CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment involves information gathering about patients and her family as well as the

community in which she lives. The outcomes of the nursing assessments are to identify nursing

problems and to establish nursing diagnosis. The assessment covers patient’s particulars, family

and medical history (both past and present). Other areas include patient’s lifestyle and hobbies.

Some of the medical investigations used are X–ray, Computer Tomography (CT scan), signs and

symptoms, Erythrocyte Sedimentation Rate (ESR) and Blood Urea Nitrogen (BUN).

PATIENT’S PARTICULARS

A 39 year old Vivian Duodu was born on Friday, 28 th August 1970, to Madam Pinamang and Mr

Akwasi Nsiah, who hail from Offinso Nnamon, a town in Ashanti Region. She is the sixth born

of eight (8) children. She resides at Offinso Nnamon and her house has no house number. She is

fair in complexion, 1.5 metres tall and weighs 60 kilograms. She speaks Asante Twi and

understands a bit of English. She is a Christian and worships at Offinso Methodist church. She

had formal education up to class six (6). Mrs Vivian Duodu is a widow with one child (a son).

Her next of kin is Mr Kwadwo Asamoah Mensah. Her husband died after a short illness. He

complained of abdominal pain and died.

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 FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY

Client says she has no idea of any disease common in her family such as epilepsy, diabetes

mellitus, mental illness, hypertension etc. They seek for medical treatment whenever they are

sick. She said that none of her family members has ever been hospitalized. She however

admitted that they sometimes experience minor ailments such as fever, headache which they

usually buy some drugs from pharmacy shops to relieve them of the symptoms. Miss Duodu’s

parents were farmers which is the major occupation of her family.

PATIENT’S DEVELOPMENTAL HISTORY

Miss Vivian Duodu according to her was born in a clinic at Offinso as was informed by her

parents. She remembers she was immunized. She was breastfed for one and half years when her

mother started weaning.

At age 5, she started school at Offinso government school. She dropped out of school at form 4

and could not continue again the reason being that she had to help her mother and also for her

five brothers to get the best in their education. At the age of thirteen, Vivian had her menarche.

She got married at age 27 to Mr. George Osei in 1997. Client is a petty trader who sells gari,

groundnuts and washing powder. Her source of income is from the things she sells and

sometimes get financial support from her relatives.

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 PATIENT’S LIFESTYLE /HOBBIES

According to client’s relatives, she is jovial and quick tempered. She usually goes to bed at 9pm

and wakes up between 4am – 5am since she has to do her household chores before going to sell

her things. She brushes her teeth with toothpaste and brush and sometimes uses chewing stick.

She empties her bowels twice a week before going to do her trade. My client often returns from

work at 4.30pm to prepare food for her family. Her resting days are only on Sundays as she has

to go to church. She enjoys watching television and singing gospel songs as her hobbies.

CLIENT’S PAST MEDICAL HISTORY

According to client she sometimes experiences anorexia, fever, headache, blurred vision, etc but

has not been hospitalized before. She says it was only about two months ago when she was

feeling unwell. She was sent to Ashtown clinic and was diagnosed of Hypertension for which she

is being managed on some medication she does not know.

CLIENT’S PRESENT MEDICAL HISTORY

Miss Vivian Duodu was well until a month ago when she developed Periorbital swelling which

reduces in the evening. She also had bipedal swelling over a month. It is associated with onset of

early morning facial puffiness which is palpitated and easily fatigued on mild exertion,

abdominal distinction. She also develops anorexia on feeding. She reported back to Ashtown

clinic on accounts of the above and was referred to Komfo Anokye Teaching Hospital (KATH).

She reported to KATH in the company of her relatives. She was taken to the Accident and

3
Emergency Unit (A & E) and after treatment was transferred out to Females’ Ward C6. After

presenting signs and symptoms, laboratory investigations, CT scan etc, client was diagnosed of

chronic renal failure.

ADMISSION OF THE PATIENT

On Tuesday 29th of December 2009, client was admitted at A & E – KATH at 3.30pm. She was

accompanied by an admission team member and relatives. Client was ambulant when she came

in. Miss Vivian Duodu and her family were received by the triage team. Client’s particulars were

taken and recorded into the triage books/records. Client’s vital signs were checked and recorded.

She was then taken to the Medical Emergency Unit (MEU) when she received further treatment.

Vital signs of client such as Temperature, Pulse, Respiration and Blood pressure were checked

again and recorded on the Temperature, Blood pressure charts and the nurse’s notes as well. The

values are as follows:

Temperature – 37.2oC

Pulse – 64 bpm

Respiration – 18 cpm

Blood pressure – 220/130 mmHg

Immediately, 40 mg of sublingual nifedipine was administered as prescribed by the doctor. The

client was made stable in bed. With the help of relatives, client’s particulars were taken and

4
recorded into the Admission and Discharge book as well as the Ward state. Client and family

were reassured that the necessary nursing care shall be rendered to enable her to recover without

any complications. This was done to gain their full cooperation and to allay any form of fear and

anxiety during the period of hospitalization. Orientation was done by the nurse-in-charge; the

policies of the hospital were also explained to them along with the cash and carry system and

National Health Insurance Scheme (NHIS). At 9.30pm, client was transferred out to the Females’

ward C6 by the admission team and relatives. The appropriate nursing care was also done at the

ward. Client was discharged on Monday 4th January 2010.

