PATIENT/FAMILY CENTERED CARE STUDY

(A NUSRING PROCESS APPROACH)

ON A PATIENT WITH ACUTE GASTRITIS

WRITTEN BY:

FOSU QUEENSTER

(COHSARGN230084)

A FINAL YEAR STUDENT OF COLLEGE OF HEALTH,

SEFWI ASAFO WESTERN-NORTH REGION

SUBMITTED TO THE NURSING AND MIDWIFERY COUNCIL OF GHANA IN

PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

PROFESSIONAL CERTIFCATE IN REGISTERED GENERAL NURSING.

MAY, 2026.
 PATIENT/FAMILY CENTERED CARE STUDY

(A NUSRING PROCESS APPROACH)

ON MRS. P. N. WITH ACUTE GASTRITIS

WRITTEN BY:

FOSU QUEENSTER

(COHSARGN230084)

A FINAL YEAR STUDENT OF COLLEGE OF HEALTH,

SEFWI ASAFO WESTERN-NORTH REGION

SUBMITTED TO THE NURSING AND MIDWIFERY COUNCIL OF GHANA IN

PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

PROFESSIONAL CERTIFCATE IN REGISTERED GENERAL NURSING.

MAY, 2026.

i
 PREFACE

In the contemporary, rapid-paced healthcare landscape, the trajectory toward a nursing career is

multifaceted and rigorous. Trainees must reconcile the mastery of sophisticated clinical

techniques with a deep respect for foundational nursing principles and the social determinants

influencing health outcomes. This integration of expertise cultivates competent practitioners

dedicated to lifelong learning. This manuscript functions as an indispensable resource for

educators and pupils, demonstrating the application of the nursing process within modern

medical settings.

The nursing process provides a methodical framework, guaranteeing that every individual

receives comprehensive and systematic attention.

As medical paradigms shift, an increasing emphasis on primary healthcare has emerged. This

transition necessitates advanced training for nursing professionals to manage expanded roles,

ultimately enhancing the efficiency and accessibility of health services for the public.

The Patient Care Study stands as a mandatory scholastic endeavor for all nursing candidates in

the final year of study. Completion is an obligatory prerequisite established by the Nursing and

Midwifery Council (NMC) for professional registration. This directive encompasses third-year

NMC pupils and Level 400 university scholars across various disciplines, including General

Nursing (RGN), Mental Health (RMN), Community Health (RCN), and Midwifery (RM).

Within the Ghanaian triennial nursing syllabus, this project represents a critical milestone for

attaining the status of Registered General Nurse. To fulfill this criterion, a student delivers "total

care" to a specific individual. This entails managing the health experience from admission

through discharge, conducting post-hospitalization visits, and fostering a collaborative

relationship with the patient and the domestic circle.

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Adhering to ethical standards regarding confidentiality, the actual identity of the patient remains

undisclosed. Throughout this report, the initials of the patient’s name, Mrs. P. N. is used.

iii
 ACKNOWLEDGEMENT

Deepest appreciation is first extended to the Almighty God, whose guidance and fortitude

permitted the successful conclusion of this work.

Sincere thanks are offered to the patient, Mrs. P. N., and the family members. Willingness to

participate and steadfast cooperation during the care delivery phase proved indispensable.

Profound gratitude is directed toward the Principal, Dr. Susan Yaa Aframa Arkah, and the

supervisor, Mr. Jacob Nrenzah. Exceptional patience and expert direction were vital in refining

this project. Appreciation is also extended to the faculty at the College of Health, Sefwi Asafo,

for establishing the academic groundwork necessary for professional advancement.

Recognition is due to Mrs. Grace Adu Mintah, the Ward Head, and the entire medical team at the

female medical unit of St. John of God Hospital, Sefwi Asafo. Assistance in patient selection and

general cooperation were fundamental to the realization of this clinical inquiry.

To the immediate family, especially the parents, Mr. Kwadjo Fosu and Mrs. Esther Twumwaa,

thank you for the enduring love and support provided at every stage. Gratitude is also shared

with friends and colleagues for the encouragement and motivation offered during this process.

Finally, acknowledgment is given to the researchers and publishers whose academic

contributions provided the necessary evidence and theoretical framework for this documentation.

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 INTRODUCTION

The Patient and Family Care Study is a mandatory academic requirement mandated by the

Nursing and Midwifery Council (NMC) of Ghana. Every final-year candidate must produce this

detailed written work as an essential condition for the award of a Diploma in Nursing. The

central objective involves utilizing the nursing process to assist an individual in attaining and

maintaining a peak state of health.

Furthermore, this assignment enables the student nurse to synchronize theoretical knowledge

with practical clinical application through holistic interventions. It serves as a vital assessment of

the ability to view the patient as a whole person, situated within a family and community context,

rather than merely a medical diagnosis.

This specific report outlines the care administered to Mrs. P. N., a 46-year-old resident of Sefwi

Akontombra in the Western North Region. Admission to the female medical ward at St. John of

God Hospital, Sefwi Asafo, occurred on September 24th, 2025, at 11:13 a.m. Following a

thorough physical exam and diagnostic evaluations, the diagnosis was determined to be Acute

Gastritis.

Mrs. P. N. arrived at the unit accompanied by her spouse and a nursing officer. After receiving

the necessary paperwork, greetings were exchanged and the couple was made comfortable.

Details were validated by comparing the medical folder with verbal responses. Following a

review of the initial documentation, an interview regarding symptoms was conducted,

confirming the clinical assessment.

Upon recording the arrival in the official logs, the bedside environment was prepared, and

introductions to the ward personnel were made. A tour of the facility was provided, highlighting

v
essential areas such as the pharmacy and restrooms. The objectives of the academic study were

then explained, and formal consent was obtained from both Mrs. P. N. and her husband.

On September 28th, 2025, following a successful recovery and a concluding medical review,

Mrs. P. N. was officially discharged.

To ensure high-quality continuing care, three distinct home visits were conducted:

First Home Visit: Conducted on September 27th, 2025 (prior to discharge), to evaluate the

living environment and identify community factors impacting health.

Second Home Visit: Conducted on October 12th, 2025, to monitor progress and reinforce the

importance of medication adherence and lifestyle modifications.

Third Home Visit: Conducted on October 17th, 2025, for a final assessment. Upon confirming

the patient remained healthy and well-supported, the case was officially closed.

This report is partitioned into five chapters:

Chapter One entails the assessment of the patient and family. This includes demographic data,

family history, the admission narrative, personal perceptions of the illness, a literature review of

the medical condition, and data validation.

Chapter Two centers on the interpretation of findings. It contrasts information from the patient

and family, emphasizes clinical strengths, identifies health deficits, and establishes specific

nursing diagnoses.

Chapter Three presents the nursing care plan, detailing the objectives and interventions

designed to meet the immediate and future health needs of the patient and family.

Chapter Four provides a chronological account of the care delivered, documenting the specific

interventions and the procedures followed during the discharge phase.

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Chapter Five offers a concluding evaluation. This section includes adjustments for unmet goals,

the formal conclusion of the professional relationship, a summary, a final conclusion, and

recommendations for future nursing practice.

vii
 TABLE OF CONTENT

PREFACE.......................................................................................................................................II
ACKNOWLEDGEMENT.............................................................................................................IV
INTRODUCTION..........................................................................................................................V
TABLE OF CONTENT...............................................................................................................VII
LIST OF TABLES..........................................................................................................................X
CHAPTER ONE..............................................................................................................................1
ASSSESSMENT OF PATIENT / FAMILY...............................................................................1
1.0 INTRODUCTION.................................................................................................................1
1.1 PATIENT’S PARTICULARS...............................................................................................2
1.2 PATIENT/ FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY..........................2
1.2.1. PATIENT/FAMILY MEDICAL HISTORY.................................................................2
1.2.2. PATIENT/FAMILY SOCIO-ECONOMIC HISTORY................................................3
1.3. PATIENT DEVELOPMENTAL HISTORY.......................................................................3
1.4 PATIENT’S LIFE STYLE/HOBBIES..................................................................................5
1.5 PATIENT PAST MEDICAL/SURGICAL HISTORY/ OBSTETRIC HISTORY...............6
1.5.1. PAST MEDICAL/SURGICAL HISTORY...................................................................6
1.5.2. PAST OBSTERIC HISTORY.......................................................................................6
1.6 PATIENT PRESENT MEDICAL HISTORY.......................................................................6
1.7 ADMISSION OF PATIENT.................................................................................................7
1.8 PATIENT’S CONCEPT OF HER ILLNESS......................................................................10
1.9 LITERATURE REVIEW....................................................................................................10
1.10 VALIDATION OF DATA................................................................................................15
CHAPTER TWO...........................................................................................................................16
2.0 ANALYSIS OF DATA.......................................................................................................16
2.1 COMPARISON OF DATA WITH STANDARD...............................................................16
2.1.1 DIAGNOSTIC INVESTIGATIONS / TEST...................................................................16
2.1.2 CAUSES OF PATIENT’S ILLNESS...........................................................................20
2.1.3 Clinical Features...........................................................................................................20
2.1.4 SPECIFIC MEDICAL TREATMENT.........................................................................20
[Link] PHARMACOLOGY OF DRUGS ORDERED.....................................................21

viii
 2.1.5 COMPLICATIONS......................................................................................................27
2.2 PATIENT/FAMILY STRENGTH......................................................................................27
2.3 PATIENT’S HEALTH PROBLEMS..................................................................................27
2.3.1. PATIENT’S STRENGTH ACCORDING TO IDENTIFIED PROMBLEMS...........28
2.4 NURSING DIAGNOSIS.....................................................................................................28
CHAPTER THREE.......................................................................................................................29
3.0 PLANNING FOR PATIENT AND FAMILY CARE.........................................................29
3.1 OBJECTIVES AND OUTCOME CRITERIA....................................................................29
CHAPTER FOUR.........................................................................................................................43
IMPLEMENTATION OF PATIENT / FAMILY CARE PLAN..............................................43
4.0 INTRODUCTION.....................................................................................................................43
4.1 SUMMARY OF ACTUAL CARE RENDERED TO PATIENT/FAMILY.......................43
4.1.1 SUMMARY OF ACTUAL NURSING CARE RENDERED..........................................43
4.1.2 DAY OF ADMISSION (24/09/2025)..........................................................................44
4.1.3 FIRST DAY ON ADMISSION (25/09/2025)..............................................................48
4.1.4 SECOND DAY ON ADMISSION (26/09/2025).........................................................50
4.1.5 THIRD DAY ON ADMISSION (27/09/2025).............................................................51
4.1.6 FOURTH DAY ON ADMISSION (DAY OF DISCHARGE) - 28/09/2025...............52
4.2 PREPARATIONS OF PATIENT AND FAMILY TORWARD DISCHARGE AND
REHABILITATION..................................................................................................................53
4.3 FOLLOW-UP / HOME VISITS / CONTINUITY OF CARE............................................54
4.3.1 FIRST HOME VISIT (27/09/2025)..............................................................................55
4.3.2 SECOND HOME VISIT (12/10/2025)........................................................................55
4.3.3 DAY OF REVIEW (14/10/2025).................................................................................56
4.3.4 THIRD HOME VISIT (17/10/2025)............................................................................57
CHAPTER FIVE...........................................................................................................................58
EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY...............................58
5.0 INTRODUCTION.....................................................................................................................58
5.1 STATEMENT OF EVALUATIONS..................................................................................58
5.2 AMENDMENT OF CARE PLAN......................................................................................59
5.3 TERMINATION OF CARE................................................................................................60

