CHAPTER ONE

ASSESMENT OF PATIENT/FAMILY

Assessment involves the systematic collection of data about the health status of the client, of

which can be obtained from client’s relatives, friends and client`s folder. The data gathered is

used to make nursing diagnoses and plan care to solve client problems. The data was collected

through observations, investigations such as laboratory information, x-ray findings and results as

well as literature from books.

PATIENT’S PARTICULARS

Miss. Akosua Naa, a 24 year old lady is born to Mr. KwadwoSule and Madam AfiaNaa, all

Ghanaians. Akosua is tall, fair in complexion, and weighs 55kg. She has no tribal mark on the

face and is the third born in the family of six children of which one is a male and five are

females. She was born in Nasole at Wasa in the Western region of Ghana, where she comes

from. Akosua lives in Ejura with two of her elder siblings and the parents live in Oku, a suburb

of Ejura. She left the parents to live in Ejura to learn how to sew. She is a Christian and worships

with the Catholic Church. Akosua speaks Dagaate and Twi but never attended school. The next

of kin is Madam AfiaNaa, her mother. She was admitted in KomfoAnokye Teaching Hospital on

the 4th of January 2010.

1
 FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY

FAMILY’S MEDICAL HISTORY

A family is a group of people, related by blood, marriage or adoption, living together and

interacting with each other. There are two types of families, namely Nuclear family, comprising

of mother, father and children. The second type of family called the Extended family also

comprises of the nuclear family and the other relatives living together in a household or apart.

Akosua Naa belongs to the extended family type, and to regain her health to normal, her

family’s medical and socio-economic status is taken into consideration.

According to my client, Akosua, there are no known hereditary disease conditions like

Hypertension, Diabetes Mellitus, Sickle cell disease, Asthma, or Mental disorders in the family.

She also added that there are no known chronic infections such as Leprosy, and Tuberculosis in

the family, however, she admitted that an Aunty from her paternal side had epilepsy and died of

it. Her sister next to her had jaundice but was treated and completely recovered from the illness.

Minor ailments like Fever, Headache, Abdominal pain, Malaria and Common cold in the family

are usually treated with herbal preparations and over the counter drugs. The mother confirmed

the above information received.

SOCIO-ECONOMIC HISTORY

Miss Akosua Naa is an apprentice seamstress, who does no other work aside the seam stressing

but depends on her parents for financial assistance. She goes to her parents from time to time to

collect money and some foodstuff. The father, Mr. Sule is a Cocoa farmer and the breadwinner

2
of the family and the mother is a cereal crop farmer who assists the father to care for the

children. Her elder brother sometimes also assists her financially.

With respect to the standard of living of Akosua and her family, it can be said that, they are

below the average socio-economic background by Ghanaian standard. Due to this, the patient

and the mother always resist from any issue involving money.

PATIENT’S DEVELOPMENTAL HISTORY

Development is the process whereby one changes from a stage of maturity to another.

Development takes place from the very day of conception till the death of an individual. These

stages include physical, psychological, psychosexual, cognitive and emotional development.

According to Madam AfiaNaa, the client’s mother, she had normal pregnancy and deliver at term

spontaneously per vagina. She delivers at home with little assistance from the traditional birth

attendants and has no associated pregnancy, labour and pueperium problems. She did not attend

antenatal clinic but for immunization, she made sure all her children received them accordingly.

Akosua Naa does not know her exact date of birth but presumed she is about 24 years. She did

not attend school. She had her menarche at 15 years and 4 days is her normal menstrual flow.

Akosua is not married yet.

PATIENT’S LIFESTYLE/HOBBIES

Ms. Akosua Naa is a Catholic, who goes to church every Sunday. Her favorite diet is Fufu and

palm nut soup. She also like taking in soft drinks like Fanta. She usually baths twice a day with

soap, sponge and cold water and brushes her teeth once a day with toothbrush and paste. She

empties her bowels usually once a day. Her hobbies are cooking and charting with friends. She is

3
an introvert but goes on well with friends. Akosua sleeps as early as 8p.m and wakes up around

5:00am. when she wakes up in the morning; she prays to God and begins her daily activities. She

sweeps the house and fetches water; afterwards, she prepares breakfast for herself and other

siblings or sometimes buys food from outside. She then goes to work.

According to Akosua, she does not usually eat in the afternoon except water and sometimes

snacks like ice kenkey and bread. Around 4:30p.m, she closes from work and goes home to

prepare the evening meals or buys food outside.

All these assertions by the client were confirmed by her elder sister, Adwoa.

PATIENT’S PAST MEDICAL HISTORY

Ms. Akosua Naa has no previous major illness or admission into the hospital. She has not

engaged herself in any serious accident or injury before. However, she occasionally has

headache and stomach ache of which she takes pain relievers for example buying paracetamol

tablet from nearby drug store. She has no known food or drug allergies.

PRESENT MEDICAL HISTORY

Miss Akosua Naa decided to spend the Christmas holidays with her parents at Oku, a village

inside Ejura. All was well until the 1st of January, 2010 when she started experiencing headache;

she took paracetamol and decided to rest for a while. Upon waking up, the headache had

subsided but had severe abdominal pain. Her mother made some herbal preparations for her but

her pain aggravated and she was taken to Oku Health Center and was admitted for Two days

where she was given some infusions. Later she was transferred to Ejura Hospital. Upon

assessment, Ejura Hospital also transferred her to Mampong Government Hospital. Series of

4
investigations like pregnancy test which was negative, HB count and WBC count were

performed on her. She was Haemo-transfused one pint of Whole blood because she was anaemic.

Mampong Government Hospital referred her to KomfoAnokye Hospital for further treatment on

the same day, they admitted her.

On the 4th of January, 2010 around 8:40pm, the client and the mother reported at the accident and

emergency department as a referred case from Mampong Government Hospital with generalized

peritonitis. She was given some palliative treatment and some investigations were done.

ADMISSION OF PATIENT

Ms. Akosua Naa was admitted through the Triage unit of the Accident and Emergency

Department in a conscious state with IV Dextrose Saline insitu. She was brought in well dressed,

very ill and in a wheel chair, accompanied by her mother.They were warmly welcomed into the

nurses’ station. The mother was offered a seat and gave the necessary information about the

client including name, age, sex, religion, residential address and next of kin. The data was

recorded into the admission and discharge book as well as the daily ward state form. The client

was immediately admitted into a warm and a comfortable bed. Her vital signs were checked and

recorded as follows;

Temperature 38.0 Degrees Celsius

Pulse 106 Beats per minute

Respiration 23 Cycles per minute

Blood pressure 83/60 mm/Hg

5
Upon these assessments, the client was sponge with tepid water to reduce the body temperature

from 38.0 to 37.5 after an hour.

The health problems identified were abdominal pain and distension, headache, pyrexia and

malaise. Noso-gastric tube was passed to decompress the abdomen. Catheterization was also

done and her IV line was very patent. The medical doctor on duty attended to her and prescribed

the following medications to her;

IV Pethidine 100mg b.d× 24hrs

IV Ciprofloxacin 400mg b.d× 48 hrs

IV Flagyl 500mg t.d.s ×48 hrs

IV Dextrose saline 2 litres

IV Normal saline 2 litres

Ringers lactate 2 litres

The investigations ordered were Fasting blood sugar, grouping and cross matching, chest x-ray,

abdominal x-ray (supine and erect).

The relatives were informed about the hospital policies which include payment of deposit if she

had no health insurance, time of visits and the items the patient may need during hospitalization

which includes cup, spoon, bucket, towel, bowl or plate and others.

The client and the mother were reassured that competent health personnel were willing to help

Akosua recover without complication. These words of encouragement helped relieved their

anxiety.

The medical treatments prescribed by the doctor were explained to the client and the due ones

administered. Blood samples were taken to the laboratory and she was taken to the x-ray

6
department for an x-ray examination. She was also instructed not to take anything by mouth

since she would possibly undergo an emergency surgery. My client was reviewed by the leader

of the surgical teamand the diagnosis was confirmed as typhoid fever with perforation.

PATIENT’S CONCEPT OF ILLNESS

When Miss Akosua Naa and her mother were asked about their knowledge about Typhoid Fever,

it was found out that they know little about the condition. The client accepted the diagnoses and

expressed her willingness to corporate with health personnel to facilitate an early recovery. The

mother was disturbed and said all the people in their village were saying that her daughter

committed an abortion that was why she had severe abdominal pain. This form of misconception

about her daughter by the society worried her and said she prays to God that everything goes on

successfully. Besides they did not attributed the occurrence to any evil force or witch crafting but

rather it is a natural occurrence.

7
 LITERATURE REVIEW ON PATIENT’S CONDITION

DEFINITION:

Typhoid fever is an acute infectious disease that produces fever, prostration, stupor, enlarged

spleen and intestinal inflammation in the individual. Typhoid perforation is a disease condition

which is said to be a complication to an uncontrollable or untreated typhoid fever.

