. Sitz baths taken three or four times each day can relieve soreness and pain by relaxing

sphincter spasm

24
 7. Flotation pads should be placed under the buttocks when sitting help to decrease the

pain, as may ice and analgesic ointments. Warm compresses may promote circulation

and soothe irritated tissues.

8. Plan nursing care effectively to minimize disturbance so that patient can rest well.

9. Give analgesic such as such as Suppository anusol as ordered by doctor to reduce the

pain.

10. Asses effectiveness of the analgesic after 30 minutes to make sure the dosage is enough

for the pain.

11. Inform doctor if pain still persist after analgesic to prevent any complication.

Prevention of bleeding

1. Inspect anal site for any bleeding

2. Advise patient to take diet that are high in fiber such as fruits and vegetables in

avoidance of constipation.

3. Advise patient to drink a lots of water at least 2 liter/day in avoidance of

constipation.

4. Give stool softener such as liquid paraffin as ordered by doctor in avoidance patient

straining during passing motion.

5. Advise patient not to strain during passing motion to prevent any bleeding.

6. Tell patient to use soft tissue for wiping to prevent any bleeding.

7. Encourage warm sitz bath after each stool or three times a day.

25
 Ensuring rest and sleep

The following measures should be implemented to ensure good rest and comfortable sleep to

promote recovery;

1. Restrict or limit visitors when necessary and explain to the patient the need for rest and

sleep in aiding speedy recovery

2. The environment should be properly ventilated and noise minimized to promote rest

and sleep.

3. Put patient in well prepared, comfortable bed and make sure bed is free from creases

and cramps

4. Carry out bulk nursing when applicable

5. Encourage patient to take warm bath after meals and warm drinks before bed

6. If patient has pain-related insomnia, serve prescribed analgesics to relieve pain. Also

serve prescribed hypnotics and sleep inducers and monitor for therapeutic and adverse

effects.

Ensuring personal hygiene

Ensure patients hygienic needs are equally met as other medical needs of the patient are

established. The following measures can be followed;

1. Ensure patient takes his/her bath twice a day. Assist or carry out bed bath when

necessary

2. Encourage patient to maintain adequate mouth care by brushing his/her teeth at least

twice in a day

3. Teach and encourage patient and relatives to observe hand washing techniques after

visiting the toilet.

4. Ensure patient keeps a short and well-kept nails. Carry out hand and feet care when

necessary.

26
 5. Perineal area care and warm sitz bath is encouraged.

Relieving Constipation

1. The nurse encourages intake of at least 2 L of water daily to provide adequate hydration

recommends high-fiber foods to promote bulk in the stool and to make it easier to pass

fecal matter through the rectum.

2. Bulk laxatives such as Metamucil and stool softeners are administered as prescribed.

3. The patient is advised to set aside a time for moving the bowels and to heed the urge to

defecate as promptly as possible.

4. It may be helpful to have the patient perform relaxation exercises before defecating to

relax the abdominal and perineal muscles, which may be constricted or in spasm.

5. Administering an analgesic before a bowel movement is beneficial.

Reducing Anxiety

Patients facing rectal and anal conditions may be upset and irritable because of discomfort,

pain, and embarrassment.

1. The nurse identifies specific psychosocial needs and individualizes the plan of care.

2. The nurse maintains the patient’s privacy while providing care

3. Limit visitors, if the patient desires.

4. Soiled dressings are removed from the room promptly to prevent unpleasant odors;

room deodorizers may be needed if dressings are foul smelling.

5. Reassure patient on the competence of the health care professionals

6. Introduce patient to other patients at the ward who may be recovering from the same

ailment if so desired by the patient and it’s agreed by the other patients.

27
Observation and monitoring of complications

1. The anal site is examined frequently for rectal bleeding.

2. The nurse assesses the patient for systemic indicators of excessive bleeding (ie,

tachycardia, hypotension, restlessness, and thirst).

3. After hemorrhoidectomy, hemorrhage may occur from the veins that were cut. If a tube

has been inserted through the sphincter after surgery, evidence of bleeding may be

visible on the dressings.

4. If bleeding is obvious, direct pressure is applied to the area, and the physician is

notified. It is important to avoid using moist heat because it encourages vessel dilation

and bleeding.

Patient And Family Health Teaching

The patient is taught the following simple method the ensure He/S he stay free of haemorrhoids

1. Instructs the patient to keep the perianal area as clean as possible by gently cleansing

with warm water and then drying with absorbent cotton wipes.

2. The patient avoids rubbing the area with toilet tissue or hard paper.

3. Instructions are provided about how to take a sitz bath and how to test the temperature

of the water. Sitz baths may be given in the bathtub or plastic sitz bath unit three or four

times each day. Sitz baths should follow each bowel movement for 1 to 2 weeks after

surgery.

4. The nurse encourages the patient to respond quickly to the urge to defecate to prevent

constipation.

5. The diet is modified to increase fluids and fiber.

6. Moderate exercise is encouraged

7. Teach patient and family about the prescribed diet, the significance of proper eating

habits and exercise, and the laxatives that can be taken safely.

28
Complications of haemorrhoids

According to healthdirect.com (2018), the complications that may arise from hemorrhoids are;

1. Anemia due to excessive bleeding

2. Infection

3. Anal fistula, which is a small channel that develops between the inside of the anus and

the surface of the skin near the anus.

4. Perianal thrombosis where a pool of blood collects in the tissues of the anus.

5. Fecal incontinence where the anal sphincters are destroyed due to infection and there is

inability to control bowel movement.

6. Strangulated hemorrhoid where the blood supply to the haemorrhoids is cut off leading

to tissue death and necrosis of the anus.

1.9 Validation of Data

Validation as defined as “the process of establishing the suitability of a mechanism or system

to performing a particular task” (Weller, 2010).

To ensure that the data gathered was accurate and complete, the information were gathered

systematically and were cross checked severally. Those given to me by Mr. A.Y.I and the

accompanying wife were compared with those in the patient’s folder. Home visit to the

patient’s house also confirmed most of what Mr. A.Y.I had told me. The data collected from

patient, health workers (medical team and staff nurses), patient’s folders, laboratory

investigations and physical assessment were checked with literature review to ensure that

information collected was free from errors, bias and misinterpretations. Patient was also

reassessed when symptoms had abated to confirm information provided on admission. This

therefore makes the data valid for the study since no difference was seen in the entire sources.

29
 CHAPTER TWO

ANALYSIS OF DATA COLLECTED

2.0 Introduction

According to Weller (2010), analysis is the study of a whole in terms of its parts.

It is the second phase of the nursing process and it involves the act of deducing fact or

information from data that has been gathered on the patient and his condition in order to arrive

at the needs of the patient and the problems hindering attainment of health and intervening

where necessary to promote health and well-being. It comprises;

1. Comparism of data with standard

2. Patient/Family strength

3. Health problems

4. Nursing diagnosis

2.1 Comparison of Data with Standards

The results from laboratory investigation, history or signs and symptoms manifested by the

patient are carefully analyzed, comparing them with standard measures to aid in diagnosing the

patient’s condition.

(A) Diagnostic Investigations/Test

A diagnostic investigation is a procedure performed to confirm or determine the presence of

disease in an individual suspected of having the disease usually following the report of

symptoms or based on the results of other medical tests.

The following diagnostic tests were carried out on patient;

1. Full Blood Count

2. Malaria parasite

3. Widal test

30
 4. Stool for Routine examination

Table 1 below shows the Comparism of diagnostic tests carried out on Mr. A.Y.I with those

listed in literature review.

Table 1: Diagnostic tests/investigation in literature review compared with those

carried out on Mr. A.Y.I

Diagnostic tests outlined in literature Diagnostic tests carried out on patient

review

Proctoscopy Not requested for patient

Sigmoidoscopy Test was not ordered for patient

Digital rectal examination Test was done for patient

Barium enema study Test was not ordered for patient

Stool routine examination Stool R/E was ordered and done

Full blood count Test was ordered and carried out on patient

Signs and symptoms Signs and symptoms were observed

On the day of admission of patient, patient’s blood was taken for full blood count, malaria

parasites and Widal test. Blood test for malaria parasite was ordered to know whether

patient has malaria parasite. Widal test was ordered to ascertain if patient was suffering from

typhoid also. Stool sample was sent to the laboratory for routine examination, to identify if

there was any occult blood present in patients stool. Details of the test carried out on patient

have been presented in table 2.

31
 Table 2: Diagnostic Investigations carried out on Mr. A.Y.I

Date Specimen Investigation Result Normal Value Interpretation Remarks

1/10/2018 Blood Blood film for Negative (-) plasmodium No malaria Patient has no malaria No treatment given

malaria parasites falciparum was not seen parasite should be

seen in blood

1/10/2018 Full Blood White blood cells 4.7 x109/L 4.0-10.0 x109/L WBC count was high Patient was given
Count indicating injection
cefuroxime 300mg
bd x 3 to combat
infection.

Red blood cell 3.2 3.9 -6.5 x 10/l No treatment was

count Normal given
Neutrophils count 46% 40-75% Normal No treatment was
given
Haemoglobin levels 7.0 g/dl 12.5-18.5g/dl Haemoglobin was very Blood transfusion,
low, indicating patient Syrup iron III
was anaemic. Polymaltose
ordered
Haematocrit 22% 40-54% Indicates patient was Blood transfusion,
bleeding Syrup iron III
Polymaltose
ordered

32
 Date Specimen Investigation Result Normal Value Interpretation Remarks

1/10/18 Blood Widal test 1/20 1/20 Absence of salmonella No treatment

typhi indicating patient ordered
did not have typhoid
fever.
1/10/2018 Stool Stool for stool Macroscopic: Formed No blood should Patient was bleeding per Tab Pilex, Cap
specimen be seen in stool rectal
Routine Flucloxacillin,
Microscopic: No Intestinal
examination Suppository
spiral flagellates seen,
Blood seen in stool Anusol

administered

The table above shows that results for malaria parasite, Widal, red blood cell and neutrophils count were all normal. But the results for
haemoglobin, hematocrit, and white blood cell were not normal. Appropriate interventions such as blood transfusion and haematinics were
given to correct low haemoglobin levels.

