CHAPTER ONE

ASSESSMENT OF PATIENT / FAMILY

Assessment, the first step in the nursing process is a systemic, comprehensive process of

collecting data organizing and documenting client’s data gathered from various available

sources.

The information is collected through interviewing, observation and laboratory investigations to

help in analysis and diagnosis of client’s condition. This helps to render the exact nursing care

to the client and family.

PATIENT’S PARTCULARS

Master Kazor Kamel who is the first born of the parents was born on the 5th of June, 2006. His

parents, Mr. Kofi Nkezor and Comfort Bukari have two (2) children. Kazor Kamel comes from

Bolgatanga in the upper east region but he resides currently with family at Asuofua new site, the

district of Atwima Nwabiagya with house number AS 45. He is a Ghanaian by nationality and

Frafra by tribe. He speaks the Akan language because of his interactions with the Akan people

at his area. He is a Muslim by religion, although traditional practices like giving sacrifices to the

lesser gods cannot be overlooked.

Kazor Kamel is a pupil of the Good Samaritan international school at Asuofua. Master Kamel’s

mother is a trader who sells second hand cloths and the father a butcher. He lives with the

family in a rented apartment with toilet and bathroom. His next of kin is his father, Mr. Kofi

Nkezor.

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FAMILY MEDICAL HISTORY

Client belongs to the nuclear family which consists of parents and siblings. Through my

interactions with Mr. Kofi Nkezor, the father of Master Kazor Kamel, there has been no history

of family or hereditary disease like epilepsy, mental illness, diabetes mellitus, hypertension and

sickle cell disease in the family. He however confirmed that minor ailment like common cold,

headache, diarrhoea, abdominal pains and fever do prevail in the family. He said these are

usually managed at home going to the chemical shops and to the hospital if symptoms persist

for days.

FAMILY SOCIOECONOMIC HISTORY

Client lives in a rented house with his parents and a sibling. The father is the breadwinner of the

family, who is a butcher. He goes to the place where they rear cows and buy them. After that, he

slaughters the animal and sells it in other to earn some income. He uses the income to cater for

the family in terms of food, shelter, medical bills and electricity bills.

The mother who also sells second hand clothing also supports the husband financially. She

collects the cloths from someone and sells it. According to the mother, the income derived is

shared between her and the owner of the cloths.

Refuse made in the house is gathered into a big bucket and emptied every morning. They collect

some amount of money and are given to someone who is employed to empty it every morning.

2
PATIENT’S DEVELOPMENTAL HISTORY

According to Master Kamel’s mother, pregnancy was uneventful, she went to farm and

experience labour. She delivered by spontaneous vagina delivery (SVD) and she was sent to

hospital. After delivery, the baby cried but was admitted to maternal baby’s unit (MBU) on

account of difficulty in breathing and it was managed for week.

Master Kamel is the first born of Mr. and Mrs. Nkezor. He was immunized against all the

childhood preventable killer disease such as poliomyelitis, tuberculosis, measles, tetanus and

whooping cough. The mother of Master Kamel added that, the child was able to sit with support

at three (3) months after birth. At four months, he could sit alone. She said at the eighth (8)

month, the child started crawling and at ten (10) months, he could stand erect on his own.

Master Kamel started walking at one year of age.

According to the mother, the baby was not exclusively breastfed. Supplementary feeding started

at 6 months and the child currently takes what is served at home.

PATIENT’S LIFESTYLE AND HOBBIES

Master Kamel likes watching television. According to the mother, Mrs. Comfort Bukari, he

likes playing with toys and football with friends and that sometimes it becomes difficulty to get

him to eat. Master Kamel’s favorite dishes include rice and tomatoes stew, Fufu with light soup

and ‘Tuo-zaafi’ with okro soup. However, among these dishes mentioned above, his most

favourite is the rice and tomatoes stew.

3
The mother says, she maintains his personal hygiene by bathing him twice daily. That is, when

he is to go to school in the morning and late in the evening when he is to go bed. She also

carries Master. Kamel’s oral hygiene twice daily. This also covers morning when he wakes up

from bed and late in the evening before he retires to bed with a tooth paste and brush if it is

available.

