PATIENT/FAMILY CENTERED CARE STUDY

(A NUSRING PROCESS APPROACH)

ON A PATIENT

WITH PNEUMONIA

WRITTEN BY:

AIDOO FELICITY

(COHSARGN230185)

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 MR. J. K.

WITH PNEUMONIA

WRITTEN BY:

AIDOO FELICITY

(COHSARGN230185)

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.
 PREFACE

Becoming a nurse in the modern era requires navigating a rigorous and multifaceted

educational journey. Students are expected to master complex clinical knowledge and

technical skills while maintaining a deep respect for the heritage of the profession and the

diverse factors that influence patient outcomes. By integrating these elements, students

develop into competent professionals dedicated to lifelong learning. This guide is designed as

a resource for both educators and students, focusing on the application of the nursing process

within the clinical setting through a contemporary lens on healthcare.

The nursing process serves as a systematic, organized framework that ensures practitioners

address the comprehensive needs of every patient.

As the healthcare landscape transforms, there is an increasing shift toward primary care roles.

Nurses in these positions must pursue advanced training to meet rising levels of responsibility

and professional recognition, a transition that also contributes to making healthcare more

sustainable and accessible.

The Patient Care Study is a formal academic report required of all final-year nursing students.

It is a mandatory component of the Nursing and Midwifery Council (NMC) final practical

examination for professional licensure. This requirement applies to third-year NMC students

as well as Level 400 university students across all nursing disciplines, including Registered

General Nursing (RGN), Registered Mental Health Nursing (RMN), Registered Community

Nursing (RCN), and Registered Midwifery (RM).

Consequently, this study is a fundamental requirement of the three-year nursing curriculum in

Ghana and is a prerequisite for attaining a license as a Registered General Nurse. To fulfill

this, the student selects a single patient to receive "holistic care." This involves managing the

patient’s health from admission through discharge, conducting home follow-ups, and

fostering a therapeutic relationship with both the patient and their family.

i
To uphold the standards of patient confidentiality and privacy, the patient’s identity has been

protected. Throughout this report, he will be referred to by the pseudonym Mr. J. K.

ii
 ACKNOWLEDGEMENT

I would like to begin by expressing my profound gratitude to the Almighty God for granting

me the wisdom, guidance, and perseverance required to bring this project to a successful

conclusion.

I am deeply indebted to my patient, Mr. J. K., and his family, for their immense kindness in

consenting to this study and for their steadfast cooperation during the entire process.

I wish to extend my sincere appreciation to our Principal, Dr. Susan Yaa Aframa Arkah, and

my supervisor, Mr. Jacob Nrenzah. I am truly grateful for their exceptional patience,

insightful mentorship, and the significant effort they dedicated to reviewing this work and

helping me navigate every challenge. I also thank the entire faculty of the College of Health,

Sefwi Asafo, for their academic guidance.

My heartfelt thanks go to the Ward In-charge, Mrs. Linda Ackah, and the dedicated team at

the male ward of the Wiawso Government Hospital for their permission and assistance in

identifying a suitable patient for this study.

To my family, especially my parents, Mr. Benjamin Aidoo and Mrs. Grace Kwarteng, I thank

you for your unconditional love and unwavering support. I am also grateful to my friends,

classmates, and all those who provided encouragement and contributed to the successful

completion of this work.

Finally, I would like to acknowledge the various authors and publishers whose literature and

research provided the essential foundation and references for this document.

iii
 INTRODUCTION

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

Nursing and Midwifery Council (NMC) of Ghana. This comprehensive written report is

completed by all final-year students as a core prerequisite for the conferment of a Diploma in

Nursing. The fundamental objective of this assignment is to apply the nursing process

framework to assist a patient in achieving and maintaining their highest possible state of

health.

Moreover, this study provides an opportunity for the student nurse to bridge the gap between

theoretical concepts and clinical practice by delivering holistic care. It serves as a vital

assessment of the student’s ability to view the patient not merely as a medical diagnosis, but

as a unique individual situated within a specific family and community structure.

This specific report focuses on Mr. J. K., a 57-year-old resident of Sefwi Ahwinam District in

the Western North Region. He was admitted to the male ward of the Wiawso Government

Hospital on September 25th, 2025. Based on a thorough physical examination and clinical

investigations, he was diagnosed with Pneumonia.

Mr. J. K. arrived at the ward in the company of his granddaughter and a transferring nurse.

Upon receiving the patient’s records, I welcomed them and ensured they were comfortably

seated. I confirmed his identity by cross-referencing his folder with his verbal response. After

a preliminary review of his medical records, I interviewed him regarding his symptoms,

which were consistent with the clinical documentation.

Following the documentation of his details in the admission and discharge register, I prepared

his bedside and introduced myself along with the ward personnel. I oriented him to the

ward’s layout, including essential facilities like the washrooms and pharmacy. Subsequently,

I explained the objectives of my study and requested his formal consent, which was kindly

granted by both the patient and his family.

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On September 30th, 2025, following a successful recovery and a final evaluation by the

medical officer during ward rounds, Mr. J. K. was discharged.

To ensure comprehensive continuity of care, I performed three subsequent home visits:

First Home Visit: Conducted on September 28th, 2025 (pre-discharge), to evaluate his

domestic environment and identify any environmental or community factors that might have

influenced his health status.

Second Home Visit: Conducted on October 13th, 2025, to monitor his progress at home and

reinforce education regarding medication compliance and the lifestyle adjustments discussed

during his hospitalization.

Third Home Visit: Conducted on October 21st, 2025, for a final assessment. Observing that

he was in good health and had strong family support, I formally concluded his care.

This study is structured into five distinct chapters:

Chapter One encompasses the assessment of the patient and family. This includes personal

data, family and developmental history, the admission narrative, the patient’s perception of

his condition, a literature review of pneumonia, and data validation.

Chapter Two centers on the analysis of the collected data. It contrasts information from the

patient and family, identifies clinical strengths and problems, and establishes relevant nursing

diagnoses.

Chapter Three presents the nursing care plan, outlining the specific strategies and

interventions designed to manage both the actual and potential health needs of the patient and

his family.

Chapter Four provides a detailed report on the implementation of care for Mr. J. K. and his

family, summarizing the interventions performed and the discharge planning process.

v
Chapter Five offers a final evaluation of the care provided. It includes modifications to the

care plan for unmet goals, the formal termination of the nurse-patient relationship, a

summary, a conclusion, and professional recommendations for future nursing management.

vi
 TABLE OF CONTENT

PREFACE...................................................................................................................................I

ACKNOWLEDGEMENT.......................................................................................................III

INTRODUCTION...................................................................................................................IV

TABLE OF CONTENT..........................................................................................................VII

LIST OF TABLES....................................................................................................................X

CHAPTER ONE........................................................................................................................1

1.0. ASSESSMENT OF PATIENT AND FAMILY.............................................................1

INTRODUCTION..................................................................................................................1

1.1. PATIENT’S PARTICULARS........................................................................................2

1.2. FAMILY’S MEDICAL AND SOCIO-ECONOMIC HISTORY...................................2

1.3. PATIENT’S DEVELOPMENTAL HISTORY..............................................................3

1.4 PATIENT’S LIFESTYLE/HOBBIES.............................................................................4

1.5. PATIENT’S PAST MEDICAL HISTORY....................................................................5

1.6. PATIENT’S PRESENT MEDICAL HISTORY.............................................................5

1.7. ADMISSION OF PATIENT...........................................................................................6

1.8. PATIENT’S CONCEPT ABOUT HIS ILLNESS..........................................................7

1.9. LITERATURE REVIEW ON PNEUMONIA................................................................8

1.10. VALIDATION OF DATA..........................................................................................18

CHAPTER TWO.....................................................................................................................19

2.0 ANALYSIS OF DATA......................................................................................................19

2.1 COMPARISON OF DATA WITH STANDARD.........................................................19

2.1.1 DIAGNOSTIC INVESTIGATIONS / TEST..........................................................19

2.1.2 CAUSES OF PATIENT’S ILLNESS.....................................................................23

2.1.3 Clinical Features......................................................................................................23

vii
 2.1.4 SPECIFIC MEDICAL TREATMENT...................................................................24

[Link] PHARMACOLOGY OF DRUGS ORDERED...............................................25

2.1.5 COMPLICATIONS................................................................................................30

2.2 PATIENT/FAMILY STRENGTH.................................................................................30

2.3 PATIENT’S HEALTH PROBLEMS............................................................................30

2.3.1. PATIENT’S STRENGTH ACCORDING TO IDENTIFIED PROMBLEMS......31

2.4 NURSING DIAGNOSIS...............................................................................................31

CHAPTER THREE..................................................................................................................32

3.0 PLANNING FOR PATIENT/ FAMILY CARE................................................................32

3.1 OBJECTIVES /OUTCOME CRITERIA.......................................................................32

CHAPTER FOUR....................................................................................................................47

IMPLEMENTING PATIENT/FAMILY CARE PLAN......................................................47

4.0 INTRODUCTION...............................................................................................................47

4.1 SUMMARY OF ACTUAL NURSING CARE.............................................................47

4.1.1 DAY OF ADMISSION (25/09/2025).....................................................................47

4.1.2 FIRST ON ADMISSION (26/09/2025)..................................................................51

4.1.3 SECOND DAY ON ADMISSION (27/09/2025)...................................................53

4.1.4 THIRD ON ADMISSION (28/09/2025).................................................................54

4.1.5 FOURTH DAY ON ADMISSION (29/09/2025)...................................................55

4.1.5 FOURTH DAY ON ADMISSION/ DAY OF DISCHARGE (30/09/2025)..........57

4.2 PREPARATION OF PATIENT FOR DISCHARGE....................................................58

4.3 FOLLOW-UP/HOME VISITS/CONTINUITY OF CARE.........................................................58

4.3.1. First Home Visit (28/09/2025)...............................................................................59

4.3.2 Second Home Visit (13/10/2025)............................................................................59

4.3.3 Review Day (14/10/2025).......................................................................................60

viii
 4.3.4 Third Home Visit (21/10/2025)..............................................................................60