33
 B). Causes of Patient’s Condition

Mr. A.Y.I ’s condition was caused by constipation and also refusing to eliminate bowel

even if He has the urge. This was ascertain when patient confirmed that He normally

experiences constipation, and also the fact that He doesn’t normally eliminate His bowel

when He goes to farm. According to patient He normally waits till He returns home and

sometimes He doesn’t eliminate His bowel for days.

C. Clinical Features/ Signs and Symptoms

Comparison of clinical features exhibited by patient with those listed in the literature review

Table 3: Clinical Features Manifested By Patient Compared With Those In Literature

Review.
Clinical features of literature review. Patient features presented by Mr. A.Y.I

Passage of bright red blood at defecation Patient passed bright red blood defecation

Swelling at anus There was swelling at patient’s anus

Discomfort after opening bowels Patient complained of discomfort when

eliminating bowels
Mucoid discharge Patient didn’t experience Mucoid discharge

Pain occurs only during an acute attack of Patient experienced pain when eliminating
his bowel
prolapse with thrombosis, congestion and

oedema

Perianal irritation or itch (pruritus ani) Patient had anal itching

Redundant folds of skin (skin tags) may be seen There was no redundant folds of skin

in the position of the haemorrhoids and

straining may show the haemorrhoids

34
Clinical features of literature review. Patient features presented by Mr. A.Y.I

The patient may present with a There was profuse bleeding and patient’s HB
was low indicating patient had severe anemia
complication of the haemorrhoids e.g.

profuse bleeding, prolapse, strangulation,

thrombosis, infection or ulceration or

severe anaemia.

From the above comparism, Mr. A.Y.I exhibited most of the signs and symptoms

discussed in the literature review such as passage of bright red blood feces, swelling at

anus, profuse bleeding and patient’s heamoglobin was low indicating patient had severe

anemia, anal itching and pain when eliminating his bowel.

Patient did not experience redundant folds of skin around the anus.

Treatment of Patient

Treatment (medical/surgical) is referred to as a therapy intended to stabilize or reverse a

morbid process or state. Treatment may be pharmacologic, using drugs; surgical, involving

operative procedures; or supportive, building the patient’s strength. It may be specific for the

disorder, or symptomatic to relieve symptoms without affecting a cure.

The drugs below were prescribed for Mr. A.Y.I to treat for condition throughout

admission.

1. Capsule Flucloxacillin 500mg qid for 7 days

2. Tablet Pilex II tid for 30 days

3. Ointment Pilex tid for 30 days (apply after each stool)

4. Tablet Zincovit I daily for 15 days

35
 5. Table Folic Acid 5mg daily for 15 days.

6. Intravenous Metronidazole 500mg tid for 2 days

7. Tablet Metronidazole 400mg tid for 5 days

8. Suppository Anusol I tid for 7 days

9. Syrup Lactulose 10mls tid for 5 days.

10. Syrup Iron III Polymaltose 10mls tid for 10 days was ordered.

Table 4 below shows the treatment given to Mr. A.Y.I compared with those in the literature

review

Table 4: Comparison of treatment outlined in the literature review with those given to

Mr. A.Y.I

Treatment according to literature review Patient’s drug administered

Analgesics such as paracetamol, diclofenac, Analgesic i.e Suppository Anusol was

Suppository Anusol, pilex ordered, Tab Pilex I tid for 30 days, Pilex

cream tid for 30 days

Stool Softeners or laxatives such as Liquid Stool softener such as Syrup Lactulose

paraffin, Senna granules, Syrup lactulose was ordered

Lubricants in the form of Ointments or No lubricant was ordered for patient

suppositories cocoa butter, lanolin, glycerin,

cod-liver oil, and vegetable oil

36
 Treatment according to literature review Patient’s drug administered

Anesthetic agents such as benzocaine, None was ordered

lidocaine

Antibiotics such as Gentamicin, tab Metronidazole 400mg tid for 5 days,

Metronidazole, Ciprofloxacin, Amoxicillin, Capsule Flucloxacillin 500mg qid for 7

Flucloxacillin days and IV Metronidazole 500mg tid for

2 days was ordered and administered

Antimicrobial such as oral or Suppository Tab Pilex I tid for 30 days,

Pilex, metronidazole
Pilex cream tid for 30 days,

and tab metronidazole were

ordered

Iron preparation such as ferrous Syrup Iron III Polymaltose 10mls tid for

sulphate/fumarate, Iron III Polymaltose,

10 days was ordered

Multivitamin such as Zincofer, Zincivit, Capsule Zincovit I daily for 30 days,

Folic acid.
Tablet folic acid 5mg daily for 15 days

was ordered.

According to the literature review, Lubricants in the form of Ointments or suppositories cocoa

butter, lanolin, glycerin, cod-liver oil, and vegetable oil and also Anesthetic agents such as

benzocaine, lidocaine were stated but not ordered for patient. Majority of drugs stated in the

literature review such as analgesics such as suppository anusol, Stool Softeners or laxatives such

37
as Syrup lactulose, Antibiotics in the form of tab Metronidazole 400mg tid for 5 days, Capsule

Flucloxacillin 500mg qid for 7 days and IV Metronidazole 500mg tid for 2 days, Antimicrobial

such as Tab Pilex I tid for 30 days, Pilex cream tid for 30 days, Iron preparation such as Syrup

Iron III Polymaltose 10mls tid for 10 days, Multivitamin such as Capsule Zincovit I daily for 30

days, Tablet folic acid 5mg daily for 15 days was all ordered.

With reference to the literature review, it can be concluded that Mr. A.Y.I treatment met the

approved treatment modality which helped him to recover early and fully.

None of the surgical procedures stated in the literature review was carried.

Table 5 shows the pharmacology of the drugs given to Mr. A.Y.I

38
 Table 5: Pharmacology of drugs for Mr. A.Y.I

Drug Dosage/route of Classification Desired effect Actual action Side effects/

administration observed Remarks
Tablet 400mg three times daily x 4 Synthetic Antibiotic A synthetic antibacterial and Therapeutic effect Should be
Metronidazole days orally antiprotozoal agent that inhibits of drug was administered with
the nucleic acid disrupting the meals to decrease
Antimicrobial observed as there
DNA of microbial cells. GI upset; may cause
500mg three times daily for was remission of anorexia and metallic
2 days signs and taste
Patient should avoid
Intravenous symptoms of
alcohol; Flagyl
infection increases blood-
thinning effects of
warfarin (Coumadin).
None was observed
Zincofer 1 capsule daily for 30 days Multivitamin To increase appetite and Patient’s condition Diarrhoea, black
haemoglobin level improved. stools, epigastric pain,
Orally constipation. Patient
did not exhibit any of
the above of these
were exhibited
Folic acid 5mg daily for 30 days Multivitamin To help correct lack of red blood Patient condition Headache, nausea,
cells improved. vomiting, and
abdominal pain.
None of these were
observed as a result of
the drug.

39
DRUG DOSAGE/ROUTE OF CLASSIFICATION DESIRED EFFECT ACTUAL SIDE EFFECTS/
ADMINISTRATION ACTION REMARKS
OBSERVED
Pilex 2 tablets three times daily Analgesic It contains local analgesic Patient was relieved Skin rashes,
for 30 days properties that relieves pain and of excruciating pain gastrointestinal
Orally Antimicrobial ensures pain free stool excretion, when defecating. distress, diarrhoea,
fatigue, lower blood
Cream Pilex It also prevents secondary Patient was free pressure levels
Per rectal microbial infections in the body from infection None was observed in
(apply after each stools). or the part of the body that it is patient.
applied.
Anusol 1 suppository three times Analgesics it decreases the irritation in the Patient was relieved Allergic skin rashes,
daily for 7 days anus and also contains analgesic of irritation and increased body hair
properties that aid to relief pain. growth, burning
per rectal localised pain sensation, rectal pain
None was observed in
patient.
Lactulose 10mls three times daily for 5 Stool softener Lactulose is not absorbed by Patient was able to Abdominal cramps,
days small intestines, thus stays in the pass stools easier as borborygmus,
orally digestive bolus through the he was relieved of flatulence. Nausea and
intestines, causing water constipation. Vomiting.
retention leading to softer and None was observed
easier stools.
Flucloxacillin 500mg four times daily for 7 b lactam antibiotic it inhibits the synthesis of Patient was free skin rash, nausea,
days bacterial cell wall leading to from infection vomiting
death of bacterial. None was observed in
patient .
Iron III 10mls three times daily for Haematinics, For treatment of megaloblastic Patients Urticarial, heart burns
Polymaltose 14 days Patient did not
and iron deficient anaemia haemoglobin
orally iron supplement experience any side
gradually increased effect

40
Complications

With reference to the complication stated in the literature review such as infection,

anal fistula, perianal thrombosis, fecal incontinence and strangulated hemorrhoid,

Mr. A.Y.I didn’t develop such complication.

Patient Hemoglobin level was 7.0 g/dl indicating patient had severe anemia which

is a complication of bleeding haemorrhoids.

