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Typhoid Fever

NURSING AND MIDWIFERY TRAINING COLLEGE-SUNYANI PATIENT AND FAMILY CARE STUDY ON A PATIENT WITH TYPHOID FEVER BY BOAKYE DANQUAH ABIGAIL [INDEX NUMBER 6620220095] SUBMITTED TO THE NURSING AND MIDWIFERY COUNCIL GHANA MAY, 2024 PREFACE The patient and family care study is a comprehensive description of the total nursing care rendered to a patient and the family. This is to meet the physical, emotional, psychological, spiritual and social-economic needs of the patient and her family within a specified duration. This care study, forms part of the assessment of the final year student in the awarding of Diploma certificate in Registered General Nursing, issued by the Nurses’ and Midwives’ council of Ghana (NMC). The patient and family care study helps to broaden the scope of knowledge of the student nurse. It helps the student nurse to put her theoretical knowledge and skills acquired through training together to give a comprehensive care to patient and family. The preparation of the care study offers the student nurse an opportunity to combine classroom academic work with clinical study of the practices of the nursing profession. It encourages learning by doing, the development of analytical and decision-making skills as well as reporting skills. The student nurse becomes familiarized with the use of the nursing process as a basis for practice thereby encouraging evidence-based nursing care. Finally, the study improves upon the interpersonal relationship between the student nurse and the patient and family as well as other members of the health team The patient and family care study also enhances the interpersonal relationship of the student nurse as she constantly communicates with the patient, relatives, friends and other health team in the various units of the hospital to provide comprehensive care of the patient. For the purpose of confidentiality, my patient’s identity was not disclosed; hence Mrs. S.G was used to represent my patient’s name throughout the script. ACKNOWLEDGEMENT This care study would not have been a reality and a success without the assistance of some devoted persons who offered interest and encouragement during the preparation of this care study. My utmost and sincere gratitude goes to the Almighty God who gave me the strength, knowledge and understanding for the successful compilation and completion of this script. May your name be praised now and evermore. My appreciation also goes to Mrs. S.G and her family for their awesome cooperation and tolerance I received during interaction and for giving me all the needed information willingly, both at the ward and at home for the completion of the care study successfully. My profound gratitude also goes to my supervisor Mrs. Vivian Annan for the corrections, editing, patience and for taking her time and pain to go through my work. My greatest line of appreciation is reserved for my parents, Mr. Andrews Boakye Danquah and Mrs. Felicia Frimpong for always being there for me, through all the difficult moment in my tertiary education. For all the financial support, encouragement, nurturing and guidance showed me throughout my tertiary education, I am forever indebted to you. May God bless you. I express my warmest gratefulness to the Matron, all the nursing staff of the Sunyani Teaching Hospital and most importantly the Ward-in-charge, and all the nurses at the female medical ward who ensured continuity of care for my patient in addition to giving me support for the write-up of this care study. I am equally grateful to the numerous authors from whose medical literature I extracted my literature review for the purposes of this care study. TABLE OF CONTENT PREFACE i ACKNOWLEDGEMENT ii TABLE OF CONTENT iii LIST OF TABLES v INTRODUCTION vi CHAPTER ONE 1 ASSESSMENT OF PATIENT AND FAMILY 1 1.0 Introduction 1 1.1 Patient Particulars 1 1.2 Patient/Family Medical and Socio-Economic History 1 1.3 Patient’s Developmental History 2 1.4 Patient’s lifestyle and hobbies 3 1.5 Patient’s Past Medical / Surgical /Obstetric History 4 1.6 Patient’s Present Medical / Surgical / Obstetric History 4 1.7 Admission of Patient 4 1.8 Patient’s concept of illness 6 1.9 Literature Review On Typhoid Fever 6 1.10 Validation of data 10 CHAPTER TWO 11 ANALYSIS OF DATA 11 2.0 Introduction 11 2.1. Diagnostic Investigations/Test 11 2.2 Causes Of Patient Condition 13 2.4 Treatment Prescribed 13 2.4 Surgical Treatment 16 2.5 Complications 16 2.6 Patient health problems 16 2.7 Patient and family strength 16 2.8 Nursing diagnosis 16 CHAPTER THREE 17 PLANNING OF PATIENT/FAMILY CARE 17 3. 0 Introduction 17 3.1 Objectives / Outcome Criteria 17 CHAPTER FOUR 24 IMPLEMENTING THE PATIENT/FAMILY CARE PLAN 24 4.0 Introduction 24 4.1 The Summary of the Actual Nursing Care 24 4.2 Preparation of Patient/Family for Discharge and Rehabilitation 29 4.3 Follow-up/Home visit/continuity of care 29 CHAPTER FIVE 33 EVALUATION OF CARE RENDED TO PATIENT AND THE FAMILY 33 5.0 Introduction 33 5.1 Statement Of Evaluation 33 5.2 Amendment of Nursing Care Plan 35 5.3 Termination of Care 35 5.4 Summary 36 5. 5 Conclusion 37 5.6 Recommendation 37 BIBLIOGRAPHY 38 APPENDIX 39 SIGNATORIES 40 LIST OF TABLES LIST PAGE Table 2.1 shows the comparison of diagnostic tests carried out on the patient and those listed in the literature review. 11 Table 2.2: Diagnostic Investigations carried out on the patient and interpretations 12 2.3 Table 2.3: Clinical Features Manifested By My Patient As Compared To The Clinical Features In The Literature Review 13 Table 2.4: Comparism of specific Treatment Given to patient to that of literature 14 2.5 Table 5: Pharmacology of Drugs Administered to Patient 15 Table 3.1: Nursing Care Plan 19 INTRODUCTION This patient and family care study is a documentation of nursing care carried out on 34 year old Mrs. S.G. She was admitted to the female medical ward of the Sunyani Teaching Hospital on 16th November, 2023 at 10:00am after she was transferred out from the emergency ward. She was diagnosed of typhoid fever, after series of history taking, physical examination and laboratory investigations to confirm his diagnosis. My interaction with patient and her family lasted for 18 days, beginning from time of admission to when I embarked on the third home visit on 4th December, 2023 to terminate care with patient and her family. The following health problems were identified and resolved from time of admission through to time of her eventual discharge. 1. Patient complained of abdominal pain (16th November, 2023) 2. Patient complained of excessive vomiting (16th November, 2023) 3. Patient had high body temperature (38.9°C) (16th November, 2023) 4. Patient was anxious (16th November, 2023) 5. Patient complained of loss of appetite (17th November, 2023) She was admitted to the ward on 16th November, 2023 and discharged on the 20th November, 2023, spending a total of 5days on the ward. Three home visits were carried out, with the first home visit while she was still on admission on 18th November, 2023, second home visit on 26th November, 2023 to remind her of the review date and to see how she was doing after discharge and the third home visit on 4th December, 2023 to terminate care with patient and family. Throughout her period of admission through to discharge and home visits, patient was educated on her condition, mode of transmission and prevention. She and her family were educated to practice personal and environmental hygiene, wash hands frequently as possible, cover their meals to avoid housefly contamination and to cover their dustbins so houseflies will not land on it and later contaminate the meals with the germs. Throughout the period of her hospitalization, the nursing process was used to render care to her. This patient/family care study was written in five distinct chapters as below: 1. Assessment of patient/family 2. Analysis of data collected 3. Planning for patient/family care 4. Implementing of the care plan 5. Evaluation of care rendered to patient/ family Chapter one consists of assessment of patient/family care. It includes patient’s particulars, Patient/Family Medical and Socio-Economic History, Patient’s Developmental History, patient’s lifestyle and hobbies, patient’s past and present medical history, admission of patient, literature review of patient’s condition and validation of data. Chapter two consists of data analysis which involves comparison of investigations done with data collected and the comparison of the causes, clinical features, treatment and complication as in literature review and those manifested by the client. It also involves patient and family strength, health problems and nursing diagnosis. Chapter three consists of planning of patient family care and it involves the use of care plan which consists of nursing diagnosis, objectives and outcome criteria, nursing orders, nursing interventions and evaluation. Chapter four is the implementation of patient/family care plan, summary of actual nursing care rendered to the patient, preparation for patient and family for discharge and rehabilitation as well as follow ups or home visit. Chapter five consists of evaluation. It involves evaluation of care rendered to the patient and family, statement of evaluation, amendment of care. This chapter contains summary of the care rendered to patient and from the time of admission till the time of discharge, summary and conclusion made on the write up of the patient family care study. CHAPTER ONE ASSESSMENT OF PATIENT AND FAMILY 1.0 Introduction Assessment is the systematic and continuous collection of data from patient, relatives and friends through interviewing, observations, investigations to arrive at the diagnosis to enable the nurse to determine possible ways of nursing the patient so that the patient can finally lead an independent life thereafter recovery. The organized data will therefore serve as the basis upon which effective plan of care will be developed. During this period, a relationship of trust begins to develop between the nurse, the patient and patient’s family. This chapter of the patient/ family care study is made up of data collected about the patient’s particulars, patient’s/family’s medical and socio-economic history, patient’s developmental history, patient’s lifestyle/hobbies, patient’s past medical/surgical history, patient’s present medical/surgical history, admission of the patient, patient’s concept of illness, literature review and validation of the data gathered from both patient and family. 