PATIENT’S CONCEPT OF ILLNESS

Client did not attribute her condition to any supernatural forces but admitted that it is a medical

symptom. She again says that, the condition may be due to poor eating habit and lifting of heavy

objects as she has no knowledge about the illness. She believes since she has come to the

hospital, she will recover very soon.

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 LITERATURE REVIEW ON CHRONIC RENAL FAILURE

(END STAGE RENAL DISEASE)

DEFINITION

Chronic renal failure is a progressive, irreversible deterioration in renal function in which the

body’s ability to maintain metabolic and fluid and electrolyte balanced fails, resulting in uraemia

or azotemia.

CHRONIC RENAL FAILURE

Certain conditions causes chronic renal failure and these include; systemic diseases such as

diabetes mellitus (leading cause), hypertension, chronic glomerulonephritis, pyelonephritis (an

inflammation of the renal pelvis), obstruction of urinary tract, hereditary lesions, as in polycystic

kidney disease, vascular disorders, infections, medications or toxic agents. Comorbid conditions

that develop during chronic renal insufficiency contribute the high morbidity and mortality

among patients with chronic renal failure (Burrows-Hudson, 2005).

Environmental and occupational agents that have been implicated in chronic renal failure include

lead, cadmium, mercury and chromium. Dialysis or kidney transplantation eventually becomes

necessary for patient’s survival. Dialysis is an effective means of correcting metabolic toxicities

at any age.

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 INCIDENCE

May develop gradually over many years or can occur as a result of acute renal failure which the

client fails to recover.

PATHOPHYSIOLOGY

The nephrons are progressively and permanently destroyed by various process that occur in the

kidney. Renal function decreases due to ischaemia, inflammation, fibrosis, and scar of nephrons.

As renal function declines, the end products of protein metabolism (urea, uric acid and

creatinine) which are normally excreted in urine accumulate in the blood.

Uraemia develops and adversely affects every system in the body. As waste product builds up,

the symptoms become more severe. The rate of decline in renal function and progression of

chronic renal failure is related to the underlined disorder, the urinary excretion of protein and the

presence of hypertension. The disease tends to progress more rapidly in patients who excrete

significant amounts of protein or have elevated blood pressure than in those without these

conditions.

The patient tends to retain sodium and water increasing risk of oedema formation, hypertension

and occasionally acytis. There may be episodes of vomiting and diarrhoea; this may produce

gastro intestinal disturbances due to the presence of uraemia.

Anaemia also develops as a result of inadequate erythropoietin production, the shortened life

span of red blood cells, nutritional deficiencies and the patient’s tendency to bleed, particularly

7
from the gastro intestinal tract. Erythropoietin is a substance normally produced by the kidneys,

stimulates bone marrow to produce red blood cells.

In renal failure, erythropoietin production declines and profound anaemia results, producing

fatigue, angina and shortness of breath. Severe hypertension, electrolyting balance and drug

effect may produce a neurologic effect or complication in chronic renal failure.

TYPES OF CHRONIC RENAL FAILURE

There are 3 types of chronic renal failure. These are: pre-renal, post-renal and renal.

PRE-RENAL

It is often associated with certain characteristics and effects like shrinking of one’s kidney, low

blood flow to a person’s kidney, nephron function loss.

POST RENAL

Here there is a blockage of a person’s normal urine function and may result to damage nephrons

and obstructive uropathy. These problems may impede the normal flow of a person’s urine that

may eventually lead to problems such as enlargement of the prostate gland that may result in an

obstruction of the bladder outlet.

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 RENAL

It is characterised by changes that can be seen in a person’s kidneys.

CAUSES OF CHRONIC RENAL FAILURE

The following are the causes of chronic renal failure:

1. Systemic diseases such as diabetes mellitus, hypertension, hypertensive renal disease.

2. Chronic pyelonephritis.

3. Chronic glomerulonephritis.

4. Nephrotoxins such as drugs.

5. Congenital abnormalities such as polycystic kidney disease.

6. Obstruction of the urinary tract such as renal calculi.

CLINICAL FEATURES

It has been grouped under each system;

CARDIOVASCULAR SYSTEM

 Hypertension

 Engulge neck veins

 Pulmonary oedema

 Periorbital oedema

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NERVOUS SYSTEM

 Altered level of consciousness

 Confusion

 Weakness and fatigue

 Seizures

GASTRO INTESTINAL TRACT

 Hiccup

 Bleeding from the gastro intestinal tract

 Anorexia, nausea and vomiting

 Constipation and diarrhoea

MUSCULO SKELETAL SYSTEM

 Joint pain

 Muscle crumps

 Loss of muscle strength

INTEGUMENTARY SYSTEM

 Severe pruritus

 Ecchymosis

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  Dry flaky skin

RESPIRATORY SYSTEM

 Pleuritic pain

 Thick tenacious sputum

 Shortness of breath

REPRODUCTIVE SYSTEM

 Amennorrhoea

 Impotency

 Testicular atrophy

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 COMPLICATIONS OF CHRONIC RENAL FAILURE

(END-STAGE RENAL DISEASE)

HYPERKALEMIA

Due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet,

medication, fluids).