He eliminates his bowel twice daily. Master Kamel’s mother was happy to mention that he does

not urinate in bed when they are sleeping in the night. He rather always wakes her up to send

him out to do so.

Master Kamel likes going to where music is played and is always crying to be sent to watch

video at a video centre.

PATIENT’S PAST MEDICAL HISTORY

According to the mother, this is the second time Kamel has been hospitalized. The first

hospitalization was four (4) months ago at paediatric emergency units (PEU), Komfo Anokye

teaching hospital (KATH) on account of febrile illness with anaemia and he was

haemotransfused.

The second hospitalization is the current one as a result of the malaria infection. There is no

known chronic illness like asthma, tuberculosis etc. hi mother says that, Master Kamel has no

known allergies to drugs and no history of herbal medicine intake.

4
PRESENT MEDICAL HISTORY

According to Master Kamel’s mother, her child was well until two (2) days ago he developed a

fever and mother gave paracetamol syrup and fever subsided but reoccurred on the day of

presentation and was lasting about one (1) minute. She stated further that this was followed by

diarrhoea and vomiting and that Kamel’s body was very stiff and he was crying. They organized

and quickly sent him to county hospital where he was given some malaria drugs. However with

this treatment, Master Kamel condition did not improve in that he was still stiff and not feeding.

On the 22nd December, 2009, they were referred by the doctor to PEU at Komfo Anokye

teaching hospital. The doctor examined him at the PEU and according to the mother; the doctor

told him that there was altered sensorium, convulsion and delirium and body stiffness because

the malaria infection had spread to the brain (malaria of the brain).

The mother says that, the doctor carried a laboratory test for malaria parasites and the blood

group. The laboratory investigation results revealed that malaria parasites were present. His

blood group results also read A negative.

The medical officer told them it was cerebral malaria and admitted them in the children’s ward

B5, for further assessment and treatment.

5
ADMISSION OF MR. KAZOR KAMEL

Master Kazor Kamel was admitted into the children’s ward B5 at KATH on the 26th December,

2009 at 9:30am, as he was Trans in from PEU accompanied by the father and student nurse in a

semiconscious state. Client has nasogastric (N.G) tube in situ for feeding

On arrival, they were warmly welcome and offered seats by the nurses table. I collected the

admission notes from the accompanying nurse and relatives to identify and confirm Master

Kamel and his ward by calling by his name of which the parents agreed that was his name. I

introduced myself to them and informed the nurse in charge of his admission. I prepared a

comfortable admission bed for him and obtained the particulars of the patient from the mother

and recoded them into the admission book and the ward state. His vital signs were checked and

recoded as follows;

Temperature _ 39.4oc

Pulse _ 112 beats/ minute

Respiration _ 36 cycle/ minute

Body weight _ 10.9 kg

As a result of the febrile condition at the time of admission, he was put to bed immediately and

tepid sponged. After this, his temperature was checked and recorded again in 15 minutes time.

The temperature was found to have reduced to 37.3oC. A four (4) hourly vital signs chart was

instituted and his parents were oriented to the ward environment and its facilities such as toilet,

source of water, bathrooms, the ward waste disposal facilities, patients nearest to his bed, and

other staffs at the ward.

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They were also informed of the meals and visiting hours. If the client does not like the meal, the

parents can prepare what the client like best. His medical orders on admission included the

following;

1. IM quinine 300mg stat then 150mg tid x 48 hours

2. IV crystalline penicillin 0.4mu qid x 48 hours

3. IV chloranphenicol 375 qid x48 hours

4. Suppository paracetamol 250mg bd x 7

5. IV dextrose saline 1L stat.

6. IV phenobarbitone 150mg stat

All these drugs were collected from the dispensary and administered accordingly. The following

laboratory investigations were ordered;

1. Blood film for malaria parasites

2. Sickling test and blood group.

3. White blood cell count.

4. Packed cell volume.

The blood specimen was sent to the laboratory for analysis. I finally reassured the parents and

told them to ask questions about anything they did not understand and to call on any nurse if

they needed help. I finally saw the relatives off to the door of the ward.