INCIDENCE:

Typhoid Fever has an increasing rate or is endemic in many areas where environmental

sanitation is poor.

It is widely spread in Africa and other third world countries.

It affects all age group but more common among 10-25 age groups. There are estimated cases of

13-17% worlds wide resulting in approximately 600,000 deaths per annum.

It is endemic in most developing countries including Ghana as a result of rapid population

growth, inadequate human waste treatment and disposal, limited and inadequate treated water

supplies.

The disease incidence rises at the end of the rainy season resulting in its seasonal variation.

AETIOLOGY

Typhoid fever is caused by Salmonella Typhi. This flagellated gram- negative bacteria has no

known host except humans. Ingested people and carriers harbor the bacteria and pass them out in

their faeces and urine to sources of drinking water through indiscriminate refuse disposal. This

aggravates especially if these sources are not well purified before consumption. Also

8
contamination of food through food handlers who may be a carrier and water that has been

polluted with sewage are used for irrigation of vegetables like lettuce and cabbage.

PATHOPHYSIOLOGY

The bacteria usually enter the body through the mouth by ingestion of contaminated food or

water. The organisms penetrate the interstitial wall and multiply in the lymphoid tissue called the

Peyers patches. It first enters the blood stream within 24-72 hours causing septicemia and

systemic infection. The lymph follicles along the interstitial wall in which the typhoid bacilli

have multiplied, become inflamed and necrotic and may slough off, leaving ulcers in bowels

tissues which may erode blood vessels causing hemorrhage into the bowel.

This perforates the wall of the bowel allowing the contents of the bowel to enter the peritoneal

cavity causing peritonitis.

MODE OF TRANSMISSION

Salmonella Typhi is transmitted through contaminated water and food, occasionally, flies acts as

vectors. Some cases passes through chronic biliary carriers by fecal contamination.

However, many cases are acquired through travels to endemic areas.

INCUBATION PERIOD

It has an incubation period of 10-14 days.

9
 CLINICAL FEATURES

1ST WEEK (PRODROMAL SIGNS AND SYMPTOMS)

The patient develops high fever that may persist; temperature rise for the first 4-5 days is in a

step ladder fashion with a temperature difference of 0.5 degree Celsius.

Severe headache, malaise, constipation, vague abdominal pain (cannot classify the pain),

drowsiness, dry cough, may also manifest.

In children however, there is slow pulse, epistaxis, rhinorrhoea, and conjunctivitis, photophobia,

bleeding under the skin, weight loss, anorexia, and convulsion.

2ND WEEK (RASH STAGE)

The clinical features above become more severe. Appearance of rashes called rose-red-spot, on

the upper abdomen, chest and back which fades with pressure. The spleen becomes palpable.

There is diarrhoea with offensive pea soup-like stools containing undigested materials and

sometimes peelings from the intestinal walls.

3RD WEEK (BLEEDING AND COMA STAGE)

Bleeding and perforation may occur with decline in temperature. Patient becomes better and later

goes into coma. By the fourth (4th) week, the patient recovers.

Other signs and symptoms may include; tenderness, chills, dyspnoea, anaemia, dysuria,

dehydration and hepatomegaly.

10
 COMPLICATIONS

1. MEDICAL COMPLICATION

Pneumonia

Intestinal haemorrhage

Typhoid psychosis(acute)

Acute hepatitis

Endocarditis

2. SURGICAL COMPLICATIONS

- Intestinal perforation

- Intestinal haemorrhage

- Gall stone formation

- Cerebral abscess

- Cholescystitis

INTESTINAL PERFORATION: This is the most common complication of typhoid fever. It is

a break in the intestinal wall which occurs when erosion, infection or other factors like trauma

create a weak spot in the organ and intestinal pressure cause a rupture. This occurs in typhoid

fever when the disease is not diagnoses and treated earlier.

11
DIAGNOSTIC INVESTIGATION

Blood for culture reveals salmonella Typhi in different specimen and in different weeks.

1st week in blood

2nd week in stool

3rd week in urine

Haemotologic abnormalities and antibodies titres reveal typhoid fever

Widal test measures titres of antibodies formed against typhoid bacilli

Leucocytosis

History, signs and symptoms

MEDICAL/SURGICAL/NURSING MANAGEMENT

MEDICAL TREATMENT

This focuses on the eradication of causative agent and the prevention of complication.

Medical treatments given are;

Chloramphenicol 50mg/ kg daily in divided doses for 6 hours for 14 days.

Ciprofloxacin 500mg b.d orally × 14 days.

Blood transfusions to manage anemia.

Intravenous infusions to manage dehydration.

Analgesic to control pain.

Antipyretic to control pyrexia.

12
SURGICAL TREATMENT

The main focus is to repair the perforation by simple closure or resection and anastomosis.

Laparotomy was done.

NURSING MANAGEMENT

REASSURANCE: Reassurance of client to relieve anxiety and agitation. This is done to gain

her co-operation in implementation of procedures.

POSITION: When the patient is conscious, the nurse must position him or her in bed according

to the severity of the condition but in most cases, the patient is allowed to assume a position he

or she feels most comfortable. Patient, who has undergone Laparotomy, is nursed in a recumbent

position to ease breathing and prevent falling back of the tongue

REST AND SLEEP: This is ensured for the client to conserve energy, promote relaxation,

reduce stress and aid in speedy recovery. This can be ensured by the nurse providing a firm and a

comfortable bed, which is free from creases and regulating the number of visitors. Also

minimizing noise, providing adequate ventilation to facilitate relaxation and if patient is in pain,

serve prescribed analgesics to relieve pain.

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ISOLATION: The client is admitted for some days before surgery to allow time for thorough

investigation and preparation of the patient, so that any deficiencies in the patient’s blood

chemistry or in the general condition is corrected before the operation.

Client with such a condition is barrier-nursed to prevent cross infection to the health care

members and other client. This can be ensured by nursing her in an isolated room or on the

general ward with a screen around her bed. Gloves, gowns, goggles and boots should be worn

when coming into contact with client’s urine, faeces, sputum or vomitus and vaginal discharge.

Frequent hand washing, which is the cheapest way to prevent cross infection, should be adopted.

All body secretions from clients should be decontaminated before washing. The client should be

given a separate cup, spoon, plate, vomiting bowl, bed pan and urinal. All these should be

decontaminated before each use. Her left over food should be thrown away and decontaminated.

All instruments and equipment used on the patient should be properly disinfected and sterilized

to prevent cross infection.

NUTRITION: Prescribed parenthral nutrition served. This continued with oral foods as patient’s

condition improves. The food should be a balanced diet rich in vitamins to fight infections,

proteins to repair worn out tissues and to facilitate healing, carbohydrates for energy and mineral

salts for electrolytes.

ELIMINATION: Prompt provision of bedpan and urinal to prevent client from soiling herself.

Monitor fluid intake and output chart. Decontaminate stool and urine in 1:10 parazone for ten

(10) minutes before disposal.

14
OBSERVATIONS: Quarterly, half hourly, two hourly and four hourly, vital signs are checked

and recorded as client’s condition improves. Observe contents, frequency, consistency, colour,

foreign body in urine and faeces and any abnormalities in them. Again, observe breathing

pattern, the rate, rhythm, and depth. Also observe for side effects and complications of drugs,

orientation of patient to time, place and person to prevent anxiety. Weigh patients daily

depending on the condition to access the level of fluid retention and output. The intravenous

infusion in situ, is monitored to observe the drop rate, tissue infiltration, fluid overload and

swelling at the infusion site. Observe for possible complications, especially after surgery, for

example, in case of Laparotomy, which may include intestinal haemorrhage, intra-abdominal

abscess and pneumonia.

PERSONAL HYGIENE: Based on the client’s condition, bed bath or assisted bed bath, may be

given at least twice a day. The nurse must pay particular attention on the umbilicus and the skin

fold areas to remove dirt, improve circulation, to promote sleep. The skin, nails and mouth are

cared for to promote health and prevent infection. Dirty bed linen is changed regularly to prevent

bed sores and promote comfort. The nurse must make sure that the patient is always neat and

well groomed in bed.

EXERCISE: Exercise must begin as soon asclient regains full consciousness, these include deep

breathing, coughing exercise and mobilization thus turning client from side to side, sitting up in

bed and at the edge of the bed. Limb exercise, which include active and passive range of motion

exercise of the joints and massaging if the limbs are encourage. Ambulating exercise is started

15
12-24 hours after surgery, depending on client’s condition. This is to improve circulation and

prevent constipation as well as joint stiffness and bed sores.

HEALTH EDUCATION: the client is educated on the predisposing factors of the disease

condition, signs and symptoms and the preventive measures related to the disease. Advice is

given on the need to use soap to wash hands before and after meals and visiting the toilet. Also,

fruits and vegetables should be washed thoroughly with water before consumption. Education is

given on personal hygiene; skin, body cleanliness, nails, mouth and cloth care. Environmental

hygiene should be established in the endemic areas. Protection and purification of water must be

enforced. Food handlers are also educated to maintain proper hand washing, personal, food and

environmental hygiene. Client is also educated on desire effect and side effect of drugs and the

importance of completion of drugs. Client is informed of follow- ups until she is declared fit.