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 5.4 SUMMARY AND CONCLUSION....................................................................................60
5.5 RECOMMENDATION.......................................................................................................62
BIBLIOGRAPHY..........................................................................................................................63
APPENDIX....................................................................................................................................66
SIGNITORIES...............................................................................................................................67

x
 LIST OF TABLES

TABLE 1: COMPARISON OF DIAGNOSTIC TEST AND INVESTIGATION CARRIED OUT ON PATIENT

WITH THAT OF THE LITERATURE REVIEW..............................................................................17

TABLE 2: DIAGNOSTIC INVESTIGATIONS/TEST CARRIED OUT PATIENT.....................18

TABLE 3: CLINICAL FEATURES MANIFESTED BY MRS. P. N. AS COMPARED TO THAT

OF THE LITERATURE REVIEW.......................................................................................20

TABLE 4: COMPARISON OF PATIENT’S TREATMENT WITH THAT OF LITERATURE REVIEW..........21

TABLE 5: PHARMACOLOGY OF DRUGS ADMINISTERED TO MRS. P. N.........................22

TABLE 6: NURSING CARE PLAN FOR MRS. P. N...................................................................31

TABLE 7: OBSERVATIONAL CHART FOR MRS. P. N............................................................66

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 CHAPTER ONE

ASSSESSMENT OF PATIENT / FAMILY

1.0 INTRODUCTION

Assessment is the collection of data from Mrs. P. N’s, relatives, friends and other sources

systematically based on the condition. It gives information about the Mrs. P. N, family and

community characteristics. This is acquired through observation, interviewing, physical

examination, investigations such as laboratory test, x-ray reports and others from which analysis

are made to arrive at a remedy to Mrs. P. N problems. This form the first phase of the nursing

process on which it is based for diagnosis to be established.

Assessment of patient covers the following areas:

a. Patient particulars

b. Family medical and socioeconomic history

c. Patient development history.

d. Patient’s lifestyle/hobbies

e. Patient’s past medical/surgical history.

f. Patient’s present medical history

g. Admission of patient

h. Patient/family concept of illness

i. Literature review on Acute Gastritis

j. Validation of data collected.

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1.1 PATIENT’S PARTICULARS

Mrs. P. N, a 46-year-old Ghanaian woman was born at Sefwi Akontombra in the Juaboso

Municipality in the Western North region of Ghana on the 13 th June, 1979 to Mr. K. T and Mrs.

F. D. She is a native of Sefwi Akontombra. She is the fifth born of seven children, four males

and three females. She is a farmer who works from Monday to Saturday from 9:00am to 2:30pm

each day. She is currently staying in Asawinso in the Wiawso municipality of the Western North

Region with her husband Mr. D. M and five children, all females. The children are; Ms. D. J, Ms.

L. S, Ms. P. S, Ms. G. B, and Ms. H. W whose ages 17 years, 15 years, 12 years, 8 years, and 4

years respectively. Mrs. P. N is a Christian who is a member of the Assemblies of God Church.

She is Sefwi by tribe and speaks Sefwi, Twi and English languages. She is dark in complexion,

weights 68kg and is 5 feet tall. She had a formal education, but only to the upper primary level

and is currently a farmer. Mrs. P. N leaves in a blue 4-bedroom self-contain house built with

blocks and cement, and roofed with aluminum sheets. The next of kin is her eldest daughter, Ms.

D. J.

1.2 PATIENT/ FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY

1.2.1. PATIENT/FAMILY MEDICAL HISTORY.

According to the patient, her family has history of hypertension (her mother) but no

communicable diseases such as tuberculosis and mental illness such as psychosis, schizophrenia

dementia and others. Her family occasionally suffers minor ailments such as headache, general

body weakness, common cold and cough. They rely on over-the-counter drugs like Tablet

paracetamol and cold relief for treatment when any family members suffered any of these

ailments. According to Mrs. P. N, she most often goes to the hospital for treatment when she has

symptoms of malaria. She has been admitted at the Asawinso Government Hospital before for

2
malaria. She added that no surgical procedure has ever been performed on any of her nuclear

family members. According to Mrs. P. N, she has no known allergies.

1.2.2. PATIENT/FAMILY SOCIO-ECONOMIC HISTORY

Socioeconomically, Mrs. P. N is a farmer, she farms cocoa with her husband, Mr. D. M. She

earns an average income, which primarily comes from the sales of the cocoa produce. She uses

her earnings to support herself and her family. She only gets support from her husband and other

family members when the needs arise.

Patient’s family falls within the middle- class income category as they are able to provide for all

the basic needs of the family such as food, shelter and clothing. Mrs. P. N finds herself in the

nuclear family system where she is staying with her husband and children at Asawinso.

Mrs. P. N stated that, the whole family is insured by the health insurance scheme and they have

been beneficiaries since its inception in Ghana.

1.3. PATIENT DEVELOPMENTAL HISTORY.

According to Mrs. P. N her mother told her she was delivered at full-term, spontaneously per

vaginum on the 12th June, 1979 at home without any complications at Sefwi Akontombra with

the help of a traditional birth attendant, Madam S. S.

She could hardly remember if she was immunized against all the six childhood killer diseases but

there was a mark on her right deltoid muscles which indicated that she was immunized.

Mrs. P. N could recall that her mother told her that she was exclusively breastfed for only two

months and complementary feed were added because she had no idea of the six months exclusive

breastfeeding plan by then. She had a progressive and successful developmental process without

any difficulty. She sat at the age of six months, crawled at six months, stood up with support at

3
nine months, and walked at about twelve months. She was able to say “Mama” and “Dada” when

she was one and a half years and was weaned off the breast at age two.

She had her secondary sexual characteristics, thus menstruation, development of breast, growing

of hairs at the axilla and pubic area at the age of fourteen. She added that she progressed through

adolescence without any adolescent health crisis. She stated that she is not in her menopausal

stage yet because she still menstruates.

She also added she started school at the age of seven years in Primary on at Sefwi Akontombra

basic school where she stopped schooling at the age of 16 at the upper primary level herself due

to poor academic performance, after which she was forced to join her parents farm.

Ms. P. N. also stated that, she got married at the age of 26 and gave birth to her first born when

she was 29 years old. She currently have five children, all females.

According to Erik Erickson's psychological theory, every individual goes through 8 stages of

development with their corresponding ages. These stages are;

 Trust versus Mistrust (0-18 months)

 Autonomy versus Shame and Doubt (18 months-3 years)

 Initiative versus Guilt (3- 6 years)

 Industry versus Inferiority (6-12 years)

 Identity versus Role confusion (12-18 years)

 Intimacy versus Isolation (18-35 years)

 Generativity versus Stagnation (35-60 years)

 Integrity versus Despair (60 years and above)

Mrs. P. N is forty-six (46) years old so she falls in Generativity versus Stagnation.

Erikson explain generativity as specially the unconditional giving that characterized

4
positive parental love and care for their off-springs and the stagnation is an extension of

intimacy which turns inward in the form of self-interest and self-absorption. According

to Mrs. P. N., she actively invests her time in teaching, coaching and mentoring her

children and the younger people in the family. She goes on to form intimate relationship

with friends and family members. Her greatest fear is to not positively impact the

younger generation or feeling stuck in life.

1.4 PATIENT’S LIFE STYLE/HOBBIES

Mrs. P. N begins her day at approximately 6 a.m. She empties her bowel two times in a day. She

brushes her teeth ones daily, thus in the morning only. Her urination depends on the amount of

fluid she takes in. She bathes twice a day, morning and evening.

She eats three main meals daily: she eats breakfast (usually porridge) around 7:10 a.m.; she takes

lunch around 2:00 p.m., and she has dinner around 6:30 p.m. She takes her lunch, which consists

of ampesi and kontomire (she prepares it in the farm). She goes to the farm with her husband

around 8 a.m. She stated that she has no known allergies to food or medication, and she abstains

from both smoking and alcohol. She loves banku with okro soup.

According to Mrs. P. N, her husband and her go to the farm from Monday through to Saturday.

They finish the farm work and closes at 2:30 p.m. She is an introvert, but she extends respect to

all ages. When she wants to relax, she watches movies on the television or listens to music. After

she finishes supper, she spends time with her husband chatting and watching movies together.

She rests on Sundays after she attends church service.

She retires to bed around 8 p.m. after she says her evening prayers.

5
1.5 PATIENT PAST MEDICAL/SURGICAL HISTORY/ OBSTETRIC HISTORY

1.5.1. PAST MEDICAL/SURGICAL HISTORY

Mrs. P. N has no known hereditary disease such as rheumatism and hypertension. She mostly

uses over the counter drugs to treat her ailments or go to the hospital when she deems necessary.

According to Mrs. P. N, she most often goes to the hospital for treatment when she has

symptoms of not being well and has been admitted at the Asawinso Government Hospital before

for malaria. She also stated that no surgical procedure has been performed on her before.

Mrs. P. N has no known allergies.

1.5.2. PAST OBSTERIC HISTORY

According to Mrs. P. N, she has given birth to five children, all females. The children are; Ms. D.

J, Ms. L. S, Ms. P. S, Ms. G. B, and Ms. H. W whose ages 17 years, 15 years, 12 years, 8 years,

and 4 years respectively. She gave birth to them spontaneously in the hospital without any

complication. According to Mrs. P. N, she has had no abortion or miscarriage before. She said

she reached her puberty which was evident with the onset of menstruation which was

accompanied with the secondary characteristics like breast enlargement and growth of pubic

hairs at age fourteen and had her first coitus at the age of twenty. Mrs. P. N added that, even

though she adequate knowledge on several family planning methods, she has never used any

before.