With good care rendered patient’s hemoglobin was restored and he didn’t not

develop any other complication.

2.2 Patient/Family Strengths

Strength as defined by Weller (2010) is the good or beneficial qualities or attributes

of an individual or group of persons. This is explained as the ability of the patient

and his family to help or participate in the care for the achievement of set goals. The

following strengths were observed on Mr. A.Y.I and family;

1. Patient was able to voice his fears about unknown outcome of disease.(1/10/2018)

2. Patient is able to verbalise the presence of blood in his stool (1/10/2018)

3. Patient was able to describe (rate) intensity of pain on a scale and also point

to the site of pain (1/10/2018)

4. Patient’s dizziness subsides with enough bed rest (1/10/2018)

5. Patient could sleep for about three (3) hours at night (02/10/2018)

6. Patient can verbalise feeling of urge to eliminate his bowel (02/10/2018)

7. Patient and family were ready and willing to learn about the disease

condition (04/10/2018)

41
2.3 Patient/Family’s Health Problems

Weller (2010) defines problems as, any health care condition that requires diagnostic,

therapeutic, or educational action. It also refers, in nursing, to any unmet or partially met

basic human need. The patient/family’s problem means, the difficulties they faced because

of the disease condition .The following were the actual and potential health problems

identified with the patient during the period of hospitalization. They include ;

1. Patient and family were anxious (1/10/2018)

2. Patient was bleeding per anus (1/10/2018)

3. Patient complained of pain when eliminating his bowel (1/10/2018).

4. Patient experienced dizziness (1/10/2018)

5. Patient could not sleep well (02/10/2018)

6. Patient could not void well (constipation) (02/10/2018)

7. Patient had inadequate knowledge about disease condition (04/10/2018).

2.4 Nursing Diagnoses

A nursing diagnosis according to the NANDA International (2016) is a clinical judgement

concerning a human response to health conditions/ life processes, or vulnerability for that

response, by an individual, family, group or community. It is a clear and definite statement

of the patient’s health status that can be influence by nursing interventions. It is derived

from a validated, critically analysed and interpreted dated collected during assessment.

Conclusions are drawn regarding the patient’s needs, problems, concerns or human

responses. The nursing diagnosis, once identified, provides a central focus for reminder of

the stages that is based on the nursing process. The plan of care is designed, implemented

and evaluated, hence making it possible to give comprehensive health care to the problems.

42
This is done by identifying, validating and responding to specific health problems. The

nursing diagnosis also provides an efficient method of communicating the patient’s health

problems (www.nursesnanda.com).

Nursing diagnosis for Mr. A.Y.I are as follows

1. Anxiety related to unknown outcome of disease condition (1/10/2018)

2. Fluid and electrolyte imbalance (less than body requirement) related to

disease condition (bleeding hemorrhoid). (1/10/2018)

3. Acute pain related to pressure, and sensitivity on the anal veins and

nerves(1/10/2018)

4. High risk for injury related to dizziness (1/10/2018)

5. Sleep pattern disturbance ( Insomnia) related to unfamiliar environment

(02/10/2018)

6. Altered bowel movement (constipation) related to ignoring the urge to defecate

because of pain during elimination(02/10/2018)

7. Knowledge deficit related to lack of inadequate information on causes, signs and

symptoms and prevention of disease condition (bleeding hemorrhoid). (04/10/2018)

43
 CHAPTER THREE

PLANNING OF PATIENT/FAMILY CARE

3.0 Introduction

According to the Weller (2010), planning refers to consciously setting forth a scheme to

achieve a desired end or goal.

Planning deals with setting of goals and objectives to help eliminate or reduce patient’s

health problem and coming up with the appropriate nursing interventions to meet set goals.

Mr. A.Y.I and his family were actively involved in planning of nursing care.

The nursing care plan comprises of the following nursing diagnosis, objective/ outcome,

nursing orders, nursing interventions and evaluation were used to carry out the nursing care

of patient.

3.1 Objectives For Patient And Family Care

The following objectives were set for the patient and family care during the period of

hospitalization to help solve their health problems;

1. Patient and family will be relieved of anxiety within 24 hours

2. Patient will attain normal fluid and electrolyte balance throughout period of

admission

3. Patient’s pain will subside within 48 hours

4. Patient will be free from injury within 24 hours

5. Patient will regain his normal sleeping pattern within 24 hours

6. Patient will be able attain adequate eliminating pattern within 48 hours

7. Patient will gain adequate knowledge on the disease condition within 2 hours.

Table 6 shows the nursing care plan for Mr. A.Y.I

44
 Table 6: Nursing Care Plan for Mr. A.Y.I

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
01/10/18 Anxiety Patient will be 1. Reassure patient and immediate 1. Patient and immediate family was 2/10/ Goal was
family of remission with available reassured that the condition will
1:30pm related to relieved of anxiety 2018 fully met as
treatment. resolve with the available treatment.
unknown within 24hours as 1:30pm patient and
2. Reassure patient and immediate 2. Patient and immediate family
outcome of evidenced by family of the competence and readiness was reassured of the competence immediate
of the staff. and readiness of the staff.
disease 1. Nurse observing family
3. Educate patient and immediate 3. Patient and immediate family
condition that patient is relaxed verbalized
family on the condition were educated on condition
and has a cheerful 4. Encourage patient and immediate 4. Patient and relatives was relieve of
family to ask questions. encouraged to ask questions.
facial expression. anxiety and
5. Answer all questions tactfully and 5. All questions were answered
2. Patient verbalizing they wore a
honestly tactfully and honestly
that, he is no more 6. Explain all procedures carried out on 6. All procedures carried out on relaxed
patient. patient were explained.
anxious. facial
7. Maintains the patient privacy while 7. Privacy was maintained by
expression
providing care screening patient and closing
windows when performing
procedure.

45
 Table 6: Nursing Care Plan for Mr. A.Y.I continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
1/10/ Fluid and Patient will attain 1. Inspect anal site for any bleeding 1. Perianal area was inspected for 5/10// Goal fully
bleeding.
2018 electrolyte normal fluid and 2. Advise patient to take diet that are 2. Patient was advised to high fiber 18 met as
high in fiber such as fruits and diet to help prevent constipation.
imbalance electrolyte balance vegetables in avoidance of 8:00am patient’s
constipation.
1:45pm (less than throughout period of 3. Advise patient to drink a lots of 3. Patient was encouraged to drink 2 Haemoglobin
water at least 2 liter/day in avoidance to 3 litres of water per day.
body admission as of constipation. level rise
4. Give stool softener such as liquid 4. Stool softeners such as Lactulose
requirement) evidenced by paraffin as ordered by doctor in syrup 10mls administered. from 7.0g/dl
avoidance patient straining during
related to 1.patient passing passing motion. to 10.5g/dl
5. Advise patient not to strain during 5. Patient was advised not to strain
disease blood free stools passing motion to prevent any when eliminating his bowel. and there
bleeding.
condition 2. Patient hemoglobin 6. Tell patient to use soft tissue for 6. Patient was encouraged to use soft was absence
wiping to prevent any bleeding. toilet roll to clean the anus after
(bleeding level rising gradually. bowel elimination. of occult
7. Encourage warm sitz bath after each 7. Warm sitz bath was done for
hemorrhoid) stool or three times a day. patient after passing each stool. blood in
8. Inspect patient stool for blood or 8. Patient stool was inspected for
occult blood. occult or red blood. patient’s
9. Administer blood or blood products 9. Patient was transfused 3 units of
as prescribed. packed cells as prescribed. stool.
10. Prescribed iron supplement and
10. Serve prescribed haematinics multivitamin i.e (Zincovit, Iron III
Polymaltose) administered as
prescribed.
46
 Table 6: Nursing Care Plan for Mr. A.Y.I continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
01/10/ Acute pain Patient’s pain will 1. Asses level of pain according to pain 1. Patient’s level of pain was 03/10/ Goal was
2018 2018
scale level by asking the patient for assessed on a scale of 0-10 and
related to subside within 48 fully met as
2pm further management. recorded 5. Indicating adequate pain. 2pm
pressure, and hours as evidenced by patient
2. Patient’s vital signs was
2.Monitor vital sign to detect any
sensitivity on 1. Patient verbalising monitored to detect any verbalized
abnormality such as blood pressure
that pain intensity has abnormalities which may be an
the anal veins more than 140/90mmhg and that he was
reduce. indication of pain.
and nerves. tachycardia relieved of
2. The nurse observing
3. Position patient on side lying 3. Patient was positioned laterally to anal pain.
that patient has
position to reduce the pressure on the reduce pressure on the buttock and
cheerful facial
buttocks so that it’s can help to reduce anus so as to reduce pain.
expression. the pain.
4.Deep breathing exercise was
4.Teach patient how to do breathing
taught to help reduce pain.
exercise to reduce the pain

5.Give diversional therapy such as 5.Television set in the ward was

watching television, reading magazine switched on to provide divertional
so that patient do not focus on the pain. therapy

47
 Table 6: Nursing Care Plan for Mr. A.Y.I continued

Acute pain related to pressure, and sensitivity on the anal veins and nerves continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
6.Sitz baths taken three or four times 6. Patient was encouraged to do

each day can relieve soreness and pain warm sitz bath to relieve anal

by relaxing sphincter spasm soreness

7.Flotation pads made of soft

7. Flotation pads should be placed
mattress(foam) was placed on bed
under the buttocks when sitting help to
for patients to sit on to decrease
decrease the pain.
pain.
8. Apply cold ice around the anal area
8.Cold compressors was provided to
to provide provisional pain relief.
patient to apply to anal region for

provisional pain relief.