7
PATIENT’S / FAMILY’S CONCEPT OF HIS ILLNESS

The father of Master Kamel, Mr. Kofi Nkezor did not attribute his son’s sickness to any

supernatural cause. He expressed his experience, knowledge and belief in the scientific point of

viewabou8t the aetiology of the illness. He said, he believes there are some tiny organisms

responsible for disease causation.

Concerning the son’s condition, he said it came as a result of mosquito bites. However, he

added that sometimes disease causation can be traced to supernatural origin and manipulation.

But that more often than not all disease are virtually caused by germs. So in the same manner,

his son’s illness is due to mosquito bites which discharged some organisms into his blood

causing this illness of his son, Master Kamel.

8
LITERATURE REVIEW ON CEREBRAL MALARIA

Cerebral malaria is one of the complications of malaria which is a severe systemic infection

characterized by recurrent fevers, accompanied by rigors, enlargement of the spleen and

anaemia. The disease is mostly in the tropics and sub-tropics and the temperate zones caused by

one of the four (4) protozoans of the plasmodium family namely;

 Plasmodium falciparum

 Plasmodium malariae

 Plasmodium ovale

 Plasmodium vivax

CAUSES

It is caused by a protozoan of the genus plasmodium. The plasmodium is carried by the female

anopheles mosquito.

MODE OF TRANSMISSION

Malaria is transmitted through the bite of an infected female anopheles mosquito ( an

intermediate host).

Malaria has also been transmitted through blood transfusion and from the use of shared

contaminated needles and syringes by drug abusers. That is public drug paraphernalia.

INCIDECE

9
The disease occurs in all age groups irrespective of the blood group. It is most severe in children

and pregnant women. It is most prevalent in the tropics, sub-tropics, and temperate zones.

Malaria is the most common of fever and morbidity in the tropics.

INCUBATION PERIOD

The incubation period of malaria is about one to two weeks (that is, 10-15 days) depending on

the type of plasmodium.

PATHOPHYSIOLOGY OF MALARIA

The life cycle of plasmodium goes through two stages;

 The sexual stage

 The asexual stage

THE SEXUAL STAGE:

This takes place in the intestines of the female anopheles mosquito. When the male and the

female mate, they produce sporozoite which are discharged and deposited into the saliva of the

female anopheles mosquito. When it bites, it injects the saliva containing the sporozoites into

the blood stream.

THE ASEXUAL STAGE:

This takes place in the human body after the saliva has been injected into the blood stream. This

covers the pre -erythrocytic, erythrocytic and gametocyte phases

Pre-erythrocytic phase:

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In this phase, the sporozoites in the blood stream are carried to the liver where they invade the

hepatocytes. They form cyst-like structures which rupture upon maturity to release merozoites

into the blood stream. Other sporozoites remain in the liver in the latent form as hynozoites.

Erythrocyic Phase:

Here the merozoites invade the red blood cells (RBC’s) or erythrocytes. Inside the erythrocytes,

they feed on the haemoglobin leaving the ferrous part and develop into trophozoites. The

trophozoites grow into schizonts which sexually segment into numerous merozoites again. The

red blood cell then ruptures releasing the merozoites which re-invade other red blood cells.

Clinical signs such as headache, anaemia, muscular pain and enlargement of the spleen are as a

result of the parasites.

Gametocyte Phase:

In this phase, the merozoites develop into sexual form of the parasites known as gametocytes.

At this stage the person is infective.

HOW MALARIA COMPLICATES INTO CEREBRAL MALARIA / SEVERE FORM

This complicated form of malaria comes as a result of the parasites gaining access to the brain

through the blood. There are a number of theories that try to explain this transfer of the parasites

to the brain. Some of the theories are hyperparasitaemia, rosette formation and agglutination.

11
From the erythrocytic phase, when each schizonts ruptures,thousands of merozoites are

released, which invade the red blood cells attach themselves to non-parasitized erythrocytes and

this is called rosettes fotrmation or cytoadherence. The parasitized erythrocytes again attach

themselves to other parasitize erythrocytes and this is known as agglutination. When these

happen, it leads to haemolysis of both intravascular and extravascular. While some of the

merozoites are in circulation, remain in the latent form in the liverwhich in two weeks or more

become matured anhd released into the circulation resulting to hyperparasitaemia and relapse.