CHAPTER FIVE......................................................................................................................61

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY..........................61

5.0 INTRODUCTION...............................................................................................................61

5.1 STATEMENT OF EVALUATION.........................................................................................61

5.2 AMENDMENT OF NURSING CARE FOR PARTIALLY MET OR UNMET

OUTCOME CRITERIA.......................................................................................................63

5.3 TERMINATING OF CARE..........................................................................................63

5.4 SUMMARY AND CONCLUSION...............................................................................63

5.5 RECOMMENDATION.................................................................................................65

BIBLIOGRAPHY....................................................................................................................66

APPENDIX I............................................................................................................................68

SIGNITORIES.........................................................................................................................69

ix
 LIST OF TABLES

TABLE 1: COMPARISON OF DIAGNOSTIC TEST AND INVESTIGATION CARRIED

OUT ON PATIENT WITH THAT OF THE LITERATURE REVIEW.........................20

TABLE 2: DIAGNOSTIC INVESTIGATIONS/TEST CARRIED OUT PATIENT.............21

TABLE 3: CLINICAL FEATURES MANIFESTED BY MR. J. K AS COMPARED TO

THAT OF THE LITERATURE REVIEW......................................................................23

TABLE 4: COMPARISON OF PATIENT’S TREATMENT WITH THAT OF

LITERATURE REVIEW.................................................................................................25

TABLE 5: PHARMACOLOGY OF DRUGS ADMINISTERED TO MR. J. K....................26

TABLE 6: NURSING CARE PLAN FOR MR. J. K..............................................................34

TABLE 7: OBSERVATIONAL CHART FOR MR. J. K.......................................................68

x
 CHAPTER ONE

1.0. ASSESSMENT OF PATIENT AND FAMILY

INTRODUCTION

This is the first phase of the nursing process. It involves the collection of data about the patient,

his relatives and the community in which he lives. This is important because it helps the nurses

to identify the patient’s problems. It gives an idea about the patient’s condition, needs and health

problems which enables the nurses render efficient nursing care. The methods used in collecting

the data include interviewing, information from patient’s folder, observation, literature review,

patient’s relatives and medical team.

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 Pneumonia

j. Validation of data collected.

1
 1.1. PATIENT’S PARTICULARS

Mr. J. K is the patient for the care study. He is a Ghanaian born to Mr. K. K and Mrs A. A on

the 29th September, 1958 with the help of a traditional birth attendant, Madam A. N at home in

Sefwi Ahwinam in the Sefwi Wiawso Municipality in the Western North Region of Ghana

without complications. His parents are late, they both died out of natural causes. He is 67 years

old. He is the only child for his parents. He hails from Sefwi Ahwinam District in the Western

North Region. He resides at Sefwi Ewiase in the Sefwi Wiawso Municipality of the Western

North Region of Ghana. He was married to Mrs. V. B but now divorced with two children, Ms.

H. A and Mr. N. R whose ages are 37 years and 32 years respectively. He is a Sefwi by tribe and

speaks Sefwi and twi languages. He is a Christian and worships with Roman Catholic Church in

the Ewiase community. He is a form four leaver who had his primary education at Sefwi Ewiase

L/A in the year 1974. He is about 4.8 m tall and dark in complexion. He weighs 61kg. Mr. J. K

is a cocoa farmer in the Sefwi Ewiase community. He lives in a pink 4-bedroom apartment with

his granddaughter. The house is built with blocks and cement, and roofed with aluminum sheets.

His next of kin is his son, Mr. N. R. No known allegies

1.2. FAMILY’S MEDICAL AND SOCIO-ECONOMIC HISTORY

According to Mr. J. K, there are no known genetic, non-familial disease such as diabetes,

epilepsy, hypertension, asthma and mental illness in the family. Mr. J. K said that occasionally

certain minor ailments such as headache, malaria, abdominal pain, diarrhoea, constipation, chills

and dysmenorrhoea sometimes affect the family members and treated from clinics and self-

medication likes metronidazole, paracetamol and artemether lumefantrine which are purchases

from over the counter.

Socioeconomically, Mr. J. K is cocoa farmer. His main source of income is from the sales from

his produce. He also gets a lot of support form his children who are with their spouses in their

2
separate houses in the same community (Sefwi Ewiase). The son is also a cocoa farmer and the

daughter too is a teacher in the Ewiase L/A basic school. He can provide all his basic needs. The

family members have registered with the National Health Insurance Scheme (NHIS). This

enables them get free medical treatment whenever they fall sick.

1.3. PATIENT’S DEVELOPMENTAL HISTORY

The patient told me that according to his mother, he was a full-term baby delivered

spontaneously on the 29th September, 1958 with the help of a traditional birth attendant, Madam

A. N at home in Sefwi Ahwinam in the Sefwi Wiawso Municipality in the Western North

Region of Ghana without any complication. He was not breastfed exclusively due to the lack of

knowledge of exlusive breastfeeding at that time. Mr. J. K was taken through all the childhood

immunization at birth as confirmed by the Bacilli Chalmette et Guerin scar on his right upper

arm.

Mr. J. K had a normal developmental pattern and started erupting teeth in the sixth (6 th) month

and crawling on the fifth (5th) month, sitting on the ninth (9th) month, and standing and walking

on the eighteenth (18th) month. He had his secondary sexual characteristics, thus broadness of

chest, growing of hairs at the axilla and pubic area at the age of sixteen. He had his first

intercourse at the age of twenty-two (22). He started schooling at the age of four but got dropped

out at form four in the year 1974 to join his father in the farm due to financial problems.

Erickson’s theory of psychosocial development (1963), describes the human life cycle as a

series of eight ego developmental stages from birth to death. Each stage presents a psychosocial

crisis, the goal of which is to integrate physical, maturation and societal demands. The theory

focuses on psychosocial task that are accomplished throughout the life cycle. An unsuccessful

resolution leaves the individual emotionally handicapped.

The stages which are involved in Erickson’s theory of psychosocial development are;

 Trust versus Mistrust (Birth to 18 months)

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

 Initiative versus Guilt (3years to 6years)

 Industry versus Inferiority (6-12years)

 Identity versus Role Confusion (12-20years)

 Intimacy versus Isolation (20-35years)

 Generativity versus Stagnation (35 – 65 years)

 Integrity versus Despair (65 – death)

Mr. J. K is 67 years old so he falls in Integrity versus Despair. This stage begins at

approximately age 65 and ends at death. The integrity versus despair stage begins as the aging

adult begins to tackle the problem of his mortality. The onset of this stage is triggered by life

events such as retirement, the loss of a spouse, the loss of friends and acquaintances, facing a

terminal illness, and other changes of major roles in life. During this stage, people reflect back

on the life they have lived and come away with either a sense of fulfillment from a life well

lived or a sense of regret and despair over a life misspent.

1.4 PATIENT’S LIFESTYLE/HOBBIES

Mr. J. K wakes up in the morning around 6:00am and stays in bed before getting out of bed to

perform his activities of daily living like emptying the bowel two times daily (morning and in

the evening), taking care of his oral hygiene with toothpaste and toothbrush when he wakes up

in the morning only and bathing which he does it once daily, thus after returning from the farm.

According to Mr. J. K, he takes his breakfast mostly porridge with bread around 7am after

which he goes to the farm. He takes his launch at 2:00pm which is mostly rice and egg stew or

ampsi and kontomire stew at the farm. He returns home around 5pm. He takes his bath and then

takes his supper which is always prepared by his granddaughter.

His favorite food is fufu and kontimere soup with dry fish. He usually sit in the living room

with the granddaughter for a while after supper and retires to bed around 9 p.m.

4
He goes to the farm from Monday to Saturday. But he sometimes attends funeral services on

Saturdays, thus if there is any. He goes to church every Sunday morning. After church, he visits

his friends for brief conversations. He also likes alcoholic beverages but does not smoke. He

often drinks with his friends at a drinking bar closer to his house.

Mr. J. K stated that he usually returns to bed around 9:30 p.m.

1.5. PATIENT’S PAST MEDICAL HISTORY

Upon interaction with the patient and the relative (granddaughter), Mr. J. K has not been

admitted before at the hospital since birth so this is his first time being admitted to the ward and

he disclosed that occasionally he suffers from headaches and fever which he always treats with

over-the-counter medicines like metronidazole, paracetamol and artemether lumefantrine. He

also indicated that he has not undergone any surgical procedure before. Mr. J. K has no known

food or drug allergy.

1.6. PATIENT’S PRESENT MEDICAL HISTORY

Mr. J. K was well until the 24th September, 2025 at 9 a.m. when he started general body

weakness. He went to a nearby drug store to buy some medications (Gebedol). Patient noticed

his condition has improved later that day. Unfortunately for Mr. J. K, disease relapsed the

following day accompanied with difficulty in breathing and cough after taking the over-counter

drugs. His granddaughter accompanied him to the Out Patient Department of the Wiawso

Government Hospital on 25th September, 2025 at 10 a.m.

He was seen by Dr. A who upon assessment diagnosed him of Pneumonia. He was admitted to

the males’ medical ward for further management.

1.7. ADMISSION OF PATIENT

On the 25th September, 2025 in the morning around 11:08 a.m., Mr. J. K came to the ward

accompanied by a nurse and his granddaughter.

5
They were welcomed and offered seats at the nurses’ station. Assessment on the patient revealed

that he was feeling weak, had difficulty in breathing and cough, due to this he was immediately

admitted into an already prepared admission bed. He was put in a semi-fowler’s position.

His particulars such as name, age, address were taken and recorded in the admission and

discharge book, as well as the daily ward state. Since he was conscious, he was verbally

oriented to the ward and its annex and introduced to his ward mates. Relative was also oriented

as well, relative was informed of the ward protocols. The relative was informed to bring the

necessary items needed while on admission when she is coming for afternoon visit.

His vital signs were checked and recorded as follows;

Temperature 36.7 degree celsius.

Pulse 112 beats per minute.

Respiration 28 cycles per minute.

Blood pressure 145/96 millimeters of mercury.

Weight 61 kilograms.

