CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment is the first phase of nursing process, which involves the collection of data, giving a detailed
profile of the patient, his or her family and the community. The data collected helps to identify the
health problems and health status of the patient. It also serves as the basis for action and decision to
enable the nurse render effective and holistic nursing care to the patient.

It has the following sub- headings:-

PATIENT’S PARTICULARS
Mr. Akwaeson Addo is a fifty (50) year old man born on June, 1958 at James Town, Accra to Mr. Addo
and Mrs. Mary Addo all of blessed memories. According to Mr. Akwaeson, the father comes from
Anexo in Volta Region but settled in James Town, Accra for carpentry works, whiles the mother was a
petty trader.

Mr. Akwaeson Addo is an Ewe by tribe and speaks Ewe, Ga and English. He is the second of the seven
(7) siblings. He has four (4) sisters and two (2) brothers. Mr. Akwaeson is a Christian by religion and
fellowships with Roman Catholic Church at Sowutuom, a suburb of Accra.

Mr. Akwaeson Addo is a retired timber machine operator and currently staying with his sisters in a
family house, No. 32/17 at Sowutuom, a suburb of Accra. According to Mr. Akwaeson, his wife died two
(2) years ago and he has three (3) children, two (2) men and one (1) woman.

Mr. Akwaeson had his elementary education at James Town Local Authority School where he obtained
certificate in Middle Form Four (4) examination.

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FAMILY MEDICAL AND SOCIO ECONOMIC HISTORY
According to Mr. Akwaeson Addo, there is no known hereditary disease such as hypertension, diabetes
mellitus, sickle cell disease and asthma in their family. This was confirmed by their elder sister. He
however said the family occasionally suffers from minor ailments such as headache, common cold. He
said the family buys drugs such as paracetamol, pro cold among others from pharmacy shops for
treatment.

During my interaction, Mr. Akwaeson confirmed to me, he drinks strong alcohol and smokes cigarettes.
He is unemployed and the daughter and elder sister are responsible for his upkeep. The daughter is a
hair dresser who earns about GH¢ 5 a day from her hair dressing service. His sister is a petty trader who
trades in plantain, cassava, cocoyam and okro also earns about GH¢15 a day.

PATIENT’S DEVELOPMENTAL HISTORY

During my interaction with Mr. Akwaeson Addo he told me, information he gathered from the late
mother and his elder sister indicated that, he was born per spontaneous vaginal delivery at James Town
Clinic at full term in June, 1958. He was breastfed but at about three (3) months old, he had
supplements in addition to the breastfeeding in the form of porridge (“akasa”). He began crawling at
the age of six (6) months. Sat at the age of nine (9) month and started standing at the age of twelve
(12) months and walked without support at the age of sixteen (16) months. He started developing
secondary sex characteristics such as Pubic hair at the age of fourteen (14).

Mr. Akwaeson Addo started his primary education at the age of six (6) at James Town Local primary
school in 1964. He successfully completed Middle form four (4) in 1973 at the age of sixteen (16) years
at James Town Local Authority School, where he obtained a certificate in Middle School form four (4)
examination. He could not however further his education because of financial constrains and had to
assist his father at the carpentry shop. At about twenty five (25) years of age, he had employment at a
sawn milling company at Timber Market, Accra as a sawn milling machine operator. He stopped

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working about five (5) years ago because of the collapsed of the company due to inadequate lumber
and has been unemployed ever since.

According to Mr. Akwaeson, he has three (3) children, one female and two males. The daughter is
twenty- eight (28) years and two (2) sons are twenty- five and twenty two (22) years respectively.

He is currently single (not married) because the wife died two (2) years ago through a lorry accident.

PATIENT’S LIFESYLE AND HOBBIES

Mr. Akwaeson Addo wakes up at about 6:30am. He moves his bowel after which he brushes his teeth
with toothbrush and paste and baths with tepid or cold water depending on the weather. According to
Mr. Akwaeson, because he is a retired worker and currently at home after taking his breakfast of
porridge (“akasa”), he stays indoors and watch movies on television. At about 1:00pm, he comes out
from the room and chat with other co-tenants.

He takes snacks such as meat pie and soft drink for his launch and “akple” or banku with either light
soup or okro soup for supper.

Mr. Akwaeson said he is not allergic to any food. He usually retires to bed at about 7:30pm after
listening to 7:00pm television news.

For his hobbies, he said he liked playing football when he was young. At his age now, he likes reading
the bible.

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PATIENT’S PAST MEDICAL HISTORY
Mr. Akwaeson says he had never suffered from any serious disease or illness that had caused him to be
admitted to the hospital. He however says, once in a while he experiences headaches, malaria and
common cold which he treats with drugs he buy from either chemical or pharmacy shop.

PATIENTS PRESENT MEDICAL HISTORY

Mr. Akwaeson was well until a week ago, 6-05-08, when he started feeling severe pain in the chest,
difficulty in breathing, night sweat and frequent hiccough. His conditions got worse on the 13-05-08
around 5:30am. At about 7:00am the next day, the daughter rushed him to Mamprobi Polyclinic where
he had initial treatment and was referred to Korle- Bu Teaching Hospital for specialist attention on the
14-05-08. He was seen at Korle- Bu Department of chest Diseases clinic and admitted by Dr (Mrs.)
Mensah for Dr. Forson.