PERICARDITIS

Pericardial effusion and pericardial tamponade due to retention of uraemic waste products and

inadequate dialysis.

HYPERTENSION

Due to sodium and water retention and malfunction of the renin-angiotensin-aldosterone system.

ANAEMIA

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Due to decreased erythropoietin production, decreased red blood cell life span, bleeding in the

gastrointestinal tract from irritating toxins and ulcer formations, and blood loss during

haemodialysis.

BONE DISEASE AND METASTIC AND VASCULAR CALCIFICATIONS

Due to retention of phosphorous, low serum calcium levels, abnormal vitamin D metabolism and

elevated aluminum levels.

DIAGNOSTIC INVESTIGATIONS

1. Urinalysis is done to determine physical properties and chemical composition of urine.

Physical properties such as specific gravity, colour, and amount of daily urine. Chemical

composition such as determination of protein urobilirubin by assessing the creatinine in

urine.

2. Blood Urea Nitrogen (BUN) is done to determine glomerular filtration rate.

3. Test for calcium phosphate.

4. Chest X- ray.

5. Erythrocyte Sedimentation Rate (ESR), to assess the kidneys ability to secrete

erythropoietin.

6. Fasten Blood Sugar (FBS)

7. Computer Tomography Scan (CT Scan) of the kidneys.

8. Haemoglobin level test to rule out anaemia.

9. Lipid level of the blood is sometimes done to isolate hypertension.

10. Urine culture to identify the presence of any urinary tract infection.

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11. Finally, the signs and symptoms exhibited by the client can also help in the diagnostic

investigation as well as physical examination.

MEDICAL TREATMENT OF CHRONIC RENAL FAILURE

1. To maintain kidney function and homeostasis for as long as possible.

2. To control hypertension.

3. To increase urine output to reduce oedema and uraemia.

4. To prevent severe complications.

DRUGS USED IN THE TREATMENT OF CHRONIC RENAL FAILURE

1. 10mg of sublingual nifedipine is administered.

2. Administer prescribed diuretics eg laxis.

3. Nifedipine tablets 20mg is given to control blood pressure.

4. Analgesics to relieve pain.

5. Antibiotics such as ciprofloxacin 500mg bid × 5 days.

6. Amoxiclax tablets 625 mg bid × 10 days is given to elevate the pathogenic organism.

7. Dialysis either petritoneal or haemodialysis

8. Give 10% calcium gluconades intravenously, 10-20 mls over 2-5 minutes to treat

hypercalcaemia.

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 NURSING MANAGEMENT

PSYCHOLOGICAL CARE

Reassure client that measures will be put in place to provide good care for her by the health

workers since he/she is in the hands of competent staff. This will help her to adjust her lifestyle

and that she will be treated to meet the normal urinary elimination. This will enhance relieve of

anxiety and promote co-operation during the period of hospitalization.

REST AND SLEEP

Patient is admitted by a nurse into a comfortable position for her to attain complete bed rest.

Client’s bed should be free from creases and cramps and well laid with a neat bed sheet. Patient

should also be nursed in a well ventilated and noise-free environment. Radio and T.V set should

be lowered. This will enhance patient’s sleep. The nurse should plan to perform all activities at a

go to avoid interruption with the client’s sleep.

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 PERSONAL HYGIENE

The nurse should encourage or assist the client to bath at least once daily to increase circulation

and also raise patient’s morale.

Oral toileting should also be performed by the nurse or by the patient if he/she is able to. This

will help stimulate patient’s appetite and also prevent any pathogenic infection which can worsen

the condition.

Change patient’s clothes and bed linen whenever they are dirty to prevent infection and

discomfort. Patient’s nails should be kept clean and short to prevent micro-organisms from

harbouring in it.

NUTRITION

Diet should be planned with client and preference must be taken into consideration. The rationale

behind dietary restrictions must be explained to client. Easily digestible diet must be given.

Calories, carbohydrates and fat are given to prevent wasting. Vitamin supplement is given since

there is no protein diet to provide the necessary supplements. Restrict protein diet. Give low

sodium, potassium diet and fluid intake to balance fluid losses.

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Serve food in bits to stimulate patient’s appetite and swallowing. Avoid fruits that contain acid.

Decrease thirst by giving frequent oral hygiene and ice chips. Strict intake and output.

OBSERVATION

Check vital signs 4hourly to detect and correct any abnormalities. Maintain intake and output

chart. Measure and record the amount of urine and colour etc. Also note the amount of fluid

intake.

Monitor fluid status every 4hourly by assessing the mucous membrane, skin turgor, apical

course, heart sounds, vital signs and mental status. Monitor patient for seizures. Observe for

signs of oedema such as puffiness around the eyes and pedal oedema. Weigh patient twice daily

to assess the status of oedema.

Monitor haemoglobin level every 2-4 weeks of induction phase of erythropoiesis stimulation

agents’ therapy.

EXERCISE

Encourage or assist patient to walk around the bed and some passive exercises should also be

done by the nurse as condition permits to promote elimination and circulation.

ELIMINATION

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Apply warm compresses on patient’s abdomen to dilate the blood vessels to help in the excretion

of urine. Add roughages to patient’s diet in cases of constipation to eliminate and form faeces.

Nurse must also serve client with warm bed pan and urinal or assist the client to toilet whenever

client wants to void.