1.6 PATIENT PRESENT MEDICAL HISTORY

According to Mrs. P. N, she felt seriously sick on the 23 rd September, 2025. She exhibited the

following signs and symptoms: abdominal pains, loss of appetite, and headache. She took

paracetamol and mist magnesium trisilicate of which she bought from a nearby drug store. There

6
was an improvement in her condition for about 10 hours after taking the above mentioned over

the counter medications.

Unfortunately for Mrs. P. N, the previous signs and symptoms reoccurred the following day

morning and her condition was worse this time round with vomiting (4 times). She was rushed to

the St. John of God Hospital, Sefwi Asafo on the 24 th September, 2025 at 11 a.m. by her

husband. Upon arrival to the hospital, they went to the Out-Patient Department where she was

seen by Dr. A. Upon the doctor’s examination, he diagnosed her of acute gastritis and admitted

her to the female’s medical ward for management.

1.7 ADMISSION OF PATIENT

Mrs. P. N. was admitted to the Female’s Medical Ward of the St. John of God Hospital, Sefwi

Asafo on the 24th September, 2025 at 11: 13 a.m. through the Out-Patient Department with the

diagnosis of acute gastritis. Patient was accompanied by a nurse and her husband. Patient and

relatives were warmly welcomed. Patient’s name was confirmed by calling out the name on the

electronic system and patient responded. Patient and husband were reassured of getting good

medical and nursing care. They were welcomed and she was admitted into an already prepared

admission bed. Her relatives were reassured that she was in safe hands and would be given the

best of care. All the necessary information were gathered and other related documents from her

relatives and the accompanying nurse. Her personal information was carefully read and patient’s

name, sex, occupation, diagnosis and other details were confirmed with the help of the husband

and the accompanying nurse. Upon examination, patient presented with the following health

problems; loss of appetite, abdominal pain, vomiting and headache.

The vital signs were checked and recorded as follows:

Temperature 36.4 degrees Celsius

7
Pulse 80 beat per minute

Blood pressure 148/83 millimetre of mercury

Respiration 21 cycle per minute

The patient and the relatives were once again reassured that she was in the hands of competent

staff and all possible measures were going to be put in place to bring the condition under control.

This was done to allay all fears and anxiety and to build their confidence and co-operation. The

vital signs were recorded on the 4 hourly vital signs chart, and nurses’ note written. The drug

administration sheet, nurses’ notes, fluid charts and the costing sheet were made ready and were

filled with appropriate documents (information). Due to the vomiting, IV Fluid Ringers Lactate

1litre was set up to help prevent dehydration and also help maintain the electrolyte balance.

The following laboratory investigation were requested by the physician on duty to confirm the

diagnosis:

 Full blood count.

 Blood for malaria parasite to rule out malaria

 Blood for widal test

A tray was set, blood samples was taken, it was sent to the laboratory together with laboratory

request form.

The following medications were prescribed for the patient:

 Intravenous Amoxiclav 1.2g tds x 24 hours

 Intravenous Omeprazole 80mg stat 40mg bd x 48 hours

 Intravenous Metronidazole 500mg tds x 24 hours

 Intravenous Paracetamol 1g/100ml tds x 24 hours

 Intravenous Metoclopramide 10mg bd x 24 hours

8
  Tab. Nexium 20mg bd x 7 days

 Suspension Nugel O 10mls tds x 7 days

 Intravenous fluid Normal Saline 2litre x 48hours

 Intravenous fluid Ringers Lactate 1litre for 24hours

A tray was set and the start doses were administered and documented

After the care and drug administration, there was an improvement in the patient`s condition.

When she was a bit calm, patient and her mother were made to understand my intension to use

her as a patient for my Care Study as a prerequisite to complete my licensure exam indicated by

the Nursing and Midwifery Council. They agreed and promised me their full participation and

cooperation.

Her valuables were neatly arranged in the bedside locker according to the institution’s policy. No

consent form needed because the patient did not need any intervention that required an

endorsement from the patient. The National Health Insurance Scheme was explained to the

patient and her mother. They were informed of the institutions' policy on visiting hours; her

mother was also informed of items needed by the patient on admission such as bucket, plate,

spoon etc.

The patient and her mother were orientated to the ward and its annexes and thanked for their co-

operation when she was stable. Patient was introduced to other patients on the ward. Her

demographic information such as name, occupation, age among others was entered into the

admission and discharge book and the daily ward state. The necessary documentation was done

in the nurse’s notes.

Looking at Mrs. P. N and the diagnosis, Acute Gastritis, I found it interesting to use her for my

study, most especially because everyone is at risk of developing such condition. In addition,

9
writing on such condition will enable me to gain much knowledge on the causes, management

and prevention of Gastritis and enable me provide a comprehensive care to patients with Gastritis

who come my way whenever practicing Nursing.

1.8 PATIENT’S CONCEPT OF HER ILLNESS

Patient was very anxious about her condition due to unknown outcome of it. But she concluded

that her condition is only a medical condition and nothing else. She was hopeful that with the

help of God and services of the competent health staffs she will recover.

1.9 LITERATURE REVIEW

This gives the textbook picture of the condition. Here selected textbooks are used to help the

nurse get a broad knowledge about the condition, treatment and prevention.

DEFINITION

Acute gastritis is a sudden inflammation or swelling of the gastric mucosa (the stomach lining).

It involves temporary damage to the mucosal barrier, leading to redness, erosion, and bleeding. It

is often a short-term, intense condition that resolves quickly once the cause is removed. (Brunner

& Suddarth’s Textbook of Medical-Surgical Nursing).

INCIDENCE

Acute gastritis is a very common condition affecting people of all ages. It is often transient and

related to lifestyle factors like alcohol use or the temporary use of certain medications.

RISK/PREDISPOSING FACTORS

1. Heavy Alcohol Consumption: Alcohol directly irritates and breaks down the stomach

lining.

2. Drug Use (NSAIDs): Frequent or high-dose use of Non-Steroidal Anti-Inflammatory

Drugs (like aspirin, ibuprofen) damages the protective mucosal barrier.

10
 3. Stress/Trauma: Severe physiological stress from major surgery, extensive burns

(Curling's ulcer), or trauma can cause stress ulcers and subsequent gastritis.

4. Infection: Acute infection with the Helicobacter pylori (H. pylori) bacteria or viral

infections can irritate the stomach.

5. Corrosive Substances: Ingestion of strong acids or bases (rare, typically accidental or

intentional).

6. Radiation Therapy: Exposure to high-dose radiation in the stomach area.

CAUSES OF ACUTE GASTRITIS

The primary cause is anything that disrupts the stomach's protective mucous barrier, allowing

acid to damage the underlying tissue:

 Chemical Irritation: Excessive use of NSAIDs, alcohol, or bile reflux from the small

intestine.

 Infections: Bacteria such as H. pylori, or food poisoning from organisms like

Staphylococcus or E. coli.

 Autoimmune Disorders: The body's own immune system attacks the stomach lining (less

common cause of acute form).

PATHOPHYSIOLOGY

The stomach lining maintains a protective barrier of mucus and bicarbonate that normally shields

it from highly acidic gastric juices.

When H. pylori bacteria enter the stomach, they use flagella to burrow through the protective

mucus layer and attach to the gastric lining cells. They produce the enzyme urease, which breaks

down urea into ammonia and carbon dioxide. The ammonia neutralizes the acid in the immediate

area around the bacteria, allowing them to survive and colonize the stomach.

11
The colonization and the resulting inflammatory response damage the gastric lining. The bacteria

and the body's immune response release toxins and enzymes that directly compromise the

mucosal barrier. This damage allows stomach acid and pepsin to back-diffuse into the tissue.

This process leads to localized inflammation (gastritis), edema, and ultimately, surface erosions

and chronic tissue damage. This inflammatory damage triggers the common symptoms like

epigastric pain and nausea. If the erosion is severe, it can result in mucosal bleeding and,

eventually, peptic ulcers.

CLINICAL MANIFESTATION

Patients with acute gastritis typically exhibit the following:

 Epigastric Pain: A sudden onset of burning or aching pain in the upper middle part of the

abdomen.

 Nausea and Vomiting: Often severe; vomiting may relieve the pain temporarily.

 Anorexia: Loss of appetite.

 Hematemesis or Melena: Vomiting blood (hematemesis) or passing dark, tarry stools

(melena), indicating mucosal bleeding.

 Malaise: A general feeling of discomfort or illness.

 Hiccups: Persistent or intermittent hiccups may occur.

DIAGNOSTIC INVESTIGATIONS

Healthcare providers confirm the diagnosis using:

1. History and Physical Examination: Identifies potential causes (e.g., recent heavy alcohol

use, NSAID history) and symptoms.

2. Upper Endoscopy (EGD): The most definitive test. A flexible tube is inserted to visualize

the stomach lining, confirming inflammation, erosions, and bleeding.

12
 3. H. pylori test.

4. Hemoglobin and Hematocrit: May be checked to assess for blood loss if bleeding is

suspected.

5. Stool for Occult Blood: Checks for microscopic amounts of blood in the stool (melena).

MEDICAL MANAGEMENT

The primary goal is to remove the causative agent and protect the stomach lining while it heals.

Treatment typically requires:

1. Acid-Suppressing Medications:

o Proton Pump Inhibitors (PPIs): (e.g., Omeprazole, Pantoprazole) block acid

production to allow healing.

o H2 Receptor Blockers: (e.g., Ranitidine, Famotidine) reduce acid secretion.

2. Antacids: (e.g., Aluminum Hydroxide, Magnesium Hydroxide) quickly neutralize

existing stomach acid for temporary relief.

3. Antibiotics: Prescribed if H. pylori are identified as the cause.

NURSING MANAGEMENT

Promoting Gastric Rest and Nutrition

Maintain the patient's NPO status as prescribed and administers IV fluids to maintain hydration.

When introducing oral intake, the nurse starts with small, frequent meals of non-irritating, bland

foods and avoids highly seasoned, acidic, or fatty foods.

Pain and Symptom Management

Administer prescribed PPIs/H2 blockers and antacids as scheduled to control pain. Teach the

patient relaxation techniques and proper positioning to alleviate epigastric discomfort.

Monitoring for Bleeding

13
Monitor the patient closely for signs of GI bleeding, including checking for hematemesis

(vomiting blood) and observing stool for melena (black, tarry appearance). Monitor the blood

pressure and heart rate for signs of shock.

Patient Education

Educate the patient on the crucial need to avoid the irritants (e.g., stopping NSAIDs, limiting or

stopping alcohol). They instruct the patient on the proper use of antacids and the importance of

completing any prescribed antibiotic therapy (if H. pylori are present).