ADMISSION OF PATIENT
Mr. Akwaeson Addo was admitted to the Department of Chest Diseases on the 14-05-08 as a referral
from Mamprobi Polyclinic, Accra at 2:30pm with the diagnosis of smear positive pulmonary Koch’s.
Mr. Akwaeson Addo walked into the ward with the support by a health care assistant accompanied by
his daughter. The patient was admitted by Dr. Mrs. Mensah for Dr. Forson.

The ward in charge was earlier informed by the nurse at chest clinic about Mr. Akwaeson admission, a
bed was prepared to receive him. They were welcomed, his folder collected and the patient was
identified by calling his name. He presented a history of chest pain, hiccough, vomiting and general
weakness and coughing for about two (2) weeks. Mr. Addo and his daughter were reassured that, he is
in the hands of competent health personnel and the client will be well. The necessary admission papers
such as vital signs charts, treatments sheets, front index sheet, costing sheet, nurses’ notes and input
and output charts were filled. His name was also entered into the admission and discharge book and
again entered on the daily word state.

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Mr. Akwaeson was orientated to the ward. His personal belonging were kept in the side bed locker and
locked. His daughter was informed about the visiting time. From the interaction and information
available in the patients folder, named his daughter Monica Akwaeson as next of Kin.

His vital signs checked on arrival were as follows:

Temperature 36.60 degree Celsius
Pulse rate 76 beats per minute
Respiration 22 beats per minutes
Blood pressure 90/60 millimeters per mercury.
Body weight 54 kilogrammes

He was put on tablet ciprofloxacin 500mg bd for five (5) days, syrup Nugel O 10mls tid for five (5) table
maxolon 500mg for three (3) days.
The following investigations were also requested:-
 Chest X- ray
 Haemoglobin level examination
 Blood film for malaria parasite
 Full Blood count
 Sputum for Acid Fast Bacilli test
 Retrovirus screening
 Electrocyte Sedimentation rate.

PATIENT’S CONCEPT OF HIS ILLNESS

Mr. Akwaeson Addo said, to his best knowledge, the pulmonary tuberculosis is as a result of coming in
contact with an infected person either through the person coughing without covering the mouth
thereby releasing the causative organism into the atmosphere or by working in a dusty environment.
He did not attribute his illness to any super natural forces or any demonic influences.

5
He believes that with the medical treatment he is receiving he will be cured.

LITERATURE REVIEW
According to medical and surgical text books written by Brunner and Saddarth, pulmonary tuberculosis
is an acute or chronic infectious disease that primarily affects the lung parenchyma. The authors also
said the disease may be transmitted to other parts of the body, including the meninges, kidneys, bone
and lymph nodes.

Again, Nurses dictionaries, twenty-second (22nd) Edition, revised by Barbara F. Weller defines
pulmonary tuberculosis as infectious inflammatory, notifiable bacillus mycobacterium tuberculosis that
is chronic in nature.

CAUSATIVE ORGANISM
Pulmonary tuberculosis is caused by tubercle bacillus which is acid fast aerobic rod that grows slowly.

MODE OF TRANSMISSION
The tubercle bacillus spreads by direct contact from person by air bone transmission. An infectious
person releases droplet nuclei through talking, cough, sneezing, laughing or singing.

INCUBATION PERIOD
This is about four (4) to six (6) weeks after infection.

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INCIDENCE
Pulmonary tuberculosis occurs in all age groups but children under three (3) year are susceptible. It is
also common in alcoholics and malnourished people who have not received the Bacille Calmette Guerin
(BCG) immunization.

OTHER TYPES OF TUBERCULOSIS

Bovine Tuberculosis:-This is found in cattle and spread through infected milk.
Avian Tuberculosis:-This usually affects birds.

RISK FACTORS FOR TUBERCULOSIS

Poor nutrition associated with excess consumption of alcohol and excess smoking.
Poor housing and over overcrowding and poor sanitation.
People who work in a dusty atmosphere. For example: miners, sawn millers and road construction
workers.
Low resistance people. For example patients with HIV/AIDS.

PATHOPHYSIOLOGY
Pulmonary tuberculosis begins when an individual who is susceptible to the mycobacterium, inhales
the mycobacterium tubercle. The particles of the organism settle in the lungs and the body mobilizes
phagocytes which attempt to destroy the mycobacterium tubercle by so doing the mycobacterium
tubercles is engulfed. The tubercle breaks into a soft cheesy mass which may liquidify to form tubercle
pus. This may rupture and expectorated as mucopurulent offensive sputum leaving a cavity known as
caseation which is a form of necrosis.

Acute fibrous tissue and calcium deposit formed around the tubercle to form a defense wall. This is
called fibrosis when the tubercle is near a blood vessel, the vessels are eroded and during a rupture of
the tubercle, free haemorrhage or haemoptysis occurs.