In plasmodium falciparum malaria, these erythrocytes containing schizonts are transported to

the brain where they adhere to the lining of capillaries in the brain as well as causing

mechanical obstruction. The schizonts in the brain capillaries rupture, releasing toxins and

stimulating further cytokine release. Clinical signs such as diminished consciousness, confusion

and convulsions often processing to coma are seen as a result of the ‘sequestration’ (adherence),

obstruction and the toxins release which deprives the brain of adequate nutrients and oxygen.

Hence, malaria of the brain / cerebral malaria.

TYPES OF MALARIA

There are four main clinical types of malaria including;

 Benign tertian malaria

 Quartan malaria

 Malignant tertian malaria

 Mild tertian malaria

BENIGN TERTIAN MALARIAN

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This is caused by chronic relapsing malaria. It is common in people suffering from malnutrition.

Relapse occurs within 42-48 hours. Its incubation period ranges form 12-17 days. It is

characterizes by bouts of fever every three days. This pyrexia is accompanied by severe rigors

and the patients teeth chatter, profuse sweating, prostrating headache, vomiting and malaise.

Hepathomegaly and spleenomegaly may also be present on physical examination.

QUARTAN MALARIA

This is caused by plasmodium malariae. The incubation period is about 30-40 days and relapse

occurs in 72 hours. It most occurs in children, but predominantly seen in male adult. It si

characterized by fever occurring every four (4) days. Rigors are more commonly and may be

pronounced. Jaundice is less and severe and spleenomegaly is frequent and may be pronounced.

The liver is less affected and the anaemia pronounced. Jaundice is less pronounced.

MALGNANT TERTIAN MALARIA

This is the most dangerous of all the types of malaria. It is caused by plasmodium falciparum.

Incubation period is 9-14 days with an average of 12 days. The relapse period is 48 hours. This

plasmodium falciparum causes cerebral malaria in children. Children can deteriorate rapidly

over 1-2 days, going into coma.

The clinical features include herpes labialis and herpes simplex. Rigor is less marked or absent.

However, if rigor occurs or present, the hot and sweating stages are prolonged. The primary

signs include chills. This followed by vomiting, intestinal irritation and diarrhoea. There is

pyrexia, headache, supra-orbital neuralgia, anorexia, and delirium, irritability (convulsion,

13
coma, stupor, and confusion). Altered consciousness and focal neurological deficits or

psychoses and generalized weakness. This denotes cerebral malaria. There is also marked

haemolytic anaemia and patient complains of pain in the joint and bones.

OVALE TERTIAN MALARIA (MILD TYERTIAN MALARIA)

This type of malaria is caused by plasmodium ovale. It resembles the benign tertian, but is

milder. Its incubation period is 14 days. The clinical features of this type of malaria and its

attack are sudden, short and mild. Relapses are less common. Rigors are often present in the

evenings. Rheumatoid pain especially in the lumber region is characterized signs.

GENERAL CLINICAL FEATURES OF CEREBRAL MALARIA

1. Rigors

2. Fevers, headache

3. Altered sensorium

4. Vomiting

5. Neurological signs; altered consciousness made up of the following

6. Confussion, delirium, stupor, coma

7. Convulsion (50% generalized)

8. Focal neurological deficits and psychoses

9. Brain stem signs

10. Irritability

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 11. Severe haemolytic anaemia

12. Jaundice

13. Hypoglycaemia

14. Black water fever; due to the widespread intravascular haemolysis, affecting both

parasitized and unparasitized erythrocytes giving rise to dark urine.

DIAGNOSTIC INVESTIGATION / TESTS

1. Blood film for malaria parasites

2. Full blood count

3. Blood for haemoglobin level

4. Blood for sickling test

5. Cerebrospinal fluid examination (lumbar puncture), to exclude bacterial meningitis (that

is children with unarousable coma for no obvious cause).

MEDICAL TREATMENT (ANTI-MALARIA DRUGS)

Quinine:

Adult; initial dose of 600mg every 8 hours for 7 day.