9.Prescribed analgesics such as

9. Give analgesic such as such as
suppository Anusol was
Suppository anusol as ordered by
administered as ordered.
doctor to reduce the pain.

48
 Table 6: Nursing Care Plan for Mr. A.Y.I continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
01/10/20 High risk for Patient will be free 1. Reassure patient that he will be 1. Patient reassured that he will be 02/10/ Goal fully
met as
18 injury related from injury within 24 relieved of the dizziness with good relieved of the dizziness with good 2018
evidenced by
to dizziness hours as evidence by ; health care. health care.
patient
2:15pm
1. Patient verbalizing 2. Elevate side rails 2. Side rails were elevated. 2:15pm verbalizing
absence of
absence of dizziness 3. Remove all source of injury from 3. All source of injury was removed
dizziness and
2.Nurse observing that patient e.g. needle i.e. sharps e.g. free needles
nurse
patient demonstrates 4. Ensure complete bed rest 4. Complete bed rest was ensured assessing
that, patient
absence of injury. 5. Assist patient in self-care activities 5. Patient was assisted in self-care
demonstrates
activities ie. bathing, mouth care
absence of
6. Serve prescribed medications and 6. Prescribed analgesics, antibiotics injury

monitor patient for side effects of drugs was administered and side effects of

on patient. drugs was monitored.

49
 Table 6: Nursing Care Plan for Mr. A.Y.I continued

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Outcome Criteria Time
02/10/20 Sleep pattern Patient will be able 1. Reassure patient that he will be able 1. Patient was reassured that good care 03/10/2 Goal fully
18 to sleep with good nursing care will be rendered to help him sleep 018 met as
disturbance to sleep rendered. well.
2.Restrict or limit visitors when 2. Visitors were restricted and the evidenced by
(Insomnia) uninterrupted for 6- necessary and explain to the patient the need for rest in aiding speedy recovery 7:15am
7:15am nurse
need for rest and sleep in aiding speedy was explained thoroughly for patients.
related to 8hours in the night observing
recovery
that patient
unfamiliar and 1 hour in the day 3. The environment should be properly 3. Fans were switched on, and
ventilated and noise minimized to windows opened to ensure well has been able
environment within 24 hours promote rest and sleep. ventilated room. Noise in the ward
to sleep
was also minimise by lowering the
evidenced by volume of television set. throughout
4.Put patient in well prepared, 4.Patient’s bed laid comfortable, free the night (6-
1.Nurse observing comfortable bed and make sure bed is from creases and cramps
free from creases and cramps 8hours) and
patient sleep
5.Carry out bulk nursing when 5. Routine nursing care such as 1hour in the
throughout the night applicable monitoring vital signs, medication, etc afternoon
were carried out in bulk to prevent
disturbing of patients when sleeping. and patient
and
6.Encourage patient to take warm bath 6. Patient was encouraged to take verbalizing
2. Patient after meals and warm drinks before warm bath every night before
that he is
bed sleeping.
verbalizing that he 7.If patient has pain-related insomnia, 7. Prescribed analgesics (Suppository able to sleep.
serve prescribed analgesics to relieve Anusol and Tab Pilex) was
was able to sleep. pain and monitor for therapeutic and administered and its therapeutic and
adverse effects adverse effects monitored.

50
 Table 6: Nursing Care Plan for Mr. A.Y.I continued

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Outcome Criteria Time
02/10/20 Altered bowel Patient will be able 1. Encourages intake of at least 2 L of 1. Patient was encouraged to take at 04/10/ Goal fully
water daily to provide adequate least 2 L of water and diet high in
18 movement attain adequate 2018 met as
hydration recommends high-fiber foods fiber such as kontomire stew or
(constipation) eliminating pattern to promote bulk in the stool and to orange. evidenced by
make it easier to pass fecal matter
7:30am related to within 48 hours 7:30am patient
through the rectum.
ignoring the as evidenced by; 2. Administer stool softeners such as 2. Stool softeners such as Syrup eliminating
lactulose as prescribed. Lactulose 10mls administered as
urge to 1.Patient eliminating prescribed. his bowel at

defecate his bowel once daily 3. Advise to set aside a time for moving 3. Patient was advised to heed to the least once
the bowels and to heed the urge to urge to defecate promptly as possible.
because of 2. Patient verbalising defecate as promptly as possible. daily and

pain during that his stools are 4. Teach patient to perform relaxation 4. Patient was taught to perform nurse
exercises before defecating to relax the relaxation exercises before emptying
elimination soft abdominal and perineal muscles, which his bowel to help relax the abdominal observing
may be constricted or in spasm. and perineal muscles.
patient stool
5. Administer analgesic before a bowel 5. Suppository Anusol was
movement to reduce pain. administered and Cream Pilex applied soft.
before and after each stool to reduce
pain associated with constipation.

51
 Table 6: Nursing Care Plan for Mr. A.Y.I continued

Date/ Nursing Objective/ Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Outcome Criteria Time
04/10/ Knowledge Patient will gain 1. Reassure patient /family that with 1. Patient /family was reassured that 04/10/ Goal fully met
2018 detailed information they will have detailed information on bleeding 2018
adequate knowledge as patient and
deficit related
9am on the disease understanding of bleeding hemorrhoid will be given for better 11am family give
to lack of hemorrhoid understanding.
condition within 2 correct
2. Schedule time with patient and 2. Time was scheduled with patient
inadequate hours as evidenced answers to
relatives to educate them on bleeding and relatives to educate them on
by; hemorrhoid. bleeding hemorrhoid. questions
information
1. Patient / family 3. Make patient comfortable by lying in 3. Patient was made comfortable by asked on
on causes, bed whiles relatives and the nurse sit lying in bed whiles relatives and the
being able to answer bleeding
signs and some questions on by bedside. nurse sit by bedside. hemorrhoid
4. Assess patient and family knowledge 4. Patient and family knowledge on
bleeding hemorrhoid correctly and
symptoms and level on bleeding hemorrhoid bleeding hemorrhoid was assessed.
correctly and .patient/
prevention of 5. Correct any misconception and 5. Accurate information on the
2.Patient/family provide accurate information on the predisposing causes, signs and family
disease verbalizing predisposing causes, signs and symptoms, prevention, drug verbalizing
understanding on the symptoms, prevention, drug management and lifestyle understanding
condition
information given management and lifestyle modification were provided to on the
(bleeding modification correct misconceptions
them. information
6. Invite questions and answer them 6. Questions were invited and tactfully
hemorrhoid). given them
tactfully. answered.
7. Give patient pamphlets on bleeding 7. Pamphlets on bleeding hemorrhoid
hemorrhoid to read were given to patient

52
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT/FAMILY CARE PLAN

4.0 Introduction

According to Weller (2010), implementation is the act of implementing (providing a practical

means for accomplishing something, an aim or executing an order); carrying into effect. It

also covers the follow up visits made to ensure continuity of care rendered to the

patient/family.

4.1 Summary of Actual Nursing Care Rendered

First day of Admission; 1/10/2018

On 1/10/2018 at 1pm, Mr. A.Y.I was admitted at the general ward of Sampa Government

Hospital, Sampa per ambulatory from out- patient department accompanied by an OPD

nurse and his wife. Patient’s folder was collected from the OPD nurse and his name was

mentioned to ascertain and confirm the identity of the patient. Mr. A.Y.I was immediately

made comfortable in an already prepared simple bed in male’s ward with bed number M-2

because he looked weak. And I introduced myself and other staff on duty to Mr. A.Y.I and

his wife. Mr. A.Y.I ’s. particulars were documented into the admission and discharge book

and daily ward state. From the folder, I was ascertained patient was referred from the Kokoa

Health Centre. Upon assessment patient looked very pale, weak and generally looked ill. He

complained of bleeding per anus any time he eliminated his bowel, waist pains, palpitations,

dizziness, easy fatiquability and burning sensation in the anus. Patient and family were

observed to be anxious also.

Vital signs was checked and recorded as follows

53
Temperature - 36.9oc

Pulse - 84bpm

Respiration - 21cbm

Blood Pressure - 120/60mmHg

SPO2 - 97%

Laboratory investigations requested on admission were

Blood for Full blood count

Blood for malaria parasite

Widal test

Stool for Routine examination

Blood sample was taken, sample bottle labelled and sent to the laboratory for the

investigations to be carried out.

Patient was placed on the following medications;

Capsule Flucloxacillin 500mg qid for 7 days

Tablet Pilex II tid for 30 days

Ointment Pilex tid for 30 days (apply after each stool)

Tablet Zincovit I daily for 15 days

Table Folic Acid 5mg daily for 15 days.

Syrup Iron III Polymaltose 10mls tid for 10 days

All drugs were procured from the pharmacy and administered to the patient immediately.

Patient and relative were then orientated to ward and its environs such as the toilet, bath

room and the nurses station. They were also introduced to the other patients on the ward.

The wife of Mr. A.Y.I was encouraged to bring patient’s personal that He may need at the

54
ward such as towel, sponge, tooth brush, toothpaste and bucket from the house. They were

asked to talk to any of the nurses around if they needed anything or help.

After these interventions, I told the ward in-charge of my intention of using the patient and

the family for a case study and I was given the permission. I introduced myself to the

patient/family that, I am a student nurse of Nurses’ Training College, Sampa, conducting a

study at the hospital. I then made it known to them my desire to give Mr. A.Y.I a special

nursing care for his speedy recovery. I told them that, as part of my training, final year

students are to take a patient each, nurse him or her from the time of admission till time of

discharge and home visits. The patient and family accepted and promised their cooperation

and readiness to give me any information needed for my study. They were told that, they

would be discharged home once the patient’s condition is stable and that they were not

going to be on the ward forever. They were also informed that, as part of my care, I would

visit their home whiles he was on admission and after he has been discharged. I choose to

write my care study on bleeding hemorrhoid because even though hemorrhoid it’s very

common in most people, there are a lot of misconception about it and people usually treat it

at home and come to the hospital only after complications. I wanted to know more about this

condition and to holistically nurse a patient who was suffering from this ailment.