1.1 Patient Particulars Particulars refer to details about something. The particulars of patients consist of the patient’s name, age, sex, date of birth, marital status, residential address, occupation, educational status, languages spoken among others. This care study is about Mrs. S.G. She is a 34-year-old woman born at Tamale in the Northern Region of Ghana to Mr. A. M.G and Mrs. A. T.T. She is the first of four siblings. She is a Dagaare by tribe, Muslim by faith and a Ghanaian by nationality. She speaks Twi, English and Dagaare language. She has been educated up to the secondary level. She is a farmer who cultivates both food crops and cash crops. She is happily married to Mr. M.B and blessed with three awesome kids. Currently, Mrs. S.G stays with her nuclear family at Abesim Dominase. She is dark in complexion, has a height of about 1.6 metres tall, and weighed 67kg on admission. Her next of kin is her sister, Mrs. H.A. Patient has no physical deformity or disability on any part of her body. 1.2 Patient/Family Medical and Socio-Economic History Patient/Family Medical and Socio-Economic History provides information about the possible factors which may have contributed to the patient’s current health status and also helps the nurse in caring for the patient as well the family efficiently. Mrs. S.G said that there are no known acute and chronic conditions as well as hereditary conditions such as sickle cell disease, hypertension, Diabetes Mellitus, mental illness, goitre among many others that runs through her parents’ family. Patient verbalized she has been hospitalized as a result of ill health on several occasions, with the recent hospitalization on account of acute gastritis at the Sunyani Teaching Hospital, few months ago. She was managed on analgesics and antibiotics for 5 days until she got better and discharged subsequently. She has no known allergy to any drug, animal, insect or food. She usually resorts to orthodox drugs to treat minor illnesses such as headaches, fever, and bodily pains. However, if symptoms persist, she seeks for medical attention from the nearest health facility. She belongs to the nuclear type of family which comprises of her husband and her three kids. Mrs. S.G is a farmer. She grows both cash crops and food crops. She depends on the profit made from the sales to cater for herself. As a Muslim, she says she and her family celebrates all the festivities on the annual Islamic Calendar, which includes Iddul Fitr, Iddul Adha, Ramadan amongst others. She does not belong to any social club in her community. She has a cordial relationship with members of her extended family as well as her neighbours. She has signed on to the National Health Insurance Scheme (NHIS) as the primary health care insurance provider for her healthcare. 1.3 Patient’s Developmental History Development is the qualitative change in an individual in which there is an increase in skill or ability to perform a specific task. Growth is the quantitative change in an individual with an increase in size, number of cells and height. Maturity on the other hand is a state of being mentally, emotionally and spiritually well developed. According to patient, she was delivered per vaginum after nine months of normal pregnancy at Tamale by a qualified midwife without any complications. At the 18th week of pregnancy, patient’s mother said she could feel the movement of the foetus in utero and every antenatal visit indicated that the foetus was healthy. Mrs. S.G said her mother breastfed her for the first six months after which she was introduced to complementary food. Within the first two months of life, visual fixation on objects was established and her eyes followed moving objects. Patient’s mother said baby could sit at the 5th month with support while resting on the fore-arms, she began crawling at the 9th month and the first tooth erupted during the sixth month of life. Patient received all her childhood immunization as scheduled against all the childhood preventable disease. She began her basic education at the age of 3, completed Junior High at 17, and senior High at 21 years. She developed secondary sexual characteristics such as the enlargement of sex organs, growing of pubic hairs and menarche at the age of fifteen. She married at 27. She had always loved to be a military personnel growing up. However, her dream has not been materialized yet. According to Erik Erikson’s psychosocial theory of development, every individual passes through eight stages or phases of development throughout their lifespan which ends only when one dies. He stated eight (8) stages of development which is centrally focused on crisis, and is specific pertaining to certain developmental stage. Each stage must be resolved in order for the individual to move to the next stage. A successful transition through all of these stages prepares the individual to face all challenges in life. But failure in any of these stages, leaves an individual stagnated or stuck at that particular stage causing that individual to be lacking in that stage. Mrs. .G is at the Intimacy versus isolation (20-40 years, early adulthood) stage. At this stage, young adults are still eager to blend their identity with friends and develop close, committed relationships with other people. Those who are successful at this stage will have the ability to love and to have a committed and secured relationship. People who are unable to complete this stage successfully normally are unable to build a committed relationship, lacking the security and warmth of a loving relationship. 1.4 Patient’s lifestyle and hobbies According to patient, she usually wake up from sleep each morning at 4:30am. She sweeps around her compound and dispose the refuse into the nearby refuse dump. Nextly, she washes her dirty utensils and pack them up in the corridor. She brushes her teeth with tooth brush and toothpaste, and afterwards empties her bowel. She then performs ablution, go to the nearby mosque and observe the early morning Muslim prayer. On her return, she wakes her kids up from bed, bathes, grooms and prepares them for school. She makes a breakfast for them so they can carry to school. Upon her return from escorting them for school, she takes her bath, make breakfast for herself and husband and afterwards set off for farm. She normally returns from working on the farm at 3:00pm to prepare supper for the family. During her leisure time, she either watch movie on TV or relax in bed. She takes her bath later in the evening and afterwards retires to bed after 10:00pm. On Saturdays, she washes her dirty clothes and bed linen, cleans her room and surroundings. She normally attends funerals and weddings of loved ones within the community on Saturdays. She does not go to the farm on Sundays. Rather, she carries her farm produce to a nearby market place to sell for profit. Mrs. S.G says akple and okro soup with dry fish is her favourite meal. She has a good social cohesion with all her family members as well as the indigenes in her community regardless of their social class, ethnic background or age. 1.5 Patient’s Past Medical / Surgical /Obstetric History Patient says she suffered no childhood illness such as measles and whooping cough. She is also non-allergic to any drug, animal, insect or any other substance. She was admitted to the Municipal Hospital a year ago after suffering acute gastritis. She was managed on antibiotics, analgesics and got discharged 6 days after hospitalization without developing any complication of the condition. She has had three successful pregnancies with all the pregnancies carried to term. She delivered all her last three pregnancies through spontaneous vaginal delivery. She has three children, all alive. She has no history of contraceptive use. 1.6 Patient’s Present Medical / Surgical / Obstetric History Mrs. S.G said she experienced sudden sharp and unbearable pain in her abdomen three days ago. She bought some drugs from the pharmacy with the aim of relieving her pain and discomfort in the abdomen. Unfortunately, it proved otherwise. Symptoms became worse than she could imagine. She proceeded to seek further medical treatment at Bono Regional Hospital. 