VALIDATION OF DATA

This is the act of verifying data; a double checking data which is collected to ensure that the data

is free from any errors, bias and misinterpretation as much as possible. To achieve this, the signs

and symptoms exhibited by the client should correspond to those in the literature review.

Again data gathered from client was cross checked with those obtained by the health workers

and client’s folder and was found to be valid.

Also, the laboratory investigations carried out on client with those stated in literature review, text

books used, internet etc are all accurate. Therefore, the data is described as valid.

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 CHAPTER 2

ANALYSIS OF DATA

This involves breaking down the assessment of information gathered to draw conclusion about

client’s condition. This nursing diagnosis is made after data collected has been analyzed and it

helps to draw conclusion from the data collected. The nurse uses personal knowledge as well as

past experience when comparing the data obtained with standards.

The following tables illustrate the comparison of data collected with standard values:

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20
21
 CAUSE OF PATIENT’S CONDITION

With reference to text books, internet and all available sources used, the causes of patient’s

condition may be attributed to inappropriate use of drugs (Nephrotoxins), with an example being

the use of analgesics, which led to destruction of the kidneys.

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TABLE TWO: COMPARISON OF CLINICAL FEATURES EXHIBITED BY CLIENT

TO THAT IN LITERATURE.

CLINICAL FEATURES OUTLINED CLINICAL FEATURES EXHIBITED BY

IN LITERATURE REVIEW CLIENT

01 Hypertension Present with patient with BP of

220/130mmHg

02 Periorbital oedema Also present with client

03 Weakness and fatigue Patient presented this symptom

04 Drowsiness Present

05 Anorexia, nausea and vomiting Present with patient

06 Constipation No constipation

07 Anaemia Client had anaemia

08 Thick tenacious sputum Patient did not present this symptom

09 Severe pruritus Absent in client

10 Ecchymosis Was not seen with client

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 TREATMENT GIVEN TO PATIENT

The following drugs were prescribed and administered to patient;

1. Tablet Nifedipine 40mg b.d. × 30days

2. Tablet Fersolate 1mg t.i.d. × 30days

3. Tablet Aldomet 250mg b.d. × 30days. Continue to end.

4. Injection erythropoietin (intramuscular) 4000IU weekly × 4/52 (1month).

5. Tablet Paracetamol 500mg t.i.d. × 5 days

6. Lasix (intravenous) 80mg b.d. × 30days

7. Calcium carbonate salts (CaCO3) 1mg t.i.d. × 30days

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25
26
27
 COMPLICATIONS DEVELOPED BY CLIENT

With reference to the literature review, the complications of chronic renal failure are:

1. Hypertension

2. Anaemia

3. Fractures

4. Pericardia effusion

5. Hypercalcaemia

Among these, client developed anaemia and hypertension.

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 PATIENT AND FAMILY STRENGTH

Miss Vivian Duodu and family established a good interpersonal relationship with ward staff and

other patients in the ward.

Client was able to maintain personal hygiene with assistance be it bathing and care of the mouth.

She was also able to sit up in bed. Client’s relatives visited her every morning and afternoon

during visiting hours.

Financially, client had support from relatives in the buying of drugs and settlement of hospital

bills.

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 PATIENT HEALTH PROBLEMS

1. Breathlessness

2. Headache

3. Anorexia and vomiting

4. Lack of knowledge

5. Weakness, fatigue and dyspnoea

6. Periorbital oedema

NURSING DIAGNOSIS

1. Ineffective breathing pattern related to chronic renal failure.

2. Insomnia related to headache.

3. Excess fluid volume related to decreased urine output, dietary excesses and retention of

sodium and water.

30
 4. Imbalanced nutrition, less than body requirements related to anorexia, nausea, vomiting

and dietary restrictions.

5. Activity intolerance related to fatigue and dyspnoea.

6. Knowledge deficit regarding condition and treatment.

CHAPTER THREE

PLANNING FOR CLIENT AND FAMILY CARE

The daily management of the client’s problems was done with the nursing diagnosis, objectives,

nursing orders, nursing intervention, evaluation, etc. specified in the table. This allows full

involvement of the patient and family in identifying the actual and potential health problems of

the patient and also setting goals and objectives for effective nursing management.

NURSING OBJECTIVES

1. Client will have periorbital and pedal oedema reduced within the period of

hospitalization.

31
2. Client will maintain normal breathing pattern within 48 hours.

3. Client will sleep normally within 24 hours.

4. Client will have adequate nutritional requirement within the period of hospitalization.

5. Client will tolerate activity within 24 hours.

6. Client will have knowledge on her disease condition (Chronic renal failure) within the

period of hospitalization.

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 CHAPTER FOUR

IMPLEMENTATION OF CLIENT/FAMILY CARE PLAN

It includes summary of the actual nursing care rendered to the patient and family from the time

of admission till the time of discharge or till she left the ward.

It also involves a well and strategic planning and implementation of nursing activities.

SUMMARY OF THE ACTUAL NURSING CARE

This involves the actual implementation of the nursing orders in the nursing care plan. The

nursing care given to the client, started on the 29 th of December, 2009, until the day the client

was discharged thus, 4th January, 2010. The care provided was aimed at restoring health and the

prevention of complications. The care rendered was done on daily basis as follows:

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 FIRST DAY OF ADMISSION: - 29TH DECEMBER, 2009

On the day of admission, client had excess fluid volume due to decreased urine output. The

following nursing measures were undertaken to help client demonstrate no rapid weight changes.