PREVENTION OF ACUTE GASTRITIS

1. Limit NSAID Use: Avoid taking Non-Steroidal Anti-Inflammatory Drugs on an empty

stomach and use the lowest effective dose for the shortest duration.

2. Moderate Alcohol Consumption: Limit or avoid heavy alcohol use, which is a direct

gastric irritant.

3. Stress Management: Develop coping strategies for severe stress and trauma, as prolonged

stress increases acid production.

4. Safe Food Handling: Practice good hygiene and safe food preparation to prevent bacterial

food poisoning.

5. Protect the Stomach: If NSAID use is necessary long-term, talk to a healthcare provider

about taking a concurrent PPI to protect the stomach lining.

COMPLICATIONS OF ACUTE GASTRITIS

1. Gastrointestinal Bleeding: Severe mucosal erosion can lead to significant bleeding,

potentially causing anemia or hemorrhagic shock.

2. Gastric Ulcer: If the inflammation is prolonged or severe, the erosions can deepen into a

chronic gastric ulcer.

14
 3. Anemia: Chronic, low-level blood loss can eventually lead to iron-deficiency anemia.

4. Chronic Gastritis: Repeated episodes or failure to remove the cause can lead to persistent

inflammation.

1.10 VALIDATION OF DATA

Validation of data is the act of verifying or confirming data. The purpose of this is to keep data

free from errors, bias and misinterpretation as much as possible. Gathered information was

compared with those in the patient’s folder, family member, health team, medical records and

there was consistency. With reference to data collected, the information gathered is valid.

15
 CHAPTER TWO

2.0 ANALYSIS OF DATA

This is the second phase of the nursing process. Data analysis involved comparatively assessing the

collected patient information against established clinical standards. This ensured meaningful

inferences could be drawn to plan and administer accurate, appropriate nursing interventions.

Furthermore, this stage allowed for the identification and rectification of any data discrepancies

before final reporting.

This phase consists of the following:

1. Comparison of data with standards

2. Patient/ family strength

3. Health problems identified

4. Nursing diagnosis

2.1 COMPARISON OF DATA WITH STANDARD

A comparison is being made between the actual experiences of the patient and the standard

documented evidence to identify deviations.

This includes:

1. Diagnostic investigation/test

2. Causes

3. Clinical features

4. Treatment

5. Complications

2.1.1 DIAGNOSTIC INVESTIGATIONS / TEST

To establish the diagnosis, all diagnostic investigations and tests conducted on Mrs. P. N are

compared against established standards found in the literature review. The following tests were

performed:

1. Helicobacter Pylori Test

16
 2. Full Blood Count

3. Blood Film for Malaria Parasites

4. Blood for Widal Test

Table 1: Comparison of Diagnostic Test and Investigation Carried out on patient with that of

the Literature Review

Diagnostic Test in Literature Diagnostic Test Carried Out on patient

Review

History and Physical Examination Patient’s history was taken and physical

examination done.

Upper Endoscopy (EGD) Was not done for the patient.

H. pylory test Blood sample was taken for Helicobacter

pylori test

Hemoglobin and Hematocrit Was not done for the patient.

Stool for Occult Blood Was not done for the patient.

From the table above, it is obvious that most of the diagnostic investigations stated in the literature

review such as, history taking and physical examination, and blood for H. Pylori test were done for

patient. Full blood count and blood film for malaria parasite tests too were also requested for the

patient to rule out other conditions.

17
 Table 2: DIAGNOSTIC INVESTIGATIONS/TEST CARRIED OUT PATIENT

DATE SPECIMEN INVESTIGATION RESULTS NORMAL VALUES INTERPRETATION REMARKS

24/09/25 Blood Helicobacter Pylori Positive Negative i.e. Patient has helicobacter pylori Antibiotics:

Test Helicobacter Pylori infection and this may be the Amoxiclav, and

antigen should not be cause of Mrs. P. N’s gastritis metronidazole were

present in stool given.

24/09/25 Blood Full Blood count;

Haemoglobin Level 12.4g/dL Male: 12 – 18 gm / dl Values were within normal range No treatment was

Estimation Female: 11- 16 gm / dl indicating patient has enough given.

hemoglobin to sustain the

operation.

White blood cells 13.5×103/µL 4.0-10.0×103/µL Values were not within normal Amoxiclav was given.

Count range indicating infection

Values are normal indicating

Red blood cells No treatment was

18
 Count 4.9×106/µL 4.31-6.40×106/ µL enough red blood cells. given

Platelets or The value was within the normal No treatment was

thrombocytes 135×103/µL 140-440×106/µL range. given

24/09/25 Blood Malaria Parasite No malaria No malaria parasite No malaria parasite present No treatment was

parasite seen given

24/09/225 Blood Widal test:

S. Typhi H Styphi H 1/40 1:80 - 1:160 Negative/non-reactive. Indicates No treatment was

(Flagellar) no active infection or recent given.

exposure/vaccination.

S. Typhi O Styphi O 1/40 1:80 - 1:160 Negative/non-reactive. Indicates No treatment was

(Somatic) no active or recent infection with given.

S. Typhi.

19
2.1.2 CAUSES OF PATIENT’S ILLNESS

Considering the factors that acute gastritis as indicated in the literature review, the patient’s

acute gastritis was caused by the Helicobacter pylori bacteria.

2.1.3 Clinical Features

Upon observation and assessment of patient. She presented with the following clinical

features: loss of appetite, abdominal pain, vomiting and headache.

Table 3: CLINICAL FEATURES MANIFESTED BY MRS. P. N. AS COMPARED TO

THAT OF THE LITERATURE REVIEW

Clinical Features in the Literature Clinical Features Presented by

Review Patient.

Epigastric Pain Patient complained of abdominal pain

Nausea and Vomiting Patient experienced vomiting.

Anorexia Patient complained of loss of appetite

Hematemesis or Melena Patient did not experience

hematemesis or melena

Malaise Patient did not experience malaise

Hiccups Patient did not experience hiccups.

Patient manifested key signs and symptoms associated with gastritis such as abdominal pain,

loss of appetite and vomiting. Patient also experienced headache even though it was not part

of the literature review.

From the above comparison, there is no doubt that the patient suffered from gastritis.

2.1.4 SPECIFIC MEDICAL TREATMENT

With reference to the literature review, the following specific drugs were prescribed for the

patient;

 Intravenous Amoxiclav 1.2g tds x 24 hours

20
  Intravenous Omeprazole 80mg stat 40mg bd x 48 hours

 Intravenous Metronidazole 500mg tds x 24 hours

 Intravenous Paracetamol 1g/100ml tds x 24 hours

 Intravenous Metoclopramide 10mg bd x 24 hours

 Tab. Nexium 20mg bd x 7 days

 Suspension Nugel O 10mls tds x 7 days

 Intravenous fluid Normal Saline 2litre for 48hours

 Intravenous fluid Ringers Lactate 1litre for 24hours

Table 4: Comparison of Patient’s Treatment With that of Literature Review

Treatment According to Literature Treatment Given to Patient

Review

Acid-Suppressing Medications Omeprazole and Nexium were given.

Antacids Suspension Nugel O was given

Antibiotics Amoxiclav was given

[Link] PHARMACOLOGY OF DRUGS ORDERED

Pharmacology of drugs ordered for the patient has been organized in the tabular form.

Emphasis has been paid on the name of drugs, dosage, route of administration, drug action,

drug classification and its side effects.

21
 Table 5: PHARMACOLOGY OF DRUGS ADMINISTERED TO MRS. P. N.

Date Drug Standard In Dosage / Route of Classification Desired Effects Actual Effect Side Effects and

Literature Administration Observed Remarks

24/09/25 Amoxiclav Adult Dose: Patient Dosage: Antibiotic To treat and prevent Patient’s infection Eosinophilia,

1.2 -2.2g every 8 1.2g tds x 24 hrs. bacterial infection. was resolved as thrombocytosis,

hours. her white blood elevated liver

Route: Intravenous count reduced to enzymes, diarrhea

Paediatric Dose: normal leukopenia, and rash.

30mg/kg every 8 (8.3×103/µL) None was observed

hours.

24/09/25 Omeprazole Adult Dose: Patient Dosage: Proton Pump To reduce Epigastric pain Headache, abdominal

40mg every 12 80mg stat then Inhibitors abdominal pain by subsided pain, nausea, and

hours. 40mg bd × 48 hrs. suppressing gastric diarrhea, stuffy nose,

22
 Route: Intravenous acid secretion. sneezing, sore throat

Paediatric Dose: Patient did not

0.5-1.0mg/kg in 40mg bd × 7 days experience any of the

24 hours. Route: Oral above side effects

24/09/25 Metronidazole Adult Dose: Patient Dosage: Antiprotozoal/ It inhibits bacterial Patient was freed Headache, nausea,

500mg every 8 500mg tds×24 antibiotic DNA synthesis from infection. anorexia

hours. hours mainly by blocking

Route: Intravenous DNA gyrase to None was observed

Paediatric Dose: 500mg tds x 5 prevent infection.

7.5-15mg/kg days

every 12 hours. Route: Oral

24/09/25 Paracetamol Adult Dose: 1g Patient Dosage: Antipyretics To treat pain and Patient’s bodily Drowsiness,

every 6 or 8 hours 1g tds × 24hours and Analgesics reduce high body pain was relieved vomiting, renal

temperature by failure.

Paediatric Dose: Route: Intravenous activation of

15-30mg/kg in 24 descending
23
 hours period. serotonergic Patient did not

pathways. experience any of the

above side effects

24/09/25 Metoclopramide Adult Dose: Patient Dosage: Antiemetic To treat nausea and Patient was Restlessness,

10mg 3 times 10mg bd × agent vomiting relieved of nausea headache, and

daily. 24hours and vomiting confusion

Paediatric Dose: Patient did not

0.1-2.5mg 3 times Route: Intravenous experience any of the

daily. above side effects

24/09/25 Suspension Adult Dose: Patient Dosage: Antacid To reduce or Relieved patient of Nausea, vomiting,

Nugel O 10-15mls 3 times 10mls tds x 7 days neutralize the the stomach pain headaches, abdominal

daily. amount of acid caused by the pain, increased

Route: Oral produced in the gastric acid. intestinal gas.

stomach and relieve Patient did not

patient of gastric experience any of the

24
 irritation. above side effects.

24/09/25 Tablet Nexium Adult Dose: 20- Patient Dosage: Proton pump Binds to an enzyme Patient’s Dizziness, headache,

40mg every 12 or 20mg bd x 7 days inhibitor on gastric parietal abdominal pains flatulence,

24 hours. cells in the presence were relieved constipation.

Route: Oral of acid pH, indicating reduced

Children (1-17 preventing the final gastric secretions. None was observed.

years) Dose: transport of

10-20mg daily. hydrogen ions into

the gastric lumen.