1.7 Admission of Patient Mrs S.G was admitted to the female medical ward of the Sunyani Teaching Hospital on 16th November, 2023 at 10:00am after she was transferred out from the emergency ward. She was brought to the ward lying supine in bed, with IV Normal Saline 500mls in situ in the company of patient relatives, a staff nurse and two student nurses. Handing over of the patient was done. Patient and her relatives were warmly welcomed to the nurses’ station. A quick introduction was made between the staff present on the ward and patient’s relatives. Patient was admitted into an already prepared bed. Her OPD card was received to admit her to the LHIMS system to the ward. Her details such as name, sex, emergency contact person, residential address, telephone number, and many others were taken from patient and documented into the admission and discharges book, daily ward state and nurse’s note. Her vital signs were monitored and recorded as; • Temperature - 38.90C • Pulse - 89bpm • Blood Pressure - 124/72mmHg • Respiration - 23cpm • Oxygen Saturation - 99% She was introduced to other patients she will share the same cubicle with. Patient and her relatives were orientated to the ward and its annexes like the nurses’ station, bathroom, urinal, treatment room and the washroom. Ward protocols such as visiting hours, ward rounds, mealtime were all made known to patient and her relatives. A brief assessment of patient’s condition on admission was made. She was alert, conscious, acyanosed and not in any obvious respiratory distress. The following medications were prescribed for her by the doctor; • Tab Ciprofloxacin 500mg bd • Tab Metronidazole 400mg bd • IV Ringers’ lactate 500mls bd • IV Normal saline 500mls bd The following laboratory investigations were requested by the doctor for proper drug management and confirmation of diagnosis; • Full blood count • Blood Film for Malaria Parasite (BF for MPs) • Widal Test An IV line was passed for blood sample to be taken for the ordered laboratory investigations. A nursing care plan was drawn based on patient’s presenting problems whilst interventions were instituted. I took the opportunity to calm and reassure patient and her relatives to relieve her of anxiety. I re-introduced myself to patient as a final year Student Nurse from Nursing and Midwifery Training College- Sunyani and willing to conduct a care study on her condition as part of the requirement for the award of Diploma in nursing certificate. I decided to use typhoid fever for my care study because I wanted to gain more knowledge on the condition and get practical knowledge on the management of the condition. I reassured patient and her relatives that, I will ensure confidentiality of every information that will be obtained from them. Discharge plans started on the day of her admission as I informed the patient and relatives that, her condition would improve, and that, she will be discharged after her condition had improved since the hospital is just a temporary place for nursing her. 1.8 Patient’s concept of illness Patient was ignorant about the cause of her condition; she thought it was a normal abdominal pain no associated with any pathology. Mrs. S.G believed that her condition came naturally and therefore did not attribute it to any supernatural force or powers. She believed that with good medical and competent nursing care from the health team, she will be fit within the shortest possible time. 1.9 Literature Review On Typhoid Fever Typhoid fever is an acute systemic bacterial infection caused by Salmonella typhi, a strict human pathogen which invariably gains entry into the body per os and invades the bowel wall through payer’s patches. Incidence It mostly affects people between the ages of 5 years and 40 years and only 5% of them are above 40 years. It accounts for 40-50% of deaths in typhoid and also responsible for 20% of cases of peritonitis excluding salpingitis. The male / female ration of 3:1 is a reflection of the sex incidence of typhoid fever. Causes Apart from Salmonella typhi being the main cause of Typhoid Fever, it may also result from the following: • Drinking water contaminated by excretion of a carrier or from ingested contaminated shellfish • Contact with infected people or animals or ingesting contaminated dry milk, chocolate bars or drugs of animal origin. Mode Of Transmission The disease is transmitted faeco – orally thus ingestion of contaminated food such as inadequately processed fish from polluted water. It can also be transmitted through contact urine of infected person. Incubation Period This takes 10-14 days but usually last from 1 – 4 weeks. Pathophysiology When the organism enters the body through the mouth, they invade the walls of the gastrointestinal tract and multiply there giving rise to bacteraemia that last for about 10 days. The organism becomes localized in the mesenteric lymph nodes and the mass of lymphatic tissue in the mucus membrane of the intestinal wall which is called the payers’ patches. Blood vessels of the payer’s patches become thrombosed and swollen. The lymph follicles (payer’s patches) become hyperplastic and necrosed due to oedema and vascular obstruction which develops from the inflammatory reaction. The typical “pea soup” stools sphacelation are observed with bleeding or perforation of the intestines. Clinical Manifestation First Week • Anorexia • Slow pulse • Malaise • Fever • Headache • Abdominal pain Second Week • Diarrhoea in the later phase • Remittent fever up to 40 degrees Celsius usually in the evening • Rose spot on the chest, abdomen and back • Chills • Hepatomegaly • Splenomegaly • Diaphoresis • Weakness • Delirium Third Week • Fever subsides with increasing weakness as the symptoms gradually subside • Diarrhoea with pea stool Diagnostic Investigations It is dependent on recognition of the clinical syndrome with minimum of confirmatory investigations. Other investigations include; • Diagnostic X – ray of the abdomen to rule out only perforation • The quadrant peritoneal tap • Urine and intestinal secretion for culture and sensitivity test to isolate the organism • White blood cell count will increase to show infection • Haemoglobin level estimation to confirm anaemia • Widal Antigen Test Complications • Perforation • Intestinal bleeding • Anaemia lesions • Wound sepsis • Burst abdomen • Residual intra – abdominal abscesses • External bowel fistula • Septicaemia • Septic shock may occur Medical Treatment • Chemotherapy • Drugs include:  Chloramphenicol, 50mg/kg body weight daily  Ampicillin, 1-2g daily divided in four doses  Amoxicillin, 750mg – 1.5g daily divided in three doses  Ciprofloxacin, 500mg bd  Metronidazole, 250mg – 500mg tds Surgical Treatment In this case, where there is perforation of the intestine, laparotomy is done to cut and repair the perforated intestine. Nursing Management Reassurance Patient is made to know that she is in the hands of competent medical staff that are ready to manage her condition with all the skills they can muster to aid her quick recovery. This will allay her fears and anxiety. Patients who had similar condition and are recovering are introduced to patient and family to share their experience with patient to give her hope and alleviate all her fears and anxiety. Isolation Patient with this condition are barrier nursed or isolated to prevent cross infection to other patients and health personnel because the condition is infectious. Gloves and gowns should be worn when carrying out procedures on patient. Good hand washing techniques should be employed with each contact with patient to prevent the spread of infection. Body fluids, secretion and soiled bed linen should be decontaminated with antiseptic solution to prevent infection. All instruments used on the patient should be properly sterilized or disinfected before and after use to prevent cross infection. Patient should have separate items such as bowls, cups and plates to avoid infecting others the disease. Nutrition Intravenous fluid such as normal saline, dextrose saline and ringers lactate are given to maintain fluid and electrolyte balance and provide energy. If patient can tolerate, light nourishing diet should be given in small amount but frequently to maintain patient’s nutritional status. Diet should be rich in calorie to provide energy. It should also contain enough protein and vitamin to repair worn out tissues. Patient meal should also contain fiber to prevent constipation. Personal Hygiene Based on patient condition, bed bath or assisted bath may also be given at least twice daily to improve hygiene, promote circulation and induce sleep. Mouth care is done at least twice daily to prevent halitosis and infections and also stimulate appetite. Bed linen is changed regularly when they are soiled to prevent spread of infections. The nurse should advise patient and relatives to wash hands before handling food especially after visiting the toilet. Patient Health Education Patient and relatives are educated on the signs and symptoms; mode of transmission and the associated complications of the condition. The condition should be explained in simple terms to their level of understanding. Patient and relatives are taught how to wash their hands properly especially after defeating and before handling food. Advise also that all foods from animal origin should be cooked properly. Stress on the patient’s compliance with prescribed medications. The nurse should teach the patient and relatives how the medications are taken. Educate patient and relatives on the side effects of drugs so that they can report to the hospital when they occur. Advise patient and relatives for medical examination and treatment if culture tests are positive. Stress on the importance of periodic medical checkups and reviews to the patient and relatives. Preventive Measures 1. Adequate protection of water supply. 2. Sanitary disposal of human excreta. 3. Pasteurization of milk and dairy products. 4. Fly control. 5. Scrupulous cleanliness in preparing food at home and public eating places. 6. Careful control on shell fish sources and cooking. 7. Identification and supervision of carriers of enteric fever. Control Measures 1. Hospital care with proper sanitary precaution such as proper hand washing is recommended. 2. Investigations should be conducted to determine actual or probable cause of the infection for every community. 3. Necessary measures should be taken to control any carrier who may be identified. 