At 1:30pm, upon interaction with patient it was observed that patient and family were

anxious about disease condition and its outcome. A nursing diagnosis of anxiety related to

unknown outcome of disease condition was formulated. An objective was set to be achieved

within 24 hours to ensure patient and family was relieved of anxiety. The following nursing

interventions were carried out to ensure goal set was achieved; Firstly, patient and immediate

family was reassured that the condition will resolve with the available treatment and also

patient and immediate family was reassured of the competence and readiness of the staff to

deliver professional care to them. Furthermore, patient and immediate family were educated

55
on condition and they were encouraged to ask questions. All questions they asked were

answered tactfully and honestly. All procedures carried out on patient were explained before

being carried out. Lastly, privacy was maintained by screening patient and closing windows

when performing procedure.

At 1:45pm, also patient complained of bleeding per anus. A nursing diagnosis of fluid and

electrolyte imbalance (less than body requirement) related to disease condition (bleeding

hemorrhoid). An objective was set to be met within period of admission. Nursing

interventions carried out included; Perianal area was inspected for bleeding. Patient was

advised to high fiber diet to help prevent constipation. Patient was also encouraged to drink 2

to 3 litres of water per day. Stool softeners such as Lactulose syrup 10mls was administered.

Patient was advised not to strain when eliminating his bowel. Moreover, patient was

encouraged to use soft toilet roll to clean the anus after bowel elimination. Warm sitz bath

was done for patient after passing each stool. Patient stool was inspected for occult or red

blood. Patient was transfused with packed cells (blood) as prescribed. Prescribed iron

supplement and multivitamin i.e (Zincovit, Iron III Polymaltose) were all administered as

prescribed.

Also, at 2pm on the day on admission, patient complained of pain in the anus. A nursing

diagnosis of acute pain related to pressure, and sensitivity on the anal veins and nerves was

formulated and a goal to help patient’s pain to subside within 48 hours was set. Patient’s level

of pain was assessed on a scale of 0-10 and recorded 5. Indicating adequate pain. Patient’s

vital signs was monitored and charted on the temperature sheet to detect any abnormalities

which may be an indication of pain. Also, patient was positioned laterally to reduce pressure

on the buttock and anus so as to reduce pain. Moreover, deep breathing exercise was taught to

help reduce pain. Television set in the ward was switched on to provide divertional therapy.

Patient was encouraged to do warm sitz bath to relieve anal soreness. Flotation pads made of

56
soft mattress (foam) was placed on bed for patients to sit on to decrease pain. Cold

compressors was provided to patient to apply to anal region for provisional pain relief.

Prescribed analgesics such as suppository anusol was administered as ordered.

At 2pm, on the day of admission, Mr. A.Y.I also complained of dizziness. A nursing

diagnosis of high risk for injury related to dizziness was formulated. A goal was set to ensure

patient remained free from injury due feeling of dizziness within 24 hours. Nursing orders

carried were; Patient was reassured that he will be relieved of the dizziness with good health

care and bed side rails were elevated to prevent patient from fallen. All source of injury was

removed i.e. sharps e.g. free needles. Moreover, complete bed rest was ensured and patient

was assisted in self-care activities i.e. bathing, mouth care.

At 3pm, patient’s laboratory results were collected from the laboratory. Results read

Malaria parasite Negative

White blood cells 4.7 x109/L

Red blood cells 3.2 x 10/l

Hemoglobin 7.0 g/dl

Hematocrit 22%

Neutrophils 46%

Medical officer on duty was called to review patient’s laboratory results. Dr. Arthur

ordered for patient to be transfuse with 1 unit (pint) of packed cells blood. No

premedication was ordered. Patient also to do sickling and G6PD test before the

transfusion. Laboratory forms was filled and sent to laboratory for the investigations

to be done and also grouping and cross matching. At 3:15pm, patient 1 pint (unit) of

A+ blood with batch number YK10 and expiry date 7/10/2018 was set up on patient.

Patient was educated on intra-transfusion reaction and reassured. Pre-transfusion

vital signs recorded

57
Temperature 37.1

Pulse 78bpm

Respiration 19cpm

Blood pressure 100/75mmHg

Patient was closely monitored for any sign of blood transfusion reaction such as

urticaria rush, fever, pruritis or chills. Blood successfully completed at 7pm with no

transfusion reaction. Post transfusion vital signs was also checked and charted on

patient’s vital signs sheet.

Patient then had banku and okro soup for his supper. Due medications were served at

10pm and patient retired to bed after having warm bath and also doing sitz bath.

Second Day of Admission (02/10/2018)

Mr. A.Y.I looked very tired in the morning. Patient complained of intermittently

waking up throughout the night. At 5am, in the morning, patient took his bath with

warm water and brushed his teeth. Patient was visited by members of church around

5:30am during the first visiting time of the day. Vital signs for the morning was

checked and recorded as

Temperature 36.9oc

Pulse 84bpm

Respiration 21cpm

Blood pressure 110/70mmHg

SPO2 (Oxygen saturation) 99%

Patient had “kooko”(porridge) with bread for breakfast.

At 7:15 am, due to patient’s complain of sleeplessness, a nursing diagnosis of sleep pattern

disturbance (Insomnia) related to unfamiliar environment. An objective was set to ensure

58
patient was able to sleep adequately within 24 hours. Nursing orders carried out included;

Patient was reassured that good care will be rendered to help him sleep well. Visitors were

restricted and the need for rest in aiding speedy recovery was explained thoroughly for

patients.

Fans were switched on, and windows were opened to ensure well ventilated room. Noise in

the ward was also minimise by lowering the volume of television set. Also, patient’s bed was

laid comfortable, free from creases and cramps. Routine nursing care such as monitoring vital

signs, medication, etc were carried out in bulk to prevent disturbing of patients when

sleeping. Patient was encouraged to take warm bath every night before sleeping. Prescribed

analgesics (Suppository Anusol and Tab Pilex) was administered and its therapeutic and

adverse effects monitored.

At 7:30am, patient also complained of constipation. A nursing diagnosis of altered bowel

movement (constipation) related to ignoring the urge to defecate because of pain during

elimination. The following nursing interventions were carried out during patient’s stay at the

hospital. Patient was encouraged to take at least 2L of water and diet high in fiber such as

kontomire stew or orange. Stool softeners such as Syrup Lactulose 10mls administered as

prescribed .Patient was advised to heed to the urge to defecate promptly as possible. Patient

was taught to perform relaxation exercises before emptying his bowel to help relax the

abdominal and perineal muscles. Suppository Anusol was administered and Cream Pilex

applied before and after each stool to reduce pain associated with constipation.

At 8am, routine ward rounds was conducted by Dr. Arthur and patient was placed on IV

Metronidazole 500mg tid for 2 days. Patient’s laboratory results of sickling and G6PD was

also reviewed. Since sickling was negative and G6PD was normal, treatment was not

necessary. Dr. Arthur ordered for haemoglobin of patient to be checked the following

59
morning. Laboratory slip was sent to the laboratory for hemoglobin level of patient to be

checked the next day.

Patient had Yam with kontomire stew for his lunch.

At 1:30pm, patient was assessed, whether the goal set on the first day of admission to ensure

patient was relieved of anxiety. Goal set was fully met as evidenced by patient and immediate

family verbalizing relieve of anxiety and they wore a relaxed facial expression.

At 2pm vital signs was checked and charted. At 2:15 pm, an evaluation was made on the

objective set to ensure patient was free from injury. The goal was fully met as patient

verbalized absence of dizziness and patient demonstrated absence of injury. Patient was

visited again by his relatives during the afternoon visiting hours.

Patient was supervised to take yam with garden eggs stew as supper. Mr. A.Y.I took a

warm bath at 7:40pm after due medications were served and vital sign also checked and

recorded at 8:00pm. After the routine medications, he was reassured of readiness of staff to

assist with care and to call for a nurse when in need. He was made comfortable in bed and

handed over to the night nurse. Patient finally went to bed around 8:40pm.

Third day of Admission (03/10/2018)

On this day, patient woke up about 5:30am, brushed his teeth and took his bath. Patient

was also encouraged to continue with the warm sitz bath. His bed was laid and the locker

cleaned. Patient and the night nurse affirmed that patient had a good night sleep with no

complaints. His vital signs were checked and recorded in the vital sign chart at 6:30am as;

Blood pressure 110/80mmHg

Temperature 36.70c

Pulse rate 87bpm

Respiration 24cpm

60
After the vital signs, patient was served with breakfast which was corn porridge and bread.

Due medications such as IV metronidazole 500mg, Tablet Zincovit, Tablet Folic acid,

Syrup Iron III Polymaltose, Suppository anusol, Syrup Lactulose, Pilex cream and Tablet

Pilex were all served and charted on the medication chart. The therapeutic and adverse

effects of the drugs were closely observed.

At 7:15am, goal set to ensure patient was able to sleep well was evaluated. Goal was fully

met as night nurses observed that patient was able to sleep throughout the night (6-8hours)

and also patient verbalizing that he is able to sleep well.

