CHAPTER TWO

ANALYSIS OF DATA

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

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

formulates the nursing diagnosis and intervenes accordingly.

This chapter comprises of

Comparison of data with standard

The patient/family strength

Health problems

Nursing diagnosis

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 COMPARISON OF DATA WITH STANDARD

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

complication are compared with standards.

TABLE ONE:DIAGNOSTIC INVESTIGATION/TEST

DATE SPECIMEN INVESTIGATIONS RESULTS NORMAL RANGED INTERPRETATION REMARKS

19/11/24 Blood Neutrophil, 89.4% 40-70% Higher than normal Antibiotics given as

lymphocytes range, indicating prescribed

bacteria infection

19/11/24 Blood Sickling test Negative Negative Client does not have No specific care

sickle cell disease given

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19/11/24 Blood Creatinine 91umol/l 44-106umol/l Within normal range No specific

treatment given

19/11/24 Blood Hemoglobin level 12.5g/dl Male-12-18g/dl Within normal range No specific

estimation Female-11-16g/dl treatment given

19/11/24 Blood Red blood cell 5.47 4.50-5.50 Red blood cell fall No specific

within the normal range treatment given.

19/11/24 blood White blood cell 7.48 4-10 WBC falls within No specific

count(WBC) normal range treatment given

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 CAUSES OF PATIENT’S CONDITION

With reference to etiological factors of typhoid fever, indicated in the literature review and the data gathered from my interaction with

the client and her relative, Miss M.T condition was caused by unhygienic cooking and eating habit.

Considering her sanitation and where she buys food from.

TABLE TWO:

COMPARISON OF CLINICAL FEATURES OF PATIENT AND THAT OF LITERATURE

LITERATURE FEATURES MIIS M.T CLINICAL FEATURES

There is fever Patient’s had pyrexia of 39.4.0 degree Celsius.

There is anorexia Patient’s complain of anorexia.

Patient’s did not complain of abdominal pain.

There is abdominal pain

Abdominal tenderness absent

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There is abdominal tenderness

No rash was present

Spots or rashes on trunk of body

Patient’s complained of headache

Headache may be present

Joint pain was experienced by patient

There may be joint pain

Patient’s experienced general malaise

There may be malaise

Patient’s did not experience prostration

Prostration may be present

She did not experience constipation.

There is constipation

Patient’s did not experience diarrhea

There is diarrhea

Dysuria was not present

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 Dysuria may be present

Abdominal distention absent

There may be abdominal distention

There was no Anaemia

There may be anaemia

SPECIFIC TREATMENT GIVEN TO CLIENT

 Intravenous Dextrose Saline 1-2 litres daily for 2 days

TABLE THREE:PHARMACOLOGY OF DRUGS GIVEN TO CLIENT

DATE DRUG LITERATURE ACTUAL CLASSIFICATION DESIRED ACTUAL SIDE

DOSAGE AND DOSAGE AND EFFECTS ACTION EFFECT/

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 ROUTE OF ROUTE OF REMEDIES

ADMINISTRATION ADMINISTRATIO

N GIVEN TO

19/11/24 Paracetamol Dosage: varies CLIENT Analgesic and To relief pain Patient was Large dose

according to antipyretic. and fever. relieved of may lead to:

patient’s age. 1000mg tds oral pain and Blood

Adults: 500mg- over 72 hours. hyperthermi disorder, low

1000mg a. blood

Children: 480mg - pressure,

600mg. flushing,

Route: nausea. None

Intravenously, per observed.

oral.

19/11/24 Normal saline Dosage: varies 500mls infused bd Fluid and electrolytes Replace loss Fluid and Large doses

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

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

and electrolyte restored and potassium

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 requirement. electrolytes. client did not imbalance.

Route: Intravenously show signs of Client did not

electrolytes have any

deficit. notable side

effect.