Children; initial dose of 10mg/kg of quinine every 8 hours for 7 days.

Fancidar:

150mg 3 tablet as a single administration, 1.5g stat.

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Coartem:

Artemether and lumefanterine tablets

Artemether - 20mg

Lumefantrine - 120mg

Artesunate Amodiaquine:

Currently the drug combination choice for the treatment of uncomplicated malaria in Ghana.

Adults ; 25-30 mg/kg amodiaquine over 3days = 200mg

Amodiaquine – base tds x 3 days (1800mg in total)

Children; 25-30mg/kg amodiaquine over 3 days.

Treatment Uncomplicated Malaria From Standard Treatment Guidelines

Weight Age Artesunate Tablets Amodiaquine base Tablets

(kg) (years)

Day 1 Day 2 Day 3 Day 1 Day 2 Day 3

5 -10 Infants 25 mg 25 mg 25 mg 75 mg 75 mg 75 mg

11 – 24 1–6 50 mg 50 mg 50 mg 150 mg 150 mg 150 mg

24 -50 7 - 13 100 mg 100 mg 100 mg 300 mg 300 mg 300 mg

50 + 17 + 200 mg 200 mg 200 mg 600 mg 600 mg 600 mg

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INTERMITTENT PREVENTIVE TREATMENT- (ITP) FOR PREGNANT WOMEN

 Sulphadoxine- pyrimethamine (fansidar) given by directly observed therapy (DOT).

 Begins in the second trimester, after quickening or after16 week gestation- give 3 tablets

of SP 500mg/25mg.

 Give second dose one month later.

 Give third dose one month later (before 36 weeks gestation.)

OTHER DRUGS

A. Antipyretic-Analgesic:

PARACETAMOL

ADULTS: Tablets 250 -500 milligrams 4 -6 hourly.

CHILDREN: Two month babies 6 mg for post immunization pyrexia.

10 mg/kg or 5 mg/kg if baby is jaundiced.

3 months babies to 1 year 60 – 120 mg/kg body weight.

1 -5 years 120 -250 mg

Children 6 -12 years 250 -500 mg

Doses may be repeated every 4 to 6 hours and a maximum of doses in 24 hours. This is given

to control pain and reduce temperature symptoms.

B. Anticonvulsant

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PHENOBARBITONE

This may be prescribed to protect against convulsion or stop the convulsion.

ADULTS: 60 -180 mg at night orally

CHILDREN: 8 mg/kg daily orally.

Intramuscular Injection

ADULT: 200 mg, repeated after 6 hours if necessary

CHILDREN: 15 mg/kg body weight. In status epilepticus, dilute injection 1 in 10 with water

for injection

C. Haematinics

Multivites and vitamins B complex are given to correct anaemia.

D. Intravenous Infusions

Dextrose 5%, 10% and dextrose saline is given to provide energy and expand blood volume.

Normal saline is given to provide sodium electrolytes depletion or loss. Other drugs like

corticosteroids may be given in situation where there is cerebral oedema.

PREVENTION OF CEREBRAL MALARIA

Since cerebral malaria is one of the complications of malaria, malaria prevention is therefore

considered. As with many vectors-born disease, control (prevention of malaria relies on a

combination of case treatment, vector eradication and personal protection from vector

(mosquito) bites. These include the following:

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1. Treating infected persons with malaria chemotherapy.

2. Preventing the breeding of mosquitoes through regularly spraying with chemicals,

insecticides such as DDT.

3. Use of mosquito repellent such as the coils.

4. Keeping the environment clean by clearing the bushes, or by manipulation of the

habitation (such as marsh drainage). That is encouraging proper drainage system in

the environment.

5. Covering of all water containers

6. Proper refuse disposal

7. Pouring of kerosene on stagnant waters to break the surface tension of water bodies

which serve as their breeding grounds.

8. House dustbins should have fitting lids and covered properly.

9. Weed around the house, empty bins, broken pots and bottles should be destroyed and

buried to prevent mosquitoes breeding in them.