At 8am, ward rounds was conducted by Dr. Arthur and patient was reviewed. Mr. A.Y.I

didn’t lodge any complain. Patient’s haemoglobin results from the laboratory was

10.5g/dl. No new treatment was ordered as patient was to continue with his old treatment

regimen. After the ward rounds all nursing orders to ensure patient’s pain subsided,

bleeding was stopped and patient was able to freely eliminate his bowel without any

difficulty were continued.

At 12:00pm, Mr. A.Y.I was served with rice and palaver sauce with fish for lunch and was

able to eat all the meal served. At 2pm, patient was evaluated on the objective set to ensure

patient’s anal pain subsides. Upon evaluation, goal was fully met as patient verbalized that

he was relieved of anal pain. Patient was informed of my intention to visit his house the

following day. He readily agreed and gave the direction to his house.

Patient’s due medications were administered and documented at 4:00 pm as well as vital

signs were checked and recorded as follows:

Blood pressure 110/80mmHg

Temperature 36.70c

Pulse rate 87bpm

Respiration 24cpm

61
At around 6:00pm, patient was served with fufu and groundnut soup with chicken as

supper. He was encourage to bath and also to do warm sitz bath. Patient was served with

his due medication and documented at 8:00pm.

At 10:00pm his vital signs were checked and recorded as follows:

Blood pressure 110/60mmHg

Temperature 35.70c

Pulse rate 82bpm

Respiration 24cpm

Patient retired to bed after watching the ward television with other patient at the ward.

Fourth day of admission (04/10/2018)

On this day, patient woke up at 5:00am and was looking very well and very relaxed in bed.

He had a warm bath and also performed oral hygiene after which patient was served with a

cup of porridge and bread of which he was able to eat all the food served. Patient did not

lodged any complain upon enquiry. Due medications were served and charted

appropriately on the medication sheet.

Vital signs were checked and recorded as:

Temperature 36.3℃

Pulse 72 beats per minute

Respiration 16 cycles per minute

Blood pressure 110/70mmHg

At 7:30am, patient verbalised that he was able to eliminate his bowel at least once daily

without any straining. Goal set on the 02/10/2018, was fully met.

At 8:00am, routine ward rounds was done by Dr. Arthur. Patient had no new complain.

Upon assessment by the doctor, patient anal bleeding had subsided and patient was

62
looking clinically well. Patient was to be observed for the next 24 hours and may be

possibly discharged if his condition remains stable. Patient was informed.

At 9am, patient was asked if he had adequate knowledge on the disease condition he was

suffering from. It was realised that patient had inadequate knowledge on the causes, signs

and symptoms and treatment regimen for bleeding hemorrhoid. A nursing diagnosis of

knowledge deficit related to lack of inadequate information on causes, signs and symptoms

and prevention of disease condition (bleeding hemorrhoid). An objective was set to ensure

patient will gain adequate knowledge on the disease condition within 2 hours. To achieve

this goal, Patient and family were reassured that detailed information on bleeding

hemorrhoid will be given for better understanding. Time was scheduled with patient and

relatives to educate them on bleeding hemorrhoid. Patient was made comfortable by lying

in bed whiles relatives and the nurse sit by his bedside. Patient and family knowledge on

bleeding hemorrhoid was assessed. Accurate information on the predisposing causes, signs

and symptoms, prevention, drug management and lifestyle modification were provided to

correct misconceptions .Questions were invited then invited from patient and His family

and tactful and accurate answers were provided. Pamphlets with pictures that provides

information on bleeding hemorrhoid were given to patient and his family. At 11am, when

patient and relatives were assessed and questions were asked on bleeding hemorrhoid,

patient was able to answer it. Goal set at 9am was fully met.

At 11am, I informed patient that I was paying my first home visit to his house. He

informed me that his wife was in the house. I paid my first home visit to Mr. A.Y.I house

while he was on admission and returned around 1pm.

Routine nursing (monitoring of vital sign, administration of medication) care was rendered

to patient. His lunch was yam and kontomire stew. Patient watched the television in the

ward with other patients before going to have his bath. Evening medications and vital

63
signs were dully checked and recorded. Mr. A.Y.I warmly retired to bed at 10pm after

taken his bath.

Fifth day of admission (day of discharge) 5/10/2018

On this day patient looked cheerful and had no complains. Patient woke up at 5:30am and

His personal hygiene i.e bathing and brushing of his teeth, was maintained. According to

patient, he was able to sleep soundly in the night. Patient had weanimix porridge and bread

for breakfast. Prescribed medications were also served as ordered and charted accordingly.

Morning vital signs was checked and recorded as;

Temperature - 36.0 degrees Celsius

Pulse - 82 bpm

Respiration - 21 cpm

Blood pressure - 120/80 mmHg

At 8am, objectives set on the day of admission to ensure attain normal fluid and electrolyte

balance was evaluated. Goal was fully met as patient’s haemoglobin level rise from 7.0 g/dl to

10.5g/dl and there was absence of occult blood in patient’s stool.

At 9am, ward rounds was conducted by Dr. Arthur. Patient was reviewed and no new

complain was lodged. Tablet metronidazole 400mg tid for 5 days and Suppository Anusol I

tid for 7 days were prescribed for patient and he was to continue with the other drugs also.

Patient was then discharged by the attending medical doctor. Patient was schedule for review

in a week’s time which was 14/10/2018. Patient was informed immediately and the drugs

prescribed were procured from the pharmacy department.

Patient was advised on his diet, the need for rest, the need to adhere to his treatment regimen

and also the need to take all medication that he will be discharged on as prescribed. Patient

was advised that even though he was being discharged if anything happened between now

64
and the review date he should report to the hospital. Patient was helped to pack his

belongings. Patient and his family were told to come for review on 14/10/2018. Patient was

also informed that, I will be visiting him while he is in the house.

Since Mr. A.Y.I was insured with the National Health Insurance Scheme he did not have to

pay for any bill. He was then discharged in the Admission and Discharge book and the ward

state. Mr. A.Y.I thanked all staff on duty for taking good care of him and bid them goodbye. I

accompanied patient and his wife to the hospital gate where they `pick “kumkum” (tricycle)

home.

Afterwards all the bed accessories and the bed itself were disinfected and later cleaned with

0.5% chlorine solution and air dried and the bed linens taken to the hospital laundry. The bed

was then re-made for new admission.

4.2 Preparation of Patient /Family for Discharge and Rehabilitation

Preparation of a patient and family for discharge and rehabilitation is necessary and important

in comprehensive nursing care to ensure an adequate self-care at home. This was started from

the day of admission and till the day patient was discharged. Mr. A.Y.I was reassured that his

condition would stabilize with treatment and lifestyle modification..

In my effort towards preparing patient for discharge, I visited Mr. A.Y.I house on the

fourth day of his admission in order to acquaint myself with his home environment, check for

any potential health problems in order to help meet their health needs by giving them health

education and making suggestions on how to improve their health status.

Mr. A.Y.I and his family were educated on his condition, with regards to the predisposing

factors, sign and symptoms, drug used for management, lifestyle modifications and

complications.

Diet

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The diet is modified to increase fluids and fiber diet to ensure patient do not develop

constipation. He was also advised to eat adequately balanced diet, not to eat very late in the

night and to avoid sleeping right after eating. They were educated to eat a lot of fruits and

vegetables

Personal hygiene

Ensure patients hygienic needs are equally met as other medical needs of the patient are

established. The following measures can be followed;

Patient was instructed to keep the perianal area as clean as possible by gently cleansing with

warm water and then drying with absorbent cotton wipes. Also, the patient was educated to

avoid rubbing the area with toilet tissue or hard paper and to rub the anus with soft toilet tissue

or rinse with water after visiting the toilet. Also, instructions were provided about how to take a

sitz bath and how to test the temperature of the water. Sitz baths may be given in the bathtub or

plastic sitz bath unit three or four times each day. Sitz baths should follow each bowel

movement for 1 to 2 weeks. The nurse encourages the patient to respond quickly to the urge to

defecate to prevent constipation. Moderate exercise was encouraged to ensure patient stay

active.

Drugs and Review

The patient was advised to continue the medication or treatment regimen at home as

prescribed to prevent relapse of the disease condition.

The side effects and also the therapeutic effects of the drugs were explained to him. He was

asked to come for review on 14/10/2018.

Finally, In order to ensure continuity of care and to establish rehabilitation, I informed him of

my subsequent home visits, and encouraged him to visit the hospital any time aside the

review date, when he is not feeling well. He was discharged on the 05/10/2018 and he left the

ward on the same day.

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4.3 Follow up/ home visit/ continuity of care

First home visit (04/10/2018)

The first home visit was made on 04/10/2018 at 11:00am while patient was still admitted.

Patient was pre-informed on my intention to visit his home on the 03/10/2018 and details of

the directions to his house was given by patient to me. The purpose of the visit was to assess

patient’s home environment and to create a conducive home environment for receiving him

after discharge and also to identify available resources that might facilitate care.

At 11 am, I picked a taxi from the around the hospital to Kokoa where the patient resides.

The journey last about 45 minutes. Patient’s next of kin S.M and some of his relatives were

met in the house. I was warmly welcome and a seat was offered. I explained the reason for

my visit to them. Patient’s house is located near the Kokoa Presbyterian Junior High School,

near the market. Patient’s house was easily located as he described it. The house is a three

bedroom with one large hall house with number KKS/NE 002. The house is well built with

blocks, roofed with iron sheet, plastered but painted in brown, violet and green. There were

three rooms with one bathroom and kitchen facility which is separated from the main rooms.