1.10 Validation of data Validation is the extent to which a measure, indicator, or method of data collection possesses the quality of being true, as far as it can be judged. Data collected from patient and relatives during the time of admission and hospitalization were similar to those obtained during the three home visits. Also, referencing from the clinical manifestations presented by the patient, diagnostics measures, and medical treatment prescribed for the patient in comparison with the information stated in the medical literature, it is clear that the patient was diagnosed and treated rightly, hence data collected from the patient and family is valid CHAPTER TWO ANALYSIS OF DATA 2.0 Introduction This chapter forms the second phase of the patient and family care study. It covers comparison of data with standards, patient and family strengths, health problems and nursing diagnoses as well as the pharmacology of drugs given. Data collected in this study are sorted out and recorded to be analyzed with standards. 2.1. Diagnostic Investigations/Test A diagnostic test or investigation is a laboratory examination or chemical analysis to determine the presence of a specific substance, microorganism, disease, etc. Below are the investigations ordered for the patient; • Full blood count • Blood Film for Malaria Parasite (BF for MPs) • Widal Test Table 2.1 shows the comparison of diagnostic tests carried out on the patient and those listed in the literature review. Diagnosis Test In Literature Diagnostic Test carried On My Patient A thorough health history taking Done for my patient Complete physical examination Done for my patient Full Blood Count (FBC) Done for patient Bone marrow aspiration Not done for patient Stool Culture Not done for my patient Widal Test Done for patient WBC Count Done for my patient Typhoid IGM/IGG Not done for my patient Table 2.2: Diagnostic Investigations carried out on the patient and interpretations Date Specimen Investigation Results Normal Range Interpretation Remarks 16/11/2023 Blood Full blood count Hemoglobin level White blood cell count Red blood cell count Hematocrit level Platelet count 10.4g/dl 9.96 x 109/L 3.29 x 1012/ L 33.7% 242 x 109/L 12.5- 17.5 g/dl 3.5 – 9.50 x 109/ L 3.8 - 5.10 x 1012/ L 35.0 – 45.0% 140-440 x 109/L Slightly low Hemoglobin levels Slightly elevated white blood cell Level Low Red Blood Cell Level Low Hematocrit level Normal platelet count level No treatment was given Patient was put on antibiotics (ciprofloxacin and Metronidazole) No treatment was given No treatment was given No treatment was given 16/11/2023 Blood B/F for malaria parasite No malaria parasite was seen in the blood No malaria parasite should be seen Patient has not been infected with malaria No treatment was given 16/11/2023 Blood Widal Test TO-1/320 TH-1/240 TO-1/20 TH-1/20 Patient had typhoid fever Patient was put on antibiotics (ciprofloxacin and Metronidazole) 2.2 Causes Of Patient Condition The causes of typhoid fever as outlined in the literature review include drinking of contaminated water, or food among others. From the investigation done on patient coupled with information gathered from patient’s lifestyle, it could be said patient’s condition is caused by the ingestion of unhygienic food or water containing the typhoid organism (Salmonella typhi). This can be evidenced by the elevated level of the white blood cell count. 2.3 Table 2.3: Clinical Features Manifested By My Patient As Compared To The Clinical Features In The Literature Review Clinical Features According To Literature Review Clinical Features Exhibited By Patient 1. Abdominal pain. 1. Patient complained of severe abdominal pain 2. Elevated body temperature. 2. Patient had increased body temperature of 38.9ºC. 3. There may be diarrhea or constipation. 3. Patient complained of having diarrhea. 4. General malaise. 4. Patient complained of malaise. 5. Loss of weight. 5. There was no weight loss. 6. Diaphoresis 6. Diaphoresis was absent. 7. Headache. 7. Patient did not complain of headache. 8. Anorexia. 8. Complain of anorexia was made by patient 9. Drowsiness. 9. Patient complained of drowsiness 10. Delirium. 10. Delirium did not occur in patient. 11. Chills. 11. Patient had chills. 2.4 Treatment Prescribed Treatment is the mode of dealing with a disease with drugs or other forms such as massage, psychotherapy, amongst other. Medical treatments ordered for patient include: • Tab Ciprofloxacin 500mg bd • Tab Metronidazole 400mg bd • IV Ringers’ lactate 500mls bd • IV Normal saline 500mls bd Table 2.4: Comparism of specific Treatment Given to patient to that of literature Treatment Requested According To Literature Review Treatment Given To Patient Intravenous infusions Ringers lactate and Normal saline were given to the patient Analgesics Not given Antibiotic Tab Metronidazole and Tab Ciprofloxacin were given Antispasmodic Not given Antiemetics Not given 2.5 Table 5: Pharmacology of Drugs Administered to Patient Date Drug Dosage/Route of Administration Classification Desired Effect Actual Action Observed Side Effect/ Remedies 16/11/2023 Ringers lactate Dosage: 500mls bd Route: Intravenously Isotonic solution (balanced electrolyte solution) To correct fluid and electrolyte imbalance Patients’ blood electrolyte was maintained Blurred vision, confusion, dizziness, irregular heartbeat, dyspnoea None was observed in patient 16/11/2023 Normal saline Dosage: 500mls bd Route: Intravenously Isotonic solution (fluid replacement solution) To correct the fluid imbalance and restore blood volume Patient’s blood fluid volume was maintained Hypernatremia, fluid retention, high blood pressure, electrolyte abnormalities None was observed in patient 16/11/2023 Metronidazole (flaggyl) Dosage: 400mg bd Route: orally Antibiotic Antiprotozoal Amoebicides Used to treat infections caused by bacteria. Patient was free from infection as patient's condition improved. Headache, Vertigo, nausea and vomiting abdominal discomfort. None was observed in patient 16/11/2023 Ciprofloxacin Dosage: 500mg bd Route: orally. Antibiotic (quinolone) Used to treat infections caused by bacteria. Patient was free from infection as patient's condition improved. Headache, dizziness, nausea, vomiting, dysuria, thrombophlebitis. None was observed in patient 2.4 Surgical Treatment No surgical treatment was done for patient 2.5 Complications A complication is an accident or second disease process arising during or following the primary condition. Referencing from the literature review, some of the complications of the patient’s condition are burst abdomen, perforation, intestinal bleeding, septicaemia among others. Adequate nursing and medical care were employed in the treatment of the patient’s condition hence she did not develop any of the complications of the condition as listed in the literature review. 2.6 Patient health problems A health problem is any physical, social and psychological stress on patient that can cause a change in the progress of her health. The patient /family health problems encountered were as follows; 1. Patient complained of abdominal pain (16th November, 2023) 2. Patient complained of excessive vomiting (16th November, 2023) 3. Patient had high body temperature (38.9°C) (16th November, 2023) 4. Patient was anxious (16th November, 2023) 5. Patient complained of loss of appetite (17th November, 2023) 2.7 Patient and family strength The following strengths were identified during admission of patient. 1. Patient could describe the intensity and location of the pain. 2. Patient could tolerate oral fluids 3. Patient could tolerate tepid sponging 4. Patient could verbalize the cause of her anxiety 5. Patient could take light soup 2.8 Nursing diagnosis 1. Impaired comfort (Abdominal pains) related to inflammation of stomach mucosa 2. Risk of deficient fluid and electrolyte imbalance related to Vomiting 3. Hyperthermia (38.9 oC) related to disease process. 4. Anxiety related to unknown outcome of condition 5. Imbalance nutrition: less than body requirement related to loss of appetite CHAPTER THREE PLANNING OF PATIENT/FAMILY CARE 3. 0 Introduction Planning is the third stage in the nursing process and it refers to a written plan of action designed to help deliver quality client care. It includes relevant nursing diagnoses, expected outcomes and nursing interventions. The nurse further goes on to evaluate the care given to find out whether the set objective is fully met partially met or unmet. Planning involves the following stages; • Assigning priorities to the nursing diagnosis. • Selecting appropriate nursing actions (interventions) to accomplish identified expected outcomes. • Documenting the nursing diagnosis, expected outcomes, nursing interventions and evaluations on the plan of care. 3.1 Objectives / Outcome Criteria Throughout her stay on the ward, objectives were set up with timelines to meet the health needs of the patient. The following were the nursing objectives set up for the patient. 1. Patient will be relieved of abdominal pains within 24 hours as evidenced by: a. Patient verbalizing relieve of pain. b. Nurse observing relaxed facial expression. 2. Patient will verbalize absence of vomiting and maintain normal fluid volume within 24 hours as evidenced by a. Patient seen with good skin turgor b. Patient verbalizing that vomiting has stopped 3. Patient`s body temperature will reduced to normal within 8 hours as evidenced by a. A recording of temperature between normal ranges of (36.2-37.2 oC) b. Patient confirming to the reduction of temperature. 4. Patient will experience a relieve from anxiety in 6 hours as evidenced by; a. Patient verbalizing she is no more anxious b. Nurse observe patient in a calm cheerful face 5. Patient will regain normal nutritional status within 48 hours as evidenced by; a. Patient verbalizing she has regained appetite. b. Patient being able to consume two-thirds of meal served. Date/Time Nursing Diagnosis Objective/Outcome Criteria Nursing Orders Nursing Intervention Evaluation Date / Time Signature 16/11/2023 At 10:30am Impaired comfort (Abdominal pains) related to inflammation of stomach mucosa Patient will be relieved of abdominal pains within 24 hours as evidenced by: a. Patient verbalising relieve of pain b. Nurse observing patient with a relaxed facial expression 1. Reassure patient. 2. Assess patient’s level of pain. 3. Help patient to identify foods that aggravate pain. 4. Engage patient in a diversional therapy. 