General observations were done on patient, no rashes were found on his skin neither scar. Finger

nails were clean with no artificial nails. No dentures were found and he was well dressed.

The following investigations were carried out on the patient, a tray was set, samples were taken

and was sent to the laboratory, together with laboratory request form. Results of the

investigation in awaiting.

1. Chest radiography

2. Sputum for culture and sensitivity test

3. Full blood count

4. Blood grouping.

He was put on the following prescribed medication:

1. Injection Tramadol 100mg stat

6
2. Intravenous Paracetamol 1g/100mls tds x 24 hours

3. Intravenous Amoxiclav 1.2g tds x 24 hours

4. Expect Sed Mixture 10mls tds x 5

5. Salbutamol Nebules 5mg qid x 24 hours

6. Tab Azithromycin 500mg dly x 6

7. Intravenous infusion Normal Saline 1L x 24 hours

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

Mr. J. K was told not to hesitate to ask any nurse in case he was in doubt or in need of anything.

I reassured patient/family of being in safe hands and later introduced myself as a final year

student of College of Health – Sefwi Asafo who wants to take Mr. J. K as my patient, nurse him,

study his condition and write patient/family care study on his condition. They agreed to allow

me study his condition and promised to cooperate and give me the necessary information

needed.

Patient was made comfortable in bed for all nursing activities to take place.

1.8. PATIENT’S CONCEPT ABOUT HIS ILLNESS

Mr. J. K could not tell the cause of his illness. He however, did not attribute the cause of his

illness to any supernatural powers. As a Christian he believed that taking his prescribed

medications and prayers to God, he will be well without any complications.

1.9. LITERATURE REVIEW ON PNEUMONIA

DEFINITION;

7
Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms,

including bacteria, mycobacteria, fungal and viruses. Pneumonitis is a more general term that

describes an inflammatory process in the lung tissue that may predispose or place the patient at

risk for microbial invasion. Pneumonia and influenza are the most common causes of death

from infectious diseases in the United States (Hinkle J.L&Cheever K [2014] Brunner and

Saddarth’s Textbook of medical and surgical Nursing, 13th Edition)

INCIDENCE AND PREVALENCE

Pneumonia is the common cause of death from infectious disease in the United States.

It is the seventh leading cause of death in the United States for all ages and both genders,

resulting in almost 70,000 deaths per year.

In persons 65 years of age and older, it is the fifth leading cause of death and was once referred

to as the ‘old man’s friend’ in the United States.

RISK FACTORS OF PNEUMONIA;

 Old age thus, people above 65 years of age

 Alcoholism

 Immunosuppressive disorders

 Multiple medical morbidities

 Exposure to child in a day care facility

 Smoking [cigarette smoke disrupts both mucociliary and macrophage activities

 Prolong inactivity and shallow breathing pattern

 Depressed cough reflex (Hinkle J.L&Cheever K [2014] Brunner and Saddarth’s

Textbook of medical and surgical Nursing, 13th Edition)

OTHER RISK FACTORS INCLUDES;

 Trauma to the chest

8
  Living in dusty area and

 Malnutrition

CLASSIFICATION OF PNEUMONIA

Classically, pneumonia has been categorized into one of four categories: bacterial or typical,

atypical, anaerobic/cavity, and opportunistic. However, there is overlap in the

microorganisms thought to be responsible for typical and atypical pneumonias.

A more widely used classification scheme categorizes the major pneumonias as community-

acquired pneumonia, hospital acquired pneumonia, pneumonia in the immunocompromised

host, and aspiration pneumonia. There is overlap in how specific pneumonias are classified

because they may occur in differing settings;

COMMUNITY ACQUIRED PNEUMONIA

It occurs in the community setting or within the first 48 hours after hospitalization or

institutionalization. It is frequently caused by streptococcus pneumonia, hemophiles

influenza, staphylococcus aureus and chlamydia pneumonia.

It has an abrupt onset and there is pleuritic chest pain, usually involves one or more lobes. It

usually spread by droplet inhalation and most patients affected are previously well. Viruses

are most common cause of pneumonia in infants and children but are relatively uncommon

cause of CAP in adults.

HOSPITAL ACQUIRED PNEUMONIA

HAP, also known as nosocomial pneumonia, is defined as the onset of pneumonia symptoms

in more than 48 hours after admission of in patient with no evidence of infection at the time

of admission. HAP account for approximately 15% of hospital acquired infections but is the

most lethal nosocomial infection

9
HAP occurs when at least one of the three conditions exists; host defence is impaired, an

inoculum of organisms reaches the lower respiratory tract and overwhelm the host defence or

a highly virulent organism is present.

The common organisms responsible for HAP includes the pathogens Enterobacter species;

Escherichia coli, Haemophilus influenza, klebsiella species, proteus, [Link].

PNEUMONIA IN THE IMMUNOCOMPROMISED HOST

This is also said to be opportunistic pneumonia.

Immunosuppression occurs with corticosteroids or other immunosuppressive agents,

nutritional depletion, antimicrobial agents, AIDS etc. pneumonia in immune compromised

hosts may be caused by the organisms observed in CAP or HAP (streptococcus pneumonia,

[Link], H. influenza , M . tuberculosis). It is an initial defining complication of Acquired

Immunodeficiency Syndrome (AIDS).

ASPIRATION PNEUMONIA

According to Smeltzer, S.C and Bare, B.G (2010): Brunner and Siddharth’s Textbook of

medical and surgical Nursing, 12th Edition, Aspiration pneumonia refers to the pulmonary

consequences resulting from entry of endogenous or endogenous substances into the lower

airway. The most common form of aspiration pneumonia is bacteria that commonly reside in

the upper airway. Aspiration pneumonia may occur in community or hospital setting.

Common pathogens are [Link], [Link], and [Link] among others.

Substances other than bacteria may be aspirated into the lung such as gastric content,

exogenous chemical content or irritating gases. The aspiration of ingestion may impair the

lung defences, causing inflammatory changes, and lead to bacteria growth and resulting

pneumonia.

10
CLASSIFICATION BY SITE (ANATOMICAL CLASSIFICATION)

Some books also classify pneumonia based on the anatomical site of the respiratory airway;

Pneumonias are either localized, with the whole of one or more lobes affected as in lobar

pneumonia or diffuse, when they primarily affect the lung, often in association with the

bronchi and bronchioles, a condition referred to as bronchopneumonia.

When the condition is characterized by inflammatory exudate within the intra-alveolar space

resulting in consolidation that affects a large and continuous area of a lobe of a lung, it is

referred to as lobar pneumonia [http//[Link]/wiki/9Lobar-pneumonia.

23/02/2019 at 11; 31am]

In lobar Pneumonia there are four stages of inflammatory response;

Congestion

Red hepatization

Gray hepatization

Resolution

CONGESTION: The lung is heavy, boggy and red. It is characterized by vascular

engorgement, in the alveoli wall and exudates form in the alveoli with little neutrophils and

often the presence of numerous bacteria. This change interferes greatly with oxygen

diffusion.

RED HEPATIZATION: this stage follows the congestion by massive exudation with red

blood cells; neutrophils and fibrin accumulate in the alveolar forming a solid mass in the

lobe, called consolidation.

On gross examination, the lobe now appears red, firm and airless with a liver like consistency

hence the term hepatization.

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GRAY HEPATIZATION: This stage follows progressive disintegration of red blood cells

and the persistence of exudates, produces the typical rusty sputum associated with lobar

pneumonia, giving the gross appearance of a gray brown dry surface.

RESOLUTION: In this final stage, the consolidated exudates within the alveolar spaces

undergoes progressive enzymatic digestion, the red blood cells break down, and the infection

resolves, macrophages breakdown the exudates to allow it to be expectorated or cough out or

resorbed.

12
PATHOPHYSIOLOGY

The Upper airway characteristics normally prevent potentially infectious particles from

reaching the normally sterile lower respiratory tract. Thus, patients with pneumonia caused

by infectious agents often have an acute or chronic underlying disease that impairs host

defenses. Pneumonia arises from normally present flora in a patient whose resistance has

been altered, or it results from aspiration of flora present in the oropharynx. It may also result

from blood borne organisms that enter the pulmonary circulation and are trapped in the

pulmonary capillary bed, becoming a potential source of pneumonia.

Pneumonia often affects both ventilation and diffusion. An inflammatory reaction can occur

in the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon

dioxide. White blood cells, mostly neutrophils, also migrate into the alveoli and fill the

normally air-containing spaces. Areas of the lung are not adequately ventilated because of

secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli, with a

resultant decrease in alveolar oxygen tension. Bronchospasm may also occur in patients with

reactive airway disease. Because of hypoventilation, a ventilation–perfusion mismatch occurs

in the affected area of the lung. Venous blood entering the pulmonary circulation passes

through the under ventilated area and exits to the left side of the heart poorly oxygenated. The

mixing of oxygenated and unoxygenated or poorly oxygenated blood eventually results in

arterial hypoxemia.

If a substantial portion of one or more lobes is involved, the disease is referred to as “lobar

pneumonia.” The term “bronchopneumonia” is used to describe pneumonia that is distributed

13
in a patchy fashion, having originated in one or more localized areas within the bronchi and

extending to the adjacent surrounding lung parenchyma. Bronchopneumonia is more

common than lobar pneumonia (Hinkle J.L&Cheever K [2014] Brunner and Saddarth’s

Textbook of medical and surgical Nursing, 13th Edition)

CLINICAL MANIFESTATION OF PNEUMONIA

 Pleuritic chest pain

 Fever and chills

 Tachycardia

 Cough (productive or non- productive)

 Dyspnea

 Sore throat

 Haemoptysis

 Muscle pain

 Sweating

 Fatigue

 Headache

 Leukocyte count increases

OTHER CLINICAL MANIFESTATIONS ARE;

 Crackles

 Tactile fremitus

 Percussion dullness

 Bronchial breath sound

DIAGNOSTIC INVESTIGATION

 Chest X-Ray will disclose infiltrate in the chest.

 Sputum for gram stain and culture and sensitivity test.

14
  Arterial blood gas analysis.

 Bronchoscopy.