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 CLINICAL FEATURES OF PULMONARY TUBERCULOSIS
The Major Signs and Symptoms
Unproductive cough for more than three (3) days with blood stained sputum.
Respiratory distress
Chest pains due to pleurisy

The Minor Signs and Symptoms

 Visible weight loss
 Night sweat
 Anorexia
 Headache
 Easy Fatigue

DIAGNOSTIC INVESTIGATION OF PULMONARY TUBERCULOSIS

These include
 History and physical examination of the patient
 Plain Chest X-ray
 Sputum for culture and sensitivity to reveal Acid fast bacilli
 Blood test to determine the following
o White blood counts
o Malaria parasite
o Electrolyte Sedimentation rate
o Blood Urea Electrolyte and Creatinine
 Tuberculosis skin test. That is, Mantoux test

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MEDICAL MANAGEMENT OF PULMONARY TUBERCULOSIS
The current medical management of pulmonary tuberculosis patients has been divided into two (2)
phases, namely:
 The intensive phase
 The continuation phase

AIMS OF MANAGEMENT
To increase patient’s resistance to the disease by improving nutritional status.
To improve lungs condition through the use of drugs.
To prevent the occurrence of any complications.

THE TREATMENT REGIMEN

Intensive Phase (two months)
Continuation Phase (Four Months)
NOTE
In case of re-treatment:
Intensive phase [three (3) months]
Continuation Phase [Three (3) months]

INTENSIVE PHASE
Category I
New case of TB (H R Z E)
H – Isoniazid
R – Rifampicin
Z - Pyrazinamide
E – Ethanibutol

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Category II (H R Z E +S) Re – Treatment
H – Isoniazid
R – Rifampicin
E – Ethambutol
Z – Pyrazinamide
S – Streptomycin

Category III (H R Z) Child

H – Isoniazid
R – Rifampacin
Z – Pyrazinamide

TABLE ONE
Intensive phase
INITIAL WEIGHT HRZE S INITIAL WEIGHT HR Z
30 – 39 kg 2 500mg 0 – 9 kg 1 1
40 – 54 kg 3 750mg 10 – 14kg 2 2
55 – 70 kg 4 1000mg 15 – 19 kg 3 3
>70 kg 5 1000mg 20 – 29 kg 4 4

TABLE TWO
Continuation Phase
CATEGORY I CATEGORY II CATEGORY III
New Case of TB Re- treatment Child
HR HRE HR
H – Isoniazid E - Ethambutol
R – Rifampicin

TABLE THREE
Dose Schedule

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 ADULT CHILD
INITIAL WEIGHT HR E INITIAL WEIGHT HR
30 – 39 kg 2 2 ≤ 9 kg 1
40 – 54 kg 3 3 10 – 14 kg 2
55 – 70 kg 4 4 15 – 19 kg 3
>70 kg 5 5 20 – 24 kg 4
24 – 29 kg 5
≥30 kg Adult Base

MONITORING OF TREATMENT
Sputum for Acid Fast Bacilli Test is periodically done at 0 month, 2nd month, 5th month and 6th month. In
addition, a chest X-ray may be ordered.

OUTCOME OF TREATMENT
Cured
Treatment complete
Treatment failure
Defaulter
Died

NURSING MANAGEMENT
Usually admission may not be necessary; hence patients are put on the Direct Observed Treatment
short course (DOTS).
However, some patients may need a long term admission. Some of these patients are:-
 Patient who has infected sputum
 Patient with debilitating conditions such as malnourished patients and the elderly
 Patients with pleural effusion
 Patient who has defaulted treatment or whose treatment failed.

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Also, managing patients with Tuberculosis requires skilled nursing care. This is because cross-infection
is likely to occur.

REST AND SLEEP

Reassure patient and allay all fears and anxiety by explaining the importance of admission and
educating patients on the disease condition, signs and symptoms, treatment, Complications and
prevention.
Provide a listening ear to patient’s fears and problems and answer them appropriately.
Isolate patient and receive him/her to a complete bed free of creases and cramps.
Open nearby doors and windows to ventilate room, but protect patient’s chest to prevent exposure to
cold.
Prop up patient in bed to facilitate breathing if the need be.
Use the position techniques that are most comfortable for patient. (Administer oxygen if necessary.
Encourage patient to have warm bath at night before sleep to relax muscles.
Co – ordinate and perform all nursing activities at a goal.
Provide a quiet environment.

OBSERVATION
Vital signs such as temperature, pulse, respiration and Blood pressure 4 hourly to detect early onset of
any complications such as respiratory distress.
Patient should be monitored closely for signs of haemoptysis and breathlessness and report any
changes seen.
Observe sputum for its colour and consistency.
Ensure and maintain input and output chart.
Weigh patient daily before meals.
Observe patient for any side effect of drugs such as severe headache, nausea, vomiting, abdominal pain
and skin rash.

DIET

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Ensure patient is served with nourishing diet rich in calories, protein and vitamins to aid speedy
recovery.
Food should be planned with patient and feed according to his preference.
Foods must be served regularly but in small quantities.
Patient should be served with fruits and vegetables such as oranges, banana, pawpaw, cabbages and
carrots. This enhances the body ability to fight against the disease by building immunity and to prevent
constipation.

PERSONAL HYGIENE
Assist or encourage patient to bath at least twice daily to aid his/her comfort.
Oral toileting should be encouraged twice daily to boost appetite
Change soiled linen or clothing and also when dirty.
Teach patient to cough and sneeze into tissues or handkerchief. A tape waxed bag may be placed by the
side of the bed for used tissues.
Provide patient with sputum container with lid and encourage him to spit into it. It should contain
diluted disinfectant or 0.5% chlorine.