CHEMOTHERAPY: Serve prescribed drugs such as antibiotics to fight infections, analgesics

to combat pain, intravenous fluids to prevent hypovolaemia and dehydration, check out for any

allergic reaction, desired effects, adverse effects and complications of drugs.

16
 VALIDATION OF DATA

Client’s personal data was provided by herself and mother. The data collected was confirmed by

her father on his arrival. The clinical features observed in the client were also compared to those

in textbooks as well as laboratory investigations and the direct relation indicated that the client is

suffering from TYPHOID FEVER which made her develop complications called TYPHOID

PERFORATION.

The above comparison enabled me to conclude that, the data collected is valid and free of errors.

17
 CHAPTER TWO

ANALYSIS OF DATA

Analysis is the second phase of the nursing process and it involves the separation of information

collected from the client into constituent parts, in order to compare them with standards,

formulates the nursing diagnosis and intervenes accordingly.

This chapter comprises of

Comparison of data with standard

The patient/family strength

Health problems

Nursing diagnosis

18
 COMPARISON OF DATA WITH STANDARD

This is the stage where the patient diagnostic investigation/test, cause of the disease, clinical manifestation, treatment and

complication are compared with standards.

TABLE ONE:DIAGNOSTIC INVESTIGATION/TEST

DATE SPECIMEN INVESTIGATIONS RESULTS NORMAL RANGED INTERPRETATION REMARKS

4/01/10 Blood Neutrophil, 89.4% 40-70% Higher than normal Antibiotics given as

lymphocytes range, indicating prescribed

bacteria infection

4/01/10 Blood Sickling test Negative Negative Client does not have No specific care

sickle cell disease given

19
4/01/10 Blood Creatinine 91umol/l 44-106umol/l Within normal range No specific

treatment given

4/01/10 Chest X-ray of the chest Air under There should be no air The accumulation Client prepared for

diaphragm under the diaphragm indicates that there is Laparotomy

perforation

4/01/10 Abdomen Abdominal X-ray Free fluid in There should be no This indicates Prescribed antibiotic

the abnormal fluid in the perforation and the given to manage the

peritoneum abdomen presence of bowel infection. Gastric

content in the lavage done intra-

peritoneum operatively

7/1/10 Blood Hemoglobin level 8.8g/dl Male-12-18g/dl below normal range Prescribed

estimation Female-11-16g/dl haematinics given.

20
7/1/10 Blood Red blood cell 2.47 4.50-5.50 Red blood cell falls Prescribedhaematini

below normal range cs given.

7/1/10 blood White blood cell 7.48 4-10 WBC falls within No specific

count(WBC) normal range treatment given

21
 CAUSES OF CLIENT’S DISEASE

With reference to etiological factors of typhoid fever, indicated in the literature review and the

data gathered from my interaction with the client and her relatives, Akosua’s condition was

caused by unhygienic cooking and eating habit.

Considering her sanitation and where she buys food from, and also due to delay in diagnosis and

treatment which lead to intestinal perforation, a complicated form.

TABLE TWO:

COMPARISON OF CLINICAL FEATURES OF PATIENT AND THAT OF

LITERATURE

LITERATURE FEATURES AKOSUA’S CLINICAL FEATURES

There is fever Client had pyrexia of 38.0 degree Celsius.

There is anorexia Client did not complain of anorexia.

There is abdominal pain Client complained of severe abdominal pain.

There is abdominal tenderness Abdominal tenderness present

Spots or rashes on trunk of body No rash was present

22
Headache may be present Client complained of headache

There may be joint pain Joint pain was experienced by patient

There may be malaise Client experienced general malaise

Prostration may be present Client did not experience prostration

There is constipation She did not experience constipation.

There is diarrhea Client experienced diarrhea

Dysuria may be present Dysuria was not present

There may be abdominal distention Abdominal distention present

There may be anaemia Mild anaemia was present.

SPECIFIC TREATMENT GIVEN TO CLIENT

PRE-OPERATIVE DRUGS

Intravenous Normal Saline, 500 mls, b.d for 24 hrs.

Intravenous Dextrose Saline, 500 mls, b.d for 24 hrs.

Intravenous Ringers Lactate, 500 mls, b.d, for 24 hrs.

Intravenous Metronidazole, 500 mls, t.i.d, for 48 hrs.

23
Intravenous Ciprofloxacin, 400mg, b.d, for 48 hrs.

Inj. Pethidine, 100 mg, b.d for 24 hrs.

INTRA-OPERATIVE MEDICATION

Halothane inhalation 2% of oxygen.

IM Pethidine 100mg prn

IV Saxamethonium 50mg

POST OPERATIVE DRUGS

IV Normal saline500 mlsb.d for 72 hrs.

IV Dextrose saline 500mls b.d. for 72hrs.

IV Ringers saline 500mls b.d. for 72hrs.

IV Metronidazole 500mg t.d.s for 48hrs

Inj. Pethidine 100mg b.d for 48hrs

IV Ciprofloxacin 4000mg b.d for 48hrs

IV Gentamicin 80mg b.d for 48 hrs

Tab Ciprofloxacin 500mg bd x 10

Tab Diclofenac 100mg bd x 75 hours

Tab Vitamin B complex 10mg tds x 30 days

Tab Fersolate 200mg tds x 16 days.

24
 TABLE THREE:PHARMACOLOGY OF DRUGS GIVEN TO CLIENT

DATE DRUG LITERATURE ACTUAL CLASSIFICATION DESIRED ACTUAL SIDE

DOSAGE AND DOSAGE AND EFFECTS ACTION EFFECT/

ROUTE OF ROUTE OF REMEDIES

ADMINISTRATION ADMINISTRATIO

N GIVEN TO

CLIENT

4/01/10 Normal saline Dosage: varies 500mls infused bd Fluid and electrolytes Replace loss Fluid and Large doses

(sodium according to a intravenously over of water, fluid electrolytes may give rise

chloride 0.9%) patient’s age and fluid 24 hours. and balance were in sodium and

and electrolyte electrolytes. restored and potassium

requirement. client did not imbalance.

Route: Intravenously. show signs of Client did not

electrolytes have any

deficit. notable side

effect.

25
4/01/10 Dextrose saline Dosage: Depends on 500mls infused bd Fluid and glucose. To provide Client was Fluid

patient caloric intravenously over energy and provided with overload can

requirement. 24 hours fluid. the needed lead to

Route: Intravenously energy and circulatory

was free from overload.

dehydration. None

observed.

4/01/10 Ringers lactate Dosage: Is highly 500mls infused Fluid, electrolyte and To provide Client was not Over dose can

individualized but intravenously over glucose. energy and dehydrated. lead to fluid

usually 1.5 to 3.0 litres 48 hours. fluid. overload and

is infused over 18-24 metabolic

hours alkalosis.

Route:Intravenously. No notable

side effect

detected.

4/01/10 Metronidazole Adult dose: 500mg 500mg tid x 48 Antibacterial, To fight Pre and post- Constipation,

26
 (flagyl) hours intravenously. Antiprotozoa, infection. operative vomiting,

Children: 250mg Amoebicide infections weakness,

Route: Intravenously were Headache and

(IV), oral (p.o). controlled. confusion.

Bacteria None

peritonitis observed.

was also

treated.

4/01/10 Ciprofloxacin Adult dose: 250mg - 400mg bd x 48 Antibacterial, To fight Typhoid Light

500mg hours intravenously Anti-infective; infection. infections headedness,

Children: 150mg- Quinolone. were confusion,

250mg controlled and restlessness,

Route: Intravenously, further vomiting,

per oral. infections nausea,

27
 were diarrhea and

prevented. thrombosis.

None

observed.

4/01/10 Pethidine Adult: 75mg-150mg 100mgbd x 24 hours Narcotic analgesic To relieve Abdominal Nausea,

Children:1.0-2.2mg/kg imtramuscularly. pain before pain and vomiting,

Route: and after incisional constipation,

Intramuscularly, per surgery. pain were drowsiness,

oral, subcutaneous. relieved after hypertension.

administration None

of pethidine. observed.

5/01/10 Suxamethonium 500mg stat 50mg stat Muscle relaxant. Used mainly Muscles were Tarchycardia

intravenously intravenously in anaesthesia relaxed during and cardiac

to produce period of arrest.

muscles surgery. These were

relaxation. not observed

28
 in the client.

5/01/10 Halothane 2% volume of oxygen. 2% volume of Inhalation and Works by Client had no Hypotension,

oxygen. anaesthetic agent. depressing pain during cardiac arrest

cardiovascular surgery. and cardiac

and arrhythmias.

respiratory None was

muscles. observed.

8/01/10 Diclofenac Adult: 75mg-150mg 100mg bd for 75 Non-steroidal anti- To relieve Client was Nausea,

Child: 1.3mg/kg hours orally. inflammatory and pain, fever relieved of flatulence,

Route: Intramuscular, analgesic. and prevent pain and gastro

per oral. inflammation hightemperatu intestinal

re. pain,

dizziness,

bleeding.