Procedure was explained to client and family to allay their fears and anxiety and to gain their co-

operation.

Client’s fluid intake was limited to prescribed volume to prevent any fluid overload. Client’s

fluid status was assessed. Intake and output was monitored and client’s neck was observed for

distension. Prescribed Diuretics (Laxis) 80mg was administered intravenously and sublingual

Nifedipine 40mg was also administered.

Vital signs were checked and recorded as follows:

1. Temperature – 37.2˚C

2. Pulse – 64bpm

3. Respiration – 18cpm

4. Blood pressure – 220/130mmHg

SECOND DAY OF ADMISSION: - 30TH DECEMBER, 2009.

Client was visited in the morning and she had difficulty in breathing due to the disease condition.

Procedure was explained to client and family. Client and family were reassured to allay all fear

and anxiety. Client was propped up in bed and was supported with pillows to enhance easy

breathing. Client was also taught and supervised to do deep breathing exercises according to the

39
level of her strength or capacity. Her vital signs especially respiration was monitored to assess

her level of improvement made.

Oxygen therapy was administered as prescribed to help client establish a regular breathing

pattern. Rest was also ensured in between exercises to avoid fatigue.

THIRD DAY OF ADMISSION: - 31ST DECEMBER, 2009.

On the third day of admission, client looked well and had no problems. She was able to take her

bath and brushed her teeth without any assistance. She took Milo with milk and bread for

breakfast and it was well tolerated. Due medications, such as injection Phenergan 25mg

b.d×48hours, CaCO3 1mg t.i.d. and tablet Paracetamol 500mg t.i.d. were served and recorded as

prescribed without any side effects and recorded.

Vital signs recorded as:

1. Temperature – 37.0˚C

2. Pulse – 80bpm

3. Respiration – 22cpm

4. Blood pressure – 180/70mmHg

FOURTH DAY OF ADMISSION: - 1ST JANUARY, 2010.

40
On the fourth day of admission, client complained of her inability to sleep (Insomnia) during the

night due to headache in the morning. This was also confirmed by the nurse on duty that night.

Client and family were reassured and procedure was explained to client and family. Measures

that were put in place to help client sleep well were as follows.

 A conducive environment such as noise free environment, reducing the volume of T.V

and radio set at the ward and a dim light was made to enhance client’s sleep.

 Client was asked to avoid caffeinated drinks and beverages since they interfere with

sleep.

 Client’s family was advised to adhere to the hospital’s visiting hours due to client’s

inability to sleep and should not disturb client when she is asleep. Tablet Paracetamol

500mg t.i.d. was administered to client as prescribed.

FIFTH DAY OF ADMISSION: - 2ND JANUARY, 2010.

On this day the client complained of nausea and vomiting and that she cannot eat. Client and

family were reassured to gain their cooperation. Procedure was explained to them. Dietary

restrictions and food preferences were discussed with client and family. This included, low

sodium (salt) and fat diet were noted. Client was weighed and it was documented. This continued

on a daily basis. In planning the meals, client’s past and present dietary patterns were all taken

into consideration. Prescribed dietary supplements such as vitamin C (2tab × 3) was administered

to client as prescribed. The rest of her medications were also administered; Folic acid 1daily,

Dopatab 2mg b.d, Nifedipine 2mg b.d etc.

41
 SIXTH DAY OF ADMISSION: - 3RD JANUARY, 2010.

On this day, client and family were involved in the care so that they will be able to continue the

care after discharge. Client complained of activity intolerance due to fatigue and dyspnoea.

Client and family were reassured and procedure was also explained to them. Client was made to

rest in bed and it was explained to client that she needed enough bed rest. Client was propped up

in bed to enhance breathing. Client was engaged in active and passive exercises. This was done

within client’s range of strength. Haemotransfusion 1unit (1pint) was given to client without any

complications.

Still on the sixth day of admission, it was realized that client still had knowledge about the

condition and treatments (Chronic renal failure). The nursing plan below was rendered to client

and family.

Client and family were reassured. The need for education was explained to both client and

family. Baseline information on the condition was also explained to both client and family.

Client and family were educated on the causes, signs and symptoms, management, complications

and prevention of chronic renal failure. Literature on renal failure was given to client and family.

Afterwards, client’s understanding on the condition was checked. This was done by asking her to

repeat the information given her. Client was able to provide answers to questions asked. This

implies that, client now has some knowledge on the condition.

On ward rounds that day, the doctor indicated that Miss Duodu could be discharged possibly the

next day and that her relatives should be informed. All routine activities were performed; I

helped the relatives to pack her belongings toward her discharge the following day. She took

yam and beans for lunch and kenkey with stew and fish for supper. Due medications such as

42
Dopatab 2mg b.d., Folic acid 1daily, Nifedipine 2mg b.d., Fersolate 1mg t.i.d., CaCO 3 1mg t.i.d.

were served and all routine activities were done.

SEVENTH DAY OF ADMISSION: - 4TH JANUARY, 2010.