24/09/25 Normal Saline Adult Dose: Patient Dosage: Fluid and To correct fluid and Patient’s Circulatory overload

500mls-2.5L per 2litre x 48hours electrolyte electrolyte electrolyte balance Increased blood

24 hours. replacement imbalance was normal with pressure

Route: Intravenous no sign of None observed with

Paediatric Dose: dehydration, patient

1-10ml/kg/hour Edema,

hypocalcaemia,
25
 Over hydration.

24/09/25 IVF Ringer’s Adult Dose: Patient Dosage: Isotonic To prevents It maintained fluid Fluid overload,

Lactate 500mls-2.5L per 1 liter x 24 hours solution metabolic acidosis and electrolyte agitation, decreased

24 hours. and replaces fluid balance heart rate

Paediatric Dose: Route: Intravenous and electrolyte loss None was observed

1-10ml/kg/hour

26
2.1.5 COMPLICATIONS

The patient recovered successfully and did not develop any complications stated in the

literature review.

2.2 PATIENT/FAMILY STRENGTH

The patient’s strengths and the family's capacity represent their contribution to holistic care,

which is vital for promoting recovery and streamlining the work of the healthcare team.

These were identified through client interaction.

1. All drugs that were not covered by the National Health Insurance Scheme were

purchased by relatives

2. During visiting hours, patient was visited by family and friends as well as their

spiritual leaders who provided spiritual and psychological care

3. Patient could also communicate well with caregivers as well as relatives

4. Relatives are co-operative and provided all needed information

5. Patient has no allergy to drugs served

6. Patient was fully conscious

7. Patient adhered to instructions given

2.3 PATIENT’S HEALTH PROBLEMS

These are conditions that affect the patient physically, mentally and socially which could

hinder recovery if special attention is not given to the patient. The following health related

problems were identified:

24/09/2025

1. Patient complained of abdominal pains

2. Patient complained of loss of appetite

3. Patient complained of vomiting 4 times.

4. Patient complained of headache

27
25/09/2025

5. Patient complained of easy fatiguability.

6. Patient was anxious about the unknown outcome of disease (acute gastritis)

2.3.1. PATIENT’S STRENGTH ACCORDING TO IDENTIFIED PROMBLEMS

This involves the activities the patient can do and what the family can perform in the

achievement of health goals set for early recovery.

1. Patient could describe the location and intensity of pain

2. Patient could eat about 1/3 of the meal served her.

3. Patient could tolerate oral fluids.

4. Patient cold tolerate prescribed analgesics

5. Patient cold perform activities of daily living with assistance.

6. Patient was able to express fear about the unknown outcome of condition (acute

gastritis)

2.4 NURSING DIAGNOSIS

Nursing diagnosis is a statement of health problem or of a potential health problem and the

patient health status that a nurse is professionally competent to treat. Below were the nursing

diagnoses of the patient/family;

1. Impaired comfort (abdominal pain) related to acid irritation of the gastric mucosa

2. Risk for imbalanced nutrition (less than body) requirement as evidenced by decreased

food intake associated with loss of appetite.

3. Risk for deficient fluid volume as evidenced by excessive vomiting.

4. Acute pain (headache) related to increased intracranial pressure

5. Decreased activity tolerance related to decreased nutrient absorption secondary to

disease process (acute gastritis)

6. Anxiety related to unknown outcome of disease condition (Acute Gastritis).

28
 CHAPTER THREE

3.0 PLANNING FOR PATIENT AND FAMILY CARE

Planning is the systematic assessment and identification of patient’s problem, setting objectives,

establishing interventions and evaluating results.

Planning is the third phase in the nursing process. Plans for implementation are based on

assessment and diagnose of the patient’s health status, strength and concerns.

After nursing diagnosis are validated, they provide directions for deforming how to assist the

patient in resolving concerns related to the restoration, maintenance and promotion of health.

The nursing care plan facilitates achievements of the patient goal. It communicates clearly the

nature of the patient’s problems and specifies the nursing and medical intervention necessary for

the patient.

3.1 OBJECTIVES AND OUTCOME CRITERIA

An objective is a desired outcome criterion towards which specific nursing interventions are

carried out. Objectives and outcome criteria set for Mrs. P. N were;

1. Patient will be relieved of abdominal pain within 24 hours as evidenced by:

a. Patient verbalizing absence of abdominal pain

b. Nurse observing patient being relaxed and having cheerful facial expression in bed.

2. Patient’s nutritional status will be maintained throughout the period of hospitalization as

evidenced by:

a. Patient’s verbalizing that her appetite has improved.

b. Nurse observing that patient’s body weight has been improved when checked with the

weighing scale.

29
3. Patient’s normal body fluid volume will be maintained throughout the period of

hospitalization as evidenced by:

a. Patient verbalizing that she is no more vomiting.

b. Nurse observing patient have good skin turgor.

4. Patient will be relived of headache within 24 hours as evidenced by:

a. Patient verbalizing that pain she has been relieved of the pain.

b. Nurse observing patient have relaxed and cheerful facial expression.

5. Patient will have improved activity tolerance within 24 hours as evidenced by:

a. Patient verbalizing that she can now perform activities of daily living without assistance.

b. Nurse observing patient perform activities of daily living without difficulty.

6. Patient will be relieved of anxiety within 6 hours as evidenced by:

a. Patient verbalizing that she is no more anxious.

b. Nurse observing patient having a cheerful facial expression.

30
 Table 6: NURSING CARE PLAN FOR MRS. P. N.

Date/Time Nursing Diagnosis Objective/Outcome Nursing Order Nursing Intervention Evaluation

Criteria

24/09/25 Impaired comfort Patient will be relieved of 1. Reassure patient 1. Patient was reassured that she Goal fully met as

at (abdominal pain) abdominal pain within 24 will be relieved of her abdominal evidenced by

11:41 a.m. related to acid hours as evidenced by: pain. patient verbalized

irritation of the a. Patient verbalizing 2. Assess patient for the 2. A pain rating scale of 0-10 was absence of

gastric mucosa absence of abdominal onset, duration, intensity used to assess the intensity of abdominal pain,

pain. and frequency of pain. patient’s pain and the onset, and nurse observed

b. Nurse observing patient duration, and frequency were also patient being

being relaxed and having assessed. relaxed and having

cheerful facial expression 3. Allow patient to be in 3. Patient was assisted to assume cheerful facial

in bed. the most comfortable the most comfortable position to expression in bed.

position. reduce pain. 25/09/25

4. Engage patient in a 4. Patient was engaged in a at

diversional therapy. diversional therapy that is 11:41 a.m.

31
 watching TV to divert her F. Q.

attention of the pain.

5. Serve prescribed 5. Prescribed medications that is

medication. Nexium, Omeprazole and

Metronidazole was served to

relieve pain in the abdomen.

32
 NURSING CARE PLAN CONT…

Date/Time Nursing Diagnosis Objective/Outcome Nursing Order Nursing Intervention Evaluation

Criteria

24/09/25 Risk for imbalanced Patient’s nutritional status 1. Reassure patient 1. Patient was reassured of the Goal fully met as

at nutrition (less than will be maintained measures being put in place to patient verbalized

11:58 a.m. body) requirement as throughout the period of improve her appetite that her appetite has

evidenced by hospitalization as 2. Encourage oral hygiene. 2. Oral hygiene was encouraged improved, and nurse

decreased food intake evidenced by: twice a day with toothbrush and observed that

associated with loss a. Patient verbalizing that paste patient’s body

of appetite. her appetite has improved. 3. Plan meal with patient 3. Meal was planned with weight has been

b. Nurse observing that patient to know her preferred improved when

patient’s body weight has meals and dislikes checked with the

been improved when 4. Serve meal attractively 4. Meal was served attractively weighing scale.

checked with the and assist patient to feed and patient was assisted to eat. 28/09/25

weighing scale. at

5. Remove nauseating 5. All nauseating substances 11:58 a.m.

33
substances and ensure ward were removed and cleanliness F. Q.

cleanliness. was ensured at the ward to

boost her appetite.

34
 NURSING CARE PLAN CONT…

Date/Time Nursing Diagnosis Objective/Outcome Nursing Order Nursing Intervention Evaluation

Criteria

24/09/25 Risk for deficient Patient’s normal body 1. Monitor and record 1. Patient’s vital signs were Goal fully met as

at fluid volume as fluid volume will be vital signs 4 hourly monitored and recorded evidenced by patient

12:31 p.m. evidenced by maintained throughout the paying much attention to the verbalized that she is

excessive vomiting. period of hospitalization blood pressure. no more vomiting,

as evidenced by: 2. Assess for signs of 2. Signs of dehydration and nurse observed

a. Patient verbalizing that dehydration assessed and found that patient have good

she is no more vomiting. Skin elasticity was intact as skin turgor.

b. Nurse observing patient skin returns to normal faster 28/09/25

have good skin turgor after released at

3. Monitor and record 3. Intake and output chart was 12:31 p.m.

intake and output on a maintained and balanced F. Q.

chart. every 24 hours

4. Patient was encouraged to

35
4. Encourage fluids intake take in plenty water

5. IV Ringer’s Lactate was

5. Serve patient with served for days

prescribed Intravenous

fluids

36
 NURSING CARE PLAN CONT…

Date/Time Nursing Diagnosis Objective/Outcome Nursing Order Nursing Intervention Evaluation

Criteria

24/09/25 Acute pain Patient will be relived of 1. Reassure patient 1. Patient was reassured that she Goal fully met as

at (headache) related to headache within 24 hours will be relief of her headache to evidenced by patient

12:48 p.m. increased intracranial as evidenced by: allay her fears and anxiety. verbalized that pain

pressure a. Patient verbalizing that 2. Allow patient to assume 2. Patient was assisted to she has been

pain she has been relieved a suitable position. assume a suitable position to relieved of the pain

of the pain. help relief headache. and nurse observed

b. Nurse observing patient 3. Assess patient’s level of 3. Patient’s level of pain was patient have relaxed

have relaxed and cheerful pain. assessed using the pain rating and cheerful facial

facial expression. scale of 0-10 to know the expression.

intensity of the pain. 25/09/25

at

4. The patient was engaged in 12:48 p.m.

4. Engage patient in diversional therapy thus F. Q.

37
diversional therapy. watching television.

5. Prescribed analgesic thus Tab

5. Administer prescribed Paracetamol 1g was

analgesics. administered to relieve the pain.