None

29
 observed.

8/01/10 Vitamin B Adult: 10-50mg 10mg tds for 30 days Micro-nutrient Correction of Mal- Large doses

complex Children: 5-25mg orally. (vitamin supplement). mal- absorption may lead to

Route: Per oral, absorption corrected and yellow

intravenously, and maintain client’s discolouration

intramuscularly. vitamin B in appetite of urine.

chronic/ increased. Client urisne

intermittent appeared

haemodialysis yellow but

was not

injurious

8/01/10 Tablet fersolate 200mg tds x 16 Adult: 200mg tds Iron supplement To treat iron Client Nausea,

deficiency. haemoglobinl diarrhoea,

evel increased indigestion.

gradually to None was

normal and observed.

iron

30
 deficiency

corrected.

11/01/10 Gentamicin Adult: 3mg-5mg/kg 80mg bd x 48 hours Antibiotics To fight again Client got Skin itching,

dly intravenously. Aminoglycoside. infection. relieve of redness,

Children: 6mg- infection. swallowing.

7.5mg/kg None was

Route: intravenously. observed.

11/01/10 Amoksiclav Adult: 0.75-1.5g/h. 1.2 tds x 3 days Broad spectrum To destroy Infection was Headache,

Children: 20-40mg/kg intravenously. antibiotic. bacterial controlled. sore mouth,

day growth and vaginal

Route: Intravenously, division. itching.

per oral. None was

observed.

31
32
 COMPLICATIONS IN PATIENT

With reference to the complications listed under the literature review, Akosua developed

intestinal perforation upon which she was operated to correct the perforation.

PATIENT’S/ FAMILY STRENGTHS

On admission, my client was conscious and followed nursing instructions. She had her mother at

her side always and even though the family is not rich, they were able to buy any drug which was

not covered by the National Health Insurance.

Family members used to visit her from time to time on the ward.

As her condition improved, Akosua was able to maintain her personal hygiene without

assistance; she could eat and groom herself.

These activities by the client and the family helped in her wellbeing and also contributed to her

speedy recovery.

HEALTH PROBLEMS IDENTIFIED

Health problem is any stressful activity that can cause adverse reaction to client health and

therefore needs effective management.

The following health problems were identified during the period of admission of my client,

Akosua Naa.

PRE-OPERATIVES:

Client experienced pyrexia and headache.

Client had severe abdominal pain and distension.

33
Client and family were anxious.

POST-OPERATIVES:

Client had pain at the incisional site.

Client could perform her personal hygiene.

Client could not breathe well.

Client was prone to infection.

Client had insomnia.

Client had loss of appetite.

Client had inadequate knowledge about disease condition.

NURSING DIAGNOSIS

Upon observations and complaints by the client, the following nursing diagnoses were reached;

PRE-OPERATIVES

1. Alteration in body temperature (38.00C) related to typhoid fever with perforation.

2. Alteration in comfort (abdominal pain) related to abdominal distension.

3. Anxiety related to impending surgery (laparotomy) secondary to the disease condition.

34
POST-OPERATIVES

1. Alteration in comfort (incisional wound pain) related to surgical intervention.

2. Total self deficit related to laparotomy.

3. Breathing pattern disturbances related to typhoid perforation.

4. Potential for wound infection related to incisional wound secondary to surgery (laparotomy).

5. Sleeping pattern disturbance related to change of environment.

6. Altered nutrition less than body requirement related to restriction of food by mouth.

7. Knowledge deficit related to cause and management of typhoid fever.

35
 CHAPTER THREE

PLANNING FOR PATIENT/FAMILY CARE

Planning is the third phase of the nursing process and it involves setting of goals, determination

of priorities and planning a care to prevent or eliminate client’s health problems and identifying

nursing intervention to meet the set goals.

The client and the family members must be involved in the nursing care plan.

GOALS AND OBJECTIVES

1. Client will maintain a normal body temperature of 36.2oC-37.oC within 3 hours as evidenced

by the nurse taking her temperature and observing that it has dropped to the normal range.

2. Client will be relieved of abdominal pain within 2 days as evidenced by;

a) Nurse observing that client does not have abdominal distension.

b) Client verbalizing relieve of pain and being cheerful.

3. Client and family will be relieved from anxiety within 24hrs as evidenced by client and

mother having cheerful facial expression and being cooperative.

4. Client will be relieved of post-operative pain within 1 hour as evidenced by client verbalizing

that the pain has subsided.

36
5. Client will be able to maintain her personal hygiene within 4 days post-operatively with little

or no assistance as evidenced by

a) Nurse observing client being able to maintain her personal hygiene with minimum assistance.

b) Client verbalizing that she is able to maintain her personal hygiene by herself.

6. Client will have a normal breathing pattern within 4 hours as evidenced by

a) Nurse checking respiratory rate and falling within normal range

b) Client verbalizing that she can breathe normally.

7. Client’s wound will be free from infection and wound heal by first intention within 7 days

post- operatively as evidenced by nurse observation that client’s wound appearing dry and clean

without infection.

8.Client will have a normal sleeping pattern throughout the period of hospitalization as

evidenced by; client sleeping at least 3 hours during the day and 6 – 8 hours in the night.

9.Client nutritional status will be maintained within 5days post-operatively as evidenced by

nurse observing client not malnourished and client being able to take and tolerate more than half

of the food served.

10. Client will have insight into her disease condition before discharge as evidenced by client

answering question on her condition correctly.

37
 TABLE FOUR: NURSING CARE PLAN

DATE NURSING OBJECTIVE / NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

TIME CRITERIA TIME

4/01/10 Alteration in Client will 1. Reassure 1. Client was reassured that 4/01/10 Goals fully met.

8:50pm body maintain a normal client that measures will be put in place to 11:30pm. Client’s

temperature body temperature everything will reduce her temperature to temperature has

(38.3oC) of 36.2oC-37.2oC be done to normal range. dropped to

related to within 3 hours as reduce her normal (37.0Oc).

inflammatory evidenced by the temperature to

process. nurse taking her normal.

temperature and
2. Client was tepid sponge
observing that it 2. Institute
using sweep stroke leaving
has dropped to measures to
damp water on client’s body to
the normal range. reduce client’s
dry up by evaporation by
temperature.

38
 reducing the temperature in

every 15 minutes.

3. Serve 3. Prescribed medications were

prescribed administered
medication. Like IV Ciprofloxacin 400mg

and IV Flagyl 500mg.

-Temperature, pulse respiration

were checked and findings were

within normal range and

documented

4. Monitor
4. Light clothing was used to
vital signs.
cover the client to prevent her

from generating heat. Adequate

ventilation was ensured by

opening nearby windows.

39
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND STATEMENT

TIME CRITERIA TIME

4/01/10 Alteration in Client will be 1. Reassure 1. Client and mother were 6/01/10 Goals fully met as

9:00pm comfort relieved of client and reassured that Akosua is in the 9:00pm a) client is

(abdominal abdominal pain mother that hands of competent personnel relaxed in bed

pain) related within 2 days as everything and that everything possible and verbalized

to abdominal evidenced by; will be done will be done to reduce the pain. she was relieve of

distension a) Nurse observing to reduce the pain.

that client do not pain. b) nurse observed

have abdominal reduction in

2. Assess the 2. Client’s abdomen was assess

distension. abdominal

level of pain. to ascertain where the pain is

b) Client distension.
emanating from and the
verbalizing relieve
magnitude of the pain.
of pain and being

40
cheerful. 3. Relieve 3. Nasogastric tube was inserted

client pain to aspirate gastric content to

relieve the abdominal

distention.

4. Assist 4. Client was made comfortable

client to in bed after the passage of the
assume a Nasogastric tube by assisting
more her to assume a left
comfortable lateral position.
position.

5. Engage 5. Client attention was taken of

client in a the pain by engaging her in a

diversional conversation about her past

therapy. pleasant experiences and

listening to music.

41
6. Administer 6. Intramuscular injection

prescribed pethidine 100mg was given as

analgesics ordered to reduce pain.

42
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

TIME CRITERIA TIME

5/01/10 Anxiety Client and family 1. Reassure 1. Client and mother were 6/01/10 Goals fully met,

7:00am related to will be relieved client and family reassured that everything 6:00am. client and

impending from anxiety to allay any fear possible will be done to alleviate mother

surgery within 24hrs as and anxiety. their fears and all measures put expressed a

secondary to evidenced by in place to make client cheerful face

typhoid client and mother comfortable as early as possible. and were co-

perforation. having cheerful operative more

2. Explain the 2. Client and mother were
facial expression than before.
need for surgery educated on the need for the
and being
and aftercare to surgery, the positive outcome
cooperative.
client and and the expects and machinery
family. available as well as the

aftercare measures such as

43
 medical treatment,

monitoring of vital signs such as

temperature, pulse and

respiration and aseptic wound

dressing.