The kitchen had no door to it and as such animals may wander into it. They were advised to

fix the gate. Patient didn’t have toilet facility and as such eliminate their bowel on the public

toilet which is about 500meters from the house. Each of the rooms has a door, door gate and a

mosquito proofed net. The house has access to electricity but no pipe borne water. Water is

fetched from a nearby house and temporary store them in a barrel at the kitchen. They keep

their refuse and waste in a well fitted container, which they disposes off every dawn at the

refuse dump which is about 500 meters away from his house. The house and its environment

were clean except for some small area at the back of the house which was bushy. I educated

Mr. S.M to clear the bush since it could be a breeding place for mosquitoes.

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They were congratulated for their clean environment and encouraged to continue with it since

clean environment promotes good health. They were informed about the next home visit which

will be after the patient has been discharged. After spending about an hour in the house with

the family of the patient, at 12:45pm, I asked for permission to leave which was granted. He

escorted me to the main road and where I picked a car back to the hospital.

Second Home Visit (11/10/2018)

On the sixth day after patient had been discharged that was 11/10/2018, at 1:30pm in the

afternoon I visited Mr. A.Y.I in his house. This time he was home. The aim of the visit was to

ascertain how the patient and his family were coping after discharged and to check on the

general wellbeing of the patient and again to check whether patient was adhering to the

treatment regimen. After the usual exchange of pleasantries I was given a seat to sit on. I

explain to them the reason for my visit. Mr. A.Y.I said he had not gone to his farm after

discharge. Mr. A.Y.I had no complications and complaints about his condition. His drugs

were checked to verify if he was taking them accordingly. Upon inspection, it was realised

patient had completed the tablet metronidazole but the other drugs were still available and he

was taken it as prescribed. Patient had not had any adverse effects after taking the drugs.

Patient also said he was no more bleeding per anus, neither was he having constipation.

Patient was advised to visit the toilet any time he had the urge to eliminate his bowel to

prevent relapse of the condition. I also asked if they had installed insecticides treated

mosquito nets in all their rooms which and he responded in the affirmative. I also observed

that the small amount of weed had been cleared and the gate to the kitchen had also been

fixed. Again, the patient and family were educated on the need to take balanced diet, food

high in fiber and the need to take adequate amount of fluid daily. Patient was also encouraged

to adhere to treatment regimen. They were finally reminded of the date of review, which was

68
in two days’ time (14/10/2018). I asked for permission to leave at 1:00pm. I was escorted to

the main road by Mr. A.Y.I.

Review Day (14/10/2018)

The review day was on 14/10/2018 and the patient came to the hospital in the company of his

wife, Maame S.S around 8:00am. Patient looked well, relaxed and cheerful. The patient was

assisted to collect his folder and vital signs were checked and recorded at the nurses table as

Temperature-36.7 degrees Celsius

Pulse-76bpm

Respiration-20cpm

B.P.-130/70mmHg

Patient was then was accompanied to the doctor for further assessment. On examination and

interaction with the doctor, the patient made no complains. Patient said bleeding had stopped

and he no longer had anal pain. Patient completed all the drugs prescribed for him before

discharged. He was encouraged report to the hospital anytime he felt ill. Education was also

given on the need to remove his bowel anytime he had the urge. Patient was asked to go to

laboratory to test his haemoglobin level. After about an hour the results came in from the

laboratory. Haemoglobin level was 11.1g/dl signifying an improvement on patient’s

condition

After the consultation, no new medication was prescribed. Patient was then informed that I will

pay them the last home visit, where care will be terminated and he will be handed over to a

community health nurse for continuity of care.

Patient and his wife were then accompanied to the road side to board a taxi to their house. They

bid me goodbye and left.

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Third Home Visit (18/10/2018)

My last home visit was to evaluate care rendered to patient, to show appreciation and to

terminate the care to Mr. A.Y.I On 18/10/2018, I and a community health nurse from the

public health unit of the Ghana Health service, Mr. Moro Fuseini, Sampa paid a visit to

patient. We arrived at the house at 2pm where we were warmly welcomed by patient and

family. After introductions, I made the intentions of the visit known to them. The aim was

congratulate them on cooperating with me during the period of admission to discharge, to

terminate care with patient and to hand him over to Mr. Fuseini for continuity of care. An

evaluation was made on patient/family’s knowledge on bleeding hemorrhoid and goal set

during admission was fully met as patient /family demonstrated acquisition of adequate

knowledge on the condition. They also promised to visit the hospital whenever ailments

befalls them as they were now aware of the effect of delaying before coming to hospital. I

explained the need for continuity of care and stressed on the fact that they need to cooperate

with the community health nurse for effective health care. The community health nurse also

assured them of his readiness to help them achieve the best health status.

I expressed my sincere gratitude to the patient and family for cooperating with me and

promised to keep all information confidential and to pass by whenever I was in the vicinity. I

handed over my patient to Mr. Moro Fuseini (community health nurse) who promised to visit

them whenever possible. The family also expressed their gratitude to me for caring for Mr.

A.Y.I and the education rendered throughout the period of care.

We were seen off by patient to the roadside where we departed of each other.

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 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO THE PATIENT/FAMILY

5.0 Introduction

According to Weller (2010), evaluation is the systemic examination of accomplishment and

effectiveness in program and services

This is the final phase of the nursing process it deals with re-assessment of the efficiency and

effectiveness of the nursing intervention carried out on the patient. Also, it shows the

amendments made to partially met and unmet goals and subsequently, termination of care.

5.1 Statement of Evaluation

During the admission and hospitalization of Mr. A.Y.I, seven problems were identified and

objectives were set for them. Below are the outcomes of the objectives set for the identified

problems.

1. Patient was relieved of anxiety within 24hours

On the day of admission (01/10/2018), at 1:30pm, patient was observed to be very anxious.

He was diagnosed as anxiety related to unknown outcome of disease. An objective was set to

relieve patient of the anxiety within 24 hours. The following interventions were carried out;

firstly, patient and immediate family was reassured that the condition will resolve with the

available treatment and also patient and immediate family was reassured of the competence

and readiness of the staff to deliver professional care to them. Furthermore, patient and

immediate family were educated on condition and they were encouraged to ask questions. All

questions they asked were answered tactfully and honestly. All procedures carried out on

patient were explained before being carried out. Lastly, privacy was maintained by screening

patient and closing windows when performing procedure. The objective was evaluated and

goal was fully met on 02/10/2018 at 1:30pm as patient verbalized relieve of anxiety and he

wore a relaxed facial expression.

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 2. Patient attained normal body fluid and electrolyte balance throughout admission

period

Again on the day of admission (1/10/2018), Mr. A.Y.I complain of bleeding per anus. A

nursing diagnosis of fluid and electrolyte imbalance (less than body requirement) related to

disease condition (bleeding hemorrhoid). An objective was set to be met within period of

admission. Nursing interventions carried out included; Perianal area was inspected for

bleeding. Patient was advised to high fiber diet to help prevent constipation. Patient was also

encouraged to drink 2 to 3 litres of water per day. Stool softeners such as Lactulose syrup

10mls was administered. Patient was advised not to strain when eliminating his bowel.

Moreover, patient was encouraged to use soft toilet roll to clean the anus after bowel

elimination. Warm sitz bath was done for patient after passing each stool. Patient stool was

inspected for occult or red blood. Patient was transfused with packed cells (blood) as

prescribed. Prescribed iron supplement and multivitamin i.e (Zincovit, Iron III Polymaltose)

were all administered as prescribed.

On the day of discharge i.e 05/10/2018, goal set was evaluated. Goal was fully met as

patient’s Haemoglobin level rise from 7.0 g/dl to 10.5g/dl and there was absence of occult

blood in patient’s stool.

3. Patient was relieved of anal pain within 48 hours

Moreover also on the day of admission (1/10/2018) at 2pm, patient complained of pain in the

anus. A nursing diagnosis of acute pain related to pressure, and sensitivity on the anal veins

and nerves was formulated and a goal to help patient’s pain to subside within 48 hours was

set. Patient’s level of pain was assessed on a scale of 0-10 and recorded 5. Indicating

adequate pain. Patient’s vital signs was monitored and charted on the temperature sheet to

detect any abnormalities which may be an indication of pain. Also, patient was positioned

laterally to reduce pressure on the buttock and anus so as to reduce pain. Moreover, deep

72
breathing exercise was taught to help reduce pain. Television set in the ward was switched on

to provide divertional therapy. Patient was encouraged to do warm sitz bath to relieve anal

soreness. Flotation pads made of soft mattress (foam) was placed on bed for patients to sit on

to decrease pain. Cold compressors was provided to patient to apply to anal region for

provisional pain relief. Prescribed analgesics such as suppository anusol was administered as

ordered.

On the 03/10/2018 at 2pm, goal set was evaluated. Goal was fully met as patient verbalized

that he was relieved of anal pain.

4. Patient was free of injury within 24 hours

Furthermore, on the day of admission at 2:15pm, patient complain of feeling dizzy. A nursing

diagnosis of high risk for injury related to dizziness was formulated. A goal was set to ensure

patient remained free from injury due feeling of dizziness within 24 hours. Nursing orders

carried were; Patient was reassured that he will be relieved of the dizziness with good health

care and bed side rails were elevated to prevent patient from fallen. All source of injury was

removed i.e. sharps e.g. free needles. Moreover, complete bed rest was ensured and patient

was assisted in self-care activities i.e. bathing, mouth care. On 02/10/2018, goal set was

evaluated. Goal was fully met as patient verbalized absence of dizziness and nurse assessing

that, patient demonstrates absence of injury.