38
 NURSING CARE PLAN CONT…

Date/Time Nursing Diagnosis Objective/Outcome Nursing Order Nursing Intervention Evaluation

Criteria

25/09/25 Decreased activity Patient will have 1. Assist patient with self- 1. Patient was assisted with Goal fully met as

at tolerance related to improved activity care activities. brushing of her teeth, bathing evidenced by patient

8:53 a.m. decreased nutrient tolerance within 24 hours and feeding to help her maintain verbalized that she

absorption secondary as evidenced by: and ensure proper hygiene. can now perform

to disease process a. Patient verbalizing that 2. Organize the nursing 2. Vital signs, medications and activities of daily

(acute gastritis) she can now perform procedures in bulk. all nursing procedures were living without

activities of daily living performed in bulk at the assistance and nurse

without assistance. appropriate time to avoid observed patient

b. Nurse observing patient disturbing bed rest and to perform activities of

perform activities of daily promote adequate rest. daily living without

living without difficulty. 3. Keep needed objects 3. All necessary items such as difficulty.

within reach. drinking water, bed accessories 26/09/25

were kept within patient’s reach at

39
 to enable patient have easy 8:53 a.m.

access to them when the need F. Q.

be.

[Link] patient to rest [Link] was encouraged to rest

in bed. in bed.

40
 NURSING CARE PLAN CONT….

Date/Time Nursing Diagnosis Objective/Outcome Nursing Order Nursing Intervention Evaluation

Criteria

25/09/24 Anxiety related to Patient will be relieved of 1. Reassure patient 1. Patient was reassured with Goal fully met as

at unknown outcome of anxiety within 6 hours as words of encouragement and of evidenced by patient

9:21 a.m. disease condition evidenced by: a competent health team to allay verbalized that she is

(Acute Gastritis). a. Patient verbalizing that fear about condition. no more anxious and

she is no more anxious. 2. Assess patient’s anxiety 2. Patient’s level of anxiety was nurse observed

b. Nurse observing patient level and allow patient to assessed and she was allowed to patient have cheerful

having cheerful facial express her fears about the express her fears and concerns facial expression.

expression. condition. about her condition. 25/09/25

3. Allow patient to ask 3. Patient was allowed to ask at

questions on gastritis. questions on gastritis and 9:21 a.m.

appropriate answers were F. Q.

provided in a language patient

understands clearly.

41
4. Introduce patient to 4. Patient was introduced to

other patients who had the other patients who had the same

same condition and have condition and has recovered

recovered successfully. successfully to relieve anxiety.

5. Explain all procedures to 5. All procedures carried on

the patient. patient were explained to him.

6. Introduce diversional 6. Diversional therapy like

therapy listening to music and watching

television was introduced to

patient.

42
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT / FAMILY CARE PLAN

4.0 Introduction

This chapter is concerned with the actual nursing care rendered to the patient and the family. It

comprises of activities before and after discharge including preparation of patient and family for

discharge and rehabilitation as well as follow-up or home visits for continuity of care.

It covers;

1. Summary of actual nursing care

2. Preparation of patient and family towards discharge and rehabilitation

3. Home visit/ Continuity of care/ Follow-up

4.1 SUMMARY OF ACTUAL CARE RENDERED TO PATIENT/FAMILY

This involves the actual implementation of the nursing orders in the nursing care plan. The

nursing care given to patient commenced on 24 th September, 2025 to the day of discharge, which

was 28th September, 2025. The care rendered to the patient was aimed at restoring health and

preventing complications.

4.1.1 SUMMARY OF ACTUAL NURSING CARE RENDERED

Mrs. P. N was admitted to the female medical ward of St. John of God Hospital on the 24 th

September, 2025at 11:13 a.m. with the diagnosis of acute gastritis. Her vital signs were taken

and recorded and also her drugs were collected and served as prescribed.

Specimen were taken and sent to the laboratory for investigations to be carried out and findings

were documented. To render a holistic care to the patient, physical assessment was done on the

day of admission and actual and potential health problems of the patient were identified and a

43
comprehensive nursing care plan was drawn and implemented which led to the speedy recovery

of the patient and subsequent discharge.

4.1.2. DAY OF ADMISSION (24/09/2025)

Mrs. P. N. was admitted to the Female’s Medical Ward of the St. John of God Hospital, Sefwi

Asafo on the 24th September, 2025 at 11: 13 a.m. through the Out-Patient Department with the

diagnosis of acute gastritis. Patient was accompanied by a nurse and her husband. Patient and

relatives were warmly welcomed. Patient’s name was confirmed by calling out the name on the

electronic system and patient responded. Patient and husband were reassured of getting good

medical and nursing care. They were welcomed and she was admitted into an already prepared

admission bed. Her relatives were reassured that she was in safe hands and would be given the

best of care. All the necessary information were gathered and other related documents from her

relatives and the accompanying nurse. Her personal information was carefully read and patient’s

name, sex, occupation, diagnosis and other details were confirmed with the help of the husband

and the accompanying nurse. Upon examination, patient presented with the following health

problems; loss of appetite, abdominal pain, vomiting and headache.

The vital signs were checked and recorded as follows:

Temperature 36.4 degrees Celsius

Pulse 80 beat per minute

Blood pressure 148/83 millimetre of mercury

Respiration 21 cycle per minute

The patient and the relatives were once again reassured that she was in the hands of competent

staff and all possible measures were going to be put in place to bring the condition under control.

This was done to allay all fears and anxiety and to build their confidence and co-operation. The

44
vital signs were recorded on the 4 hourly vital signs chart, and nurses’ note written. The drug

administration sheet, nurses’ notes, fluid charts and the costing sheet were made ready and were

filled with appropriate documents (information). Due to the vomiting, IV Fluid Ringers Lactate

1litre was set up to help prevent dehydration and also help maintain the electrolyte balance.

The following laboratory investigation were requested by the physician on duty to confirm the

diagnosis:

 Full blood count.

 Blood for malaria parasite to rule out malaria

 Blood for widal test

A tray was set, blood samples was taken, it was sent to the laboratory together with laboratory

request form.

The following medications were prescribed for the patient:

 Intravenous Amoxiclav 1.2g tds x 24 hours

 Intravenous Omeprazole 80mg stat 40mg bd x 48 hours

 Intravenous Metronidazole 500mg tds x 24 hours

 Intravenous Paracetamol 1g/100ml tds x 24 hours

 Intravenous Metoclopramide 10mg bd x 24 hours

 Tab. Nexium 20mg bd x 7 days

 Suspension Nugel O 10mls tds x 7 days

 Intravenous fluid Normal Saline 2litre x 48hours

 Intravenous fluid Ringers Lactate 1litre for 24hours

A tray was set and the start doses were administered and documented

45
After the care and drug administration, there was an improvement in the patient`s condition.

When she was a bit calm, patient and her mother were made to understand my intension to use

her as a patient for my Care Study as a prerequisite to complete my licensure exam indicated by

the Nursing and Midwifery Council. They agreed and promised me their full participation and

cooperation.

Her valuables were neatly arranged in the bedside locker according to the institution’s policy. No

consent form needed because the patient did not need any intervention that required an

endorsement from the patient. The National Health Insurance Scheme was explained to the

patient and her mother. They were informed of the institutions' policy on visiting hours; her

mother was also informed of items needed by the patient on admission such as bucket, plate,

spoon etc.

The patient and her mother were orientated to the ward and its annexes and thanked for their co-

operation when she was stable. Patient was introduced to other patients on the ward. Her

demographic information such as name, occupation, age among others was entered into the

admission and discharge book and the daily ward state. The necessary documentation was done

in the nurse’s notes.

To render individualized care to the patient, nursing diagnoses and interventions were carried out

for the patient to help relieve her of the health problems. The health problems presented by the

patient on the day of admission were: loss of appetite, abdominal pain, vomiting and headache.

At 11:41 a.m., a nursing diagnosis of impaired comfort (abdominal pain) related to acid irritation

of the gastric mucosa was formulated and the following nursing interventions were carried out:

Patient was reassured that she will be relieved of her abdominal pain, a pain rating scale of 0-10

was used to assess the intensity of patient’s pain and the onset, duration, and frequency were also

46
assessed, patient was assisted to assume the most comfortable position to reduce pain, patient

was engaged in a diversional therapy that is watching TV to divert her attention of the pain, and

prescribed medications that is Nexium, Omeprazole and Metronidazole was served to relieve

pain in the abdomen.

At 11:58 a.m., a nursing diagnosis of risk for imbalanced nutrition (less than body) requirement

as evidenced by decreased food intake associated with loss of appetite was formulated for

patient’s loss of appetite. The following nursing interventions carried were: patient was reassured

of the measures being put in place to improve her appetite, oral hygiene was encouraged twice a

day with toothbrush and paste, meal was planned with patient to know her preferred meals and

dislikes, meal was served attractively and patient was assisted to eat, and all nauseating

substances were removed and cleanliness was ensured at the ward to boost her appetite.

Also, at 12:31 p.m., for patient’s vomiting, a nursing diagnosis of risk for deficient fluid volume

as evidenced by excessive vomiting was formulated, hence, the following nursing interventions

were carried out: patient’s vital signs were monitored and recorded paying much attention to the

blood pressure, signs of dehydration assessed and found that Skin elasticity was intact as skin

returns to normal faster after released, intake and output chart was maintained and balanced

every 24 hours, patient was encouraged to take in plenty water, and IV Ringer’s Lactate was

served for days.

At 12:48 p.m., a nursing diagnosis of acute pain (headache) related to increased intracranial

pressure and the following nursing interventions were carried out: patient was reassured that she

will be relief of her headache to allay her fears and anxiety, patient was assisted to assume a

suitable position to help relief headache, patient’s level of pain was assessed using the pain rating

scale of 0-10 to know the intensity of the pain, the patient was engaged in diversional therapy

47
thus watching television, and prescribed analgesic thus Tab Paracetamol 1g was administered to

relieve the pain.

All other routine nursing activities were carried out and documented. Patient was reassured of

health team who will do everything to aid in her speedy recovery.

Mrs. P. N took rice and stew with fried egg as supper and retired to bed after saying her prayers

at 9:32 p.m.

4.1.3 FIRST DAY ON ADMISSION (25/09/2025)

On the first day of admission (25/09/2025), according to the night nurses’ report patient having

easy fatiguability. Interaction with patient revealed that was anxious. Both patient and relative

were reassured that they were under the care of competent health staff and would soon recover

and go home.

Mrs. P. N’s 6:00 a.m. vital signs were checked and recorded as;

Temperature: 36.40C

Pulse: 82 bpm

Respiration: 18 cpm

Blood pressure: 116/78 mmHg

Her due medications were administered and documented.

Her personal hygiene was maintained by assistance and was made comfortable in a warm

cleaned bed. She was served with a cup of porridge and a piece of bread.

