CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

PATIENT’S PARTICULARS

Due to patient’s confidentiality, name will be in initials.

Madam P.D is a forty six year old woman, slender with a chocolate complexion and
came in with a weight and height of sixty five(65) kilograms and one point seven (1.7)
meters respectively. She is a Ghanaian and comes from Larteh in the Eastern Region.
Madam P.D is the first child among eight children of Mrs. A. D. and the late Mr. S. D.
She was born on 2nd December, 1962, speaks Guan, Twi and English and fellowships at
Baptist Church in Kaneshie, a suburb of Accra.
By profession, Madam P.D is a Kindergarten teacher at Happy Children’s school and
stays in the family house with her mother and children at Kwashieman, a suburb of Accra
Due to personal reasons of her own she is not married to the father of her seven
children. Her next of kin is her first daughter, Madam V.A.

FAMILY’S MEDICAL AND SOCIO-ECONOMIC HISTORY

Madam P.D’S mother is a known hypertensive and is on Tablet Nifedipine 20 mg
daily, but for the rest of her family, she does not know if they have hypertension or any
other disease.
The extended family usually meets during social gatherings like funerals, naming
ceremonies and weddings.
The father of her children, Mr. O supports the family from his salary as a teacher at
Christ Mission Junior High near Santa Maria and Madam P.D who is also a teacher
supports the family in any way she can.

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 PATIENT’S DEVELOPMENTAL HISTORY
According to Madam P.D’s mother, Madam P.D was born spontaneously at term in
Mampong Hospital. She was breastfed for one and half years and was weaned with
complan.
She started experiencing her secondary sexual characteristics such as widening of
hips, hair at the armpit and pubic area and menarche at the age of fourteen.
She did not attend nursery but gained admission to Adumang Early Primary School
near Kumasi in 1966 since her father was a teacher in the same school.
She attended a training college in Kibi and started teaching in 1980. She and her
spouse moved to settle in Kwashieman in 1995.

PATIENT’S LIFESTYLE AND HOBBIES

Madam P.D wakes up around 5:00 am daily and prays before getting up. She
brushes her teeth and helps her children to clean the house before taking her bath. She
sees to the personal hygiene and feeding of her youngest son who is one and half years
old, then sets off to work at 7:30 am. She closes from school at 2:00 pm.
She goes to the market on Tuesdays and Fridays and only cooks in the afternoon
for the family, but buys food outside in the morning to avoid being late for work.
Sometimes her eldest daughter cooks breakfast for the family.
Madam P.D takes three meals a day with lots of fruits such as pineapple and
pawpaw. Her favorite meal is boiled plantain with palaver sauce. Her hobbies are reading
and listening to Gospel music.
Madam P.D is a non smoker but drinks alcohol occasionally.

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 PATIENT’S PAST MEDICAL HISTORY
Madam P.D had fever frequently during adolescence and used to take unprescribed
medications which were chloroquin and paracetamol. She usually reacted to the
chloroquin by having pruritus.
She sought medical treatment when the effect of the drugs decreased and was given
an injection of which she could not recall its name.
She had all her children through normal delivery except her last born who was
delivered through a Caesarean Section. According to her, she went into labour for three
days and was informed that her womb would be removed during Caesarean Section since
it was weak.

PATIENT’S PRESENT MEDICAL HISTORY

Madam P.D complained of breathlessness, easy fatigability, swelling of both legs and
palpitation, all for three months.
She was then taken to a nearby clinic called Odoi Mills Clinic where she was
managed for some time.
She was later referred to the Surgical- Medical Emergency Unit of Korle-Bu Teaching
Hospital on 21stNovember, 2008, for management.
On the 23rd November, 2008, she was transferred to Medical Ward K for further
management.

ADMISSION OF PATIENT
Madam P.D was admitted to Ward K, a medical unit of Korle-Bu Teaching Hospital
on 23rd November, 2008 at 11:00am by Dr. D Baah under Professor Owusu with a
diagnosis of Congestive Cardiac Failure Secondary to Dilated Cardiomyopathy.