ELIMINATION
Observe elimination pattern and monitor patient for signs of constipation.
Measure and record intake and output correctly

PREVENTION OF INFECTION
Nurses and relatives attending to patient must adopt universal precautions. They must make use of
protective clothes such as mask, gloves and gown to prevent cross infection.
Universal hand washing precaution should be practiced at all times.
Proper disposal of all body fluids, example sputum, soiled linen and articles should be decontaminated
in 5% chlorine preparation of 1:10 dilution for 10 to 15 minutes before disposing off or washing for next
use.

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EXERCISE
Exercises are very important in preventing development of complications such as constipation.
Encourage patients to sit up in bed, or walk for few minutes during the early state of condition. It must
be increased when condition improves.

PREVENTION AND HEALTH EDUCATION

Patient and family would be educated on causes, predisposing factors, treatment regime, prevention
and complications of the diseases condition.
Teach and encourage patient’s relatives to wear protective, clothing when caring for patients.
Family members would be advised on the importance of reporting to the clinic for prompt treatments
to avoid any form of complication.
Patient and family members would be encouraged to practice good personal and environment hygiene
such as hand washing before and after eating and after visiting the toilet with soap and water.
Ventilation of rooms, bathing and cleaning teeth at least twice daily and proper refuse disposal.
Advise patient and relatives to allow patients to get enough rest and to eat balanced diets to build
immunity.
Emphasize the importance of regular fellow ups examinations and instruct the patient and family about
the signs and symptoms of re-curing tuberculosis.
Advise and encourage patient’s family and friends who have been exposed to infected patient to report
to the hospital and receive tuberculosis tests, and if necessary, chest X – ray and prophylactic isoniazid.
Advise patient and family on proper disposal of body fluids such as sputum. Teach patient to de
contaminate sputum in 0.5% chlorine before discarding.
Advise patient and family on the need to adhere to medication instructions to complete the treatment
regime to prevent complications such as drug resistant.

COMPLICATIONS OF PULMONARY TUBERCULOSIS

 Haemoptysis
 Pleural Effusion
 Pleurisy

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  Meningitis
 Pneumothorax
 Laryngitis

VALIDATION OF DATA
With reference to the information collected from the patient, literature, signs and symptoms and
results from laboratory investigation, it was confirmed that, Mr. Akwaeson Addo had pulmonary
tuberculosis.
There was no inconsistency in the data collected and therefore free from errors and misinterpretation.

CHAPTER TWO (2)

ANALYSIS OF DATA
This is a step in nursing process which helps in identifying the patient’s actual and potential problems.

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The analysis of data covers the following areas:
 Comparison of data with standards.
 Patient and family strengths
 Health Problems
 Nursing diagnosis.

COMPARISON OF DATA WITH STANDARDS

It includes the comparison of the diagnostic investigations or tests, clinical features and treatment
gathered on the patient with the standards.

DIAGNOSTIC INVESTIGATIONS AND TESTS

The following laboratory investigations were carried out on Mr.Akweason Addo:
 Total white blood cell count.
 Sputum for culture and sensitivity and Acid fast bacilli.
 Plain chest x-ray
 Hemoglobin level Estimation
 Erythrocyte and sedimentation rate (ESR).
 Blood film for malaria parasite
 Retrovirus screening (HIV).

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DIAGNOSTIC INESTIGATIONS COME HERE

17
DIAGNOSTIC INESTIGATIONS COME HERE

CAUSES OF PATIENT DISEASE CONDITION

With reference to literature, the cause of Mr. Akwaeson Addo’s condition was bacterial infection
(Mycobacterium tuberculosis). This was confirmed by culture and sensitivity test and Acid test Bacilli
(AFB) test.

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TABLE FIVE
CLINICAL FEATURES EXHIBITED BY MY PATIENT AS COMPARED TO THE GENERAL SIGNS AND SYMPTOMS
IN LITERATURE REVIEW.

GENERAL SIGNS AND SYMPTOMS IN TEXT BOOK SIGNS AND SYPTOMS EXBITED BY PATIENT

1- There is chest pain due to pleurisy Patient complained of chest pain.

2- There is cough for about three(3) or more Patient coughed for several days.
weeks
3- There is sputum which is initially Mucopurulent Patient coughs out mucopurulent sputum.
and later becomes bloody
4- There is night sweats Patient experienced as night sweats.
5- Weight Loss Patient experienced weight loss.

6- Dyspnoea Patient had difficult in breathing.

7- Loss of appetite Patient cannot eat well

8- There is low grade or slight fever Patient did not experience low grade fever. As
body temperature ranges between 36°C-37°C.

Mr. Akwaeson Addo experienced some of the signs and symptoms outlined in the literature review but
not all.

TREATMENT GIVEN TO PATIENT

Mr.Akweason Addo was treated medically with anti- tuberculosis drugs. These include combination of
(isoniazid, Rifampicin, Pyrazinamide and Ethambutol (HRZE), three (3) tablets daily for two (2) months
(intensive phase of treatment). He was also given the following drugs:
Nugel O 10mls tid for five (5) days
Maxolon 500mg bd for three (3) days

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Ciprofloxacin 500mg bd for five (5) days
Please, refer to table five on the next page for the pharmacology of drugs used.

20
PHARMACOLOGY COMES HERE

21
PHARMACOLOGY COMES HERE

22
PHARMACOLOGY COMES HERE

23
COMPLICATIONS
With reference to the complications stated in the literature review, my patient was as the time of
compiling this report, had not developed any of the stated complications.