3. Educate
3. Client and mother were
clientand mother
educated on
about disease
Typhoid fever and how it can be
condition.
prevented. They were also

allowed to ask question about

the condition, surgery and its

outcome.Answers were given in

simple terms.

4. Ask for
4. Client and mother were asked
feedback.
questions on the condition and

44
 they were able to give

appropriate answers.

DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

TIME CRITERIA TIME

45
5/01/10 Alteration in Client will be 1. Reassure 1. Client was reassured that post- 5/01/10 Goals fully met as

6:00pm comfort relieved of client. operative pain will be catered for. 7:00pm client verbalized

(incisional post-operative that pain has

wound pain) pain within 1 subsided.

related to hour as 2. Assess for the 2. The intensity, frequency and

surgical evidenced by extent of client’s duration of painwere assessed.

intervention. client pain.

verbalizing
3. Observe client 3. It was observed the client could
that pain has
pain coping cope little with the pain.
subsided.
ability.

4. Nurse client 4. Client was nursed in the

on the unaffected recumbent position to prevent

side. pressure on the incisional wound.

5. Bed cradle was used to lift the

46
 5. Use bed cradle weight of bed linen on the

to lift the weight incisional site.

of bed linen on

the affected side.

6. I.M Pethedine 100mg was

6. Serve administered.

prescribed

analgesics.

DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

TIME CRITERIA TIME

47
6/10/10 Total self-care Client will be 1. Reassure 1. Client was reassured that she 10/01/10 Goals fully met.

5:00am deficit related able to maintain client to allay will be able to care for herself 5:00am Nurse observed

to Laparotomy her personal fear and and do normal activities as soon client maintain

hygiene within 4 anxiety. as possible but at the moment, her personal

days post- she needs temporal assistance in hygiene with no

operatively with doing them. assistance

little or no -Client verbalized

2. Serve bed 2. On request, bed pan was
assistance as that she is able to
pan served warm. After voiding, the
evidenced by do normal daily

a) Nurse amount, colour and consistency Activities by

observing client was observed and documented. herself.

being able to 1010mls. 0f normal colour urine

maintain her was emptied and 300mls of

personal hygiene aspirated fluid from the N/G

with minimum tube drainage bag.

assistance. 3. Assist client

b) Client 3. Client was assisted to bath

48
verbalizing to bath. with warm water, soap and

that she is able to sponge twice daily to improve

maintain her blood circulation. Pressure

personal hygiene areas such as elbow, heals,

by herself. scapula and sacral region were

massage with mild soap and

water. Vaseline was applied

afterward to prevent formation

of bed sores.

4. Assist client
4. Client was assisted to groom.
to groom
Her soiled bed linen and
herself and
clothing were changed,
decontaminate
disinfected in parazone for
used and soiled
20mins to kill all microbes.
articles,

49
clothing.

5. Assist client 5. Little assistance was given to

to care for the client to maintain her oral

mouth hygiene with toothpaste and

toothbrush twice daily to

prevent

mouth odour and improve

freshness. Vaseline was applied

on the mouth to prevent crack

lips.
6. Ensure early
6. Client was given support to
ambulation
walk around her bed and in the

ward on the second day post-

operatively till she was able to

walk alone.

50
51
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

TIME CRITERIA TIME

6/01/10 Breathing Client will have 1. Reassure 1. Client was reassured that 6/01/10 Goal fully met as

3pm pattern a normal patient. measures are underway to bring 7:30pm client had

disturbance breathing pattern her respiration rate to normal. effective

related to within 4 hours as breathing pattern.

typhoid fever. evidenced by 2. Check vital 2. Respiratory rate was a) Client’s

a) Nurse signs monitored as 30bpm. respiratory rate

checking especially was within

respiratory rate respiration. normal range.

and falling (20c.p.m).

3. Suction 3. The mouth and throat were
within normal
client when sucked with suction machine.
range. b) client
necessary. verbalized that
4. Remove 4. Tight clothing were removed
b) Client she could breathe

52
verbalizing that tight clothing and nearby windows and well.

she can breathe and maintain curtains were opened for good

well. good ventilation.

ventilation.

5. Nurse client 5. Client was nursed in a semi-

in a cardiac fowler’s position to aid breathing

position. with the head turned to one side

for drainage topass.

6.Administer 6. Oxygen (4 liters per minute

prescribed were prescribed and

oxygen. administered.

53
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

TIME CRITERIA TIME

6/01/10 Potential for Client’s wound 1. Reassure 1. Client was reassured that her 13/01/10 Goals fully met.

8:30pm wound will be free from client. wound will be prevented from 10:30am Client wound

infection infection and infection and will heal by first healed by first

related to wound heal by intention without infection. intention without

incisional first intention any infection.

2. Observe 2. Client’s wound was observed
wound within 7 days
wound site for for bleeding, swelling, redness -Client wound,
secondary to post- operatively
any and hotness. healed with little
surgery as evidenced by
abnormalities scar formation.
(laparotomy) Nurse
such as
observingthat
bleeding,
client’s wound is
redness,
dry and clean
hotness and
without

54
infection. swelling.

3. Open wound 3. Client’s wound was opened on

on the third the third day and was observed

day and change for pus discharge. It was dressed

dressing with methylated spirit and

aseptically. covered with dry sterile gauze

and plaster. Aseptic techniques

were employed.

4. Remove 4. Client’s alternate and

alternate remaining

Stitches on the Stitches were removed on the

seventh day, seventh and ninth day

post respectively and dressings

operatively and changed aseptically to prevent

remaining infection.

55
stitches on the

ninth day as

ordered by the

surgery.

5. Client was advised not to

5. Instruct
touch the wound with the hands
client not to
so as not to contaminate the
contaminate
wound and ensure effective
the wound.
wound healing.

6. Tablet Ciprofloxacin 500mg

6. Serve
and Flagyl, 400mg, were served
prescribed
as ordered to control infection
antibiotics as
and promote healing.
ordered.

7. A well balanced diet was

7. Ensure
served rich in vitamins and
56
 client takes in mineral salt. Fruits such as

a well balanced orange, pineapple and water

diet and foods melon were also served to aid in

rich in vitamin wound healing and prevent

C to enhance constipation.

healing.

8. Client’s bed linen was

8. Make client changed and made comfortable

comfortable in in bed, she was thanked for co-

bed, thank her operation and the procedure and

and document findings were recorded in the

procedure and nurses’ notes.

findings in the

nurses’ notes

DATE NURSING OBJECTIVES / NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND AND

57
 TIME DIAGNOSIS OUTCOME ORDERS TIME

CRITERIA

7/1/10 Sleeping Client will have 1. Reassure 1. Client was reassured that 14/1/10 Goal fully met as

8:00pm pattern a normal client that her measures are in place to enable 8:00am client was able to

disturbance sleeping pattern normal sleep her have a normal sleep pattern sleep well

(insomnia) throughout the pattern will be throughout time

related to period of maintained of hospitalization.

change of hospitalization as

2. Minimize 2. Movement of visitors are

environment evidenced by

Client sleeping noise, organized regulated, volume of radio and

nursing care television set turned down and

at least 3 hours

and do at a go, nursing procedures carried on

during the day

provide client were organized and

and 6 – 8 hours

adequate performed at once to

in the night.

ventilation and prevent interruption and noise.

good clothing Nearby windows were opened,

ceiling fan switched on to

58
 promote ventilation and induce

sleep.

3. Assist client 3. Client was assisted to have a

to take a warm warm bath to relax her muscles.
bath, groom and She was assisted to groom and

provide a put on a comfortable bed free

comfortable bed from creases and crumps to

induce sleep.

4. Serve
4. Prescribed injection
prescribed
Pethidine (I.M) 100mg was
medication.
served to relieve pain and

promote sleep.

DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

59
 TIME CRITERIA TIME

6/01/10 Altered Client 1. Reassure 1. Client was reassured that her 11/01/10 Goals fully met as

7:00am nutrition less nutritional client. nutritional status was being 6:15am client nutritional

than body status will be taking care of by the status has been

requirement maintained intravenous fluids and that oral maintained.

related to within 5days feed will start as soon as bowel a) Client ate

restriction of post-operatively sound returns and condition enough

food by mouth. as evidenced improve so as to prevent amount of food

by: abdominal distention. served.

Nurse observing
2. Ensure oral
client not 2. Client oral hygiene was cared b) Client left the
hygiene.
malnourishedan for twice daily to stimulate hospital well

d client being herappetite with toothbrush and nourished with a

able to take and toothpaste. healthy

tolerate more appearance.

3. Ensure

60
than half of the environmental 3. The environment was made

food served. cleanliness. conducive by removing

nauseating items such as

bedpans, urinals and vomiting

bowls to promote comfort.

4. Serve

medication and 4. Parentral fluids were

maintain intake administered and recorded.
and output Intravenous Dextrose saline
chart. 500mls was administered to

provide energy. Urine output,

aspiration drainage were

monitored and recorded

accordingly to ensure adequate

5. Plan diet with
nutrition.
client and start
5. Client was involved in
oral fluids and
planning the diet to know her
nutrition as
61
ordered. likes and dislikes to prevent

possible allergic reaction.

