TABLE OF CONTENT

CHAPTER CONTENT PAGE

TABLE OF CONTENTS I

LIST OF TABLES III

PREFACE IV

ACKNOWLEDGEMENT V

INTRODUCTION VI

ONE ASSESSMENT OF PATIENT/FAMILY 1

Patient’s Particulars 1

Family’s Medical And Socio-Economic History 1

Patient’s Developmental History 2

Patient’s Lifestyle And Hobbies 3

Past Medical/Surgical History 3

Present Medical History 3

Admission of Patient 4

Patient’s Concept of Illness 6

Literature Review 7

Validation of Data 23

TWO ANALYSIS OF DATA 24

Comparison of Data With Standards 24

Diagnostic Investigations/Tests 24

Causes of Patient’s Illness 26

Clinical Features 26

TABLE OF CONTENT

I
CHAPTER CONTENT PAGE

TWO Medical Treatment 27

Complications 29

Patient/Family Strengths 29

Patient’s Health Problems 29

Nursing Diagnosis 30

THREE PLANNING FOR PATIENT/FAMILY CARE 31

Nursing Care Plan 32

FOUR IMPLEMENTATION OF PATIENT/FAMILY CARE 39

PLAN

Summary of Actual of Nursing Care Rendered to Patient/Family 39

Preparation of Patient/Family for Discharge and Rehabilitation 48

Follow Up/Home Visit/Continuity of Care 49

FIVE EVALUATION OF CARE RENDERED TO

PATIENT/FAMILY 53

Statement of Evaluation 53

Amendment of Nursing Care Plan 54

Termination of Care 56

SUMMARY 57

CONCLUSION 58

BIBLIOGRAPHY 59

SIGNATORIES 60

LIST OF TABLES`

Tables List of Tables Pages

II
ONE Diagnostic Investigation/Tests 25

TWO Clinical Manifestation Compared With Standards 26

THREE Pharmacology of Drugs 28

FOUR Nursing Care Plan 32

FIVE Amendment of nursing care plan 55

PREFACE

III
 The patient/family care study is a documented and detailed account of nursing

care given to a chosen patient and the family from the day of admission till care was

terminated. This promotes health, maintain and prolong life within the specific period of

time. The patient and family care study is written by a final year student nurse in partial

fulfillment for the award of Diploma Certificate in Registered General Nursing by the

Nursing and Midwifery Council of Ghana.

The patient/family care study enables the student nurse to use all knowledge

acquired from various subjects during the course of training to render total nursing care

to the patient and family and also for the student nurse to interact with them aiming at

rehabilitating the patient back into the community and also promote health. It also

improved the student nurse typing skills, communication skills and interpersonal

relationship with others.

The patient/family care study is an essential process because it is an advanced

objective method of gaining new knowledge about human needs and people response to

ill health, treatment and other forms of therapy.

For the purpose of privacy and confidentiality, my patient shall be known as Mr.

K. B. throughout the write-up.

P. K

IV
 ACKNOWLEDGEMENT

I am grateful to my patient, Mr. K. B. and his family for the immense support,

cooperation and contribution and more especially permitting me to nurse them for my

care study. I also thank my clinical supervisor for her time, patience, constructive

suggestions and encouragement.

Special thanks go to the principal and all the tutors of Cape Coast Nurses’ and

Midwives Training College especially to my supervising tutor for sacrificing her time

and also for her encouragement, comments and suggestions throughout this work.

Many thanks to the nurse in-charge of the Male Ward and all the staff for their

support. My lovely family and course mates cannot be left out; you have been of

tremendous help to me. To the authors of books and articles I used, I say thank you.

To all, I say words cannot express my sincere gratitude.

God Bless you all.

V
 INTRODUCTION

This patient/family care study is a report of the total nursing care rendered to Mr.

K. B., a 63 year old man who was admitted at the Cape Coast Teaching Hospital on 15th

September, 2017 through the emergency unit with the diagnosis of Hypertension after

being examined by Dr. Hagan. My interaction with Mr. K.B. and his family started on

the day of admission at 11:00am when he was admitted to the Male Ward. I introduced

myself as a final year student of the Cape Coast Nursing and Midwifery Training

College and my intention of choosing Mr. K. B. for my care study. It was made known to

them what the whole patient and family care study was about and assured them of

confidentiality. They also agreed and assured me of their cooperation.

On admission, Mr. K. B. complained of headache, dizziness and anxiety and the

blood pressure read 180/100mmhg. Laboratory investigation such as blood films for

malaria parasite, full blood count, fasting blood sugar level estimation, serum lipid

profile were carried out. Assessment such as checking of vital signs especially blood

pressure monitoring was done to confirm his diagnosis. He was managed on

antihypertensives and analgesics. Patient was reassured and made comfortable in bed.

His condition improved gradually thus at the time of discharge patient’s headache has

subsided, blood pressure reduced to normal {120/80mmhg} and was finally discharged

on the 18th September, 2017. He was scheduled for review on the 25 th September, 2017.

To ensure continuity of care and rehabilitation, three home visits were made. The first

home visit was carried out on the second day of admission that is on the 17th September,

2017. Two subsequent visits were made and the care was finally terminated during the

third home visit on 5th October, 2017.

To help address patient’s health problems and render a comprehensive care, the

nursing process approach was used. Nursing process is the systematic, rational method of

VI
planning and providing nursing care. The chapters of this write-up were based on the five

steps of the nursing process as follows;

ASSESSMENT: This is the first step which deals with the systematic and continuous

collection of data with regards to the patient; this information is obtained from the

patient and relatives through interviews, observations and physical examination.

ANALYSIS: This is the second step which involves analysis of data collected to come

out with the actual problems.

PLANNING: This step involves the prioritizing the problems, setting of goals and

interventions for each problem.

IMPLEMENTATION: This is the fourth step and it involves the carrying out of the

care plan. It also includes all intervention performed by the nurse to restore the health of

the patient.

EVALUATION: This is the final step of the nursing process approach. This involves

the statement of the evaluation, amendment of nursing care plan for partially met or

unmet outcome criteria, termination of care and finally, summary and conclusion.

VII