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 Patient was wheeled in, in a conscious state by a health aid and accompanied by her
mother and daughter.
They were welcomed and the name of the patient was mentioned from the folder to
confirm her identity of which she affirmatively responded. She was made comfortable in
a well laid bed and seats were provided to her mother and daughter. Patient’s belongings
were placed in the bedside lockers. On a quick assessment, patient looked anxious.
They were then reassured that she was in the hands of competent nurses and doctors
and with God’s help and their cooperation, her health would improve for the best.
Madam P.D’s vital signs which were, pulse, respiration, temperature and blood
pressure were recorded as follow:
Temperature ---------------------- 35.5 degree celcius.
Pulse ------------------------------ 82 beats per minute.
Respiration ----------------------- 30 cycles per minute.
Blood pressure ------------------- 110/80 millimeters of mercury.
The patient and family were informed on the ward protocol such as three meals were
served in a day, visiting time which was 6:30 – 7:30 am in the morning and 4:30 – 5:30
pm in the evening everyday and were also encouraged to visit regularly.
They were also informed that if they wanted to bring food from home to Madam P.D,
they were to enquire from the nurse if the type of food they would bring would be good
for her health. Madam P.D was also introduced to other nearby patients.
Her particulars which included name, age, occupation and residence were also
recorded in the Admission and Discharge book and the Daily Ward State.
Various investigations requested and done were Full Blood count, Blood Urea and
Electrolytes and Creatinine Estimation, Blood Film for Malaria Parasites, Sickling Test,
Chest X-ray and Electrocardiogram. Patient was being managed on Tablet Aldactone
25mg daily, Tablet soluble Aspirin 75 mg daily and Subcutaneous Heparin 5000IU 8
hourly.
After completing the admission procedure, permission was sought from my nurse
incharge to use the patient for my care study. She approved and I asked the patient and
family members to grant me their consent on using her for my patient and family care

4
study. It was explained to them what the care study entailed and necessity of it to me as a
final year student nurse of Korle-Bu Nursing and Midwifery Training College and that
interaction would be terminated after the discharge of patient.
They heartily agreed and assured me that they would oblige me with any information
needed. I thanked them afterwards.

PATIENT’S CONCEPT OF HER ILLNESS

Though Madam P.D was very anxious about her condition, she did not relate the
cause to any spiritual force.

LITERATURE REVIEW ON CONGESTIVE CARDIAC FAILURE

Congestive Cardiac Failure or Heart Failure is a condition where the heart is
unable to generate adequate cardiac output to meet the body’s metabolic requirement.
Congestive Cardiac Failure is almost always a chronic condition that is managed
with medication and lifestyle changes.

INCIDENCE
More than three million people have congestive cardiac failure and more than
400,000 new patients present yearly. The prevalence rate of congestive cardiac failure is
1-2 %.

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 TYPES
LEFT VENTRICULAR HEART FAILURE
This occurs when the left ventricle cannot pump blood out into the aorta and the
systemic circulation. Pulmonary oedema is a consequence of this disorder.

RIGHT VENTRICULAR HEART FAILURE

This occurs when the right side of the heart cannot eject blood and
accommodates all the blood that normally returns to it from the venous circulation.

BIVENTRICULAR HEART FAILURE

Failure of the left and right ventricles to function adequately as a result of the
disease process such as dilated cardiomyopathy or Ischaemic heart disease which
normally affects both ventricles. Hypertension is a common cause.
The left ventricle is usually first affected then the right ventricle also fails with
time.

PATHOPHYSIOLOGY.
LEFT VENTRICULAR HEART FAILURE
Increased work load and end diastolic volume enlarge the left ventricle. Because
of the lack of oxygen however, the ventricles enlarge with stretched tissue rather than
functional tissue. The patient may experience increased heart rate, pale and cool
skin , tingling in the extremities and decreased cardiac output.
Diminished left ventricular function allows blood to pool in the left ventricle and
the atrium eventually backup into the pulmonary veins and capillaries.

6
 At this stage, the patient may experience dyspnoea on exertion, confusion,
dizziness, and postural hypotension, cold peripheries due to decreased output, cyanosis
and weak peripheral pulse.
As the pulmonary circulation becomes engorged, rising capillary pressure pushes
sodium and water into the interstitial space, causing pulmonary oedema. You will note
coughing and tachypnoea and investigation may show elevated pulmonary artery
pressure, diminished pulmonary compliance and increased partial pressure of carbon
dioxide.
When patient lies down, the fluid in the extremities moves into the systemic
circulation. Because the left ventricle can’t handle the increased venous return, fluid
pools in the pulmonary circulation worsening pulmonary oedema. Examination of the
patient will reveal decreased heart sounds, dull percussion notes of lower zone of chest
and crepitations.
The right ventricle may become stressed because its pumping against greater
pulmonary vascular resistance and left ventricular pressure.
When this occurs, the patient’s symptoms worsen as the right heart may also fail.