Sips of water and plain tea were

given and gradually progressed

to light diet such as porridge,

agidi and light soup, then full

diet as condition improves and

6. Ensure food
client tolerates.
is served in bits.

6. Meals were served

attractively, frequently and in

7. Carryout
bits to improve nutritional
painful
status.
procedures 30
7. Painful procedures such as
minutes before
wound dressing and injections
and after meals.
were carried out 30 minutes

before meals to maintain good

8. Discard left

62
 over foods, appetite.

decontaminate

articles, and 8. Client left over foods were

wash hands discarded, spoons, cup and

properly. plates were decontaminated and

kept to prevent cross infection.

9. Thank patient

and document

care rendered in
9. Client was thanked and
the nurses’
procedure documented in the
notes.
Nurses’ notes.

DATE NURSING OBJECTIVES / NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS AND

TIME CRITERIA TIME

63
5/1/10 Knowledge Client and 1. Reassure 1. Client and family were 13/1/10 Goals fully met as

9:00am deficit related family will have client and reassured that all the necessary 2:00pm client and family

to the cause insight into her family. information about typhoid fever can now answer

and disease condition will be given to enable them correctly question

management of before discharge understand the management of about the disease

typhoid fever. as evidenced by; the condition. condition

Client answering
2. Establish an
question on her 2. A good friendly relationship
environment of
condition was established to enhance
mutual trust and
correctly. learning.
cooperation to

enhance

learning.

3. Educate 3. Client and family were

client and educated on the causes,

family on predisposing factors, signs and

64
typhoid fever. symptoms and the prevention of

the condition.

4. Give room 4. Client and family were

for client and allowed to ask questions

family to ask beyondtheir understanding and

questions answers were provided in

simple terms.

5. Ask client 5. Client and familywas asked

and family to give feedback on the
questions to preventive measures of typhoid
know their level fever where they did correctly.
of insight into Client and family were thanked
the condition. for their effort and cooperation.
Thank client Procedure was documented in
and family for the nurses’ notes.

65
their

cooperation and

document in the

nurses’ notes.

66
 CHAPTER FOUR

IMPLEMENTING PATIENT/FAMILY CARE PLAN

Implementing is the fourth stage in the nursing process. It investigates actual nursing care given

to the patient and family. It aims at making patient comfortable, avoiding complication and

promoting early recovery.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT AND FAMILY

Miss Akosua Naa was admitted on the 4th of January 2010, at around 8:40pm with a provisional

diagnosis of Genelise peritonitis as a referred case from Mampong Government Hospital. Some

of the signs and symptoms she exhibited were high temperature, abdominal pain and distention,

headache and malaise.

A good interpersonal relationship was established by introducing myself to client and mother.

After acceptance by client and mother to use client for my care study, I asked few questions to

enable me carry out the study.

After admission process client and mother were reassured that client was in the hospital which

has modern machinery, equipment and competent staffs who are willing to help her recover

successfully. The client was also introduced to other patients who had similar condition and were

recovering.

67
Tempid sponging was done after checking vital signs and client having pyrexia from 38.0ºC to

37.5 ºC. All nearby windows were opened to ensure ventilation, visitors were restricted to avoid

interruption and also volume of radio and television set were reduced. Client attention was

diverted by engaging her in a conversation with the nurses to take her mind off the pain and to

ensure rest and sleep.

Client was attended promptly by the doctor on duty and series of examinations and investigations

were performed on her alongside nursing cares.

She was finally diagnosed of Typhoid fever with perforation. Prescribed medications were

administered and client was advised not to take anything by mouth as she might possibly

undergo surgery.

Nursing procedures and doctors’ orders were explained to client and mother, they were allowed

to ask questions about the condition and the operation and all misconceptions were cleared to

relieve them of anxiety.

PHYSIOLOGICAL PREPARATION

Laboratory investigations were carried out on client to assess her for surgery. The doctor was

assisted to collect blood specimen for fasting blood sugar, and grouping and cross matching to

ensure safe blood transfusion when the need be. Test for malaria parasite, Hemoglobin level

(HB) estimation and sickling has already been checked at Mampong Hospital where she was

referred from and all these were negative with HB within normal range.

68
The client was taken to the x-ray department for x-ray of the abdomen, and chest. Her

medications were collected from the dispensary. The doctor on duty was also assisted to pass

nasogastric tube to empty the stomach contentand avoid vomits during the surgical procedure.

Client was allowed to assume a suitable position and prescribed analgesic was given. Female

urethral catheter was passed for drainage of urine.

Client has a potent intravenous line and it wasmaintained andobserved for infiltration, swelling

and flow rate. IV infusions were given prescribed to prevent dehydration.

SOCIO-ECONOMIC PREPARATION

Upon assessment and interview, it was noticed that client came from a less than average socio-

economic background but fortunately client had joined the National Health Insurance Scheme

which catered for her hospital bills.

SECONDDAY OF ADMISSION AND DAY OF OPERATION (05-01-10)

Based on the results of the various investigations, it was ordered by a senior doctor on review to

prepare client for an urgent surgery (laparotomy).

Client and family were informed about it and they were reassured. This gave the opportunity for

client and family to be educated on the disease condition, the cause, the signs and symptoms, the

prevention and the complications.

Around 5:30am, client was allowed to empty the bowel, she was assisted to care for the month,

bed bathed and groomed.

69
It was explained to client the need for surgery to be done and she gave her consent by thumb

printing on the consent form.

Client was shaved from the nipple line to the middle of the thigh including the genital area and

was washed with an anti-septic solution. It was also inspected to find out and remove any

dentures to prevent dislodgement or foreign body during procedures.

Client had no rings or prosthesis on her. She was assisted to put on a theatre gown and hair cap.

Due antibiotics were given and vital signs checked and recorded as follows;

Temperature - 37.4 ºC

Pulse - 106 bpm

Respiration - 22 cpm

Blood pressure- 130/90 mm’Hg

This was to serve as a baseline data to monitor any deviation during surgery and post-surgery.

All needed particulars, laboratory results, x-ray results, IV fluids and medication together with

patient on trolley were taken to the theatre.

Client held my hands and prayed to God to see her through the surgery. She was then handed

over to the anesthetist for anesthetic assessment to be done at the theatre door.

70
After the surgery, Miss Akosua Naa was sent to the intensive care unit for monitoring until she

regained consciousness. Her vital signs were monitored as requested by the surgeon. This is

shown in appendix 1, table I.

She was nurse in a recumbent position with the head tilled to one side to aid in the secretion of

drainage and easy breathing, side rails were raised in support to prevent falling when regaining

consciousness from anesthesia.

Resuscitation equipment was assembled at the bedside in readiness for possible emergencies

such as asphyxia.

Strict intake and output of fluid and electrolytes was maintained. This was recorded on daily

basis as illustrated in appendix 2.

Other nursing cares such as administration of drugs, inspection of operation site, emptying of

drainage bags were performed. Miss Akosua Naa regained full consciousness at around 5:00pm

and when she was stable she was trans- out to ward C1B for continuation of care.

Ready in the ward, was a neatly prepared operation bed with all the necessary accessories

including temperature tray, blood pressure apparatus, drip stand, resuscitation tray, sanction

machine and oxygen apparatus. This was to arrest any emergencies in case it occurs.

71
Client pain consent was addressed post operatively by implementing nursing intervention such as

nursing client on the unaffected side and using bed cradle to lift the weight of bed linen on the

incisional site and checking recording vital signs.

Prescribed analgesics were also given.

THIRD DAY OF ADMISSION AND FIRST DAY OF OPERATION (06-05-10)

This was the first day post-operatively, client general condition was stable and looked a bit

cheerful than the previous day. She was reassured that with good nursing and medical

intervention she will recover fully like the other healthy ward mates.

Client was served with a warm bedpan on request and she passed black watery stool about

300mls, urine emptied was 800mls and 150mls of aspirated fluid from nasogastric tube. All

documented. She was given a warm bath in bed and her mouth was cared for with tooth paste

and brush. She was groomed and guided to stretch the arms, turn side and side in bed, flex and

extend the legs. This was to promote fleshiness, improve circulation and encourage early

ambulation respectively.

Vital signs were checked and recorded, values were within normal range. Prescribed intravenous

medications were served with no reaction noticed.

The wound site was inspected for discharge, bleeding and swelling. Intravenous infusions were

served and recorded as shown in table 2 appendix 2.

72
In the afternoon at around 3:00pm, client complained of difficulty in breathing. Her vital signs

were checked and it was ensured that no tight clothing or bangs was on patients. She was nursed

in a semi-flowers position to aid in breathing with head turned to one side and to assist in

drainage. Prescribed oxygen 4 liters per minute were administered. Client was reassured that

measures underway will ensure and maintain her normal breathing pattern.