Large doses

Dosage : varies Anti-emetic Vomiting and may lead to

19/11/24 Metoclopramin depending on the 10mg bd x 48 hours To prevent nausea was drowsiness,

de individual needs. intramuscular. nausea and not diarrhea,

Adult:5mg - 10mg vomiting. experience by abdominal

Children:2mg - 5mg patient. cramps.

Route: None

Intravenous, observed.

intramuscular, and

oral.

19/11/24 Dextrose saline Dosage: Depends on 500mls infused bd Fluid and glucose. To provide Client was Fluid

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 patient caloric intravenously over energy and provided with overload can

requirement. 24 hours fluid. the needed lead to

Route: Intravenously energy and circulatory

was free from overload.

dehydration. None

observed.

20/11/24 Ringers lactate Dosage: Is highly 500mls infused Fluid, electrolyte and To provide Client was not Over dose can

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

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

is infused over 18-24 metabolic

hours alkalosis.

Route:Intravenously. No notable

side effect

detected.

20/11/24 Ciprofloxacin Adult dose: 250mg - 400mg bd x 48 Antibacterial, To fight Typhoid Light

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 500mg hours intravenously infection. infections headedness,

Children: 150mg- Anti-infective; were confusion,

250mg Quinolone. controlled and restlessness,

Route: Intravenously, further vomiting,

per oral. infections nausea,

were diarrhea and

prevented. thrombosis.

None

observed.

20/11//2 Diclofenac Adult: 75mg-150mg 100mg bd for 75 Non-steroidal anti- To relieve Client was Nausea,

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

Route: Intramuscular, analgesic. and prevent pain and high gastro

per oral. inflammation temperature. intestinal

pain,

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 dizziness,

bleeding.

None

observed.

Headache,

Amoxicillin Dosage: 1.2g tds x 3 Broad spectrum To destroy Infection was sore mouth,

20/11/24 Adult 0.75 g– 1.5g intravenously. antibiotic bacterial controlled. vaginal

Children 20 mg- growth and itching

40mg division. None was

Route: observed.

Intravenous, per oral

Large dose

Vitamin B Dose: 10mg tds orally. Micro – nutrients To correct Mal- may lead to

complex mal – absorption yellow

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20/11/24 Adult 10mg - 50mg (vitamin supplement) absorption corrected and discolouration

Children 5mg - 25mg patient of urine.

Route: appetite Client urine

Per oral. increase. appeared

yellow but

was not

injurious.

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 COMPLICATIONS IN PATIENT

With reference to the complications listed under the literature review miss M.T had no

complication.

PATIENT’S/ FAMILY STRENGTHS

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

mother at her side always and even though the family is not rich, they were able to buy any

drug which was not covered by the National Health Insurance.

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

As her condition improved, M.T was able to maintain her personal hygiene without

assistance; she could eat and groom herself.

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

her speedy recovery.

HEALTH PROBLEMS IDENTIFIED

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

therefore needs effective management.

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

mss M.T.

patient experienced pyrexia.

Patient had headache.

Patient and relative were anxious.

Patient had loss of appetite.

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Patient could not perform her personal hygiene.

Patient had sleepless night.

Patient had inadequate knowledge about disease condition.

NURSING DIAGNOSIS

Upon observations and complaints by the patient, the following nursing diagnoses were

reached;

1. Hyperthermia related to the inflammation process as evidence by patient body

temperature assess and recorded 39.4 degree Celsius.

[Link] pain (headache ) related to an increase in frontal arterial load as evidenced by patient

report of a 7/10 throbbing headache, head being warm to touch and onset of symptoms 2

hours ago.

[Link] related to the unknown outcome of diseases condition as evidence by patient and

relative being restless.

4. Risk for nutritional imbalance related to inadequate oral intake(food and water).

5. Impaired ability to perform personal hygiene related to fatigue as evidence by patient

decrease ability to perform activities of daily living.

6. Insomnia related to unfamiliar hospital environment as evidenced by patient report of

sleepless night.

7. Deficit knowledge related to lack of information about disease condition as evidence by

patient not being able to answer questions asked about her condition.

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.

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