 Tran’s tracheal aspiration for collection of secretion for culture and sensitivity test.

 History from patient.

 Thoracentesis.

MEDICAL MANAGEMENT

 Appropriate antibiotics should be given following culture and sensitivity test eg

Azithromycin

 Anti-inflammatory, anti-pyretic and analgesics may be given, eg brufen, paracetamol,

aspirin etc to relief chest pain

 Intravenous or oral fluid 3-4litres may be given daily

 Expectorant example simple linctus may be given

 Oxygen administration when the need be

 Proton Pump inhibitors may be given e.g omeprazole

LUNG NECROSECTOMY

When antibiotic treatment fails and clinical course does not improve, patients might need

lung tissue resection:

Segmentectomy: The removal of section of a lobe of lung.

Bilobectomy: removal of two lobes of the right lung.

Lobectomy: is a type of lung cancer surgery in which one lobe of a lung is removed.

Lung necrosectomy is a conservative, effective surgical treatment, when solves lung

necrotizing infection avoiding resection of healthy lung parenchyma

NURSING MANAGEMENT

REST AND SLEEP

 Nurse patient in a well-ventilated and clean environment.

15
  Put patient in upright or sitting up position

 Ensure quiet and peaceful environment

 Maintain patent airway

 Nursing procedures should be planned in bulk to minimize unnecessary disturbances

 Put patient in upright position on a comfortable bed to ensure good breathing pattern

 Stay with patient until the temperature goes down more especially during times of

respiratory distress.

OBSERVATION

 Observe patient respiratory pattern

 Observe sputum for color, amount and blood.

 Observe patient for improvement of condition

 Monitor intake and output and record

 Monitor vital health signs especially respiration, temperature and blood pressure as

frequently as condition warrants and record and report deviations.

FLUID AND DIET

 Serve easily digestible food to reduce oxygen demand for metabolism

 Serve diet rich in protein, vitamins, mineral salts and carbohydrate and enhance tissue

repair

 Serve enough fruit and roughages to avoid constipation

 Encourage adequate fluid intake to prevent dehydration and to liquify bronchial

secretions for easy expectoration

 Serve food in bit but frequent times

PERSONAL HYGIENE

Mouth care is given frequently to combat dryness or cracking of the lips and to prevent

infections in the mouth

16
Provide disinfected sputum mug with cover which should be changed at least twice daily

The lips should be kept supple with Vaseline.

PSYCHOTHERAPY

Normally, patient reacts with anxiety if there is respiratory distress. Patient should therefore

be allowed to express their fear and concerns.

Explain the causes, signs and symptoms, investigation, treatment modalities and preventive

measures of condition to patient and family and allow them to ask questions for clarification.

Reassure patient and relatives that measures are being taken to help resolve the health

problem.

ELIMINATION

Ensure fluid intake of about 3-4litres a day as well as adequate intake of fruit and roughage to

promote bowel movement

Monitor patient’s bowel movement and assess patient for any abnormality

HEALTH EDUCATION

 Teach patient coughing and deep breathing exercises

 Educate patient and relatives on the cause, signs and symptoms and prevention of disease.

 Educate patient on the need to avoid alcohol, smoking and strenuous exercises

 Patient should be taught on the need for follow up care

 Educate patient to avoid dusty and cold environment

 Explain to the patient the need for rest, intake of well mixed diet, sleeping in a well-

ventilated room and avoiding over the counter drugs

 Educate patient and relatives on the need for mouth care at least once daily

17
 Educate patient and relatives on the need to rinse the mouth after productive cough,

vomiting and eating.

PREVENTION

 Educate patient and relatives on proper personal and environmental hygiene

 Educate on avoidance of indiscriminate use of antibiotics for infection

 Educate patient to cover the mouth with tissue paper or handkerchief when coughing or

sneezing

 Sleeping on the floor and extreme cold environment should be avoided

 Frequent suctioning of secretion in patient who are unconscious or have poor cough and

gag reflex to prevent aspiration

 Disease of the upper airway should be treated early to avoid organisms descending into

the lower airway to cause infections

COMPLICATIONS

 Atelectasis

 Pleural effusion

 Lung abscess

 Respiratory failure

 Shock.

 Meningitis

 Empyema

 Bronchiectasis

 Endocarditis

 Lung cancer (Richard B.Y [2007] medicine and surgical nursing: Richard printing

limited).

18
 1.10. VALIDATION OF DATA

Conscious attempt is made to ensure that the signs and symptoms such as fatigue, headache,

anorexia and others will match with that of the literature review so as to minimize errors.

Information obtained from patient’s folder, family and diagnostic investigations to ensure that

they match and tally that of the literature review. In all such cases there were virtually no

variations in the data from these sources indicating validity and accuracy of the data in the

study.

19
 CHAPTER TWO

2.0 ANALYSIS OF DATA

The patient information we collected was compared to what's considered normal or standard in

healthcare. This allowed us to understand what the data truly meant so we could plan and

provide the right, effective nursing care. Plus, we fixed any mistakes or inconsistencies in the

data at this point, which made sure our final report was accurate. This is the second phase of

the nursing process.

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

All diagnostic investigations and tests performed on Mr. J. K. are being compared against

established standards found in the literature review to establish the diagnosis.

The following tests were performed:

 Chest radiography
20
  Sputum for culture and sensitivity test

 Full blood count

 Blood grouping.

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

Chest X-Ray will disclose infiltrate Was done for the patient.

in the chest.

Sputum for gram stain and culture Was done for the patient

and sensitivity test

Arterial blood gas analysis. Was not done for the patient

Bronchoscopy Was not done for the patient

Tran’s tracheal aspiration for Was not done for the patient

collection of secretion for culture

and sensitivity test.

History from patient. Patient’s history was taken.

Thoracentesis. Was not done for the patient.

The table clearly shows that most standard diagnostic tests mentioned in the literature such as

history taking, physical examination, chest X-ray, and culture and sensitivity testing were

performed for the patient. Full blood count and blood grouping were also done.

21
 Table 2: DIAGNOSTIC INVESTIGATIONS/TEST CARRIED OUT PATIENT

DATE SPECIMEN INVESTIGATION RESULTS NORMAL INTERPRETATION REMARKS

VALUES

25/09/25 Exposed Chest x ray The solid lobe Normal bony Patient has pneumonia IV Amoxiclav and Tab

chest shows dense structure and normal Azithromycin were

shadow in the lung tissue prescribed.

right lungs

25/09/25 Sputum Culture and Inflammatory Sputum should be Patient has pneumonia IV Amoxiclav and Tab

sensitivity test cells and free from pathogens Azithromycin were

pneumoccocci prescribed.

found

25/09/25 Blood Full Blood count;

Haemoglobin Level 11.9g/dL Male: 12 – 18 gm / dl Slightly below normal range which Patient was encouraged to

Estimation Female: 11- 16 gm / indicates anaemia eat well balance diet, food

dl which contain protein, and

Values were not within normal range iron.

22
 White blood cells 17.3×103/µL 4.0-10.0×103/µL indicating the presence of infection IV Amoxiclav 1.2g and

Count Tablet Azithromycin were

Values are normal indicating enough red given.

Red blood cells 4.82×106/µL 4.31-6.40×106/ µL blood cells. No treatment was given

Count

The value was within the normal range.

Platelets or 302×103/µL 140-440×106/µL No treatment was given.

thrombocytes

25/09/25 Blood Grouping and cross Blood group Blood group A, B, Normal No treatment was given.

matching. A+ AB and O

23
2.1.2 CAUSES OF PATIENT’S ILLNESS

Based on the literature review, collected data, and risk factors, the patient's illness is caused

by an invasion of pathogens (like pneumococci) in the lungs.

2.1.3 Clinical Features

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

features: feeling weak, difficulty in breathing and cough.

Table 3: CLINICAL FEATURES MANIFESTED BY MR. J. K AS COMPARED TO

THAT OF THE LITERATURE REVIEW

Clinical Features in the Literature Clinical Features Presented by

Review Patient.

Pleuritic chest pain Patient had chest pain

Fever and chills Patient had fever

Tachycardia Patient did not experience tachycardia

Cough (productive or non-productive) Patient had productive coughs

Dyspnea Patient had difficulty in breathing

Sore throat Patient did not have sore throat

Haemoptysis Patient did not experience

haemoptysis.

Muscle pain Patient did not experience muscle

pain

Sweating Patient did not experience profuse

sweating.

Fatigue Patient experienced easy fatiguability.

Headache Patient experienced headache.

Leukocyte count increases Patient’s leucocyte counts increased

24
The patient clearly showed key signs of pneumonia, including chest pain, a cough that

produced mucus, fever, headache, trouble breathing, and fatigue. This comparison confirms

the patient definitely had pneumonia.

2.1.4 SPECIFIC MEDICAL TREATMENT

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

patient;

 Injection Tramadol 100mg stat

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

 Intravenous Amoxiclav 1.2g tds x 24 hours

 Expect Sed Mixture 10mls tds x 5

 Salbutamol Nebules 5mg qid x 24 hours

 Tab Azithromycin 500mg dly x 6

 Intravenous infusion Normal Saline 1L x 24 hours

25
Table 4: Comparison of Patient’s Treatment With that of Literature Review

Treatment According to Literature Treatment Given to Patient

Review

Antibiotics Amoxiclav and Azithromycin were given.

Anti-inflammatory, anti-pyretic and IV Paracetamol and Inj. Tramadol were

analgesics may be given, eg brufen, given

paracetamol, aspirin etc to relief chest pain

Intravenous or oral fluid 3-4litres may be IVF Normal Saline 1L was given and

given daily patient encouraged to take in more oral

fluids.

Expectorant example simple linctus may be Expect Sed Mixture was given.

given

Oxygen administration when the need be Oxygen was not administered

Proton Pump inhibitors may be given e.g Was not given.

omeprazole

[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.