FOURTH DAY OF ADMISSION AND SECOND DAY POST OPERATIVE (07-01-10)

In the morning of the second day post operatively, basic nursing procedures were performed on

client including bathing and grooming, oral care and serving of bed pan. Client was encouraged

to perform active exercises such as sitting up in bed and on chair, walking around her bed and in

the ward. The urine output and nasogastric tube content were checked and emptied and was

recorded accurately. At the time of ward rounds client’s condition was satisfactory to the surgeon

and he ordered that the urethral catheter and nasogastric tube should be removed but client

should continue IV treatments.

To prevent wound infections the site was inspected for any abnormal discharge. Vital signs were

checked regularly and prescribed anti biotic were served and documented.

In the evening, at around 8pm client complained of sleeplessness. To ensure that she enjoys

enough sleep, her bed was made comfortable regularly. Noise was reduced in the ward and

nearby curtains was raised to improve ventilation. Prescribed analgesic IM Pethidine 100mg was

administered. Client was reassured that she will recover safely.

73
 FIFTH DAY OF ADMISSION AND THIRD DAY POST OPERATIVE (8-04-10)

According to the night report client had a sound sleep. Routine nursing care was rendered to

client and now she looks very cheerful.

The wound was opened and it looked neat and dry. Wound dressing was done with methylated

spirit and covered with sterile gauze aseptically

Client was advice not to be touching the wound and be neat all the time so as not to alter the

healing process. She was also educated on what to eat to promote wound healing such as eating

fruits and vegetables,

On review doctor observed that bowel sound has resumed and ordered that intravenous fluids

should be discontinued and start slip of water. As client can tolerate plain tea could be added,

followed by fluid diet, soft diet and then normal diet.

Vital signs were checked and recorded as ordered and due medication given. Client slept at

8:00pm after evening routine care has been rendered,

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SIXTH AND SEVENTH DAY OF ADMISSION AND FOURTH AND FIFTH DAY POST

OPERATIVE (9TH AND 10TH JANUARY 2010)

Client condition was known to have improved considerably on the sixth day of admission. The

usual nursing care was carried out; vital signs were checked and recorded.

Client made no complains on review. The surgeon ordered that alternate stitches should be

removed and the remaining ones on the 9th day post-operatively. The wound site was

inspected and she was put on Tablets ciprofloxacin 500mg, Tablets Diclofenac 625 bd for

7 days, Tab vitamin B 30mg tds x5 days, Tab fersolate 200mg tds x 16 days.

Oral feeding was to proceed gradually as condition improves and client could tolerate.

On the 7th day, all routine nursing care was carried out, meals and medication served, vital signs

checked and recorded.

Requirements for the removal of stitches and wound dressing were assembled and alternate

stitches were removed, wound was made clean and dressed antiseptically. Instruments were

washed and made ready for the next use.

Diet was planned with client to know her likes and dislikes and to prevent any allergies.

In the evening client meals and drugs were served and personal hygiene maintained as well, after

which rest and sleep was ensured.

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 SECOND WEEK OF ADMISSION

When I reached the ward in the morning of the second week of admission, client had already

catered for her personal hygiene. Routine care was rendered, breakfast served, medication given

and vital signs checked and recorded.

At the time of ward rounds, client has no complains, wound site was inspected and was found

dry and healing. The doctor made no changes in the client treatment.

Daily nursing processes were carried out and recorded as required. On the ninth day, the

remaining stitches were removed and wound dressed aseptically as ordered by the doctor. She

continued with her treatment as prescribed.

On Thursday, the 14th of January 2010, at around 8am, doctors came on general ward rounds and

client has no complain to give. She was declared fit for discharge so she was discharged and to

come for review on the 21st day of January 2010.

Throughout the care of client, isolation and barrier nursing was implemented to prevent cross

infection to health care members and other clients. This was ensured by screening client, wearing

gloves and mask when coming into contact with body fluids and proper hand washing

techniques. Client’s left-over food was thrown away, plates, cups and spoons washed and placed

separately for her alone. All instruments and equipment used for the client were properly

disinfected and sterilized as well as used clothing and bed linen.

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PREPARATION OF PATIENT/FAMILY FOR DISCHARGE AND REHABILITATION

Preparation of Miss Naa Akosua and family began on the day of admission and this was known

to her and her mother that after a good medical and nursing care, she would be discharged home

to continue her care at home. When Akosua and her mother were informed of the possible date

of discharge they were overwhelmed so I took the chance to educate them on the disease

condition again.

Health education on nutrition was given and on balance diet and examples of food stuffs that are

nutritious were mentioned to her like protein foods; meat, fish, agushi just to mention but a few

to help build worn out tissues, vitamins to boast up her immune system and carbohydrates to

provide the required energy as well as minerals.

Proper refuse disposal to prevent contamination and spread of diseases in their house was also

made clear to them. Akosua and her family were educated against self-medication and advised to

report any sickness to the hospital.

Meanwhile, proper food hygiene was over-emphasized and not left out. They were also informed

about the review date on which the client should come to the hospital for review.

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 FOLLOW UP/HOME VISIT/CONTINUATY OF CARE

FIRST HOME VISIT

My first home visit was done on the 9th of January 2010 at 1:00pm with her mother while client

was on admission. This was done to familiarize myself with the living environment of the client

and to correct practices or habits that may contribute to ill health of Miss Naa Akosua and her

family.

The house is located at the far end of the town Ejura, near a public place of convenience and a

big refuse collecting dump. There were people who cook and sell all kinds of foods at the edge

of the park next to the refuse dump where Akosua usually buys food in the morning.

At the house, the compound was neat and rubbish was kept in a bucket without a lid and was

emptied at the community’s refuse collecting dump every morning. I congratulated them for

keeping the house neat but took the opportunity to advise them to cover the rubbish bin to

prevent flies contaminating their foods. Also all the windows in the house had mosquito proof

nets to prevent entry of mosquitoes. There was one stand pipe in the house.

Their house is a compound house and each room contains one family. Akosua and two sisters

share a room.

The Ejura community has some social amenities which includes seventeen (17) basic schools,

one (1) senior high school, one (1)Agric college, four rural banks, Agric development bank, a

Commercial Bank, the Ejura farm which is one of the Nation’s farm, a 40 acre square market

78
believed to be the third largest after Mankesim and Takyiman and a Government Hospital. The

hospital does receive referrals from the clinics of the surrounding towns and villages.

A community health nurse, Mrs. Prempeh Abigail was contacted and all the necessary

information about my client; Miss Akosua Naa especially about the unhygienic way the food

vendors go about preparing their food and the closeness to rubbish dump to the clients house.

I thanked them for their warm reception and left around 4pm.

SECOND HOME VISIT

On the 19th day of January 2010 at around 2:00pm I made the second home visit to my client’s

house after since her discharge. This was a scheduled visit with the aim of seeing whether things

have been going on well with her after discharge. Together with Mrs. Prempeh

Abigail the community health nurse, we reached the house and were warmly welcomed. Akosua

could even walk to embrace me. She looked fine and neatly dressed.

Food prepared in the house was under good and hygienic condition and left over foods were kept

in the refrigerator. I also reminded them of the review date should incase the joy of her discharge

after a successful surgery made her forget.

I enquired if Miss Naa Akosua was encountering any health problem but she said there was

none. The community health nurse told me that she had done a health talk for the community

especially those in that area and those who sell food around the park to improve their hygiene.

79
Akosua Naa and the family were not exceptions to the health talk. All the education I gave them

was also emphasized.

I informed the family of the day of my next visit which will be the last official visit and the time

for termination of care.

REVIEW OF MISS AKOSUA NAA

On Thursday, the 21st of January 2010 was the review date for Miss Akosua Naa. She came in

the company of her mother. They arrived at the consulting room 9 at KomfoAnokye Teaching

hospital around 9:00am. I assisted them to collect her folder and by 9:40am it was their turn to

see the doctor. The doctor on duty then was Dr. York. He requested for wider test and malaria

parasite but these proved negative when the results came out. Client did not have any complain.

She was also advised to continue her medications given her on the day of discharge till they get

finish completely. Akosua was encouraged to report any problem and abnormalities that may

arise after review for early interventions.

THIRD HOME VISIT

This took place on the 1st of February 2010, at 3pm to monitor continuity of care. Upon reaching

the house I was offered a seat and given water to drink.

80
Akosua was very happy when she saw me. I was asked my mission and I told them as stated

above. AkosuaNaa’s condition has improved very well than when she came for the review. Her

drugs were checked to find out whether she had taken them or not, how many of the drugs still

remained and how she was taking them. It was observed that Akosua has fully completed her

medication. I asked of how she was fairing and she said that she was doing well. A quick glance

of the environment was done and the whole place was clean and tidy.

In fact, I was glad that the health education has really gone down well with them. I told them

that, this was my last official visit to them, and they were also appreciative of the care and

support rendered during their hospitalization and my home visit.

They promised to use all the advices that had been given to them for good purpose. I handed

over AkosuaNaah to the community health nurse Mrs. Prempeh Abigail for the continuity of

care.