5. Assist patient resume a comfortable posture 6. Serve prescribe medication 1. Patient was reassured that her abdominal pain will be relieved as soon as possible with the implementation of the competent nursing care rendered to her. 2. Patient’s level of pain was assessed on a scale of 1-10 3. Meals that were identified to aggravate the pains were identified after interactions with patient and restricted from eating. 4. Patient was engaged in minimal discussions as a diversional therapy from pain. 5. Patient was assisted to assume a posture that is most comfortable to ease pain 6. Antacids such as acirip 10mls was given to ease the pain. Goal fully met on17/11/2023 at 10:30am as patient verbalized that she has gained relief from pain and nurse observed relaxed facial expression from patient. B.D.A Table 3.1: Nursing Care Plan Date/Time Nursing Diagnosis Objective/Outcome Criteria Nursing Orders Nursing Intervention Evaluation Date / Time Signature 16/11/2023 At 10:30am Risk for fluid volume deficit related to vomiting Patient will verbalize absence of vomiting and maintain normal fluid volume within 24 hours as evidenced by a. Patient seen with good skin turgor b. Patient verbalizing that vomiting has stopped 1. Reassure patient 2. Monitor intake and output. 3. Monitor for signs of dehydration. 4. Administer prescribed intravenous fluids. 5. Encourage intake of liberal fluids 1. Patient was reassured of competent nursing care to help relieving her of the vomiting and maintaining normal fluid volume. 2. Intake and output chart was maintained and monitored 3. Patient was monitored for signs of dehydration such as poor skin turgor and sunken eyes 4. Intravenous Normal saline and ringer’s lactate 500mls were administered to boost fluid volume. 5. Patient was encouraged to take in more liberal fluids to replace lost fluids through the vomiting. Goal fully on 17/11/2023 at 10:30am met as patient verbalized absence of vomiting and nurse observed patient having a good skin turgor. B.D.A Date/Time Nursing Diagnosis Objective/Outcome Criteria Nursing Orders Nursing Intervention Evaluation Date / Time Signature 16/11/2023 At 10:30am Hyperthermia (38.9 oC) related to disease process. Patient`s body temperature will reduced to normal within 8 hours as evidenced by i. A recording of temperature reading between normal ranges of (36.2-37.2 oC) ii. Patient confirming to the reduction of temperature. 1. Reassure patient 2. Remove extra clothing. 3. Perform tepid sponging 4. Ensure adequate intake of oral fluids. 5. Monitor temperature chart. 1. Patient was reassured of competent care to aid reduction in body temperature. 2. Extra clothing was removed to improve air circulation to her. 3. Patient was tepid sponged using tepid water and towels to reduce temperature. 4. Intake of oral fluid was encouraged to help maintain body homeostasis 5. A temperature chart was maintained for patient where her body temperature was monitored half hourly. Goal fully met on 16/11/2023 at 6:30pm as patient’s body temperature was reduced to normal range (36.4oC) and patient confirmed to the reduction of body temperature. B.D.A Date/Time Nursing Diagnosis Objective/Outcome Criteria Nursing Orders Nursing Intervention Evaluation Date / Time Signature 16/11/2023 at 10:30 am Anxiety related to unknown outcome of condition. Patient will experience a relief from anxiety within 6 hours as evidenced by; a. Patient verbalizing that she is no more anxious b. Nurse observing patient in a calm cheerful face. 1. Reassure patient. 2. Explain all necessary procedures to the patient. 3. Introduce patient to other patients who have successfully recovered from similar condition patient is suffering from. 4. Encourage patient to verbalize her fears. 5. Answer patient’s concerns relating to her condition. 1. Patient was reassured of a successful care aimed at helping her recover in time since she is in the hands of competent nursing and medical staff. 2. All necessary nursing and medical procedures were explained to patient in order to allay any form of anxiety. 3. Patient was introduced to other patients who had similar condition and had recovered with the intention of relieving her anxiety 4. Patient was encouraged to voice out her concerns and worries about her condition and they were addressed appropriately to relieve her anxiety. 5. Patient’s concerns relating to her condition was answered in simple terms to her understanding. Goal fully met on 16/11/2023 at 4:30pm as patient verbalized that she is no more anxious about her condition and nurse observe patient with calm cheerful facial expression. B.D.A Date/Time Nursing Diagnosis Objective/Outcome Criteria Nursing Orders Nursing Intervention Evaluation Date / Time Signature 17/11/2023 At 7:00am Imbalance nutrition: less than body requirement. related to loss of appetite Patient will regain her appetite and normal nutritional status within 48 hours as evidenced by; a. Patient verbalizing she has regained appetite. b. Patient being able to consume about two-thirds of meal served. 1. Assess patient's nutritional status 2. Plan diet with patient. 3. Perform oral (mouth) care 4.Serve patient’s meal in an attractive and appetizing manner 5. Remove all nauseating and unpleasant articles from patient’s bedside. 1. Patient's nutritional status was assessed 2. Diet was planned with patient taken where patient was made to choose the particular kind of meal she intends to eat. 3. Patient was encouraged to brush her teeth with toothpaste and brush in order to have a cleaner and fresher breath 4. Patient’s meals were served in an attractive manner and appetizing manner with flowers to improve upon her appetite. 5. All nauseating articles such as bedpan, soiled hospital items were removed from patient’s bedside. Goal fully met on 19/11/2023 at 7:00am as evidenced by patient verbalizing that she has regained her appetite and being able to eat two-thirds of meal served to her. B.D.A CHAPTER FOUR IMPLEMENTING THE PATIENT/FAMILY CARE PLAN 4.0 Introduction This phase entails the actual nursing care carried out after the planning is done. It also entails planning for discharge beginning from the day of admission, and the continuity of care necessary for managing the patient after discharge. It needs the co-operation and participation of both the family and the patient to achieve the aim. The extent to which the patient participates also depends on his health status. This section of the patient/family cares study can be broadly categorized into three (3), namely: 1. Summary of the actual nursing care 2. Preparation of the patient/family for discharge and rehabilitation 3. Follow-up, home visits/continuity of care 4.1 The Summary of the Actual Nursing Care Day of Admission (16th November, 2023) Mrs S.G was admitted to the female medical ward of the Sunyani Teaching Hospital on 16th November, 2023 at 10:00am after she was transferred out from the emergency ward. She was brought to the ward lying supine in bed, with IV Normal Saline 500mls in situ in the company of patient relatives, a staff nurse and two student nurses. Handing over of the patient was done. Patient and her relatives were warmly welcomed to the nurses’ station. An introduction was made between the staff present at the time of admission and patient’s relatives. Patient was admitted into an already prepared bed. Her OPD card was received to admit her to the LHIMS system to the ward. Her details such as name, sex, emergency contact person, residential address, telephone number, and many others were taken from patient and documented into the admission and discharges book, daily ward state and nurse’s note. At 2:00pm, vital signs were monitored and recorded and bother and patient were reassured appropriately. She was served with tom brown and bread as her breakfast. However, she was unable to eat, verbalizing that she had lost her appetite. An objective was set for her to regain her appetite and normal nutritional status within 48 hours. A nursing care plan was drawn with the following nursing interventions outlined towards achieving objective: patient's nutritional status was assessed, diet was planned with patient taken where patient was made to choose the particular kind of meal she intends to eat, patient was encouraged to brush her teeth with toothpaste and brush in order to have a cleaner and fresher breath, patient’s meals were served in an attractive manner and appetizing manner with flowers to improve upon her appetite, all nauseating articles such as bedpan, soiled hospital items were removed from patient’s bedside. Her vital signs were monitored and recorded as; • Temperature - 38.90C • Pulse - 89bpm • Blood Pressure - 124/72mmHg • Respiration - 23cpm • Oxygen Saturation - 99% She was introduced to other patients she will share the same cubicle with. Patient and her relatives were orientated to the ward and its annexes like the nurses’ station, bathroom, urinal, treatment room and the washroom. Ward protocols such as visiting hours, ward rounds, mealtime were all made known to patient and her relatives. A brief assessment of patient’s condition on admission was made. She was alert, conscious, acyanosed and not in any obvious respiratory distress. The following medications were prescribed for her by the doctor; • Tab Ciprofloxacin 500mg bd • Tab Metronidazole 400mg bd • IV Ringers’ lactate 500mls bd • IV Normal saline 500mls bd The following laboratory investigations were requested by the doctor for proper drug management and confirmation of diagnosis; • Full blood count • Blood Film for Malaria Parasite (BF for MPs) • Widal Test An IV line was passed for blood sample to be taken for the ordered laboratory investigations. A nursing care plan was drawn based on patient’s presenting problems whilst interventions were instituted. I took the opportunity to calm and reassure patient and her