This is the day of discharge and client had no complaints. She looked better now. Her condition

had improved considerably. According to the night nurses’ report, she woke up earlier than usual

in the morning to perform her routine activities such as bathing, grooming and brushing of teeth.

Patient took her breakfast early, since she was anxious to leave the hospital. She was very happy

to see me. Her medications were served as prescribed: CaC0 3 1mg t.i.d. for the day, Fersolate

200mg t.i.d., Nifedipine 40mg b.d and Aldomet 250mg b.d.

On ward rounds that day, the doctor discharged her after which the sister and I took her folder

for assessment. The doctor prescribed the following drugs for her:

 Dopatab 2mg b.d. × 14 days

 Folic acid 1daily × 30 days

 Nifedipine 20mg b.d.× 30 days

 Fersolate 1mg t.d.s × 14 days

 Paracetamol 500mg t.i.d. × 5 days

 Tablet Medolanone 1 daily × 14 days

 Tablet Lasix 40mg b.d. × 30 days

43
  CaCO3 1mg t.i.d. × 30 days

 Erythropoietin 4000IU weekly × 4/52 (1month)

Patient and family were educated on the condition again and on the effect and side effects of the

drugs prescribed. They were reminded of the review date which was Tuesday, 19 th January,

2010. Its importance was also stressed upon. Patient’s particulars were recorded into the

admission and discharge book and the daily ward state after assessment. Patient and family were

helped to pack her belongings after which she said goodbye to her new friends in the ward.

Patient and family were accompanied to the bus stop and I bade them goodbye. The bed linen

was removed and the bed was prepared for the next use.

44
 PREPARATION OF PATIENT AND FAMILY FOR DISCHARGE AND

REHABILITATION.

This started from the day of admission, thus, 29 th December, 2009. This was done to give the

patient and family insight into the condition. The doctor discharged her as planned. The patient

was happy and careful as indicated by her facial expression.

Patient and family were advised not to take in too much salt and to take medications as ordered

to prevent any complications. I advised her to take good care of herself and also to ensure

personal hygiene always. She was also taught to reduce fat intake and also to take in foods

containing enough roughage, example, vegetables and fruits like apples, pineapple and oranges

and to drink a lot of water to prevent constipation and to build her immunity. She was advised to

attend clinics and to report for treatment anytime she notices any changes in her body. She was

taught how to administer the drugs given to her. She was educated on the causes and

management of chronic renal failure.

The doctor requested that she comes back to the hospital on the 19 th of January, 2010 for review

thus, two weeks after discharge. Emphasis was made on the said date. Patient was discharged on

the 4th of January, 2010. Her bills were assessed but since she is a registered member of the

National Health Insurance Scheme (NHIS), they did not pay anything except drugs which were

45
not covered by the NHIS. Her name was discharged from the admission and discharge book as

well as the daily ward state. They were helped to pack their items and I accompanied the patient

and family to the lorry park to see them off and promised to visit them at home. They were

grateful to the health personnel for the care given to them.

FOLLOW-UP HOME VISITS AND CONTINUITY OF CARE

Follow-up, home visit and continuity of care play an important role in the care of patient and

family after discharge. It also helps the nurse to know how patient and family cope on their

natural habitat.

FIRST HOME VISIT: - 31ST DECEMBER, 2009.

The first home visit to the patient’s house was on the 31st December, 2009, when the patient was

still on admission. The visit was to find out the actual and potential problems that contributed to

the patient’s illness and find ways of solving them before the patient was discharged.

Patient stays at Offinso-Nnamon with no house number. The house is located about 400 meters

away from the market. I knocked and was allowed to enter. I greeted and I was given a seat.

Members of the house welcomed me since it is a family house. My purpose for this visit was

made known to them. I was given the chance to inspect their home and surroundings.

She lives in a compound house with the extended family. There are nine rooms in the house; the

windows are big enough to allow fresh air to enter the room. All members in the house use one

big kitchen. Others also cook infront of their rooms. There is one bath house and no toilet

46
facility. Members visit the public toilet. They have good supply of electricity and no pipe borne

water. They fetch water from the town’s bore hole. Each of them has barrels for reserving water.

Waste disposal in the house is done every day by themselves at the town’s dump. They also have

a good drainage system which drains all their domestic waste. The surroundings were clean and

tidy except for some few places.

The members of the house were advised to maintain good personal and environmental hygiene

and also to prevent home accidents, such as falling. This in a way will enhance quicker and faster

recovery of the patient. They were advised to cover and keep their reserved water clean. Her

room was inspected and I found out that, Miss Duodu and her son live in the room alone. The

room was spacious with the roofing sealed with plywood. I promised them another visit after the

patient have been discharged and left.

SECOND HOME VISIT: - 9TH JANUARY, 2010.

On the 9th of January, I paid another visit to the patient’s house to see how she was faring. This

time round, it was at Dechemso, where client would be staying after discharge. The house is a

compound house, with pipe-borne water, good electricity and a good refuse disposal. The

compound and their rooms are clean and tidy. I knocked and I was allowed to enter and I greeted

the family. I was warmly welcomed and I was given a seat. Miss Duodu and her sister were

happy to see me.