PATIENT AND FAMILY STRENGTHS

During my interaction with Mr.Akweason Addo and relatives, the following strengths were identified.
 Patient is able to tolerate some amount of fluid diet (akasa)
 Patient can maintain personal hygiene (oral hygiene) alone, in spite of easy fatigability.
 Mr. Akwaeson is able to sleep about 2-3 hours during the day but usually awake at night.
 Patient has knowledge deficit about his condition but believes that his condition was not due to
evil spirit.
 Patient can have optimal breathing pattern in sitting up or prop up position.
 Patient vomits after meals but can tolerate copious fluid and takes his drugs without vomiting.
 Patient coughs frequently but can tolerate copious fluid to soothen the throat.
 Patient was visited by his relatives.
 Patient relatives were able to buy prescribed drugs.

PATIENTS HEALTH PROBLEMS

Health problems encountered by Mr. Akwaeson Addo including the following:
 Lose of appetite.
 Easy fatigability
 Insomnia
 Knowledge inadequacy on his condition
 Respiratory distress
 Vomiting after meals
 Coughs

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NURSING DIAGNOSES
The following nursing diagnoses were formulated from the health problems identified:
1. Altered nutrition (less than body requirement) related to decreased appetite and
unwillingness to eat.
2. Self care deficit (bath) related to easy fatigue (general weakness)
3. Disturbed sleep pattern (insomnia) related to discomfort as a result of hiccough and
cough
4. Knowledge deficit on the disease condition related to low educational level
5. Ineffective breathing pattern (respiratory distress) related to impaired chest expansion
associated with pleurisy pain.
6. Fluid volume deficit related to vomiting.
7. Cough related to irritation of the bronchia mucosa.

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 CHAPTER THREE (3)
PLANNING FOR THE PATIENT AND FAMILY CARE
This is a written guide to nursing action used by the nurse to meet the needs and problems of
the individual patient.

OBJECTIVES AND OUTCOME CRITERIA

Patient will maintain adequate nutritional intake to meet body needs within 48 hours as
evidence by:
 eating at least 85% of each meal served.
 verbalizing improved appetite
 Patient reports satisfaction with the diet and an increase energy level.

Patients self care (bath) will be maintained within 30 minutes as evidence by:
 looking neat in bed.
 Nurses observing patient bathing unassisted.

Patient will achieve optimal amount of sleep within 48 hours as evidence by:
 verbalizing of feeling rested and good sleep during night.
 Night nurse’s observation and report that patient slept for 6-8 hours uninterrupted.

Patient will have adequate knowledge about pulmonary tuberculosis and treatment regime
within 24 hours as evidence by:
 asking questions about his condition.
 verbalizing understanding of his condition and its treatment regimen.
 answering questions correctly about his condition

Patient will maintain optimal breathing pattern within 24 hours as evidence by:
 having regular breathing pattern

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  verbalizing absence of shortness of breath.

Patient will maintain fluid balance within 24hours as evidence:

 having urine output greater than 30ml per hour.
 having moist mucous membrane.

Patient will experience absence of cough within 48hours as evidence by:

 verbalizing absence of cough.

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DATE\TIME NURSING OBJECTIVE\OUTCO NURSING ORDRES DATE\TIME EVALUATION SIGNATURE
DIAGNOSIS ME CRITERIA
14\05\08 Ineffective Patient will maintain (a) Put patient in a 17\05\08 at Goal met as
at 3:00 pm breathing optimal breathing propped up position. 7:00am. patient
pattern pattern within (b) Reassure by staying breath TABLE
(respiratory 72hours as evidence with the patient during normally
distress) related by: acute respiratory SEVEN :
to chest pain (a) having regular distress.
CARE
breathing pattern. (c) Open doors and
windows to ventilate PLAN
(b)verbalizing room.
absence of (d) Administer
shortness of breath. prescribed oxygen i.e.
3Liters per minute.
(e) remove all tight
clothing around chest
and neck

15\05\08 at Knowledge Patient will have (a)Reassure patient by 18\05\08 at Goal was
8:00pm deficit related to adequate telling him much about 8:00am fully met as
disease knowledge about his the disease condition patient and
condition disease condition and its treatment relatives
and treatment regimen. gave good
regimen within (b) Assess patient’s feedback as
48hours as knowledge about his they were
evidenced by: condition taught.
(a) asking questions (c) Educate patient and
about his condition. relatives about
28 client’s
condition.
(b)verbalizing (d) Allow client and his
understanding of his relatives to ask
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT AND FAMILY CARE PLAN

Implementation is the fourth stage of the nursing process. It involves the actual care given or
rendered according to the nursing care planned for the patient and family.

The chapter highlights on the summary of actual nursing care rendered, preparation of patient
and family for discharge as well as continuity of care through home visits and follow up.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT AND FAMILY.

Mr.Akweason Addo, aged 50, was admitted on the 14th may, 2008 to the department of chest
Diseases with the diagnosis of pulmonary Tuberculosis for Dr. Forson. He was transferred to the
ward through the chest clinic at exactly 2:15pm in a wheel chair accompanied by his daughter. I
welcome them and after making the client comfortable in bed, I offered the daughter seat at
the nurses’ station. All admission documents such as front index sheet and input and output
fluid chart were filled. Client’s name, age, sex, diagnosis, occupation and address were entered
into the admission and discharge book and the daily ward state updated.
The client and his daughter were reassured that, he is in the hands of competent health
personnel and will be cared for. His vital signs and weight checked on admission were:
 temperature 36.6oc,
 pulse rate 76 beats per minute,
 respiration 22cycles per minute and
 Blood pressure 90\60 millimeters of mercury.
 Weight of the patient 54 kilogrammes
I ensured that, client’s evening medication of Nugel “O” 10mls tid orally, ciprofloxacin 500mg
orally, maxolon 500mg bd, orally and Anti-Koch drug orally were taken.