relatives to relieve her of anxiety. I re-introduced myself to patient as a final year Student Nurse from Nursing and Midwifery Training College- Sunyani and willing to conduct a care study on her condition as part of the requirement for the award of Diploma in nursing certificate. I decided to use typhoid fever for my care study because I wanted to gain more knowledge on the condition and get practical knowledge on the management of the condition. I reassured patient and her relatives that, I will ensure confidentiality of every information that will be obtained from them. Discharge plans started on the day of her admission as I informed the patient and relatives that, her condition would improve, and that, she will be discharged after her condition had improved since the hospital is just a temporary place for nursing her. At 10;30am, patient complained of abdominal pains and the following nursing intervention were employed to resolved the problem, patient and relative were reassured, assessment of pain was done and patient was encourage and assume a comfortable position Second Day of admission (17th November, 2023) At 10; 30am, the abdominal pain managed yesterday was resolved and patient verbalizing absence of abdominal pain. Patient was educated on her condition, particularly the causes, mode of transmission, signs, symptoms and prevention. She was told to practice proper food hygiene and proper food sanitation, purification of water before use, prevention of housefly contamination and practice constant hand hygiene (especially after defaecation, before eating and after eating). I informed her of my visit to her house to observe her home situation, validate the data she gave during the time of admission and to intensify health education based on his home environment. She was then handed over to the night nurses for continuous monitoring and nursing at 10:00pm. Third Day of admission (18th November, 2023) I visited Mrs. S.G on this day at 5:30am. She told me she woke up early, around 5:00am. She said a word of prayer and was able to perform her oral and personal hygiene unassisted. Vital signs were checked and recorded at 6:00am with all indicators in the normal range. She was served with milo and bread as breakfast. Due medications were administered and documented. She had no health complain to make. Her lost appetite was evaluated at 7am. Goal fully met as evidenced by patient verbalizing that she has regained her appetite and being able to eat two-thirds of meal served to her. She was reviewed by the doctor on duty. She had a good skin turgor, acyanosed and anicteric. She had no pain on touching the abdomen. She had a normal head to toe examination and was asked to continue with treatment already prescribed. No new medications were added. I visited patient’s place of residence on this day at Abesim Dominase. I communicated with her about my impression on her home environment. I engaged her on education about her home situation and home modifications to be practiced to avoid reoccurrence of condition. All other nursing tasks and procedures were carried out as ordered. She was handed over to the night nurses for continuous monitoring and care. Fourth Day of Admission (19th November, 2023) According to Mrs. S.G, she had a sound night sleep. She woke up from bed at 6:00am, maintained her oral and personal hygiene unaided. Her bed linen was straightened to keep it free from creases and cramps. Her vital signs were checked and recorded. Due medications were served and was served breakfast of rice porridge with milk and bread. She had no health complain to make. At 9:00am, Mrs. S.G was educated on the causes, signs, symptoms, prevention, treatment and management of her condition (typhoid fever) to prevent reoccurrence. She was informed to practice proper food hygiene and proper food sanitation, purification of water before use, prevention of housefly contamination and practice constant hand hygiene ( especially after defaecation, before eating and after eating). She was reviewed at 10:00 am by the medical officer on duty. Her condition had improved significantly and the medical officer was really impressed with her state of recovery. She was anicteric on examination, no abdominal tenderness, acyanosed, not in obvious abdominal pain and respiratory distress. No new medications were added. She was reassured of possible discharge the next day. She was extremely delighted to know. She was educated on best practices to adopt, such as personal and environmental hygiene to avoid reoccurrence of her condition. She was also re-educated on meals she ought to cease eating to prevent reoccurrence of condition. Her relatives were made to prepare financially to pay her hospital bills which were not catered for by her health insurance. She was visited by some of her friends. She was extremely delighted to see them come over to visit her. She enjoyed some rest thereafter. All other nursing procedures and interventions were carried out as ordered. She was handed over to the night nurses for continuous monitoring and caring. Fifth Day of Admission/ Day of Discharge (20th November, 2023) Mrs. S.G’s condition had improved significantly on this day. On observation, she appears healthy and satisfactory. She woke up to maintain her personal hygiene including bathing, oral hygiene and grooming. Her vital signs were checked and recorded and due medications were served at 6:00am. At 6:30am, breakfast was also served. She finished the meal that was served to her. She had no health complain to make on this day. She was reviewed at 9:00am by the medical officer on duty. She was extremely impressed with her health state. Patient had no health complaints to make. She was acyanosed, no abdominal tenderness, not in any obvious respiratory distress, anicteric and normal head to toe examination. The doctor was much impressed with her state of health. She was discharged home to continue the treatment. She was scheduled for review on 28th November, 2023. Her hospital bills for the treatments that were not covered by the NHIS were paid for by her husband. They were educated on the need to support Mrs. S.G emotionally and physically since she might not be able to perform all activities of daily living immediately. She was discharged on Tab Ciprofloxacin 500mg bd and Tab Metronidazole 400mg bd. She was also educated on the storage, route and dosage of medication. She was particularly told not to eat any dairy product or egg while taking the ciprofloxacin. They were told to seek prompt medical attention whenever she gets ill even when the review date is not yet due. They were also informed of the review date and its importance to attend. Patient and family were educated to practice constant hand washing after visiting the toilet, before and after eating, and prevent houseflies from landing on their meals. avoid highly spiced up meals, fried and fatty foods so the condition does not reoccur. They expressed their profound appreciation to all the healthcare staff for the continuous competent care they rendered to her during the time of her hospitalization. Her details were entered into the discharge book as well as the daily ward state signifying her discharge. The bed and its accessories were cleaned with 0.5% diluted chlorine. Bed linen was removed and disposed into the dirty linen laundry basket. All her belongings were packed and was assisted to the hospital’s gate where a taxi was waiting to convey her to the house. 4.2 Preparation of Patient/Family for Discharge and Rehabilitation Termination of care for Ms. S.G and the family started on the day of admission, 16th November, 2023. Since separation and the fact that the patient has been hospitalized can bring anxiety and depression, they were given a gradual psychological preparation; they were told that hospitalization was a temporal procedure to help treat her condition. During her stay on the ward, the entire family was educated on her condition to ensure their cooperation and proper management after discharge. They also benefited from education on the need to keep themselves and their surroundings clean to enable them live a healthy lifestyle at all times. They were thus adequately prepared to facilitate the termination process. Patient and relatives were also made aware that, our interaction would last a few weeks after patient’s discharge and were thus encouraged to take advantage of the opportunity to learn about their health so as to enable them live a healthy and independent life Her condition improved on 20th November, 2023 and was discharged home. Patient and her family were educated on how to comply with treatment modalities and the need for follow up. They were also taught the route of administration, storage, dosage, side effect and desired effects of medications she was discharged on. She was encouraged to have enough rest and avoid strenuous activities. The relatives were also advised to serve her with highly nutritious meals rich in protein and carbohydrate without highly spiced up meal. Fruits such as pineapples, bananas and oranges were also recommended for patient to promote early recovery. They were informed to keep their environment well tidied, perform regular hand washing, cover their meals properly to avoid housefly contamination and cover their waste properly as well. They were educated on the condition: mode of transmission, signs, symptoms, management, prevention and complications. They were advised to report any complication to the hospital if she should encounter any. Her husband settled bills which were not covered by her national health insurance card. They expressed their utmost appreciation to the health care team and bid goodbye to patients she shares the cubicle with. 4.3 Follow-up/Home visit/continuity of care Home visit is a form of continuity of care using public health care approach to render nursing assistance to a client with