26
 Table 5: PHARMACOLOGY OF DRUGS ADMINISTERED TO MR. J. K.

Date Drug Dosage / Route Classification Desired Effects Actual Effect Observed Side Effects and Remarks

of

Administration

25/09/25 Injection 100mg stat Opiate analgesic To treat moderate to Patient was relieved of Nausea, dizziness, dry mouth,

Tramadol Route: moderately severe pain. pain. ingestion, abdominal pain,

Intravenous vertigo, vomiting, constipation,

drowsiness, and headache.

None was observed.

25/09/25 Paracetamol 1g/100mls tds x Non-narcotic To blocks pain impulses Fever was reduced and Dizziness, dyspnea, chest pain.

24 hours analgesics and by inhibiting pain relieved. Patient did not experience all

Route: antipyretic prostaglandins synthesis these signs.

Intravenous in the central nervous

system and action of

other substances of

sensitive pain receptors

27
 to mechanism or clinical

stimulation may relieve

fever by acting in the

hypothalamus heat

regulating center. To

relieve pain and reduce

fever.

25/09/25 Amoxiclav 1.2g daily x 24 Antibiotic It prevents bacterial cell Patient’s sign and Fever, skin rashes, vomiting,

hours wall synthesis during symptoms to infection diarrhea, and confusion.

Route: replication to were controlled None was experienced by my

Intravenous control infection Patient

25/09/25 Azithromycin 500mg daily for 6 Macrolides To inhibit bacteria The progressing of the Nausea, vomiting, diarrhea,

days growth by interfering disease was put to a halt headache, and loss of appetite.

Route: Oral their protein synthesis None of these side effects were

observed

25/09/25 Expect Sed 10mls tds x 5 Expectorant It aids in the Patient was able to expel Blurred vision
28
 Mixture days expectoration of mucous mucous from the Confusion

Route: Oral respiratory airway Drowsiness

Nausea or vomiting

Slowed respiration.

Patient experienced bodily

weakness of which he was

advised to limit movement

25/09/25 Salbutamol 5mg qid x 24 Short-Acting- To relax the smooth Patient was relieved from Tachycardia, palpitations,

Nebules hours Beta-2 Agonist muscles of around the the constriction of the tremors, headache and throat and

Route: Inhalation (SABA) airways airways hence relieving mouth irritation.

(bronchodilation) to him of the difficulty in

allow more air to flow to breathing. None was observed.

the lungs.

25/09/25 IVF Normal 1 liter x 24 hours Isotonic solution To maintain electrolyte Fluid and electrolyte Over hydration and circulatory

Saline Route: balance and raises blood balance maintained overload

29
Intravenous volume None was observed

30
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 ability to help are their direct contributions to overall

care. These are essential for faster recovery and make the healthcare team's job much

smoother. We learned about these strengths by talking with the patient and family:

1. Patient and family were positive about patient’s recovery and stayed motivated.

2. Patient had strong support system from family and friends.

3. Patient and relatives adhered to the treatment plan seriously.

4. Patient and relatives communicated with the health team effectively about their needs,

pain, or concerns.

5. The family provided the needed financial support.

6. Patient and family were willing to learn about patient’s condition

7. They were very active in participating in any decision regarding patient’s care.

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:

25/09/2025

1. Patient complained of difficulty in breathing

2. Patient complained of having productive cough.

3. Patient complained of easy fatiguability.

26/09/2025

4. Patient complained of having chest pain.

31
 5. Patient had high body temperature (37.7oC)

6. Patient had headache.

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 assume the lateral position which help in breathing with less difficulty

2. Patient could tolerate prescribed expectorant.

3. Patient could perform activities of daily living with assistance.

4. Patient could describe the location and intensity of pain.

5. Patient cold tolerate cold bath.

6. Patient cold tolerate prescribed analgesics

2.4 NURSING DIAGNOSIS

A nursing diagnosis is simply a statement about the patient’s health problem (or risk for one)

that falls within the scope of a nurse's professional care.

The patient and family's nursing diagnoses were;

1. Altered breathing patterns (dyspnea) related to increased sputum production and

accumulation in response to respiratory infection.

2. Alteration in body comfort (cough) related to excessive secretion of mucous

3. Decreased activity intolerance related to fatigue secondary loss of energy from

excessive cough and slight decline of hemoglobin level.

4. Acute pain (chest pain) related to excessive coughing

5. Altered body temperature (pyrexia of 37.70C) related to pneumococci infection

6. Acute pain (headache) related to increased intravascular pressure

32
 CHAPTER THREE

3.0 PLANNING FOR PATIENT/ FAMILY CARE

Planning for patient/family care is the third phase of the nursing process. It entails the setting of

objectives, selecting intervention, determining and organizing resources (human/material),

developing and producing plan of care.

The patient/family problems are prioritized, goals formulated, nursing interventions selected and

nursing orders given and implemented.

3.1 OBJECTIVES /OUTCOME CRITERIA

Objectives define the specific, measurable, achievable, and time-bound outcomes the nurse

expects the patient to achieve in pursuit of optimal health. These are the intended outcomes

planned for the patient and their family in response to identified health problems.

Objectives are categorized as either short-term or long-term goals.

Patient objectives may include:

1. Patient’s breathing pattern will be improved within 24 hours as evidenced by;

a. Patient verbalizing that he can now breath with less difficulty.

b. Nurse observing patient breath without the use of accessory muscles.

2. Patient will be relieved of cough within 72 hours as evidenced by:

a. Patient verbalizing absence of cough

b. Nurse observing patient lie comfortably in bed without coughing.

3. Patient will be relieved of fatigue within 48 hours as evidenced by:

a. Patient verbalizing the absence of general body weakness

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

4. Patient will be relieved of chest pain within 48 hours as evidenced by:

33
 a. Patient verbalizing absence of chest pain

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

5. Patient’s temperature will be reduced to normal within 2 hours as evidenced by:

a. Patient verbalizing a decrease in his body temperature

b. Nurse reading and recording normal temperature (36.9 0C) when checked with a

clinical thermometer.

6. Patient’s pain (headache) will be relieved within 24 hours as evidenced by:

a. Patient verbalizing absence of pain (headache).

b. Nurse observing that patient has a relaxed body position in bed

34
 Table 6: NURSING CARE PLAN FOR MR. J. K.

DATE NURSING OBJECTIVE / NURSING ORDERS NURSING INTERVENTION EVALUATION

AND TIME DIAGNOSIS OUTCOME

CRITERIA

25/09/25 Altered breathing Patient’s breathing 1. Reassure patient 1. Patient was reassured that he Goal fully met as

at patterns (dyspnea) pattern will be improved will be relieved of dyspnea evidenced by patient

11:22 a.m. related to increased within 24 hours as with a good cooperation verbalized that he can

sputum production and evidenced by; 2. Monitor and assess vital 2. Patient’s vital sign were now breath with less

accumulation in a. Patient verbalizing that sign especially respiratory checked and recorded. Also, difficulty, and nurse

response to respiratory he can now breath with rate. respiratory rate was monitored observed patient breath

infection. less difficulty. and recorded accordingly. without the use of

b. Nurse observing 3. Assist patient into a 3. Patient was put in the upright accessory muscles.

patient breath without the comfortable position position to enhance good 26/09/25

use of accessory muscles. breathing patterns and at

expansion of the chest 11:22 a.m.

4. Patient sputum was collected

35
 and observed for any A. F.

4. Observe sputum for abnormalities. It was taken to

abnormalities the laboratory for investigation

of culture and sensitivity test

and the result proved that

sputum had the pneumococci.

Present which confirmed the

diagnosis

5. Patient was encouraged and

assisted to do deep breathing

5. Teach patient of deep exercise to expectorate

breathing exercises. secretions

6. Prescribed Expect Sed

Mixture was administered and

6. Administer prescribed documented.

expectorant.
36
 NURSING CARE PLAN CONT…

DATE NURSING OBJECTIVE / NURSING ORDERS NURSING INTERVENTION EVALUATION

AND TIME DIAGNOSIS OUTCOME

CRITERIA

25/09/25 Alteration in body Patient will be relieved of [Link] patient [Link] was reassured that Goal fully met as

at comfort (cough) related cough within 72 hours as measures will be put in place to evidenced by patient

11:37 a.m. to excessive secretion of evidenced by: relief him of chest pain verbalized absence of

mucous a. Patient verbalizing [Link] patient in [Link] was assisted into an cough, and nurse

absence of cough comfortable position upright position and the back observed patient lie

b. Nurse observing supported with pillow comfortably in bed

patient lie comfortably in [Link] tight clothing [Link] clothing around patient without coughing.

bed without coughing neck, chest and waist were 28/09/25

removed to help in good at

circulation and to free patient 11:37 a.m.

from discomfort A. F.

[Link] patient to prevent 4. Patient was thought to cover

37
cross-infections the mouth with handkerchief

when coughing to prevent

spread of the infection through

cough.

[Link] prescribed cough [Link] cough mixture of

mixtures expect sed 10mls tds was

administered and recorded

accordingly

38
 NURSING CARE PLAN CONT…

DATE NURSING OBJECTIVE / NURSING ORDERS NURSING INTERVENTION EVALUATION

AND TIME DIAGNOSIS OUTCOME

CRITERIA

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

at intolerance related to fatigue within 48 hours care activities. brushing of his teeth, bathing evidenced by patient

11:50 a.m. fatigue secondary loss of as evidenced by: and feeding to help him verbalized the absence

energy from excessive a. Patient verbalizing the maintain and ensure proper of general body

cough and slight decline absence of general body hygiene. weakness and nurse

of hemoglobin level. weakness 2. Organize the nursing 2. Vital signs, medications and observed patient

b. Nurse observing procedures in bulk. all nursing procedures were perform activities of

patient perform activities performed in bulk at the daily living without

of daily living without appropriate time to avoid difficulty.

difficulty disturbing bed rest and to 27/09/25

promote adequate rest. at

3. Keep needed objects [Link] necessary items such as

39
within reach. drinking water, bed accessories 11:50 a.m.

were kept within patient’s A. F.

reach to enable patient have

easy access to them when the

need be.

4. Encourage patient to 4. Patient was encouraged to

rest in bed. rest in bed.