RIGHT VENTRICULAR HEART FAILURE

The stressed right ventricle hypertrophies with the formation of stretched tissue
increasing conduction time and deviation of the heart from its normal axis can cause
arrhythmias.
If patient doesn’t already have left ventricular heart failure, he may experience
increased heart rate, cool skin, cyanosis, decreased cardiac output, palpitation and
dyspnoea.
The back up of the blood causes pressure and congestion in the vena cava and
systemic circulation.

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 The patient will have elevated central venous pressure, jugular venous distension
and hepatic venous congestion. Backed up blood distends the visceral veins especially the
hepatic vein. As the liver and spleen become engorged, their function is impaired. The
patient may develop anorexia, nausea, abdominal pain, weakness dyspnoea seconding to
abdominal distension and a palpable liver and spleen on examination.
Rising capillary pressure force excess fluid from the capillaries into the interstitial
space. This causes tissue oedema especially in the lower extremities and abdomen. The
patient may experience weight gain, pitting oedema and nocturia.

SIGNS AND SYMPTOMS

These depend upon the side of the heart that is affected.

LEFT VENTRICULAR HEART FAILURE

 Shortness of breath
 Paroxysmal nocturnal dyspnoea
 Cough which may be productive of whitish or pink frothy sputum due to
pulmonary oedema
 Easy fatigability.
 Palpitation
 Pulmonary oedema
 Cardiomegaly
 Insomnia

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 RIGHT VENTRICULAR HEART FAILURE

 Oedema of lower limbs and abdomen

 Anorexia

 Hepatomegaly

 Weight gain

 Arrhythmias

 Nocturia

DIAGNOSTIC INVESTIGATION

Physical examination
 Patient’s history
 Clinical manifestations
 Chest x-ray
 Electrocardiogram
Shows a graphical representation of the heart’s electrical activity done to identify
possible causes.

 Echocardiography
Evaluates the size, shape and motion of various structures with in the heart.

9
 Laboratory investigation such as Blood Urea Electrolytes and Creatinine
which are done to aid in assessment of fluid and electrolyte balance in the
body.

PROGNOSIS

Early diagnosis and interventions can lower the mortality rate, reduce
subsequent hospitalization and improve the quality of life for these patients.

MANAGEMENT.
MEDICAL MANAGEMENT

 Digitalis
Slows the heart rate and improves the pumping activity of the heart.

 Diuretics such as frusemide

Remove excess salt and water therefore reducing total blood volume and
circulatory congestion

 Vasodilators Increases cardiac output by reducing the impedance of

ventricular outflow (after load). Examples include Bosentan and
Amylnitrate.

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  Angiotensin Converting Enzyme Inhibitors
This causes the lumen of blood vessel to increase therefore decreasing
workload of the heart. Examples are Lisinopril and Fosinopril.

 Potassium supplement such as Potassium Chloride or Potassium

sparing diuretic such as spironolactone.

 Beta blockers such as propranolol.

 Analgesis for pain relief Example is Morphine.

 Anticoagulants such as Heparin.

ADDITIONAL THERAPY

Supplemental Oxygen is given when necessary.

NURSING MANAGEMENT
PSYCHOLOGICAL CARE

Reassure patients that shortness of breath and other signs and symptoms
are all due to the condition and will subside with effective drugs and nursing
care.

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 POSITION
Nurse puts patient in a high fowler’s or sitting up position with a cardiac
table.

REST AND SLEEP

Bed rest mobilizes fluid from the periphery into the systemic circulation
thereby increasing venous return, hence; ensure a quiet environment with
adequate ventilation to entrance breathing.

OBSERVATION

Monitor temperature, pulse, respiration and Blood pressure four hourly,

monitor fluid intake and output, oedema and its severity, weigh patient daily

and observing for cough if productive or non productive.

DIET

Goal is to reduce sodium and water retention thereby improving Cardiac

status. Restrict oral fluids; give low sodium diet, low fat diet and high fiber
diet.

ELIMINATION
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Serve patient with bedpan or bedside commode.

PERSONAL HYGIENE

Assist patient in maintaining his or her oral care, bathing, hair and nail
care.

LIFESTYLE MODIFICATION AND PATIENT TEACHING

 Educate patient and family on disease condition.

 Encourage patient to reduce salt and fat intake.
 Eliminate cigarette smoking and reduce consumption.
 Weigh control.
 Taking the right dose of prescribed medication and at the right time.
 Encourage patient to be seen for regular checkups to monitor progress
and adjust to treatment as necessary.

COMPLICATIONS

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  Thromoboembolism.
 Uraemia.
 Myocardial Infarction.
 Hypoxia.
 Hypocalcaemia.