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 CHAPTER FIVE

EVALUATION OF CARE GIVEN

Evaluation is the assessment of outcome of nursing care rendered to the client. It is a final stage

in nursing processes. The patient was diagnosed and care plan was formulated and implemented.

STATEMENT OF EVALUATION

After the implementation of interventions, it was noticed that objectives and goals set were fully

achieved. Client condition had improved gradually by the time of evaluation without any

complications.

On the 4th of January, 2010, goal set to reduce high body temperature to normal range within 3

hours was met as client’s temperature dropped to normal (38.0 – 37.0oC).

On the same day, a goal set to relieve client’s abdominal pain and distension within 2 days was

also achieved as nurse observed reduction in abdominal distension and client verbalized relieve

in abdominal pain.

Again, on the 5th of January, 2010, goal set to reduce anxiety in client and family was achieved

after 2 days as evidenced by client and family having cheerful facial expression without anxiety

and being cooperative.

On the same day, client was relieved of incisional wound pain as client verbalized that the pain

has subsided and nurse observed client having a cheerful facial expression.

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On the 6th of January, 2010, a goal set for the maintenance of personal hygiene by client herself

was achieved within 4 days post-operatively as client verbalized that she could care for her

personal hygiene and performs normal daily activities by herself.

Another goal set for normal breathing pattern was achieved within 4 hours through good nursing

management and oxygen therapy as evidenced by client verbalizing that she could breath

normally and nurse observing that client have normal respiration rate.

Again, goal set to prevent wound infection and contamination was met throughout the period of

hospitalization as nurse observed that client wound healed by first intention without infection.

Then on the 7th of January, 2010, client had sleeping pattern disturbance and nursing

management put in place to help client to sleep 3 hours in the day and 6-8 hours in the night.

This was a goal met.

Furthermore, a goal set to achieve good nutritional status was achieved gradually 5 days post-

operatively as evidenced by client eating enoughamounts of food served and looking healthy.

Again, a goal was set to provide adequate information about client’s disease condition on the 5th

of January, 2010 before discharge and this was met as client and family was able to give a

feedback on health education.

Other nursing goals were also met.

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 AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET

OUTCOME CRITERIA

Upon careful evaluation of the nursing care rendered to Mrs. Akosua Naa and her family, all

goals and objectives set were fully met. Therefore, there was no need for amendment of any of

the objectives set during the care of the patient

TERMINATION OF CARE GIVEN

The termination of care is the last phase of interaction of the nurse, patient and relative.

Terminating the care given to Miss Akosua Naa and family was very successful since I informed

them on the day of admission about my interaction with them being temporal and the care will be

terminated after her discharge and also on my second home visit.

Consequently during my third home visit, I made them aware that it was my last official visit to

them. The community Health nurse of Ejura, Mrs. Prempeh Abigail took charge of the care over

all the important facts and documents about Miss Akosua Naa.

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 SUMMARY AND CONCLUSION

SUMMARY

Miss Akosua Naa, a 24 year old seamstress apprentice was admitted to the accident and

emergency department of KomfoAnokye Teaching Hospital (KATH) on the 4th January, 2010

with provisional diagnosis of generalize peritonitis as a referred case from Mampong

Government Hospital.

Upon various laboratory investigations it was later diagnosed as Typhoid fever with perforation.

She was sent to the theatre on the second day of admission for laparotomy to be done. The client

complained of severe abdominal pain and pyrexia. Nursing diagnosis were made and

interventions were implemented to ensure client recovery.

Vital signs were oriented and checked ordered. The drugs prescribed for client included;

antibiotics, analgesics, anti-inflammatory and intravenous fluid. Some of those drugs were

Ciprofloxacin, injection Pethidine, Diclofenac, IV Metronidazole and Normal saline. They were

administered as prescribed.

Nursing problems were managed through the use of nursing care plan. Goals set for the

management of the patients’ problems were fully met.

Client was discharged after being declared medically fit by DrAitpilla on the 14th January, 2010,

client was asked to come for review on 21st January, 2010. She was advised to take her

medications regularly throughout hospitalization and after discharge.

85
The client and mother were given health education on client’s condition, good personal and

environmental hygiene and good nutrition. Interaction with client and family lasted for twenty

eight (28) days after which the care was terminated. There were three subsequent home visits to

client’s house to know how client was fairing in her environment and whether all the education

given was being implemented.

Last but not least, my study on Miss Akosua Naa has been very successful and smooth. The

period has been useful because client and mother have learnt about typhoid fever, its causes,

clinical features, management, complications and its prevention.

CONCLUSION

In conclusion, I wish to say that choosing Miss AkosuaNaa as my client has made me to

understand how to apply the nursing process to render holistic care to patient.

This has also allowed me to put the knowledge I have acquired in the three (3) year training in

nursing into practice. I have also been enlightened on the disease condition typhoid fever.

Again, I have established good nurse-client/family relationship and I hope this knowledge will

help me in my practice as a nurse.

86
I therefore suggest that all patients should have access to equal opportunities to individualized

nursing care to promote early recovery and to reduce the incidence of mortality and recurrence of

diseases.

87
 BIBLIOGRAPHY

Carpenter, OD (2000) Nursing 99 Drug hand book.1 edition, Springhouse, London.

Christensen PJ et al (1990) Nursing Process. Application conceptual manual.3rd edition, The CU

Mosby Company, London.

HOPE R.A (1993) Oxford Handbook of Clinical medicine, 3rd edition. Oxford University press

Springhouse, London.

Margaret, P. (2008). Practical Nursing, 19th edition, Edinburg Printing press, London

Skidmore-Roth L. (2006), Nursing Drug Reference, 9th Edition, Elsevier Mosby Inc.,

Philadelphia, U.S.A.

Spark M.S (2007) Nursing Diagnosis Reference Manual, 8th edition, Springhouse Co-operation,

U.S.A.

Patient folder number 24760.

88
 APPENDIX 1

Table 1

OBSERVATION CHART FOR THE FIRST THREE HOURS

TIME TEMPERATUR PULSE (BPM) RESPIRATION BLOOD

E (CPM) PRESSURE

(ºC) (MMHG)

1:30pm 35.6 110 24 125/60

1:45pm 35.8 115 24 120/70

1:60pm 36.0 114 24 130/80

2:15pm 36.2 105 22 135/80

2:45pm 36.3 110 23 150/80

3:15pm 36.3 111 23 140/80

3:45pm 36.5 105 23 140/80

4:15pm 37.5 100 23 130/80

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 APPENDIX 2

INTAKE AND OUTPUT CHART

Table I

DATE/TIME FLUID AMOUNT DATE/TIME URINE/MLS ASPIRATE

(MLS)

05-04-10 Dextrose 1000mls 05-04-10 600mls 300mls

12:00noon Saline 3:30pm

5:00pm Ringers 1000mls 7:00pm 550mls -

Lactate

TOTAL 2000mls 1150mls 300mls

Total input 2000mls

Total output 1450mls

Balance = 550mls

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Table II

DATE/TIME FLUID AMOUNT DATE/TIME URINE/MLS ASPIRATE

(MLS)

06-04-10 Normal 1000mls 06-04-10 800mls 150mls

8:00am Saline 3:30pm

6:00pm Dextrose 1000mls 11:00pm 550mls

Saline

TOTAL 2000mls 1350mls 150mls

Total input 2000mls

Total output 1500mls

Balance = 500mls

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Table III

DATE/TIME FLUID AMOUNT DATE/TIME URINE/MLS

07-04-10 Metronidazole 1000mls 07-04-10 200mls

7:00am and ringers 10:00am

lactate

3:00pm Metronidazole 1000mls 5:00pm 150mls

and ringers

lactate

TOTAL 2000mls 350mls

Total input 2000mls

Total output 350mls

Balance = 1650mls

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Table IV

DATE/TIME FLUID AMOUNT DATE/TIME URINE/MLS

08-04-10 Ciprofloxacin 1000mls 07-04-10 1000mls

6:00am plus normal 3:30pm

saline

8:00am Dextrose 1000mls 1:30pm 550mls

1:45pm Water 50mls 3:30pm 40mls

9:30pm Plain Tea 100mls 10:00pm 70mls

09-04-10 Light soup 300mls 09-04-10 40mls

2:00am 2:00am

11:00am Water 200mls 12:00noon 100mls

TOTAL 2650mls 1800mls

Total input 2650mls

Total output 1800mls

Balance = 850mls

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 SIGNATORIES

NAME OF CANDIDATE : ………………………………………………

DATE :…………………………………………………

SIGNATURE : ………………………………………………..

NAME OF SUPERVISOR :……………………………………………………

DATE :…………………………………………………….

SIGNATURE : ……………………………………………………

NAME OF SISTER IN CHARGE :…………………………………………………

DATE :…………………………………………………

SIGNATURE : …………………………………………………

NAME OF PRINCIPAL :……………………………………………………..

DATE :………………………………………………………

SIGNATURE :……………………………………………………….

94