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FIRST DAY ON ADMISSION (15th may, 2008)
The night nurses reported that, the patient slept intermittently during the night. He complained
of difficulty in breathing. He was reassured by the night nurses that, he will breathe well, he was
propped up in bed by raising the head end of the bed slightly. This was to minimize difficulty in
breathing. On my arrival at the ward at about 8:00am, I removed all tight clothing. I assisted him
to clean his teeth and bath. His vital signs for the morning were:

Temperature 36.8 degree Celsius

Pulse 72 beats per minute
Respiration 25 cycles per minute
Blood pressure 110/70 millimeters of mercury

He took his medication of Nugel “O” 10mls tid orally, ciprofloxacin 500mg bd orally, maxolon
500mg bd orally and Anti-Koch drug orally. He drank about half a cup of warm cocoa drink with
some biscuits for breakfast. On wards round with Dr (Mrs.) Mensah, the patient was examined
and oxygen administration 3litres per minute was prescribed using face mask.
I told him to spit into the container provided anytime he coughs and to make sure it is always
covered with the lid. He should also pour a disinfectant (detol) into the container before spitting
into it. I again asked him to cover his month with a handkerchief during coughing or sneezing. At
about 10:30am, he was taken to the x-ray department for plain chest x-ray and brought back at
about 12:30pm.
He was served with agidi and light soup for supper and took his prescribed afternoon
medication.
Vital signs checked and recorded for the evening were:

Temperature 37.6 degree Celsius

Pulse 74 beats per minute
Respiration 22 cycles per minute

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Blood pressure 130/90 millimeter of mercury
Patient retired to bed at about 8:00pm.

SECOND DAY ON ADMISSION (16TH MAY, 2008)

The night nurse’s report and patient verbalization revealed that, he had a good night sleep. I
assisted the client to maintain his personal hygiene by brushing his teeth and bathing.
He took his medication of Anti-Koch drug, Nugel “O” 10mls orally, ciprofloxacin 500mg orally,
maxolon 500mg orally. He later took his breakfast which was ‘akasa and bread’. At about 8:30
am, he was taken to Voluntary Counseling Testing unit for retro virus screening. He tested
negative and was brought back at about 10:30am.
Patient was reassured and given education on the nature of his condition. Relatives especially
his daughter was also educated and allowed to ask questions about the clients’ condition. On
my afternoon visit, patient complained of vomiting and hiccough. He was reassured and given
Nugel “O” 10mls which was one of his prescribed drugs. The evening vital signs of the client was
checked and recorded as follows:
Temperature 36.8 degree Celsius
Pulse 76 beats per minutes
Respiration 20 cycles per minutes
Blood pressure 120/70 millimeters of mercury.

At about 6:30pm, client was able to tolerate about half a cup of warm akasa and small amount
of water without vomiting. He also took his Anti-Koch medication.

THIRD DAY OF ADMISSION (17TH MAY, 2008)

According to the night nurses report Mr. Akwaeson had intermittent sleep coupled with cough.
Mr. Akweason, who had not taken his bath on my arrival at the ward, was assisted to maintain

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his personal hygiene and bath. He took his breakfast of rice porridge with bread of which he
tolerated about half of the cup. His also took morning prescribed medication.
During the wards rounds with Dr. (Mrs.) Mensah and her team, at 9:15am my client was
reviewed and asked to continue with his medication. His vital signs were checked and recorded
as follows:
Temperature 37.7 degree Celsius
Pulse 56 beats per minute
Respiration 22cycles per minute
Blood pressure 130/90 millimeters of mercury

During the visiting hours, the daughter and some family members visited and prayed for him.
He took agidi with light soup as his supper as well as his evening medication. I stayed with the
client up to 7:30pm. Just before going to bed, I encouraged and assisted the client to bath using
tepid water. This is to facilitate sound sleep during the night. I straightened all bed linens to give
comfort during the night. I also maintained a well ventilated ward by opening the window and
ensured quite environment by putting the television set off. All these were done to facilitate
sound sleep during the night.

FOURTH DAY OF ADMISSION (18TH May, 2008)

Mr. Akweason condition was fairly well than the previous days. He had a peaceful sleep during
the night according to the night nurses report. I assisted Mr. Akweason to have his bath and
maintain his oral hygiene. I also treated pressure areas with Vaseline to prevent any bed sores
since he stays in bed a lot. Breakfast of akasa and bread was served and it was well taken.

Vital signs were checked and recorded as follows:

Temperature 37.2 degree Celsius
Pulse 70 beat per minute
Respiration 20 cycles per minute

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Blood pressure 130/70 millimeter per mercury

Morning medications were served as ordered. I educated the daughter to prepare food that
contains protein and bring along fruits such as oranges and banana during her visits. Vitals were
checked and recorded. I explained the importance of balanced diet to his recovery.
I advised the daughter to go and rest after the visiting hours. His evening medications were
served. I straighten the bed linen to make the bed comfortable for sleeping after he had warm
bathing for the evening. I said goodbye to him and promised to come tomorrow. He was happy
to see me again.