LITERATURE REVIEW ON DILATED

CARDIOMYOPATHY

Dilated cardiomyopathy is a condition of which the heart becomes

weakened, flabby and enlarged and cannot pump blood effectively.
It occurs more in men than women. The mortality rate for cardiomyopathy
in male is twice that in female and for blacks, it is 2.4 times that of whites.
Actually causes are not known but there are associations;
 No identifiable cause
 Coronary artery disease
 Valvular heart diseases especially aortic regurgitation and
mitral regurgitation.
 Deficiency in Vitamin BI
 Alcoholism
 Pregnancy ( usually peri or post partum period)
 Viral infections
 Hypertension

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  Thyrotoxicosis
 Autoimmune disorders.

PATHOPHYSIOLOGY

A diverse range of condition that promotes cardiomyocyte injury or loss

may cause Dilated Cardiomyopathy.
It is characterized by ventricular chamber enlargement and systolic
dysfunction with normal left ventricle wall thickness
As the main pumping chambers of the heart are dilated they contract
poorly resulting in a low output of blood from the heart harbingering the
features of heart failure.
The clinical features of Dilated Cardiomyopathy are those of heart failure,
therefore management is aimed at treating heart failure.

VALIDATION OF DATA

All information collected from patient and family, patient’s folder and
literature review have been compared and proven to be free from errors,
therefore data is valid.

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 CHAPTER TWO

ANALYSIS OF DATA

This phase consists of:

 Comparism of data with standards.

 Patient and Family strength.
 Health problems.
 Nursing diagnosis.

COMPARISM OF DATA WITH STANDARD

The following investigations were carried out on Madam P.D to aid in

effective treatment: Blood Urea Electrolytes and Creatinine, Full Blood

16
count Blood Film for malaria parasite sickling Test, Chest X-ray and
Electrocardiogram.
Please refer table I, page 20-21 for details of laboratory
Investigations and result.

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18
 CAUSES OF PATIENT’S CONDITION AS COMPARED TO
TEXTBOOK CAUSE

With reference to the causes of congestive cardiac failure in the literature

review, Madam P.D’s congestive failure was caused by Dilated
Cardiomyopathy.

TABLE II
CLINICAL FEATURES EXHIBITED BY PATIENT AS
COMPARED TO CLINICAL FEATURES FROM
LITERATURE REVIEW

CLINICAL FEATURES FROM CLINICAL FEATURES

LITERATURE REVIEW EXHIBITED BY PATIENT
Shortness of breath Patient experienced shortness of breath.
Palpitation Patient had palpitation.
Oedema of lower feet and ankles Patient exhibited this clinical feature.
Fatigue Patient experienced fatigue.
Cough Patient had a productive cough.
Insomnia Patient could not sleep at night.

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Anorexia Anorexia was present.

Paroxysmal nocturnal dyspnoea Patient experienced this clinical feature.

Cardiomegaly Cardiomogaly was present.
Hepatomegaly Hepatomegaly was present.
Weight gain Patient experienced weight gain.
Dyspnoea Patient had difficulty in breathing.
With Comparism of the clinical features in the literature review to that of
my patient, it is transparent that she had congestive cardiac failure secondary
to Dilated Cardiomyopathy.

SPECIFIC TREATMENT ORDERED FOR

MADAM P.D

 Tablet Soluble Aspirin 7.5mg daily for five days.

 Tablet Augmentin 1g 12 hourly for seven days.
 Tablet propranolol 40mg 12 hourly which was stopped when
palpitation increased.
 Intravenous Lasix 40mg 12 hourly stat dose for 24hours then
reviewed to Tablet Lasix 40 mg daily for seven days.
 Tablet Aldactone 25mg daily for seven days.
 Tablet Lisinopril 5mg daily for thirty days.
 Subcutaneous Heparin 5000IU 8 hourly for three days.

 Oxygen therapy administration when necessary.

Please refer table III, page 24-25 for pharmacology of drugs used.

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21
22
 COMPLICATIONS

My client experienced none of the complications mentioned in literature review.

PATIENT AND FAMILY STRENGTH

The following strength were identified during my interaction with Madam P.D
and family.

 Patient could follow medical instructions

 Patient could sit up to aid breathing.
 Patient could move about with little effort.
 Patient could bring out clear sputum.
 Patient could eat a little at a time.
 Patient could sleep intermittently during the day..

HEALTH PROBLEMS
Madam P.D’s prioritized health problems are as follows;

 Patient experienced difficulty in breathing.

 Patient was apprehensive of her condition.
 Patient had swelling around ankles and feet.
 Patient had productive cough.

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  Patient had loss of appetite.
 Patient could not sleep at night.