I examined the patient from head to toe and realized patient is healthy and have no oedema. I

observed the skin and conjunctiva for any pallor. I asked her if she is able to urinate and also if

she follows the dietary restrictions and takes her drugs as prescribed. She gave me a positive

47
answer which is Yes! and I was happy to hear that. I congratulated her and the sister for proper

care for herself by going according to the education given to them while on admission. Patient

had no complaints but I emphasized on the need for them to visit the hospital. I reminded them

of the review date and promised to wait for them and see them through the review process. They

were informed about the public health nurse and promised to bring her along during my last visit.

DAY OF REVIEW: - 19TH JANUARY, 2010.

Patient and family came for review around 7:30am on the said date. They obtained their folder

from the records unit through my assistance. I accompanied them to the Out Patient Department

(OPD) consulting room nine (9). The doctor examined patient physically and confirmed that her

blood pressure was normal.

They were told to continue treatment. Dopatab 2mg b.d., Folic acid 1daily, CaCO 3 1mg t.i.d.,

Tablet Lasix 40mg-100mg b.d., Paracetamol 500mg t.i.d.× 5days and Tablet Medolanone 1

daily. The above listed drugs were prescribed for her. They were asked to report for any

problem. The doctor’s advice was reinforced and they were seen off.

THIRD HOME VISIT: - 30TH JANUARY, 2010.

On the 30th of January, 2010, patient was visited again. The purpose of the visit was to introduce

the public health nurse to patient and family for continuity of care and also to terminate my care

for the patient. We knocked to be allowed in. We greeted and were warmly welcomed and we

were offered seats. Introduction of the public health nurse was made to patient and family and

after which patient and family were also introduced. Once again, I educated the patient and

48
family on personal and environmental hygiene. They were also advised to cope with the

treatment that will be offered by the public health nurse after I handed over to her. I wished them

farewell and left.

CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

Evaluation is a critical appraisal or assessment. In the health care field, this includes assessment

of the patient’s position on health. It is also the testing outcome of the nursing actions against

previous goal or objectives. In the nursing process, evaluation is the last stage.

STATEMENT OF EVALUATION

After the seventh Day of admission and while on admission, patient’s condition improved

considerably without any complications. The patient was admitted on the diagnosis of chronic

renal failure.

On the 29th December, 2009, at 3:30pm on admission, client had an excess fluid volume due to

decrease in urine output. A goal was set to increase client’s urine output within the period of

hospitalization. This was achieved within the period of hospitalization as patient’s urine output

increased. Patient demonstrated no weight gain. Client maintained dietary and fluid restrictions.

49
A goal set at the said time, was met within the period of hospitalization. Client verbalized that

her anxiety level had also reduced.

A goal was set on the 30th of December, 2009 at 10:30am to relieve patient of ineffective

breathing pattern within 24 hours. This goal was achieved on 31st December, 2009 at 8:30am as

patient was able to breathe within normal range and verbalizing that she can breathe well.

Another goal was set on 1st January, 2010 at 7:30am, patient complained of her inability to sleep.

This goal was achieved on 1st January, 2010 at 8:45pm, as patient verbalized that she had a sound

sleep and she has been relieved of the headache.

On 2nd January, 2010, client complained of her inability to eat due to nausea, vomiting and

anorexia etc. Goal was achieved on 4th January, 2010, as verbalized; she was able to consume

protein of high value and also participated in food selection within dietary restrictions and

demonstrating improved appetite. The nurse on duty also confirmed that client was able to

consume half of the food served her.

Client again complained of fatigue and dyspnoea and failure to do her usual activities. A goal

was set to identify the factors that contributed to the fatigue, to promote activities and exercise

within client’s range or strength. Nursing measures were implemented and goal was achieved as

client was able to perform routine activities herself.

On this day, it was noticed that client had no knowledge about condition (Chronic renal failure)

and treatments. A goal was set to help client gain knowledge within 48 hours. This goal was

fully met as patient was able to verbalize the causes, signs and symptoms and management of

chronic renal failure.

50
 AMMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET

OUTCOME

In the evaluation of the nursing care plan for Miss Vivian Duodu, it was deduced that all goals

and objectives set at the beginning of the interaction and interviews were met due to effective

implementation and co-operation of patient and family.

TERMINATION OF CARE

Termination is bringing something to an end. Here, the nurse and patient deal with the feeling

associated with separation and when they are distanced from each other. In view of this, the need

for termination has to be made known to patient and family from the day of admission. Rapport

was established with the patient and family on the day of admission on 29 th December, 2009.

Patient and family were made aware of the discharge procedure from the day of admission. She

was discharged on 4th January, 2010 after a good medical and nursing care has been carried out.

She and her family came for review on 19 th January, 2010. Client and family were educated on

the need to take good care of her, take her medications as prescribed and also follow the dietary

restrictions.

51
On my last visit, patient and family were handed over to the public health nurse at St. Patrick’s

Hospital for continuity of care, since it was time for me to terminate the care. They were grateful

and expressed their appreciation to me and promised to adhere to the advice given them.

SUMMARY OF CARE

Miss Vivian Duodu 39 years old, was admitted at the Accident and Emergency Unit (A&E) at

Komfo Anokye Teaching Hospital and was later transferred out to ward D4 on the 29 th of

December, 2009. She was admitted with the diagnosis, chronic renal failure.

Client presented excess fluid volume, dyspnoea, insomnia, imbalanced nutrition, activity

intolerance and knowledge deficit during the period of hospitalization.