On ward rounds at about 7:45 a.m. the physician requested that she should continue with her

treatment and be encouraged have enough rest.

At 8:53 a.m., a nursing diagnosis of decreased activity tolerance related to decreased nutrient

absorption secondary to disease process (acute gastritis) was formulated and the following

48
interventions were carried out; patient was assisted with brushing of her teeth, bathing and

feeding to help her maintain and ensure proper hygiene, vital signs, medications and all nursing

procedures were performed in bulk at the appropriate time to avoid disturbing bed rest and to

promote adequate rest, all necessary items such as drinking water, bed accessories were kept

within patient’s reach to enable patient have easy access to them when the need be, and patient

was encouraged to rest in bed.

At 9:21 a.m., a nursing diagnosis of anxiety related to unknown outcome of disease condition

(Acute Gastritis) was formulated. The following nursing interventions were carried out: patient

was reassured with words of encouragement and of a competent health team to allay fear about

condition, patient’s level of anxiety was assessed and she was allowed to express her fears and

concerns about her condition., patient was allowed to ask questions on gastritis and appropriate

answers were provided in a language patient understands clearly, patient was introduced to other

patients who had the same condition and has recovered successfully to relieve anxiety, all

procedures carried on patient were explained to him, and diversional therapy like listening to

music and watching television was introduced to patient.

At about 1:00pm, patient was served with fried yam with hot pepper sauce and fried fish as lunch

of which she ate everything.

At 2:00pm medication was served and her vital signs was checked and recorded as;

Temperature: 36.3°C

Pulse: 97 bpm

Respiration: 17 cpm

Blood Pressure: 124/78 mmHg

49
During visiting hours, her relatives came around with banku and groundnut soup for Mrs. P. N as

super at 5 p.m. She took her bath by herself at 5:50 p.m. and eat the food afterwards.

Her vital signs at 6pm was checked and recorded. A comfortable bed absence of crumps and

creases was made in order to provide comfort for sleep. Mrs. P. N slept at 8:23 p.m. after saying

her prayers.

4.1.4 SECOND DAY ON ADMISSION (26/09/2025)

On this day of admission, Mrs. P. N woke up as early as 5:10 a.m. Her condition was observed to

have improved, she was greeted with a smile and looked well. Her personal hygiene was

maintained; bed linen straightened and was made comfortable in bed. Patient showed much

improvement in her condition. She slept well that night. In the morning, she took porridge with

bread for breakfast.

Her 6:00 a.m. vital signs were checked and recorded as;

Temperature: 36.6°C

Pulse: 68 bpm

Respiration: 16 cpm

Blood Pressure: 109/69 mmHg

Prescribed oral medications were administered and documented in the nurse’s note. During ward

rounds at 8:15 a.m., patient made no new complain.

Patient was served with ampesi and stew as lunch at 1:22 p.m. She watched movie for a while

after eating.

Vital signs were checked and recorded at 2 p.m. as follows;

Temperature: 36.4°C

Pulse: 77 bpm

50
 Respiration: 17 cpm

Blood Pressure: 120/75 mmHg

Due medications were administered and documented.

I informed my patient and relatives about my interest to visit their home the following day. The

purpose of my visit was to assess the patient’s home and her environment factors that can

contributed to her care and recovery. Mrs. P. N granted me the permission to go. I thanked my

patient and her relatives for their permission.

Mrs. P. N took fufu with light soup and beef as super at 5:23 p.m. and later had her bath.

Routine nursing activities were carried out and documented.

She finally went to bed around 9:30pm after bathing and saying her prayer.

4.1.5 THIRD DAY ON ADMISSION (27/09/2025)

Daily activities of patient were done which includes bathing, brushing and clothing. No new

complaints were given from the report of the night staffs. Mrs. P. N had porridge with milk and

bread as breakfast.

Patient’s 6:00 a.m. vital signs were checked and recorded as;

Temperature: 36.5°C

Pulse: 79 bpm

Respiration: 16 cpm

BP: 122/62mmHg

Due medications were served and documented. During ward round at 9:00 a.m. patient was

reviewed by the medical doctor, she made no new complains. She was assured of possible

discharge the following day. Mrs. P. N was happy about her rapid recovery.

Patient had banku and okro stew as lunch

51
2:00 p.m. vital signs were checked and recorded as;

Temperature: 36.6OC

Pulse: 77bpm

Respiration: 18cpm

Blood pressure: 120/70mmHg

All due medications were administered and document.

I asked for permission to go the patient’s house from the patient and the husband agreed to go

with me since he was going to do something at the house. We left the hospital premises at 4:15

p.m. I returned to the hospital from the home visit at 5:50 p.m.

Patient had rice ball and groundnut soup with beef as super after taking her bath at 4:50 p.m.

All other routine care such as bathing, checking of vital signs and drug administration were

carried out and recorded in the nurses note and drug administration accordingly

Patient retired to bed at 9:25 p.m. after brushing her teeth and saying her prayers.

4.1.6 FOURTH DAY ON ADMISSION (DAY OF DISCHARGE) - 28/09/2025

Mrs. P. N slept soundly the previous night as reported by the night nurses’ note. Her personal

hygiene as well as her nutritional status was maintained. Patient looked cheerful in bed.

6:00 a.m. vital signs checked and recorded as follows;

Temperature 36.3OC

Pulse: 79bpm

Respiration- 19cpm

Blood pressure: 100/79mmHg

During ward rounds the patient was reviewed by the doctor on duty and was finally discharged

after doctor was satisfied that patient’s condition was stable.

52
The date of discharge and diagnosis were recorded in the admission and discharge book and her

name was recorded on the daily ward state.

Patient was discharge to continue treatment at home with the following medication;

 Tab. Nexium 20mg bd x 7 days

 Suspension Nugel O 10mls tds x 7 days

Patient’s folder was taken to the revenue office for the assessment of Bill. Her drugs were picked

from the pharmacy and were educated on how to be taken at home. They were also educated on

the dosage, route of administration and the time of administration of drugs prescribed. Patient

and family were once again advised to report at the hospital quickly anytime she falls sick.

Emphasis was made to confirm to the drug regimen. Patient and family were advised on the need

for proper personal hygiene. Patient and relatives were advised on the need to report for review

on the 14th October, 2025. I informed patient and relative of my home visit, which was scheduled

to be on the 12th October, 2025.

Patient and relative were assisted to pack patient’s things into a bag. Thay thanked and bade the

staff and other patients and their families on the ward goodbye. The patient’s bed linen and

pillow case were removed and put into the laundry container, then patient’s bed was carbonated,

cleaned and left dry. Patient and relatives were accompanied to the entrance to go home.

4.2 PREPARATIONS OF PATIENT AND FAMILY TORWARD DISCHARGE AND

REHABILITATION

Preparation of patient and family for discharge was initiated from the day of admission. The

family and patient were educated on the causes, risk factors and preventive measures of gastritis.

Patient was advised on the need to avoid food rich in spices, avoid the intake of NSAIDs and to

53
take well- balanced diet that contains adequate amount of proteins, carbohydrates, vitamins, fats

and oils and minerals.

Patient and her family were educated on good personal hygiene such as brushing her teeth twice

daily, bathing at least once daily and washing their hands with soap and water after visiting the

toilet, before and after meals. They were also advised to keep their environment clean by

weeding bushy areas, cleaning gutters, disposing of refuse properly.

On the 28th September, 2025, during the doctor’s usual ward rounds, patient was examined and

declared fit for discharge to continue treatment at home with the following medication;

 Tab. Nexium 20mg bd x 7 days

 Suspension Nugel O 10mls tds x 7 days

Patient’s folder was taken to the revenue office for the assessment of Bill. Patient’ drugs were

picked from the pharmacy and were educated on how to be taken at home. Patient and relatives

were advised on the need to keep follow-up appointment which is 14th October, 2025.

Afterwards, patient and family were helped to pack patient’s belongings and remaining

medication handed over to them. Patient and family thanked the ward staff for their efforts

before leaving the ward. I informed patient and relatives of my second home visit to their house

on the 12th October, 2025.

4.3 FOLLOW-UP / HOME VISITS / CONTINUITY OF CARE

This is the act of rendering health service to a patient in her or his home environment to ensure

continuity of care. It also determines the health status of the patient following discharge, identify

other problems and help find solutions to the identified problems and know the resources at

home as well as in the community that can be used to solve actual and potential health problems

54
This involves visiting the patient home before and after discharge to have first-hand information

on the condition of the house and its influence on the patient’s health. This is of a great

importance in the care of the patient.

4.3.1 FIRST HOME VISIT (27/09/2025)

First home visit was made on the 27 th September, 2025 to the patient’s home in Asawinso. I

arrived at the house at 4:30 p.m. The purpose of the visit to get familiar with the patient’s home

and to assess her environmental situations that could predispose her not only to gastritis again,

but other disease like malaria, typhoid fever, dysentery etc. Mrs. P. N’s husband accompanied

me to the house. I had a warm reception from patient’s relatives in the house and I was offered a

seat and a sachet of water to drink after which I introduced myself and my mission for the visit.

Patient lives in a 4-bedroom apartment. The house is built with blocks and was roofed with iron

sheets. The house has two bathrooms and toilets facility.

During my observation, their compounds as well as their surrounding were kept clean and tidy. I

recommended them for keeping their environment and home clean and encouraged them on the

need to keep it up to prevent the occurrence of diseases and to maintain a healthy life. I also

encouraged them to assist and remind patient to take her medication on schedule to promote total

recovery when patient is discharged home. I thanked them for their kindness and warm reception

and promised them of another visit when Mrs. P. N is discharged home.

4.3.2 SECOND HOME VISIT (12/10/2025)

On the 12th October, 2025, I paid my second home visit to patient’s house. The purpose of the

visit was to find out how the patient was doing at home and to determine whether the patient is

taking her medication as prescribed. The visit was also made to find out whether patient’s

55
relatives had put into practice the health education given to them during my predischarge visit

and also to find out for any health complaints.

We exchanged greetings and after a few minutes of interactions with the patient and relatives, I

observed that there were no defaults in patient’s treatment regimen as patient has taken all the

medication as prescribed and her condition had improved tremendously. Patient admitted that

there was no health problem to complain about. I commended patient and relatives for adhering

strictly to the treatment regimen, taking care of patient’s personal hygiene and also keeping the

environment clean. I encouraged patient to continue taking her medication and advised her not to

hesitate in reporting to the hospital whenever there is any health problem.

Patient and relative were reminded on the prevention of gastritis and the need for good personal

and environment hygiene. Patient and relative thanked me and I reminded them about the

reviewed date which is 14th October, 2025.