NURSING DIAGNOSIS

The identified health problems were used to formulate nursing diagnoses

in order of priority.

 Altered emotional state (anxiety) related to shortness of breath.

 Ineffective breathing pattern (dyspnoea) related to Congestion in
lungs.
 Altered tissue perfusion (Oedema of both feet and ankles) related to
venous congestion.
 Cough related to lungs congestion.
 Altered nutrition (less than body requirement) related to loss of
appetite.
 Sleep pattern disturbance (insomnia) related to cough.

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 CHAPTER THREE

PLANNING FOR PATIENT AND FAMILY

OBJECTIVES AND OUTCOME CRITERIA

The following were the outcome criteria set for my patient and family after
identifying her health problems:

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

a. Patient verbalizing that she can breathe effectively.

b. Nurse observing that patients respiration and breathing pattern is within normal
range.( 16-20 cycles s per minute)

2. Patient’s anxiety level will reduce within 24 hours as evidenced by;

c. Patient verbalizing that she is less anxious

d. Nurse observing that patient is looking less anxious.

3. Oedema will subside within 48 hours as evidenced by;

a. Patient verbalizing that her feet can fit into flippers.

b. Nurse observing that;

I. Patient weight has reduced.

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 II. Patient can fit her feet into her slippers.

4. Patient will be relieved of cough within 72 hours as evidenced by;

a. Patient verbalizing that she is relieved of cough.

b. Nurse observing that cough has subsided

5. . Patient will have appetite for food within 48hours as evidenced by;

a. Patient verbalizing increase in appetite.

b. Nurse observing that patient eats all meals served her.

6. . Patient will have normal sleeping pattern within 72 hours as evidenced

by;

a. Patient verbalizing that she sleeps well at night.

b. Nurse observing that patient has been able to sleep well

26
27
28
29
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT/ FAMILY CARE PLAN.

SUMMARY OF ACTUAL NURSING CARE
DAY OF ADMISSION
( 23/11/08)

On the 23rd day of November, 2008 at 11:00 am , Madam P.D a forty

six(46) year old woman was admitted into the Medical Ward K under the
Physician Specialist Team Two ( Ps 2) through the Surgical Medical
Emergency Unit of Korle-Bu Teaching Hospital.
Patient arrived in a wheel chair with her mother and daughter and was
accompanied by a health aid. Patient was quickly assessed and it was noted
thet she was anxious. She was encouraged to voice out her fears and was
also educated on her condition with her family members.
Her vital signs were recorded as follows:
Temperature ----------- 35.5 degree celcius
Pulse---------------------- 82 beats per minute
Respiration --------------30 cycles per minute
Blood pressure ---------110 /80 millimeters per mercury

30
 On admission patient was on the following drugs;
 Intravenous lasix 40 mg 12 hourly then reviewed to tablet lasix 40 mg for
seven days.
 Tablets Aldactone 25 mg for seven days.
 Subcutaneous Heparin 5000 IU 8 hourly for three days.
 Soluble aspirin 75mg daily for seven days.

Various investigations requested and done were as follows;

 Full Blood Count.
 Sickling test.
 Blood film comment for Malaria parasite.
 Blood urea electrolye and Creatine.
 Chest x- ray.
 Electrocardiogram.

At about 1:00 pm, Madam P.D started having dyspnoea. My incharge

was quickly informed and then patient was placed in a sitting up position
with pillow supporting her back. All tight clothing’s around her neck and
chest were loosened and nearby windows were opened for adequate
ventilation. Finally oxygen therapy was administered.

FIRST DAY AFTER ADMISSION.

24/11/08

31
 According to the night nurses report, patient slept peacefully in a sitting
up position. I noticed that she was off the oxygen inhalation. I enquired from
her how she was faring and she answered that her breathing pattern had
improved and she was less anxious.
She was assisted in maintaining her personal hygiene and was made
comfortable in bed. She was served with the millet porridge and bread her
mother brought from the house of which she took enough.
Her medication were given and they included; Soluble Aspirin 75mg, Tablet
Aldactone 25mg, Tablet Lasix 40 mg and Subcutaneous Heparin 5000 IU.
On general ward rounds, patient was to continue with her treatment. In
the afternoon, Madam P.D told me that she wished to take a stroll in the
ward but could not since her feet could not fit into her slippers. She was
reassured that the problem would be solved with the appropriate nursing
care.
Since the foot end of the bed could not be elevated, pillow were placed
under her feet to elevate them, fluid intake was restricted and monitored
with the fluid intake and output chart. Patient was observed for tachypnoea
and encouraged to have low sodium diets. She was also informed that her
weight would be checked daily to ascertain the reduction of the oedema and
the prescribed drug had already been administered.
Madam P.D had a normal diet throughout the day which included Yam
and stew in the afternoon and Agidi with light soup in the evening.