10. Use of insecticides treated mosquito bed nets

11. Use of mosquito proof nets for doors and windows in the house and offices.

12. Administration of ante malaria chemoprophylaxis to people in the endemic areas.

13. Encourage patient to complete their course of treatment.

14. Regular health education on preventive measures of malaria.

15. Encourage pregnant women to attend antenatal clinic (ANCs) for proper screening

and treatment.

16. Implementation of the new ‘rolls back malaria campaign which was announced by

WHO in 1998.

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COMPLICATIONS OF CEREBRAL MALARIA

1. Speech disorders

2. Paralysis of limbs

3. Retinal haemorrhage, blindness

4. Cerebella ataxia (unsteady gout)

5. Cortical blindness

6. Mental retardation, mental confusion

7. Diffuse cerebral dysfunction with unrousable coma, altered senorium.

8. Cerebral palsy and spastic limbs

9. Hypotonia, acidosis and respiratory distress

10. Hypostatic pneumonia

11. Haemolytic anaemia

12. Septicaemia secondary to shock

13. Oliguria and uraemia

14. Jaundice, black water fever

15. Hepatospleenomegaly and bleeding tendency

16. Pulmonary oedema.

NURSING MANAGEMENT

Nursing management is a series of care rendered to the patient by the nurse to improve upon the

patient’s condition to prevent complications.

In the management of a patient with Malaria, some of the goals include;

20
 1. Reducing anxiety

2. Relieving headache

3. Preventing fluid volume deficit

4. Maintaining optimum comfort of the patient

5. Maintaining the progress of the patients condition

Reassurance

Patient and relatives are reassured of competent care and measures being taken to resolve the

health problems. This is done to relieve the patient of anxiety.

Rest and Sleep

This is ensured to promote the healing process. Rest and sleep is maintained by providing a

comfortable bed free from crambs. The environment should be properly ventilated and noise

minimized to promote rest and sleep. Pain must also be controlled to induce sleep. Lastly

Patient’s personal hygiene such as oral care, bathing should be maintained to induce sleep and

relaxation.

Observation

Patients vital signs were monitored regularly and the findings recorded.

Infusion site was also observed for patency, with accurate fluid intake and output chart

maintained. Patient was monitored with fever and more clothes were added to keep him warm.

Nearby windows were closed and fans put off.

Personal hygiene

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Personal hygiene was ensured by assisting the patient to provide his bath twice daily to remove

dirt and microbes from the skin and to improve circulation.

Patient was also given oral care to stimulate his appetite.

Nutrition

The patient is given a well balanced diet rich in vitamins to improve the immune system,

carbohydrates for growth, energy and development, proteins to build up worn out tissues.

Patient’s best meal was served attractively to stimulate his appetite.

Exercise

The patient was encouraged to do active and passive exercises to aid in circulation, to relieve

boredom and then to help in peristalsis and flush out toxins from the body.

Elimination

The patient is served with bedpan and urinal on demand and encouraged to take in more fluids

and roughage to prevent constipation.

Patient Education

The Patient was educated on the need to complete the prescribed dosage even if he is no longer

experiencing the signs and symptoms of malaria.

Education on the predisposing factors of malaria such as stagnant water, weedy environment

and chocked gutters which serve as breeding places for mosquitoes was emphasized.

22
The signs and symptoms such as high temperature (pyrexia), nausea and vomiting should be

known to the people to enable seek early treatment.

The patient was also educated on the importance of review to find out how he is progressing

after discharge.

VALIDATION OF DATA

The clinical features manifested by Patient and the diagnostic investigation conducted o him

were in line with information from text book sources which confirm that he was suffering from

malaria. Data collected from his mother was also compared with information in Patients

records confirm the validity of data.

CHAPTER TWO

ANALYSIS OF DATA

Analysis of data is the breaking down or categorizing information in order, to draw a final

conclusion about the client’s condition. The client’s health problems are then identified to

enable the nurse to establish nursing diagnosis.

COMPARISM OF DATA WITH STANDARD

This is comparing the data collected with that of the standards which includes diagnostic

investigations, causes, clinical features, treatment and complications.