40
 NURSING CARE PLAN CONT…

DATE NURSING OBJECTIVE / NURSING ORDERS NURSING INTERVENTION EVALUATION

AND TIME DIAGNOSIS OUTCOME

CRITERIA

26/09/25 Acute pain (chest pain) Patient will be relieved of 1. Position patient in the 1. Patient was positioned in the Goal fully met as

at related to excessive chest pain within 48 semi-Fowler’s position. Semi-Fowler’s position to evidenced by, patient

8:33 a.m. coughing hours as evidenced by: promote patient comfort and verbalized absence of

a. Patient verbalizing maximize lung expansion to chest pain, and nurse

absence of chest pain improve oxygenation. observed patient being

b. Nurse observing 2. Monitor and document 2. Patient’s vital signs were relaxed and having

patient being relaxed and patient’s vital signs 4 checked and recorded 4 hourly cheerful facial

having cheerful facial hourly. to track the patient’s expression in bed.

expression in bed. hemodynamic response to pain 28/09/25

and treatment, and detect signs at

3. Encourage patient to of worsening cardiac function. 8:33 a.m.

limit movement and 3. Patient was encouraged to

41
 activity. limit movement and activity to A. F.

reduce physical exertion and

4. Reassure patient and cardiac workload.

speak calmly. 4. Patient was reassured and

spoke to calmly to make patient

feel secure and allay him of

5. Administer prescribed fear and anxiety.

analgesics. 5. Prescribed Tramadol and

Paracetamol were administered

and documented.

NURSING CARE PLAN CONT…

42
DATE NURSING OBJECTIVE / NURSING ORDERS NURSING INTERVENTION EVALUATION

AND TIME DIAGNOSIS OUTCOME

CRITERIA

26/09/25 Altered body Patient’s temperature will 1. Reassure patient. 1. Patient was reassured that he Goal fully met as

at temperature (pyrexia of be reduced to normal is in the hands of competent evidenced by patient

8:54 a.m. 37.70C) related to within 2 hours as health team who will help in verbalized a decrease in

pneumococci infection evidenced by: the management of his his body temperature

a. Patient verbalizing a temperature to allay him of fear and nurse read and

decrease in his body and anxiety. recorded normal

temperature 2. Tepid sponged patient 2. Patient was tepid sponged temperature (36.90C)

b. Nurse reading and every 15 minutes. every 15minutes to help reduce when checked with a

recording normal and maintain patient body clinical thermometer.

temperature (36.90C) temperature 26/09/25

when checked with a 3. Vital signs were checked at

clinical thermometer. 3. Check and record vital after every tepid sponging to 10:54 a.m.

signs.
43
 serve as baseline for treatment. A. F.

4. Remove all tight and 4. Tight and excess clothing

excess clothing from were removed to help reduce

patient. patient body temperature

5. Serve prescribed 5. Prescribed IV Paracetamol

antipyretics. was administered to patient to

help reduce the temperature.

NURSING CARE PLAN CONT…

44
DATE NURSING OBJECTIVE / NURSING ORDERS NURSING INTERVENTION EVALUATION

AND TIME DIAGNOSIS OUTCOME

CRITERIA

45
26/09/25 Acute pain (headache) Patient’s pain (headache) 1. Assist patient to assume 1. Patient was placed in semi- Goal fully met as

at related to increased will be relieved within 24 a comfortable position. fowlers position to make evidenced by patient

9:32 a.m. intravascular pressure hours as evidenced by: patient feel comfortable. verbalized absence of

a. Patient verbalizing 2. Maintain bed rest 2. Patient was put to rest pain (headache) and

absence of pain calmly in a well-prepared bed. nurse observed that

(headache). 3. Nurse patient in quite 3. Movement and all noise patient has a relaxed

b. Nurse observing that environment. producing materials were body position in bed.

patient has a relaxed restricted to ensure quite 27/09/24

body position in bed environment. at

4. Check vital signs at 4. Vital signs were checked and 9:32 a.m.

frequent intervals recorded 4hourly to serve as A. F.

baseline treatment for any

anomaly.

5. Prescribed IV Paracetamol

5. Administer prescribed 1g/100mls was administered

analgesics. and recorded to reduce his

46
 pain.

47
 CHAPTER FOUR

IMPLEMENTING PATIENT/FAMILY CARE PLAN

4.0 Introduction

Implementation means the process of carrying out all plans to meet the patient’s needs. It is

the fourth phase in the nursing process. The purpose of implementation is to ensure that direct

nursing care, is delivered to the patient in the most professionally and humanly beneficial

way using the care plan as a guide.

It covers;

 Summary of actual nursing care

 Preparation of patient and family towards discharge and rehabilitation

 Home visit/ Continuity of care/ Follow-up

4.1 SUMMARY OF ACTUAL NURSING CARE

The nursing management of Mr. J. K started on the day of admission, which was the 25 th

September, 2025 at 11:08 a.m. to the time of discharge on the 30th September, 2025.

The nursing care given throughout his stay at the ward was aimed at meeting the patient

psychological and physiological needs.

4.1.1 DAY OF ADMISSION (25/09/2025)

On the 25th September, 2025 in the morning around 11:08 a.m., Mr. J. K came to the ward

accompanied by a nurse and his granddaughter.

They were welcomed and offered seats at the nurses’ station. Assessment on the patient

revealed that he was feeling weak, had difficulty in breathing and cough, due to this he was

immediately admitted into an already prepared admission bed. He was put in a semi-fowler’s

position.

48
His particulars such as name, age, address were taken and recorded in the admission and

discharge book, as well as the daily ward state. Since he was conscious, he was verbally

oriented to the ward and its annex and introduced to his ward mates. Relative was also

oriented as well, relative was informed of the ward protocols. The relative was informed to

bring the necessary items needed while on admission when she is coming for afternoon visit.

His vital signs were checked and recorded as follows;

Temperature 36.7 degree celsius.

Pulse 112 beats per minute.

Respiration 28 cycles per minute.

Blood pressure 145/96 millimeters of mercury.

Weight 61 kilograms.

General observations were done on patient, no rashes were found on his skin neither scar.

Finger nails were clean with no artificial nails. No dentures were found and he was well

dressed.

The following investigations were carried out on the patient, a tray was set, samples were

taken and was sent to the laboratory, together with laboratory request form. Results of the

investigation in awaiting.

5. Chest radiography

6. Sputum for culture and sensitivity test

7. Full blood count

8. Blood grouping.

He was put on the following prescribed medication:

1. Injection Tramadol 100mg stat

2. Intravenous Paracetamol 1g/100mls tds x 24 hours

3. Intravenous Amoxiclav 1.2g tds x 24 hours

49
 4. Expect Sed Mixture 10mls tds x 5

5. Salbutamol Nebules 5mg qid x 24 hours

6. Tab Azithromycin 500mg dly x 6

7. Intravenous infusion Normal Saline 1L x 24 hours

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

Mr. J. K was told not to hesitate to ask any nurse in case he was in doubt or in need of

anything.

I reassured patient/family of being in safe hands and later introduced myself as a final year

student of College of Health – Sefwi Asafo who wants to take Mr. J. K as my patient, nurse

him, study his condition and write patient/family care study on his condition. They agreed to

allow me study his condition and promised to cooperate and give me the necessary

information needed.

Patient was made comfortable in bed for all nursing activities to take place.

Patient reported to the ward with the following health problems: difficulty breathing,

productive cough and fatigue. To relieve patient from these health problems, appropriate

nursing diagnoses were formulated for these problems respectively together with their

nursing interventions carried out aid in the speedy recovery of the patient.

At 11:22 a.m., a nursing diagnosis of altered breathing patterns (dyspnea) related to increased

sputum production and accumulation in response to respiratory infection was formulated for

patient’s difficulty in breathing. The following nursing interventions were carried out: patient

was reassured that he will be relieved of dyspnea with a good cooperation, patient’s vital

signs were checked and recorded. Also, respiratory rate was monitored and recorded

accordingly, patient was put in the upright position to enhance good breathing patterns and

expansion of the chest, patient sputum was collected and observed for any abnormalities.

50
It was taken to the laboratory for investigation of culture and sensitivity test and the result

proved that sputum had the pneumococci. Present which confirmed the diagnosis. Patient was

encouraged and assisted to do deep breathing exercise to expectorate secretions, and

prescribed Expect Sed Mixture was administered and documented.

At 11:37 a.m., a nursing diagnosis of alteration in body comfort (cough) related to excessive

secretion of mucous was formulated, hence, the following nursing interventions were carried

out: patient was reassured that measures will be put in place to relief him of chest pain,

patient was assisted into an upright position and the back supported with pillow, tight

clothing around patient neck, chest and waist were removed to help in good circulation and to

free patient from discomfort, patient was thought to cover the mouth with handkerchief when

coughing to prevent spread of the infection through cough, and prescribed cough mixture of

expect sed 10mls tds was administered and recorded accordingly.

Also, for patient’s fatigue, a nursing diagnosis of decreased activity intolerance related to

fatigue secondary loss of energy from excessive cough and slight decline of hemoglobin level

was formulated at 11:50 a.m. The following nursing interventions were carried out: patient

was assisted with brushing of his teeth, bathing and feeding to help his 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.

Mr. J. K slept at 9 p.m. after the routine nursing activities such as vital signs checking and

administration of medications have been carried out.

51
4.1.2 FIRST ON ADMISSION (26/09/2025)

Patient woke up at 5:25am but stayed in bed with the complaint of chest pain, high body

temperature and headache. He could not brush his teeth nor take his bath. According to the

night staffs, he was reassured and given IV Paracetamol 1g to help relieve him of the pain.

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

Temperature – 37.70C

Pulse - 80 bpm

Respiration - 23 cpm

Blood pressure - 132/90 mmHg

Due medications were administered and documented, and patient was made comfortable in

bed.

At 8:00 a.m., the Doctor on duty reviewed patient. Patient made complaints of chest pain,

high body temperature and headache. He was reassured by the doctor that measures will be

put in place to relieve him of these health problems.