In the evening subcutaneous Heparin 5000IU was given. Her vital signs
for the day ranged between;
Temperature--------------------36.5-37.0 degree celcius
Pulse-------------------------------90-94 beats per minute
Respiration-----------------------20-24 cycles per minute

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Blood Pressure------------------150/100-140/90 millimeters
of mercury.
Her weight was checked which read 64.81kg and the total fluid intake and
output were 700mls and 500mls respectively.

SECOND DAY AFTER ADMISSION

25/11/08

According to the night nurses report, Madam P.D could not sleep at night.
She confirmed it that she coughs at night with a whitish sputum which
prevents her from sleeping. She was encouraged that with the appropriate
nursing intervention those problems would subside.
Her personal hygiene was maintained with assistance and was made
comfortable in bed and had a half cup of tea with bread.
Her due medication were given which included soluble aspirin 75mg,
tablet Aldactone 25mg and tablet lasix 40mg.
On ward round, she was put on Tablet Augmentin 1g 12 hourly for
seven days and possible addition of Digoxin if patient did not improve with
lisinopril.
After propping up patient in bed a sputum mug with a lid was provided
and patient was advised to cover her mouth with handkerchief when
coughing and to take food in bits.
Fluid diet was recommended and food such as peanuts and popcorn were
advised not to be taken since they induced coughing she had a plate of
cooked plantain and stew for lunch and Agidi with light soup for supper.
Patient was engaged in less stressful activities such as reading of
magazine and conversation during the day to limit the amount of day time
sleep. Caffeinated drinks were avoided; a noise free environment was
provided and nearby window opened.

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 A warm beverage was served at night with patient propped up in bed and
light dimmed.
The weight of the patient was 64.6kg and the total fluid intake and
output were 750mls and 520 mls respectively. Vital signs ranged from;
Temperature----------------------36.0- 37.5 degree celcius
Pulse---------------------------------86-90 beats per minute.
Respiration-------------------------22-24 cycles per minute
Blood pressure--------------------140/90-130/80
millimeters of mercury.

THIRD DAY AFTER ADMISSION

26/11/08

The next morning, Madam P.D looked quite relaxed and said that she was
able to sleep a little last night since the cough was subsiding.
The nurse’s note said so and was assisted in maintaining her personal
hygiene. Her feet and ankles looked less oedematous and she confirmed it by
saying that her slippers now fitted her.
It was further confirmed by checking her weight which read 64.5 kg. She
was made comfortable in bed and had a cup full of corn porridge with bread
of which she took little. She complained that she was suddenly losing her
appetite. She was reassured that with the appropriate nursing intervention
her appetite would improve.
Due medication for the morning which were given were; Tablet
Augmentin 1g, Tablet lisinpril 5mg, Tablet Aldactone 25mg and Tablet lasix
40mg.
The importance of nutrition was made known to her. Her family was
advised not to bring food containing high fat and spices.

34
 Nauseating articles such as her sputum mug were placed away. Meals
were served attractively in an odour free environment and in bits.
She was also encouraged to brush teeth or rinse month before and after
eating. Lunch and supper served were Agidi with light soup and Yam and
stew respectively which were quite tolerated Tablet Augmentin was served
and taken in the evening. Total fluid intake and output were 650mls and
470mls respectively. Vital signs checked were recorded as follows;

Temperature------------------------36.5-37 degree celcius

Pulse-----------------------------------82-86 beats per minute.
Respiration---------------------------20-22 cycle per minute.
Pressure------------------------130/80-110/80 millimeters of mercury.

DAY OF DISCHARGE
27/11/08

Madam P.D looked much better today. According to the night nurses
report, she slept soundly without coughing and she confirmed it that her
cough had subsided and she felt refreshed since she had a good night’s sleep.
Patient was able to maintain her personal hygiene without assistance and
had her breakfast.
At lunch time, she commented that she could eat well and demonstrated
by eating all the meal served her. She was later discharged at 3 pm from the
ward to do Echocardiogram and bring it for review on the 29th December
2008
Madam P.D and her family were educated on the necessity of the review
and the importance of taking all medications prescribed for her.
She was then officially discharged from the admission and discharge book
and ward state after settling her bills. She was discharge on the following

35
drugs; Lisinopril 5mg daily, Lasix 4mg, Aldactone 25mg daily and to
complete Augmentin 1g twice daily.
After helping her to pack her belongings, she thanked the nurses and said
good bye to the other patients.
I escorted them outside to the taxi her mother had called. I said goodbye to
them and promised to visit them at home.