FIFTH DAY ON ADMISSION (19TH May, 2008)

Mr. Akwaeson’s condition had improved with the persistence of cough slightly reduced. His
personal hygiene had already been maintained by himself before I arrived on the ward.
According to the nurse’s report, he had a sound sleep during the night.

He took his breakfast of rice porridge and bread after which he took two oranges as dessert.

I advised him on the needs to adhere to proper hygiene by covering his mouth when coughing
and always ensure that he puts disinfectant in the container before spitting into it. His
medications were served. His vital signs were checked and recorded for the morning.

In the evening, vital signs were checked and recorded. Medications ordered for the evening was
given. I prepared him to sleep by straightening his bed linen and prepared warm water for him
to bath before sleeping.

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SIXTH – NINTH DAY FOR ADMISSION (20TH – 22ND MAY, 2008)
Mr. Akweason condition had improved than the previous day. He maintained his personal and
oral hygiene. Routine procedures were done and recorded, that was vitals administration of his
drugs.
I observed that, Mr. Akweason became active and was smiling at relatives who visited him.

Afternoon meals enriched with protein and fruits were served. His evening medications were
served daily.

TENTH – FOURTEENTH DAY OF ADMISSION (23RD – 29TH MAY 2008)

Mr. Akwaeson had a sound sleep and woke up looking cheerful throughout these periods.
Routine procedures, such as vital signs were checked morning and evening and documented per
chart. During the ward rounds on the 24th May, 2008 at about 9:30am with Dr. (Mrs.) Mensah,
both the team of Doctors and nurses, they were impressed about improvement in his condition.

Mr. Akwaeson during these periods maintained his personal hygiene had his medications and
meals regularly. Vital signs checked ranged between these values:-
Temperature – 36.9 – 37.2 degree Celsius
Pulse – 70 – 76 beats per minute
Respiration – 18 – 20 cycles per minute
Blood pressure 136/90 – 140/90 millimeters per mercury.
He usually watches television and retires to bed at 8:30pm through out this period.

PREPARATION OF PATIENT AND FAMILY FOR DISCHARGE AND REHABILITATION

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The preparation towards discharge and rehabilitation began from the day of admission. Whiles
on admission, Mr. Akwaeson was given education on health especially on his condition from
time to time. He was educated on how to avoid crowdy places and to sleep in a well ventilated
room. I emphasized on the need to eat nutritious food, fruits and adequate intake of fluids. I
also explained to the daughter, the importance of balanced diet to the father’s recovery.

I also visited his house to identify any conditions that can be detrimental to his health after
discharge. Health problems such as choked gutter running in front of the house, has observed.
He was educated on to need for the gutter to be drained periodically to avoid breeding of
mosquitoes.

I again advised them to visit the clinic when they are sick and avoid self medications.

Mr. Akwaeson was educated on self care and his drug administration since any omission will
affect the treatment regimen. I advised his daughter on the need to protect herself when
attending to the father as the father’ ailment is infectious. I however, emphasized that after the
intensive treatment phase which will last for three (3) months, it is less infectious.

I finally advised the daughter and other family members to do sputum test to know their status.

FOLLOW – UP, HOME VISIT AND CONTINUITY OF CARE

FIRST HOME VISIT
I visited Mr. Akwaeson’s house at Sowutuom in the company of his daughter on the fourth day
of admission. The reason for this visit was to know where the patient lives, acquaint myself with
the environment and to carry out continuity of care after discharge.

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They live about hundred (100) meters from the trotro bus stop, popularly known as “Auntie
Aku” stop. The road leading to the house is well planned, tarred with street lights. The house is
situated not very far from a mini market.

They live in a compound house, which I was told is a family house. It is built of cement blocks,
roofed with corrugated iron sheets. The house has five bedrooms including where my client
sleeps. There are two (2) toilet facilities, a bathroom and a kitchen. The kitchen is not big
enough and can accommodate only two people during cooking. The toilet facilities and the
bathroom are about twenty (2) meters from the kitchen. I took the opportunity to educate my
client’s daughter and family members to close the toilet doors at all time as it was too close to
the kitchen.

My client sleeps in a single room with only one window, located behind the room. I also
detected a chocked gutter running in front of the house which needs draining. I informed the
family members and educated them on the need to drain the chocked gutter periodically.

Their source of water is pipe borne and it is stored in a big poly-tank situated on a concrete
stand behind the house.

Dry refuse is collected into a container without a lid and disposed off every morning into refuse
container provided by Accra Metropolitan Assembly. I again educated them on the need to
cover the refuse container with a well fitted lid.

I thanked them for their time and co-operation and encouraged them to take good care of
themselves and Mr. Akwaeson when he comes home. I asked permission and left.

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SECOND HOME VISIT
My second home visit was on the 25th May, 2008 when my client was still on admission. I got to
the house in the afternoon. The daughter and family members welcomed me warmly. After this,
I took the opportunity and asked them of any health problem which they said no. I also realized
that, the refuse container was covered with a well fitting lid as well as the toilet. I congratulated
them for their efforts.

I informed the family members that, I would be bringing our interaction to an end three (3) days
after my second visit. This was as a result of other academic assignment.