At 8:33 a.m., a nursing diagnosis of acute pain (chest pain) related to excessive coughing was

made, hence, the following nursing interventions were carried out: patient was positioned in

the Semi-Fowler’s position to promote patient comfort and maximize lung expansion to

improve oxygenation, patient’s vital signs were checked and recorded 4 hourly to track the

patient’s hemodynamic response to pain and treatment, and detect signs of worsening cardiac

function, patient was encouraged to limit movement and activity to reduce physical exertion

and cardiac workload, patient was reassured and spoke to calmly to make patient feel secure

and allay him of fear and anxiety, and prescribed Tramadol and Paracetamol were

administered and documented.

52
For patient’s fever, a nursing diagnosis of altered body temperature (pyrexia of 37.70C)

related to pneumococci infection was formulated at 8:54 a.m. The following nursing

interventions were carried out: patient was reassured that he is in the hands of competent

health team who will help in the management of his temperature to allay him of fear and

anxiety, patient was tepid sponged every 15minutes to help reduce and maintain patient body

temperature, vital signs were checked after every tepid sponging to serve as baseline for

treatment, tight and excess clothing were removed to help reduce patient body temperature,

and prescribed IV Paracetamol was administered to patient to help reduce the temperature.

Again, at 9:32 a.m., a nursing diagnosis of acute pain (headache) related to increased

intravascular pressure was made, hence, the following nursing interventions were carried out:

patient was placed in semi-fowlers position to make patient feel comfortable, patient was put

to rest calmly in a well-prepared bed, movement and all noise producing materials were

restricted to ensure quite environment, vital signs were checked and recorded 4hourly to

serve as baseline treatment for any anomaly, and prescribed IV Paracetamol 1g/100mls was

administered and recorded to reduce his pain.

Patient had rice and stew with fried eggs as lunch at 1 p.m.

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

Temperature: 36.70C

Pulse: 74 bpm

Respiration: 18 cpm

Blood pressure: 112/65 mmHg

His due medications were administered and documented. He stayed in bed after taking his

medications.

He had his bath at 4:54 p.m. He took banku and groundnut soup with chicken as supper.

53
At 6 p.m., his due medications were administered and documented as well as vital signs

checked and recorded as:

Temperature: 36.40C

Pulse: 89 bpm

Respiration: 17 cpm

Blood pressure: 132/73 mmHg

Mr. J. K retired to bed at 9 p.m. after the routine nursing care.

4.1.3 SECOND DAY ON ADMISSION (27/09/2025)

Mr. J. K woke up in the morning at about 5:00 a.m. He brushed his teeth with toothbrush and

paste by his bedside. He was able to take his bath by himself without assistance.

His vital signs were checked and recorded as follows

Temperature: 36.40C

Pulse: 83 bpm

Respiration: 20 cpm

Blood pressure: 121/88 mmHg

He was made to rest in a comfortable position in bed.

The doctor on rounds at 8:30 a.m. reviewed him. Mr. J. K verbalized that he had no new

complaint, he also said that he is much better.

He took porridge with milk and bread as breakfast at 8:57 a.m. He spent time talking to his

granddaughter for a while.

At 2:00pm, vital signs were checked and recorded as follows;

Temperature: 36.4oC

Pulse: 88 bpm

Respiration: 18 cpm

Blood pressure: 115/72 mmHg

54
His due medications were administered and documented. He took kenkey with hot pepper

and fried fish as lunch.

Mr. J. K was informed of a visit to his home the next day in the company of his

granddaughter to enable me familiarize with his environment and to find out health problems.

He gladly agreed with the request.

In the evening, he was visited by friends from his community.

He took his bath at 5:30 p.m., after which he had rice and stew as supper.

At 6:00pm, his vital signs were checked and recorded as follows;

Temperature: 36.50C

Pulse: 81 bpm

Respiration: 19 cpm

Blood pressure: 126/70 mmHg

He watched news on the ward for a while. Nearby fan was switched on and a quite

environment was ensured to promote sleep. Patient slept around 8:30 pm.

4.1.4 THIRD ON ADMISSION (28/09/2025)

According to Mr. J. K, he woke up around 4:40 a.m., and had his personal hygiene performed

(bathing and brushing of teeth).

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

Temperature: 36.50C

Pulse: 80 bpm

Respiration: 17 cpm

Blood pressure: 115/65 mmHg

Due medications were administered. On ward rounds lead by the doctor on duty, patient

made no new complaint. The doctor ordered to continue current treatment. He took porridge

and bread as breakfast.

55
Due medications were served and documented as well as vital signs checked and recorded at

2:00 p.m. as follows;

Temperature: 36.3oC

Pulse: 89 bpm

Respiration: 18 cpm

Blood pressure: 118/80 mmHg

Patient took fufu and light soup as lunch.

I informed patient and the in charge my intension to visit patient’s house, they all agreed and

I left with the patient’s granddaughter as planned the previous day for the visit at 3:15 p.m., I

got to the house in Sefwi Ewiase around 3:48 p.m. I was warmly welcomed by the son.

Education was given to patient’s granddaughter on personal and environmental hygiene. I left

the house and returned to the ward around 5:35 p.m. Patient was encouraged to walk around

the ward as a form of exercise.

Patient ampesi with kontomire stew with boiled eggs as supper after taking his bath.

At 6:00pm, vital signs were checked and recorded as follows;

Temperature: 36.50C

Pulse: 75 bpm

Respiration: 18 cpm

Blood pressure: 124/85 mmHg

His due medications were served and documented. He went to bed around 9:15 p.m. after

saying his prayer.

4.1.5 FOURTH DAY ON ADMISSION (29/09/2025)

Mr. J. K woke up around 4:40 a.m., and had his personal hygiene performed without any

assistance. He looked very cheerful and verbalized that he is really doing well.

His 6:00 a.m. vital signs were checked and recorded as follows;
56
Temperature: 36.4oC

Pulse: 67 bpm

Respiration: 16 cpm

Blood pressure: 125/75 mmHg

Due medications were administered. On ward rounds lead by the doctor on duty at 8:00 a.m.,

patient made no new complaint. The doctor told him that he would be discharged home

tomorrow if no issue arises. Mr. J. K was very happy to hear this news from the doctor. He

took waakye as breakfast at 8:40 a.m.

Due medications were served and documented as well as vital signs checked and recorded at

2:00 p.m. as follows;

Temperature: 36.2oC

Pulse: 99 bpm

Respiration: 19 cpm

Blood pressure: 111/70 mmHg

Patient took fried yam with fried fish as launch. He watched movie on the phone with his

granddaughter whilst chatting.

At 4:30 p.m., he took his bath and later ate banku with okro soup as supper.

At 6:00pm, vital signs were checked and recorded as follows;

Temperature: 36.20C

Pulse: 66 bpm

Respiration: 18 cpm

Blood pressure: 114/91 mmHg

His due medications were served and documented. He went to bed around 8:30 p.m. after

saying his prayer.

57
4.1.5 FOURTH DAY ON ADMISSION/ DAY OF DISCHARGE (30/09/2025)

Patient woke up at 6:00 a.m., had his bath and brushed his teeth.

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

Temperature: 36.70C

Pulse: 85 bpm

Respiration: 21 cpm

Blood pressure: 130/80 mmHg

Medications were served as prescribed. Mr. J. K took tea and bread as breakfast.

During ward rounds at 8:00am, the doctor assessed the patient for any respiratory problem

but found none. Patient lodge no complain. He was discharged and scheduled for review on

14/10/2025. His take home medications were tablet Azithromycin 500mg dly x 3, and Expect

Sed Mixture 10mls tds x 3.

Patient was educated on how to take his medications. He was also educated on his lifestyle

modification too so as not to predispose him to suffering from other heath conditions too.

His items were arranged and packed; making sure nothing was left behind. At around 10:30

a.m., his bill was assessed at the account department and his granddaughter paid the rest of

the bill which wasn’t covered under National Health Insurance. Patient was to come for

review on 24/10/2025. Arrangements were made with patient and his family about my second

home visit on the 13/10/2025. Mr. J. K and granddaughter thanked the entire staff on duty for

the care rendered. Patient was discharged in the admission and discharge book, bed linen was

removed and sent to sluice room. Bed was prepared for next admission. They were

accompanied to the hospital gate to a taxi home, emphasis was once again made on the

review (14/10/2025) before the biding them goodbye.

58
4.2 PREPARATION OF PATIENT FOR DISCHARGE

Preparation of patient toward discharge started as soon as patient was admitted to the ward.

Patient and his granddaughter were given insight into pneumonia and how best to prevent

future occurrence. They were therefore encouraged to take active part in the care to ensure

speedy recovery. During admission, a home visit was made with the aim of familiarizing

myself with patient’s family, his vicinity and environment, also to identify environmental

condition that might have contributed to patient’s condition and also to help prepare patient

for discharge.

On the day of discharge, patient and relatives were educated on the need to complete his

medication. They were also educated on the need to serve patient with nutritious diet rich in

protein, carbohydrates and vitamins to aid in the wound healing process. The review date was

emphasized which was scheduled on 14th October, 2025 and patient was told not to hesitate to

visit the hospital when he falls sick before the review date.

Patient’s relatives congratulated the staff for the care rendered to the patient. They said

goodbye to the patients at the ward and wished them speedy recovery.

They were escorted to the hospital gate to board a taxi home. I reminded of the review date

again and then bade them goodbye with the promise coming to visit them on the 13 th October,

2025.

4.3 Follow-up/Home Visits/Continuity of Care

This is the act of rendering health service to a patient in 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.

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

information on the condition of the house and how it influence patient’s health. This is of a

great importance in the care of the patient.

59
4.3.1. First Home Visit (28/09/2025)

The first home visit was made on the 28th September, 2025, while patient was still on

admission. The patient’s granddaughter accompanied me to their home at Sefwi Ewiase. The

aim of the visit was to familiarize myself with patient’s family, his vicinity and environment

and also to identify environmental conditions that have contributed to patient’s condition.

This will help in the giving of health education which will help to promote and maintain

patient’s health and also prevent the occurrence of the disease condition after discharge.