PREPARATION OF PATIENT/ FAMILY FOR DISCHARGE

AND REHABILITATION

Preparation for discharge and rehabilitation started the day of admission

to the day of discharge.
During admission, Madam P.D and her family were assured on the
competency of the hospital team and the necessity for their cooperation.
They were also educated on the disease condition, the causse, signs and
symptoms and treatment.
Her family was also cautioned not to do things that were contrary to what
the health staffs had said since it could aggravate the patient’s condition.
Patient was also educated on the rapeutic effect of the drugs and her
family was encouraged to visit regularly.
Whiles on admission, I visited her home on 23 rd November, 2008 to
investigate if there was any situation that could harm her health.
On 27th November 2008, patient was discharged home looking much better
than when admitted and 29th December, 2008 was the date set for review.

FOLLOW UP/ HOME VISIT/ CONTINUITY OF CARE.

FIRST HOME VISIT

36
 On the day of admission which was 23/11/08, I visited Madam P.D’s
house. I had made known my intentions to them earlier and left with her first
daughter and mother.
The purpose of my first visit was to investigate and confirm data and also
to find anything that could hinder her recovery when discharged.
We got to the house at 3:00 pm and I was welcomed with a glass of water
by Madam P.Ds fourth child called Linda.
My patient’s mother decided to take me around the house. T he house
was located at Kwashieman a suburb of Accra in the Greater Accra Region.
The house belongs to Madam P.Ds husband. It was a storey building made
of terrazzo with good roofing system and it was fenced with cement blocks
and a brown gate. It had a big compound with lots of shipped goods, such as
car tires and fridges which belonged to Madam P.Ds cousin.
The whole house was cemented and the entrance had a trap door. The
upper apartment consisted of a kitchen, a toilet, a bath, a bedroom and a hall

for entertaining visitors. The lower apartment also consisted of two toilet
and a bath, a kitchen, six bedrooms and a hall for entertaining guest. All the
bedrooms had atmost four mosquito netted windows with metallic wiring at
the back therefore making room, airy.
Their source of water was pipe borne and there were clean gutters for the
drainage of liquid waste. They also had access to electricity and kept their
refuse in large rubbish bins with lids which were regularly emptied on
Fridays by refuse collectors.
Even though they had mosquito net I advised them to sleep in mosquito
nets or use mosquito insecticide spray to prevent malaria since most of the
tires in the house were filled with rain water which could provide an
adequate breeding place for the mosquitoes.

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 I also educated Madam P.Ds mother on her condition which was
hypertension, I didn’t have the opportunity to meet Madam P.Ds spouse
because he had travelled to Lagos in Nigeria.
I asked permission to leave and Madam P.Ds first daughter, Victoria saw
me off to the bus stop. I boarded a vehicle and headed back to school.

SECOND HOME VISIT

The second visit was done to assess the patient’s condition after
discharge. This was on the 25th November 2008, a day after Madam P.D was
discharged. It was warming to have the family receive me so nicely.
She looked healthier on assessment but she complained of easy fatigability.
I reassured her and cautioned her not to stress herself too much.
I also advised her children not to stress their mother, since she was still
recovering and also in order to prevent complication.
Later I stressed on the date of review and told her to report if she observed
any uncomfortable signs. I sought permission and left.

THIRD HOME VISIT

On the 4th November, 2008 which was a Sunday, I visited Madam P.D at
about 2:30pm after calling to ascertain if she was at home. She warmly
welcomed me and I took the opportunity to remind her the date of review
and asked if she had done the test Echocardiogram. She said she hadn’t done
it but would do soothe next week since she had no money at the moment.
I explained to her that the test was needed in order to delve more into her
condition.

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 I got the chance to meet her youngest child who was a year old boy. He
looked healthy and I educated Madam P.D on the importance of
immunization. I also educated the family on personal hygiene, good diet,
exercise and rest.
Finally I explained to them that it was time for me to officially end our
interaction. They looked sad but I assured them that I would still be at their
service if they needed my help. They thanked me and I thanked them in
return for their support and cooperation throughout my interaction with
them.
I sought permission and left to the station to board a vehicle back to
school.

CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT/

FAMILY.
STATEMENT OF EVALUATION

This phase indicates whether the nurse was able to help patient meet her
needs. Madam P.D was admitted as a transfer from surgical medical
emergency unit of Korle-Bu Teaching Hospital with the diagnosis of
Congestive Cardiac Failure Secondary to Dilated Cardiomyopathy. Various
problems were identified and objectives were set to intervene those
problems.
Madam P.D’s anxiety level reduced after the condition was reassuringly
explained to her and encouraged her to ask questions. She was relieved of
dyspnoea after she was positioned correctly with light clothing’s around

39
neck and chest loosened, nearby windows opened for adequate ventilation
and oxygen administration.
She was relieved of cough after she was propped up, fluid diet served, a
sputum mug provided and nearby window opened for good ventilation.
The relief of cough enhanced her sleeping pattern. She was able to sleep
well at night. She was engaged in less stressful activities in the day to limit
day time sleeping, lights were dimmed and nearby windows opened to
enhance adequate ventilation. A noise free environment was also ensured.
Patient’s appetite improved when all articles were cleaned away from her,
meal was served attractively and in bits. She was also encouraged to brush
or rinse her teeth before and after meals. All goals and objectives were fully
met.
AMENDMENT OF NURSING CARE FOR MET OR UNMET
OUTCOME CRITERIA

Madam P.D and family cooperation with the health team in her care
which enable her needs to be met by achieving the set objective and goals.
All goals and objectives set for Madam P.D were fully met therefore
amendment of nursing care plan was not needed.

TERMINATION OF CARE

This is breaking the nurse-patient relationship. On the day of admission,

the patient and family were made aware that the interaction was temporal
and that it would be terminated on the day patient was discharged.
It was officially made known to the patient and family on the third home
visit that the interaction had come to an end and that I would not visit them
anymore.

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 The families was not very happy but were satisfied and appreciative of
the nursing care rendered. The care was therefore terminated on 4 th
November, 2008.

SUMMARY

Madam P.D a forty six (46) year old woman was admitted to Ward K,
medical unit of korle-Bu Teaching Hospital on 23rd November 2008 at 11:00
am by Dr.D Baah under Professor Owusu with a diagnosis of Congestive
Cardiac Failure Secondary to Dilated Cardiomyopathy.
In using the nursing process approach her health problems were identified
and a care plan was drawn. This care plan was then used in rendering
effective nursing care for the patients.
During her hospitalization, Madam P.D and her family were educated on
her condition. They were also educated on the necessity of the review and
the importance of taking all her prescribed medications.
The interaction with my patient lasted for five (5) days and she went
home with an improved condition.

CONCLUSION

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 The patient and family care study has enabled me to acquire a broader
knowledge on the causes, signs and symptoms and management of
Congestive Cardiac Failure and Dilated Cardiomyopathy.
It also gave me the opportunity to care for such patients and gain more
skills in using the care plan.
The knowledge I have gained in this study will enhance me to provide
adequate nursing care to all patients I will care for.
Lastly, it has also benefited Madam P.D and her family since they
acquired knowledge on the patient’s condition.

BIBLIOGRAPHY

A. Boon, A.N et al;(2006), Davidson’s Principles and Practice of Medicine.

(20th edition). Elsevier limited

B. Hand book of Diseases (1996).Springhouse Corporation

C. Monohan, F.D.Neighbours, M ;( 1998), Medical-Surgical Nursing

Foundations for Clinical Practice. (2nd edition); WB Saunders Company.

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D. Rose, B; (1995), Physician’s Drug Handbook. (6th edition) ‘Springhouse
Corporation.

E. Smeltzer, C. S et al; (2008) Brunner and Suddarth’s Textbook of Medical-

Surgical Nursing.(11th edition). New York; Lippincott Williams
Company.

F. Zaas, A. Cheng, A;(2003) The Osler Medical Handbook; The John

Hopkins University

G. Patients Folder Number; 269308

SIGNATORIES

NAME OF HEALTH OF INSTITUTION ………………………………

RANK……………………………………………………………………
SIGNATURE…………………………………………………………….
DATE ……………………………………………………………………

NAME OF DOCTOR …………………………………............................

RANK …………………………………………………………………..
SIGNATURE …………………………………………………………….
DATE …………………………………………………………………….

NAME OF SUPERVISING TUTOR ………………………………….

RANK ……………………………………………………………………
SIGNATURE …………………………………………………………….
DATE …………………………………………………………………….

NAME OF CLINICAL SUPERVISOR……………………………………

RANK …………………………………………………………………..
SIGNATURE …………………………………………………………….
DATE …………………………………………………………………….

NAME OF CANDIDATE ………………………………………………..

RANK ……………………………………………………………………

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SIGNATURE ……………………………………………………………..
DATE ……………………………………………………………………..

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