5. Patient was able to sleep uninterrupted within 24hours

On the 02/10/2018 at 7:15am, patient complained of sleeplessness. A nursing diagnosis of

sleep pattern disturbance (Insomnia) related to unfamiliar environment. An objective was set

to ensure patient was able to sleep adequately within 24 hours. Nursing orders carried out

included; Patient was reassured that good care will be rendered to help him sleep well.

Visitors were restricted and the need for rest in aiding speedy recovery was explained

thoroughly for patients.

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Fans were switched on, and windows were opened to ensure well ventilated room. Noise in

the ward was also minimise by lowering the volume of television set. Also, patient’s bed was

laid comfortable, free from creases and cramps. Routine nursing care such as monitoring vital

signs, medication, etc were carried out in bulk to prevent disturbing of patients when

sleeping. Patient was encouraged to take warm bath every night before sleeping. Prescribed

analgesics (Suppository Anusol and Tab Pilex) was administered and its therapeutic and

adverse effects monitored.

Goal was fully met on the 03/10/2018 when patient was assessed. This was evidenced by

nurse observing that patient has been able to sleep throughout the night (6-8hours) and 1hour

in the afternoon and patient verbalizing that he is able to sleep.

6. Patient attained adequate eliminating pattern within 48 hours

On the 02/10/2018 at 7:30am, patient also complained of constipation. A nursing diagnosis of

altered bowel movement (constipation) related to ignoring the urge to defecate because of

pain during elimination. The following nursing interventions were carried out during patient’s

stay at the hospital. Patient was encouraged to take at least 2L of water and diet high in fiber

such as kontomire stew or orange. Stool softeners such as Syrup Lactulose 10mls

administered as prescribed .Patient was advised to heed to the urge to defecate promptly as

possible. Patient was taught to perform relaxation exercises before emptying his bowel to

help relax the abdominal and perineal muscles. Suppository Anusol was administered and

Cream Pilex applied before and after each stool to reduce pain associated with constipation.

On 04/10/2018, goal set was evaluated. Goal was fully met as patient verbalised eliminating

his bowel at least once daily and nurse observing patient passing stool soft.

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 7. Patient gained adequate knowledge on the disease condition (bleeding

hemorrhoid) within 2 hours.

On the 04/10/2018 at 9am, patient was asked if he had adequate knowledge on the

disease condition he was suffering from. It was realised that patient had inadequate

knowledge on the causes, signs and symptoms and treatment regimen for bleeding

hemorrhoid. A nursing diagnosis of knowledge deficit related to lack of inadequate

information on causes, signs and symptoms and prevention of disease condition

(bleeding hemorrhoid). An objective was set to ensure patient will gain adequate

knowledge on the disease condition within 2 hours. To achieve this goal, Patient and

family were reassured that detailed information on bleeding hemorrhoid will be given for

better understanding. Time was scheduled with patient and relatives to educate them on

bleeding hemorrhoid. Patient was made comfortable by lying in bed whiles relatives and

the nurse sit by his bedside. Patient and family knowledge on bleeding hemorrhoid was

assessed. Accurate information on the predisposing causes, signs and symptoms,

prevention, drug management and lifestyle modification were provided to correct

misconceptions .Questions were invited then invited from patient and His family and

tactful and accurate answers were provided. Pamphlets with pictures that provides

information on bleeding hemorrhoid were given to patient and his family. At 11am,when

patient and relatives were assessed and questions were asked on bleeding hemorrhoid,

patient was able to answer it. Goal set at 9am was fully met.

5.2 Amendment of Nursing Care Plan

All the objectives set to help Mr. A.Y.I out of his health problems were met within the

stipulated times therefore there was no amendment to be done to the care plan originally

75
drawn. Mr. A.Y.I and family aided in the fulfillment of the objectives set for him by given

their maximum cooperation during the hospitalization.

Therefore no care plan was amended.

5.3 Termination Of Care

Termination is the end stage of the care and interaction between patient and the health care

professional (Weller,2009). Interaction with the patient started on the 1/10/2018when patient

was admitted at the males’ ward of Sampa Government Hospital, through to the date of

discharge which was 05/10/2018. It continued till home visit and follow-up after discharge.

Due to good nursing and medical care patient got well and was discharged.

Patient was educated thoroughly on his disease condition and how to avoid it reoccurrence.

He was also taught the need the ensure adherence to treatment regimen and also on

prevention of constipation. Patient was advised to visit the hospital as soon as possible

anytime he felt unwell to prevent complication. The termination was done in a suitable

manner from the beginning of admission to prevent separation anxiety. Patient was

successfully handed over to Mr. Moro Fuseini a community health nurse on 18/10/2018 for

continuity of care.

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 CHAPTER SIX

SUMMARY AND CONCLUSION

6.0 Introduction

This is the last stage of the patient and family care study and it contains a summary of all the

care rendered to Mr. A.Y.I and family throughout the period of hospitalization to the time the

care was terminated

6.1 Summary

This is a compiled documentation of the comprehensive nursing care rendered to Mr. A.Y.I, a

51 year old man and his family. He was admitted to the males’ ward at Sampa Government

Hospital on 1/10/2018by Dr. Arthur with a diagnosis of bleeding hemorrhoid. Some of the

health problems identified during the period of his hospitalization are:

 Anxiety

 Bleeding per anus

 Pains in the anal area

 Dizziness

 Sleeplessness

 Constipation

 Inadequate knowledge on the disease condition

Patient was managed on the following medications

 Capsule Flucloxacillin 500mg qid for 7 days

 Tablet Pilex II tid for 30 days

 Ointment Pilex tid for 30 days (apply after each stool)

 Tablet Zincovit I daily for 15 days

 Table Folic Acid 5mg daily for 15 days.

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  Syrup Iron III Polymaltose 10mls tid for 10 days

 Intravenous Metronidazole 500mg tid for 2 days

 Tablet metronidazole 400mg tid for 5 days

 Suppository Anusol I tid for 7 days

 Syrup Lactulose 10mls tid for 5 days

Various laboratory investigations were also requested and done. They include

 Blood for full blood count

 Blood for Full blood count

 Blood for malaria parasite

 Widal test

 Stool for Routine examination

Patient was transfused with 2 unit of packed cells on the day of admission due to very low

blood haemoglobin level of 7.0g/dl which gradually rise to 10.1 g/dl before discharge.

During patient’s 5 days stay at the hospital, nursing care plan was drawn for patient to aid

address the health problems of the patient and family. Some the interventions carried out on

patient were reassurance, education on condition, provision of calm restful environment,

maintaining normal nutritional pattern, dietary advice, serving of prescribed medication,

monitoring side effects of drugs, prevention of injury, relieve of anxiety etc.

At the end of his stay in the hospital, all the set objectives towards rendering care to Mr.

A.Y.I were achieved on time without the need amendment. Throughout the patient’s period

of hospitalization, no complications were observed. The patient and his family were educated

on his condition including its management prevention and complications. He was advised to

embark on follow up visit after he was discharged on 05/10/2018 at 10am and was asked to

come for review on 14/10/2018.

78
Three home visits were made to patient’s house during the period of care. During my third

visit, I handed over Mr. A.Y.I and the family to the community health nurse to continue with

care and care was finally terminated.

6.2 Conclusion

According to Weller (2009), conclusion is a final decision reached by reasoning

The benefit of patient/family care study to the student-nurse cannot be overemphasized.

This study has helped me to apply the theoretical knowledge of nursing and related courses

gained in the classroom in the clinical and community setting.

In undertaking this study, the author’s research knowledge and skills in report writing

improves the writer. Also I gained immeasurable knowledge on the disease condition;

bleeding hemorrhoid and its management. This aspect of the training program in nursing is

quite challenging but a worthy professional and academic exercise. The patient/family care

study is an effective and holistic approach to nursing a patient and so nurses should be

encouraged to apply it in the care and management of their patients in all settings.

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 APPENDIX

Table 7 :Vital Signs Chart for Mr. A.Y.I

Date Time Temperature Pulse (bpm) Respiration(cpm) Blood pressure

(0C) (mmhg)

1/10/2018 1:00pm 36.9 84 21 120/60

3:15pm 37.1 78 19 100/75

10pm 37.0 82 20 110/75

02/10/2018 6am 36.9 84 21 110/75

2pm 36.1 85 21 110/80

10pm 36.5 79 22 120/70

03/10/2018 6am 36.7 87 24 110/80

2pm 36.3 81 21 120/75

10pm 36.0 80 20 110/70

04/10/2018 6am 36.3 72 17 110/70

2pm 36.3 81 21 120/75

10pm 36.1 85 21 110/80

05/10/2018 6am 36 82 21 120/80

14/10/2018 8am 36.7 76 20 130/70

80
References

Hinkle, J.L., & Cheever, K.H. (2010). Brunner and Saddarth's Textbook of Medical –

Surgical Nursing.( 12 th edition ). London: Wolter's Kluwer Health/ Lippincott

Joint Formulary Committee(2015) , British National Formula (75th edition), London;

BMJ Group and pharmaceuticals press, London

Marilyn E., Mary F.M., & Alice C.M., (2012), Nursing care plans guidelines for

individualizing client care across the life span, 8th edition, F.A Davis

Company. Philadelphia

Ministry of health /Ghana health service.(2010).standard treatment guidelines, 10th edition,

Accra, Ghana.

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

illness. 11th Edition Elsevier limited

Weller, F.B. (2009).Bailliere’s Nurses’ Dictionary for Nurses and Health Workers.

(25thed.) New York: Bailliere Tindal Elsevier.

Others

www.healthdirect.gov.au/complication-of-hemorrhoids accessed on 5th October,

2018

www.nursesnanda.com

Patient folder number : Sampa Government Hospital. 14066/13

81