On reaching the house I was warmly welcomed by patient’s son. We had a conversation

concerning patient’s current condition and the way to ensure patient’s speedy recovery. The

4-bedroom apartment had one kitchen, a bathroom and a toilet with well-ventilated rooms

and a good sanitation facility. I also took the opportunity to educate the family on malaria and

measures to be taken to prevent future occurrence of malaria.

I thanked the family and returned to ward at 5:35 p.m.

4.3.2 Second Home Visit (13/10/2025)

The second home visit was made on 13th October, 2025. The purpose of the visit was to find

out how patient was fairing and remind him about the review date which is on the 14 th

October, 2025. On my arrival, patient and family were highly pleased to see me. From

general observation, the patient looked healthy and had no complaints. Education was given

to patient’s family to ensure that predisposing factors of pneumonia. Patient had completed

his take home medication as prescribed when I asked him, this was confirmed by his

granddaughter. I emphasized on the need to serve patient with nutritious diet. The

granddaughter was congratulated on the part she played towards a successful recovery of the

patient. Patient was reminded on the need to report for review the next day on the 14th

October, 2025 as scheduled. They were informed that the next visit will be the last visit

60
where our interaction will be terminated. They were sad to hear this but understood that I had

to return to school.

4.3.3 Review Day (14/10/2025)

On the day of review, I met Mr. J. K at the out-patient’s department (OPD) at 10:00 a.m. We

exchanged greetings and he was welcomed. I collected patient’s folder from records and sent

it to the nurses’ table at the OPD where his vitals were checked and recorded as

Temperature: 36.3 ⁰C

Pulse: 62bpm

Respiration: 18cpm

BP: 121/73mmHg

We all entered the consulting room and after examination by the doctor, he expressed

satisfaction and advised the patient to continue taking good care of his health. There were no

prescribed drugs. I then informed my patient about my next home visit which will be

termination of the care after which I bade them good bye.

4.3.4 Third Home Visit (21/10/2025)

The purpose of the visit was to ensure maintenance of health and terminate care. On 21st

October, 2025, I made my third visit to my patient’s home. Health instruction on cleanliness,

personal hygiene, and nutrition were repeated again. They were also prompted on the need to

avoid over-the-counter drugs and report clinical features to the hospital for early treatment.

I appreciated their obedience to my education because their environment was neat and they

were all neatly and nicely dressed. My patient was looking fine and sound. They expressed

their sincere gratitude to me for my care for their relative. They were made aware that it’s the

care that has been terminated but not the friendship, I promised to come and visit them again

when I get the chance. I also thanked them for their support and co-operation and they saw

me off.
61
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

5.0 Introduction

Evaluation is a critical appraisal or judgment of value, worth, character or effective of what is

being assessed. It includes assessment of the patient’s position on the health and illness

continuum, the effectiveness of care rendered to patient and family and to bring about a

change in patient’s condition and identification of the extent to which the patient’s goals for

nursing care were met. This chapter includes;

 Statement of evaluation

 Amendment of nursing care plan.

 Terminations of care

5.1 Statement of Evaluation

Mr. J. K, a 67-year-old man was admitted to the males’ ward of the Wiawso Government

Hospital on the 25th September, 2025 with the complains of difficulty breathing, productive

cough, and fatigue. He was diagnosed of pneumonia and was nursed for 6 days and

discharged on 30th September, 2025. During this period, he was given nursing care using the

nursing process. Various health problems were identified, objectives were set and care plans

were made to implement the set objectives.

25/09/2025

The health problems identified on this day of admission were; difficulty breathing, productive

coughs, and fatigue. The following objectives were formulated respectively: patient’s

breathing pattern will be improved within 24 hours as evidenced by patient verbalizing that

he can now breath with less difficulty and nurse observing patient breath without the use of

accessory muscles, patient will be relieved of cough within 72 hours as evidenced by patient

verbalizing absence of cough and nurse observing patient lie comfortably in bed without
62
coughing, and patient will be relieved of fatigue within 48 hours as evidenced by patient

verbalizing the absence of general body weakness and nurse observing patient perform

activities of daily living without difficulty.

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

goals were fully met on their said dates.

26/09/2025

On this day, Mr. J. K experienced the following health problems: chest pain, fever (37.7oC),

and headache.

The following objectives were set; Patient will be relieved of chest pain within 48 hours as

evidenced by patient verbalizing absence of chest pain and nurse observing patient being

relaxed and having cheerful facial expression in bed, patient’s temperature will be reduced to

normal within 2 hours as evidenced by patient verbalizing a decrease in his body temperature

and nurse reading and recording normal temperature (36.9 0C) when checked with a clinical

thermometer, and patient’s pain (headache) will be relieved within 24 hours as evidenced by

patient verbalizing absence of pain (headache) and nurse observing that patient has a relaxed

body position in bed.

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

objectives were fully met at the said dates.

63
5.2 AMENDMENT OF NURSING CARE FOR PARTIALLY MET OR UNMET

OUTCOME CRITERIA

With effective nursing care and the use of individual nursing approach, all the goals and

objectives that were set for the care of Mr. J. K were fully met. He did not develop any

complications and there was no need for amendment of the care plan.

5.3 TERMINATING OF CARE

It is the last stage of the relationship between the nurse and patient. It is the most difficult and

important part of the cordial relationship that existed between the patient and health team.

This aspect was made known to Mr. J. K and his granddaughter on the day of admission. As a

result, there was no separation anxiety since it was made known to them on the day of

admission. During my last visit, patient was encouraged to eat a well-balanced diet to

promote healthy immune system. Good personal hygiene and environmental sanitation was

stressed upon. The need to take roughage and enough water was explained to the patient.

Patient and family were reminded on the need to report to the health facility in case of any

problem. They were therefore not surprised when they were finally told about the termination

of the care but not my relationship with them on the 21 st October, 2025. I promised to visit

them anytime I had the opportunity. I thanked them sincerely for their co-operation. They in

turn thanked me for the care rendered.

5.4 SUMMARY AND CONCLUSION

This is a detailed report on Mr. J. K a 67-year-old man who was admitted to the males’ ward

of the Wiawso Government Hospital on the 25 th September, 2025 at 11:08 a.m. with the

diagnosis of pneumonia. Patient came to the ward with complaints of difficulty breathing,

productive cough, and fatigue and various diagnostic evaluations were conducted to confirm

diagnosis.

64
The following laboratory investigations were requested on admission

 Chest radiography

 Sputum for culture and sensitivity test

 Full blood count

 Blood grouping.

He was put on the following medications;

 Injection Tramadol 100mg stat

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

 Intravenous Amoxiclav 1.2g tds x 24 hours

 Expect Sed Mixture 10mls tds x 5

 Salbutamol Nebules 5mg qid x 24 hours

 Tab Azithromycin 500mg dly x 6

 Intravenous infusion Normal Saline 1L x 24 hours

Prescribed medications were collected from the pharmacy and served accordingly.

With effective nursing care, all objectives set in the care of patient were fully met. Patient

was discharged on the 30th September, 2025 in a good health. In all, patient’s home was

visited on three different occasions. The first home visit was made while patient was still on

admission to assess patient’s home environment and discover if there are any factors at home

that may have contributed to patient′s current condition, and to validate data given to me. The

second home visit was to ensure patient was complying with treatment regimen and to remind

him of the review date (14/10/2025). The third home visit was to terminate care. During the

home visits, education on patient’s condition and its management, personal and

environmental hygiene was done. Care was terminated on the 21 st October, 2025 during the

third home visit.

65
In conclusion, the writing of this care study has given me deep insight into pneumonia; it

causes and predisposing factors, signs and symptoms, management and prevention of

recurrence. It has enabled me put into practice the theoretical knowledge acquired during

three-year period of nursing and also build my interpersonal relationship with patient and

relatives. I hope to use these skills and knowledge I have acquired through this project to

nurse all patients who come under my care in the near future.

5.5 RECOMMENDATION

It is my recommendation that all students are given the opportunity to embark on the

patient/family care study to implement the nursing process in order to render individualized

comprehensive care to patients and families. As this care study is kept in the college library,

it will be used for research purposes and future reference for students. This should be a

fundamental requirement for obtaining professional certification from the Nursing and

Midwifery Council.

66
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European Respiratory Society. (2025). White Book: The Burden of Pneumonia in the

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Frontiers in Medicine. (2025). Diagnostic Accuracy of Procalcitonin and C-Reactive Protein

in Viral vs. Bacterial Pneumonia. Frontiers Media, 12, 1088-1102.

Global Initiative for Chronic Obstructive Lung Disease. (2025). Global Strategy for the

Diagnosis, Management, and Prevention of COPD: 2025 Report (Pneumonia

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Infectious Diseases Society of America. (2024). Clinical Practice Guideline on the

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Kumar, S. T., & Miller, R. A. (2026). Recent Updates on Diagnosis and Treatment of

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Kyu, H. H., et al. (2025). Global, Regional, and National Burden of Lower Respiratory

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 APPENDIX I

Table 7: OBSERVATIONAL CHART FOR MR. J. K.

DATE TIME TEMPERATURE PULSE RESPIRATION BLOOD PRESSURE

(OC) (BPM) (CPM) (MMHG)

25/09/202 11:08 a.m. 36.7 112 28 145/96

26/09/202 6:00 a.m. 37.7 80 23 132/90

5 4:00 p.m. 36.7 74 18 112/65

10:00 p.m. 36.4 89 17 132/73

27/09/202 6:00 a.m. 36.4 83 20 121/88

5 6:00 p.m. 36.4 88 18 115/72

10: 00 p.m. 36.5 81 19 126/70

28/09/202 6:00 a.m. 36.5 80 17 115/65

5 6:00 p.m. 36.3 89 18 118/80

10:00 p.m. 36.5 75 18 124//85

29/09/202 6:00 a.m. 36.4 67 16 125/75

5 6:00 p.m. 36.2 99 19 111/70

10:00 p.m. 36.2 66 18 114/91

30/09/202 6:00 a.m. 36.7 85 21 130/80

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 SIGNITORIES

NAME OF CANDIDATE: AIDOO FELICITY

SIGNATURE: …………………………………………

DATE: …………………………………………

NAME OF NURSE IN-CHARGE: LINDA ACKAH (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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