The nursing process was applied to help nurse, patient and family. The above nursing problems

identified were dealt with accordingly because of effective nursing measures that were

implemented.

Nursing care, such as mouth care, assisted bathroom bath, feeding, checking of vital signs was

carried out successfully.

Drugs prescribed included Anti hypertensive, Haematinics, Analgesics, Diuretics, Electrolyte,

etc. Miss Vivian Duodu was discharged on 4th January, 2010 and her family was reminded of the

review date that was on 19th January, 2010 and the need for her to take her drugs as prescribed

was stressed on.

52
Patient and family were advised on the need to keep themselves and their environment clean and

also to follow the dietary restrictions. Follow up visit was made and patient’s condition was fair.

Finally, they were handed over to the public health nurse for continuity of care.

CONCLUSION

In conclusion, the study enlightened me to understand the care that should be given to an

individual patient. I have therefore gained insight on what chronic renal failure is; its causes,

signs and symptoms, treatment, prevention, management and complication through this patient

and family care study.

It has really helped me to gain more experience in my relationship with people of diverse socio-

economic and cultural backgrounds.

The knowledge I have gained on chronic renal failure will help me to educate the general public

about the condition. This case study has enabled me to put theory into practice and has given me

the chance to completely take charge of patients’ care. I have also had the chance to establish

good nurse-patient relationship.

53
 BIBLIOGRAPHY

1. George, C.F. (1998). British National Formulary, No. 35, Tavistock square: London

Pp 64, 84, 99-100, 196, 392, 396, 413.

2. Harwood-Nuss A. (2001). The Clinical Practice of Emergency Medicine, 3rd Ed., Florida:

Lippincott Williams and Wilkins, P 567.

3. Rees, P.J. and Williams, D.G. (1995). Principles of Clinical Medicine, 2nd Ed., 338

Euston Rd: London, Pp 433-439.

4. Smeltzer, S.C. and Bare, B.G. (2007). Brunner and Suddarth’s Textbook of Medical-

Surgical Nursing, 11th Ed., New York: Lippincott Williams and Wilkins Pp 1527-1537.

5. Weller, B.F. (2005). Bailierès Nurses’ Dictionary, 24th Ed. New York: Elsevier limited Pp

1-420.

6. Web search. (www.nephrology channel.com/crf/index).

7. Patient’s folder. – 77502/09.

54
 APPENDIX A

TABLE FIVE: FLUID BALANCE CHART

INTAKE

DATE TIME FLUID AMOUNT OUTPUT

29/12/09 6:00pm Koko 500mls Urine

6:30pm Water 200mls

4:45pm 500mls

Total 700mls 500mls

Total intake – Total output = Balance

Total intake = 700mls

Total output = 500mls

55
Balance = 700mls – 500mls

= 200mls

INTAKE

DATE TIME FLUID AMOUNT OUTPUT

30/12/09 7:30am Beverage 500mls Urine

8:15am Water 200mls

11:45am 400mls

Total 700mls 400mls

Total intake – Total output = Balance

Total intake = 700mls

Total output = 400mls

Balance = 700mls – 400mls

= 300mls

56
 INTAKE

DATE TIME FLUID AMOUNT OUTPUT

01/01/10 7:00am Koko 400mls Urine

11:30am Water 200mls

1:00pm 400mls

Total 600mls 400mls

Total intake – Total output = Balance

Total intake = 600mls

Total output = 400mls

Balance = 600mls – 400mls

57
 = 200mls

INTAKE

DATE TIME FLUID AMOUNT OUTPUT

02/01/10 8:00am Beverage 300mls Urine

8:45am Water 100mls

10:30am 200mls

Total 400mls 200mls

Total intake – Total output = Balance

Total intake = 400mls

Total output = 200mls

Balance = 400mls – 200mls

= 200mls

58
 INTAKE

DATE TIME FLUID AMOUNT OUTPUT

03/01/10 6:30am Beverage 500mls Urine

8:30am Water 400mls

10:00am 400mls

11:45am 400mls

Total 900mls 800mls

Total intake – Total output = Balance

Total intake = 900mls

Total output = 800mls

Balance = 900mls – 800mls

59
 = 100mls

INTAKE

DATE TIME FLUID AMOUNT OUTPUT

04/01/10 8:30am Koko 400mls Urine

10:00am Water 100mls

11:00am 400mls

Total 500mls 400mls

Total intake – Total output = Balance

Total intake = 500mls

Total output = 400mls

Balance = 500mls – 400mls

= 100mls

60
 APPENDIX B

TABLE SIX: WEIGHING CHART

DATE MORNING EVENING

29/12//09 - 64.0kg

30/12/09 63.8kg 63.8kg

31/12/09 63.6kg 63.5kg

01/01/10 63.0kg 63.1kg

02/01/10 62.0kg 61.9kg

03/01/10 61.4kg 61.4kg

04/01/10 61.2kg -

61
 APPENDIX C

SIGNATORIES

Name of student: ……………………………………………

Signature:……………………………

Date:……………………

Name of Ward-in-charge:…………………………………….

Signature:……………………………

Date:…………………...

Name of Supervisor:…………………………………………

Signature:……………………………

62
Date:…………………...

Name of Principal……………………………………………

Signature:…………………………….

Date:…………………...

63
64
65