consideration of available resource to solve client’s problem. This is the act of rendering health service to patient and her family at home environment to ensure continuity of care. This involves visiting the patient for the first time while she is still on admission and on two different home visits after discharge to have first-hand information on condition of the house and its influence on the health status of the patient. First Home Visit (18th November, 2023) My first visit to the patient’s house was made on 18th November, 2024 while she was still on admission. The purpose of the visit was to know the home situation and the type of health education to give in order to correct any possibility of condition reoccurrence before patient is discharged. The necessary arrangements were made, and we set off upon boarding a taxi at the hospital entrance. The trip to the house was made with patient’s husband. It took us approximately 15 minutes to arrive at patient’s residence at Abesim. She lives few metres away from St. James senior High School. Patient lives with his nuclear family in a rented single room. They have adequate water and electricity supply. The house was built with cement and blocks, and painted in white and ash colour with a green aluminium roofing sheet. The house has been walled, limiting the movement of untoward malicious animals into the compound. A mango tree was situated in front of the house with some grassy patches laying around some parts of the compound. An open gutter lay in front of the house serving to facilitate the passage of waste water. On inspection, the gutter was choked with cans and trash. I educated them to desilt the gutter regularly so that it does not serve as breeding grounds for mosquitoes and houseflies. Their house is well supplied with water from the Ghana Water Company. They have been connected to the national grid which provides electricity to their house. The items and belongings in their rooms are well arranged for easy identification. There is a veranda in front of the house where they have a cupboard where she keeps her cooking items. She prepares her food on the veranda in front of her house because there was no kitchen. Inspection of the environment portrays several plastics and trash thrown out in no order. The containers for keeping their refuse were full and not covered. I charged them to empty their dustbin when full and even cover it up when half full so that houseflies will not land on it and cause illness. I charged the family members and co-tenants to be supported to the patient when she is eventually discharged home. Such expected show of support of being loving, caring and paying close attention to the needs of the patient would unequivocally help in boosting her morale psychologically thus endearing her towards her ultimate recovery. They all concurred and expressed readiness to render such supportive care as expected to the patient once she returns home. Away from that, it was again understood by them upon a health education given by me the need also to regularize hand washing after visiting the washrooms, empty their dustbins when full and to cover it up to prevent houseflies from landing on it. After spending about an hour at the patient’s house, I sought permission to leave. Second Home Visit (26th November, 2023) The second home visit was made on the 26th November, 2023 at 3:00pm. The purpose of the home visit was to remind patient of the review date (and its importance to attend) and also to know how she was fairing following her discharge home. I was warmly welcomed to their house on arrival. I met patient in the company of other tenants interacting. I was so happy because this alone gave me signal that she was in good health state. I reminded patient and relatives of the review date and its importance to attend. I utilized the occasion to admonish family members to adhere to good hand washing technique before eating, anytime they get to the house after spending several hours outside and after visiting the toilet. They were told to cover their trash to prevent houseflies form landing on it. I assessed patient’s vital signs of temperature, pulse, respiration and blood pressure of which all of them were within normal parameters and provided no cause for alarm. She had no other health problems. She added that none of the presenting problems she came to the hospital with reoccurred. She also indicated to me that she had completed the dose of medications prescribed on discharge. I congratulated her for adhering to her treatment plan as she had been advised by the medical team. She stated that she experienced some side effects of the drugs she was given at the ward. She was reassured that it was much expected and she will be relieved of it soon. I encouraged her to report to the nearest health facility if she experiences a deterioration of health state. I informed her that on my next visit, care will be terminated. I promised to pay them occasional visits as and when time will permit. I then sought permission to leave and when granted I bade them good-bye. Day of Review (28th November, 2023) Mrs. S.G and her husband reported for review at the hospital on 28th November, 2023 at 7:00am. Prior to their arrival to the ward, she called me on the phone to alert me of her coming. I met them at the Out Patient Department and assisted them to have her OPD card serviced so she could see the doctor. Her vital signs were checked and recorded as all parameters were within the normal range. She was made to join a queue until it was her turn to see the medical officer. I accompanied them to the consulting room. She was examined head to toe by the doctor. He remarked that patient is healthy and ought to adhere to the education she was given on discharge so that condition does not reoccur. She was acyanosed, no abdominal tenderness on touch, anicteric and not in any obvious pain and respiratory distress. She had a normal head to toe examination. She was asked if she had any complaint and she said there was none. No new drug was prescribed after the review. I reminded her about my next home visit to terminate care as I had already informed her that, the interaction will not be permanent. I eventually saw them off in front of the hospital gate and bid them good bye. Third Home Visit (4th December, 2023) My third and last home visit to Mrs. S.G’s place of residence at Abesim was carried out on the 4th December, 2023 at 10:00am. The purpose of the visit was to follow up to know how patient and family were doing with respect to their health after the second home visit and the review and to terminate care. I was welcomed to the house and was offered seat on arrival. Water was given to welcome me as custom demands. I told her the mission of my visit, which is to terminate care. A quick assessment on her indicated she was doing really well in terms of recovery after her eventual discharge from the hospital. Her vital signs were checked and all parameters were within the normal range. She had no health complain to make. I educated them again to practice constant hand hygiene technique. I informed them to cover up their meals so that houseflies will not contaminate it and later cause illness. I formally informed them of the end of my formal visit to their home, yet I promised to pay them occasional visits as could be permitted. I thanked them all for their co-operation throughout the interaction. I promised to keep every detail and information obtained from her confidential. A permission to leave was requested which was granted. I left off after the request was granted. CHAPTER FIVE EVALUATION OF CARE RENDED TO PATIENT AND THE FAMILY 5.0 Introduction The evaluation of care is the last step in the nursing process. Evaluation in simple terms is the outcome of nursing actions against the anticipated goals (Bare and Smeltzer, 2014). It determines the extent of progress of patient and family care and effectiveness of nursing orders implemented towards the achievement of objectives set for the care of the patient and family. This chapter involves:  Statement of evaluation.  Amendment of the nursing care plan for partially met or unmet outcome criteria.  Termination of care. 5.1 Statement Of Evaluation Mrs. S.G, a 34 year old lady was admitted to the Female Medical ward of the Sunyani Teaching Hospital on 16th November, 2023. She was diagnosed as having typhoid fever after series of laboratory tests to confirm her diagnosis. She was nursed for 5 days on the ward and subsequently discharged on 20th November, 2023. During this period, Mrs. S.G was given comprehensive nursing care using the nursing process as a guide. Various health problems were identified, objectives were set and care plans were made to implement the set objectives. Patient was relieved of abdominal pain Patient complained of abdominal pains on 16th November, 2023 at 10:30am. A goal was set to relieve her of abdominal pains within 24 hours. The following nursing interventions were carried out towards achievement of goal. Patient was reassured that her abdominal pain will be relieved as soon as possible with the implementation of the competent nursing care rendered to her, patient’s level of pain was assessed on a scale of 1-10, meals that were identified to aggravate the pains were identified after interactions with patient and restricted from eating, patient was engaged in minimal discussions as a diversional therapy from pain, patient was assisted to assume a posture that is most comfortable to ease pain. Goal fully met as patient verbalized that she has gained relief from pain and nurse observed relaxed facial expression on 16th November, 2023 at 10:30am. Patient verbalized absence of vomiting and maintained normal fluid and electrolyte volume. Patient complained of excessive vomiting on 16th November, 2023 at 10:30am. An objective was set to relieve patient of vomiting and maintain normal