I however reassured them that, in my absence, there are other competent health professionals
to care for Mr. Akwaeson. I again told them, I will visit them occasionally. I advised them to
make their health problems known to the hospital when such need arises. Also since Mr.
Akwaeson is still on admission, I will be visiting him from time to time until he is discharged.

I finally, emphasized and advised them on adequate nutritious diets, personal and
environmental hygiene.

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 CHAPTER FIVE
EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

Evaluation of care is the result of the nursing care rendered to the patient and his family. It is
the final step in the nursing process, where the nurse assess the intervention, so as to see, if it
corresponds to his outcome criteria and amends plans of action where they were not achieved.

STATEMENT OF EVALUATION
Mr. Akwaeson Addo is being nursed using the scientific approach to nursing care, which is the
nursing process. His health problems were identified and goals were set to solve them.
Patient’s anxiety during the early part of his hospitalization, the persistent coughing, a hiccough,
self care deficit were some of the health problems identified. Nursing diagnosis and criteria
outcome set were met.
Mr. Akwaeson’s condition improved considerably during the period of our interaction. I left the
ward after two (2) weeks on the ward. The relatives understood the need for prompt medical
care.

AMENDMENT OF NURSING CARE FOR PARTIALLY MET OR UNMET OUTCOME CRITERIA

During my two (2) weeks interaction, goals set to solve Mr. Akwaeson’s health problems were
fully met, because of quality nursing care rendered to him and the cooperation from the patient
and relatives, especially the daughter. In view of this, Mr. Akwaeson requires no amendment in
his care plan.

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TERMINATION OF CARE
Preparations towards termination of care began on the day the patient was admitted on the
ward. During my first day of interaction with Mr. Akweason and his daughter, I made them
aware that, my interaction with them was temporal and therefore would be given period of
time. On my last home visit, I informed the family members that, I might not be able to visit
them again due to my tight schedule in school and thank them for allowing me in their home. I
however assured them that, though I am leaving the ward, Mr.Akweason is still in the hands of
competent health professionals and that they will care for him even in my absence. They all
accepted it and wished me well in my other academic endeavors
During my last duty on the ward, I informed my client about the end of our interaction and
reassured him that, I will still be visiting him during my free periods until he is discharged. I also
assured him of continuous care from the other health team and counseled him to communicate
his problem to them.

SUMMARY
This care study is about Mr. Akweason Addo aged 50 years who was admitted on 14 th may, 2008
with the diagnosis of pulmonary Tuberculosis. He was referred from the Mamprobi polyclinic.
He was under the care of Mr. Forson and his team. Laboratory investigations were requested
and done. He was put on Anti Koch’s drugs and other medications Mr. Akweason Addo was
nursed using the nursing process. Problems identified were solved using nursing care strategies.
His health condition kept on improving from the day of admission till I terminated my care. All
goals and objectives set were met during the period of interaction. Mr. Akweason Addo and his
family were educated on good personal hygiene and environmental hygiene, the importance of
seeking early medical care anytime and were counseled to avoid indiscriminate use of drugs.
Mr. Akweason Addo’s condition improved tremendously when care was terminated whilst still
on admission.

CONCLUSION

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The patient and family care study has offered me adequate knowledge in pulmonary
Tuberculosis, its causes and features, investigations done, its management and the needed
education to be given to infected patients. Nursing Mr. Akweason Addo, who came in with
pulmonary Tuberculosis has made me efficient and will enable me to give individual nursing
care to patients who will be under my care.
The use of the nursing process in nursing patients has been very effective and therefore wishes
to state that, patients should be nursed using the nursing process.

BIBLIOGRAPHY

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  Barbara F. Weller (1996) BAILLIERE’S NURSES DICTIONARY. 22nd Edition, Caledonian,
London, International Book Manufacturers.
 Bare GB and Smeltzer, C. et al (1992): Brunner and Suddarth’s Textbook of Medical-
Surgical Nursing 7th ed. Philadelphia: JB Lippincott Company.
 Cook G. C. (1988) COMMUNICABLE AND TROPICAL DISEASES 2nd Edition, UK, Richard
Clay Ltd.
 Fischer P. (2004) NURSING DRUG HANDBOOK 3rd Edition, New York, B Lanchard and Loeb
Publishers.
 Gulanick Myers (2003) NURSING CARE PLAN: NURSINNG DIAGNOSIS INTERVENTION (5th
Edition) Mosby Inc. 11380. USA, Westline Industrial Drive, St. Louis Mo 63146.
 http:// www.pulmonarychannel.com
 Patient’s Folder No. A. 01901/M

SIGNATORIES

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Name of Candidate ………………………………………………………

Signature …………………………………………………………………

Date ………………………………………………………………………

Name of Supervising Tutor ……………………………………………...

Rank ……………………………………………………………………..

Signature …………………………………………………………………

Date ………………………………………………………………………

Name of Clinical Supervisor …………………………………………….

Rank ……………………………………………………………………..

Signature …………………………………………………………………

Date ………………………………………………………………………

Name of Doctor …………………………………………………………

Rank …………………………………………………………………….

Signature ………………………………………………………………..

Date ………………………………………………………………………

Name of Head of Institution ……………………………………………..

Rank ……………………………………………………………………..

Signature …………………………………………………………………

Date ………………………………………………………………………

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