4.3.3 DAY OF REVIEW (14/10/2025)

Mrs. P. N came for review on 14 th October, 2025 as scheduled with her husband. She called me

on phone on their arrival; I met them at the Out-Patient Department (O.P.D) of St. John of God

Hospital, Sefwi Asafo where I assisted her to retrieve her folder. The patient’s vital signs were

checked and recorded in the folder as:

Temperature: 36.50C

Pulse: 79bpm

Respiration: 18cpm

Blood pressure: 125/80mmHg

Patient was accompanied to the consulting room where she was reviewed by the doctor. She was

examined by a doctor who confirmed that the patient condition has improved.

56
Mrs. P. N made no complaints to the doctor. We had a short conversation and she was reminded

of the next home visit which will be on the 17 th October, 2025. I accompanied them to pick a car

and bid them goodbye.

4.3.4 THIRD HOME VISIT (17/10/2025)

On the 17th October, 2025, I visited my patient as promised after her medical review. The

purpose of my visit was to assess the general well-being of the patient and to terminate the

therapeutic relationship between the patient and nurse.

I got to the house at about 11:10 a.m. I was warmly welcomed, offered a seat and a water to

drink. They Upon observation of the patient, her condition had improved tremendously.

After a few minutes of interactions with the patient and relatives, I then made my mission known

to them. Mrs. P. N and family were not happy about the termination of care but I reassured them

that I would always come and visit them as a friend whenever I get the chance.

I advised the patient and relatives to report to the hospital on time with their health problems and

to avoid self-medications. I asked for permission to leave which was granted and I thanked them

for their co-operation.

57
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

5.0 Introduction

The fifth and final phase of the nursing process is evaluation of care rendered to the patient and

family. This phase of the nursing process is a planned, systematic comparison of patient health

status with expected outcome. Evaluation determines the patient progress to meet specified goal

and objectives. It helps to judge the effectiveness of the nursing process components used. It is

also an integral part of each nursing process with initial assessment. Evaluation of the nursing

process involves the patient, the nurse and other health care team member.

This phase consists of:

a. Statement of evaluation

b. Amendment of nursing care for met partial or unmet outcome care.

c. Termination of care

d. Summary and conclusion

5.1 STATEMENT OF EVALUATIONS

During evaluation, objective or goals were set up for the care of patient with good nursing and

medical management of these goals or objectives were all fully met and patient’s condition

improved remarkably.

24/09/2025

On admission, patient had loss of appetite, abdominal pain, vomiting and headache.

The objectives set for these problems respectively are; Patient will be relieved of abdominal pain

within 24 hours as evidenced by patient verbalizing absence of abdominal pain and nurse

observing patient being relaxed and having cheerful facial expression in bed, patient’s nutritional

58
status will be maintained throughout the period of hospitalization as evidenced by patient’s

verbalizing that her appetite has improved and nurse observing that patient’s body weight has

been improved when checked with the weighing scale, patient’s normal body fluid volume will

be maintained throughout the period of hospitalization as evidenced by patient verbalizing that

she is no more vomiting and nurse observing patient have good skin turgor, and patient will be

relived of headache within 24 hours as evidenced by patient verbalizing that pain she has been

relieved of the pain and nurse observing patient have relaxed and cheerful facial expression.

Through the implementation of good nursing interventions as outlined in the care plan, these

goals were fully met on their said dates.

25/09/2025

On this day, patient experienced easy fatiguability and anxiety. The following objectives were

set for the problems respectively: Patient will have improved activity tolerance within 24 hours

as evidenced by patient verbalizing that she can now perform activities of daily living without

assistance and nurse observing patient perform activities of daily living without difficulty, and

patient will be relieved of anxiety within 6 hours as evidenced by patient verbalizing that she is

no more anxious and nurse observing patient having a cheerful facial expression.

With the implementation of good nursing interventions as outlined in the care plan, these goals

were fully met on their said dates.

5.2 AMENDMENT OF CARE PLAN

During evaluation of nursing care rendered to Mrs. P. N, all goals and objectives set from the

beginning of the interaction were fully met. This was due to the effectiveness of the medical and

nursing care rendered as well as co-operation and support of the patient and her family.

Therefore, the nursing care plan needed no amendment.

59
5.3 TERMINATION OF CARE

Preparation towards termination of care started on the day of admission. On the day of

admission, the patient and her relative were made to understand that their stay in the hospital was

temporal and they will be discharged home as soon as patient is declared fit for discharge by the

doctor.

As patient condition improved nurse-patient relationship was gradually reduced so as not to

create dependency on health staffs whilst independent functioning was encouraged. I made a pre-

discharge visit to patient home to assess the environmental situations in order to get a clear

picture of patient home environment and to give the necessary health education.

Patient and family were given basic education on gastritis and were also educated on how to

continue treatment at home. In view of this, by the time of discharge, patient was physically and

psychologically prepared to go home.

During the routine ward rounds, on the 28th September, 2025, the doctor examined patient and

declared her fit for discharge to continue treatment at home. Following the discharge, two

follow-up home visits were made to patient’s home to find out how patient was doing at home

and the necessary health education was given. On my third/last home visit on the 17 th October,

2025, the therapeutic care was terminated. Patient was not handed over to a community nurse

because patient recovered successfully and the conditions was not a chronic condition.

5.4 SUMMARY AND CONCLUSION

This case study was written on Mrs. P. N, a 46 years old woman and her family. She was

admitted into the female medical ward of the St. John of God Hospital on the 25 th September,

2025 at 11:13 a.m. through the Out-Patient Department. She was diagnosed of having acute

gastritis.

60
Dependent notes such as taking and recording of vital sign, serving of prescribed medication and

bed making were successfully carried out.

Nursing problem identified on admission were: loss of appetite, abdominal pain, vomiting and

headache.

Mrs. P. N’s medical treatment included;

 Intravenous Amoxiclav 1.2g tds x 24 hours

 Intravenous Omeprazole 80mg stat 40mg bd x 48 hours

 Intravenous Metronidazole 500mg tds x 24 hours

 Intravenous Paracetamol 1g/100ml tds x 24 hours

 Intravenous Metoclopramide 10mg bd x 24 hours

 Tab. Nexium 20mg bd x 7 days

 Suspension Nugel O 10mls tds x 7 days

 Intravenous fluid Normal Saline 2litre x 48hours

 Intravenous fluid Ringers Lactate 1litre for 24hours

Health education was given to the patient and her family. Throughout her stay at the hospital,

many problems were identified and goals were set which were achieved through the nursing

interventions carried out. The patient’s condition improved rapidly without any complication.

She was finally discharged on the 28 th September, 2025. Follow up visits to educate patient,

monitor her health and assess compliance with medication were done. She was finally declared

fit during review on 14th October, 2025. After my third visit on the 17th October, 2025, the

therapeutic care was terminated.

Conclusively this care study has made it possible for me to understand and render individualized

nursing care to a patient.

61
It has strengthened my desire for good interpersonal relationship and made it possible for me to

put into practice all the knowledge I have acquired during my three-year nursing training course.

It has actually broadened my knowledge on gastritis. It has also taught me how to give a

comprehensive nursing care to a patient and her family.

5.5 RECOMMENDATION

Apart from the patient and family care study being a course requirement for the award of

Registered General Nursing (RGN) certificate, it is also a worthy academic exercise as it helps

the student nurse get the opportunity to render effective nursing care to the patient and family

through the use of the nursing process.

I will therefore recommend that the nursing process should be strictly adhered to in the wards in

the management of patient as it is a tool for effective nursing care delivery by nurses

globally and also, it raises the standards of nursing as a noble profession.

62
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Approach. 3rd ed. New York: McGraw-Hill Education.

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Nashrul Ummah Lamongan. Journal of Vocational Nursing, 2(1), 10–15.

[Link]

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Management of H. pylori Infection and Associated Gastritis. Bethesda, MD: ACG

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Berman, A., Snyder, S., & Frandsen, G. (2022). Kozier & Erb's Fundamentals of Nursing:

Concepts, Process, and Practice. 11th ed. London: Pearson Education.

BMJ Best Practice. (2025). Gastritis - Symptoms, diagnosis and treatment. [Online]

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Study. Kumasi: Academic Press.

Fansiwala, K., Lewis, M. S., & Pisegna, J. R. (2024). Gastritis: Pathophysiology and clinical

management. American Journal of Gastroenterology, 120, 5–12.

[Link]

Gulanick, M., & Myers, J. L. (2022). Nursing Care Plans: Diagnoses, Interventions, and

Outcomes. 10th ed. St. Louis: Elsevier Health Sciences.

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Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2023). Lewis’s

Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. St.

Louis: Elsevier.

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Nursing. 15th ed. Philadelphia: Wolters Kluwer.

Inoue, K., & Takagi, T. (2025). Role of mucosal protective agents in the healing of acute

gastric lesions. International Journal of Molecular Sciences, 26(2), 442–458.

Jones, K. R., & Webb, G. (2024). Dietary influences on acute gastritis: A systematic review.

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Disease. 10th ed. Philadelphia: Saunders Elsevier.

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complications and gastritis. Gastroenterology Today, 18(4), 112–119.

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 APPENDIX

Table 7: OBSERVATIONAL CHART FOR MRS. P. N.

DATE TIME TEMPERATUR PULSE BLOOD RESSURE RESPIRATION

E (BPM) (MMHG) (CPM)

(OC)

24/09/2025 11:30 a.m. 36.4 80 148/83 21

25/09/2025 6:00 a.m. 36.4 82 116/78 18

2:00 p.m. 36.3 97 124/78 17

6:00 p.m. 36.4 88 113/87 17

26/09/2025 6:00 a.m. 36.6 68 109/69 16

2:00 p.m. 36.4 77 120/75 17

6: 00 p.m. 36.4 81 123/81 17

27/09/2025 6:00 a.m. 36.5 79 122/62 16

2:00 p.m. 36.6 77 120/70 18

6:00 p.m. 36.6 87 119/79 17

28/09/2025 6:00 a.m. 36.3 79 100/79 19

66
 SIGNITORIES

NAME OF CANDIDATE: FOSU QUEENSTER

SIGNATURE: …………………………………………

DATE: …………………………………………

NAME OF NURSE IN-CHARGE: GRACE ADU MINTAH (MRS.)

SIGNATURE: …………………………………………

DATE: …………………………………………

NAME OF SUPERVISING TUTOR: JACOB NRENZAH (MR.)

SIGNATURE: …………………………………………

DATE: …………………………………………

NAME OF PRINCIPAL: SUSAN YAA AFRAMA ARKAH (DR.)

SIGNATURE: ………………………………………….

DATE: ………………………………………….

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