fluid and electrolyte balance within 24hours.The nursing interventions implemented towards achieving set objectives were: patient was reassured of competent nursing care to help relieving her of the vomiting and maintaining normal fluid volume, intake and output chart was maintained and monitored, patient was monitored for signs of dehydration such as poor skin turgor and sunken eyes, intravenous Normal saline and ringer’s lactate 500mls were administered to boost fluid volume, patient was encouraged to take in more liberal fluids to replace lost fluids through the vomiting. Goal was fully met on 17th November, 2023 at 10:30am as patient verbalized absence of vomiting and nurse observed patient having a good skin turgor. Patient’s body temperature was reduced to normal (36.4°C) Patient had an elevated body temperature of 38.9°C on 16th November, 2023 at 10:30am. An objective was set to reduce patient’s body temperature to normal within 8 hours. The nursing interventions carried out to achieve objective were: patient was reassured of competent care to aid reduction in body temperature, extra clothing was removed to improve air circulation to her, patient was tepid sponged using tepid water and towels to reduce temperature, intake of oral fluids were encouraged to help maintain body homeostasis, temperature chart was maintained for patient where her body temperature was monitored half hourly. Goal was fully met on 16th November, 2023 at 6:30pm as patient’s body temperature was reduced to normal range (36.4oC) and patient confirmed to the reduction of body temperature. Patient was relieved of the anxiety Patient was anxious on 16th November, 2023 at 10:30am as she did not know the outcome of her condition. An objective was set to relieve her of the anxiety within 6 hours. The following nursing interventions were carried out so as to achieve the objective. She was reassured of a successful care aimed at helping her recover in time since she is in the hands of competent nursing and medical staff, all necessary nursing and medical procedures were explained to patient in order to allay any form of anxiety, patient was introduced to other patients who had similar condition and had recovered with the intention of relieving her anxiety, patient was encouraged to voice out her concerns and worries about her condition and they were addressed appropriately to relieve her anxiety, patient’s concerns relating to her condition was answered in simple terms to her understanding. Goal was fully met on 16th November, 2023 at 4:30pm as patient verbalized that she is no more anxious about her condition and nurse observe patient with calm cheerful facial expression. Patient regained her appetite and normal nutritional status Patient complained of loss of appetite on 17th November, 2023 at 7am. An objective was set for patient to regain her lost appetite and normal nutritional status within 48 hours. The nursing interventions carried out towards achieving set objective were: patient's nutritional status was assessed, diet was planned with patient taken where patient was made to choose the particular kind of meal she intends to eat, patient was encouraged to brush her teeth with toothpaste and brush in order to have a cleaner and fresher breath, patient’s meals were served in an attractive manner and appetizing manner with flowers to improve upon her appetite, all nauseating articles such as bedpan, soiled hospital items were removed from patient’s bedside. Goal fully met as evidenced by patient verbalizing that she has regained her appetite and being able to eat two-thirds of meal served to her on 19th November, 2023 at 7:00am. 5.2 Amendment of Nursing Care Plan No amendment of care plan was made due to the maximum co-operation received from patient and her family, all objectives were fully achieved. 5.3 Termination of Care This marks the last phase of relationship that exists between the nurse, patient and family from time of admission to discharge. Her family was informed that the therapeutic relation with them will last for a specific period of time on the day of admission. The termination of care started from the day of admission and it was done gradually till the third home visit on the 4th December, 2023 where care was officially terminated. She was again reminded of all the health education given and importance of adhering to the education. Patient was educated on her condition, particularly the causes, mode of transmission, signs, symptoms and prevention. She was told to practice proper food hygiene and proper food sanitation, purification of water before use, prevention of housefly contamination and practice constant hand hygiene (especially after defaecation, before eating and after eating). I expressed my utmost gratitude to patient and her entire family for their maximum co-operation in making my nursing care a successful one. The family also expressed their profound gratitude for the assistance and care I rendered to her during the home visits, health education and advice given to them. 5.4 Summary Mrs S.G was admitted to the female medical ward of the Sunyani Teaching Hospital on 16th November, 2023 at 10:00am after she was transferred out from the emergency ward. She was brought to the ward lying supine in bed, with IV Normal Saline 500mls in situ in the company of patient relatives, a staff nurse and two student nurses. After series of history taking, physical examination and laboratory investigations, patient was diagnosed of typhoid fever. Patient and her family were deeply involved in giving total care that resulted to her recovery. The comprehensive care given was based on the components of the nursing process. Patient received all the necessary attention such as medical care from the medical team, nursing care and social support from her close relatives while on admission. This resulted in her fast recovery process making it possible for her to be discharged after 5days of hospitalization. She was managed on the following medications throughout period of hospitalization. • Tab Ciprofloxacin 500mg bd • Tab Metronidazole 400mg bd • IV Ringers’ lactate 500mls bd • IV Normal saline 500mls bd The following laboratory investigations were requested by the doctor for proper drug management and confirmation of diagnosis; • Full blood count • Blood Film for Malaria Parasite (BF for MPs) • Widal Test The health problems below were identified throughout period of hospitalization; 1. Patient complained of abdominal pain (16th November, 2023) 2. Patient complained of excessive vomiting (16th November, 2023) 3. Patient had high body temperature (38.9°C) (16th November, 2023) 4. Patient was anxious (16th November, 2023) 5. Patient complained of loss of appetite (17th November, 2023) Three separate home visits were embarked, with the first home visit made while she was still on admission with the motive to familiarize with her home environment and ascertain if her current home environment had a major cause of her hospitalization so that education could be intensified. The second visit was to remind her of the date of review and its importance to attend and to know how she was doing after the discharge. The third home visit was embarked to officially terminate care with patient and her family. The care rendered to Mrs. S.G and her family was a comprehensive individualized nursing care. The nurse and patient relationship was finally terminated on the 4th December, 2023 on the third home visit. Patient suffered no complications of her condition. 5. 5 Conclusion The care rendered to Mrs. S.G and her family has made me gain adequate knowledge on typhoid fever with regards to the causes, mode of transmission, clinical features, drugs management, nursing management, personal hygiene, prevention and complications. It has equipped me with skill on how to render total individualized nursing care. It has again, broadened my ideas on how to effectively use the nursing process to render care to a patient and family. I therefore suggest that public education on typhoid fever be intensified, especially at the rural areas in order to eradicate this condition. 5.6 Recommendation I recommend the case study for other students as it enables student nurses to put into practice, all clinical and theoretical skills acquired over their years of study while still exposing them to how to go about patient care once they are employed as nurses at any health facility to improve nursing care in Ghana. 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Dirksen, Lewis H (2017). Medical-Surgical Nursing, Assessment and Management of clinical Problems, 9th Edition. Missouri: A Harcourt Health Sciences Company USA APPENDIX VITAL SIGNS DATE TIME TEMPERATURE (oC) PULSE (bpm) RESPIRATION (cpm) BLOOD PRESURE (mmHg) OXYGEN SATURATION (%) 16/11/2023 10:30am 2:00pm 6:00pm 10:00pm 38.9 38.0 36.4 37.0 89 72 71 76 23 21 22 21 124/72 118/74 129/79 122/72 99 98 99 99 17/11/2023 6:00am 10:00am 2:00pm 6:00pm 10:00pm 36.8 36.4 36.2 36.2 36.5 83 81 75 70 78 21 21 23 22 21 112 / 72 113/71 117/79 114/73 118/82 100 98 99 97 100 18/11/2023 6:00am 10:00am 2:00pm 6:00pm 10:00pm 36.4 36.3 36.5 35.9 36.1 75 76 81 73 78 22 20 20 22 19 114/74 113/72 128/81 119/75 121/74 98 99 98 98 98 19/11/2023 6:00am 10:00am 2:00pm 6:00pm 10:00pm 36.5 36.8 36.5 37.3 36.1 79 74 79 78 83 21 19 20 22 21 119/67 129/71 114/77 117/81 124/84 97 97 99 98 99 20/11/2023 6:00am 10:00am 36. 4 36.9 86 80 21 19 122/ 72 119/77 100 98 SIGNATORIES NAME OF PRINCIPAL: ……………………………………………………... SIGNATURE…………………………………………………………………. DATE…………………………………………………………………………. NAME OF SUPERVISOR …………………………………………………... SIGNATURE…………………………………………………………………. DATE…………………………………………………………………………. NAME OF WARD IN CHARGE: …………………………………………… SIGNATURE…………………………………………………………………. DATE…………………………………………………………………………. NAME OF STUDENT: ………………………………………………………. SIGNATURE…………………………………………………………………. DATE………………………………………………………………………….