23
 TABLE ONE: DIAGNOSTIC INVESTIGATION ON MASTER KAZOR KAMEL

DATE SPECIMEN INVESTIGATION NORMAL RESULT INTERPRETATION REMARKS/TREATMENT

VALUE

26/11/09 Blood Blood for malaria Negative Malaria parasite Client has malaria Antimalaria drugs were given

parasite was present parasite in his blood intramuscularly (I.M) Quinine

which he had 3+ 300 mg stat then 150 mg tid x 48

plasmodium hours was ordered and

parasite present administered

(plasmodium

falciparum)

26/11/09 Blood White Blood Cell 5-10 x 10 9/l 6 x 10 9/l White blood cell No treatment given

Count count was within

normal range

26/11/09 Blood Packed Cell Males 40 – 54% 45% Patient had a normal No treatment given

Volume Females 35 – 40% value

26/11/09 Blood Sickling test and Blood group Group A Rhesus Client is a blood Matches with client’s blood

24
blood group negative group of “A’’ group and rhesus factor.

A negative

AB

25
CAUSES OF CLIENTS CONDITION

According to the literature review, it was clear that client’s condition is probably due to the bites

of an infected female anopheles mosquito parasite (plasmodium)

TABLE TWO: COMPARISM OF CLINICAL FEATURES IN LITERATURE

REVIEW WITH THOSE EXHIBITED BY CLIENT

CLINICAL FEATURES INDICATED IN CLINICAL FEATURES EXPERIENCED

THE LITERATURE REVIEW BY CLIENT

Pyrexia Patient experienced pyrexia of 39.4 °C

Rigor Patient did not experience rigor

Headache Patient complained of headache

Loss of appetite Patient experienced loss of appetite

Nausea and Vomiting Patient experienced nausea and vomited

There may be diarrhoea or constipation Client did not experienced any of these

Convulsion in children Patient did have convulsion

Confusion and irritability There was irritability.

Jaundice Patient did not experience or have jaundice

26
TREATMENT GIVEN TO CLIENT

With reference to the treatment indicated in the literature review, the following specific treatment

was given to client.

 IM quinine 300mg stat then 150mg tid x 48 hours

 IV crystalline penicillin 0.4mu qid x 48 hours

 IV chloranphenicol 375 qid x48 hours

 Suppository paracetamol 250mg bd x 7

 IV dextrose saline 1L stat.

 IV Phenobarbital 150mg stat

On the 29th December, 2009, these drugs were prescribed for the patient

 IV Gentamycin 80mg daily x 2

 IV Cefuroxime 450mg tds x

27
28
 TABLE THREE: PHARMACOLOGY OF DRUGS ADMINISTERED TO MASTER KAMEL KAZOR

DATE DRUG DOSAGE AND ROUTE DOSAGE AND CLASSIFICATION DESIRED ACTUAL SIDE EFFECT AND

OF ADMINISTRATION ROUTE OF EFFECT EFFECT REMEDIES

ACCORDING TO ADMINISTRATI

LITERATURE -ON GIVEN TO

CLIENT

26/12/ 09 quinine Adult; tablet quinine I.M quinine 300mg Antimalaria Destroys It CNS; vertigo, confusion,

600mg every 8 hours for 7 stat then 150mg malaria decreases headache, pallor,

days three times daily parasites the restlessness

Children; tablet quinine for 48 hours severity of GIT; abdominal cramps,

25mg 8 hours for 3-7 days pains in nausea, vomiting

Syrup quinine joints and SKIN; pruritus, rashes.

legs None of these were

observed

26/ 12/09 Phenobar- Adults; 60-250mg P.O. Intravenous Anticonvulsants To prevent It relieves Delirium, vertigo. Lethargy,

29
 bitone daily, in divided doses tid. Phenobarbitone seizures, patient diarrhoea, arthralgia,

Children; 1-6mg/kg P.O. 150mg stat tonic-clonic from myalgia, neuralgia,

daily, divided q 12 hours partial status seizures conjunctivitis, hypotension,

for total of 100mg; can be epilepticus, but no rhinitis. None of them

given once daily. insomnia, signs of observed.

hypnosis insomnia

26/ 12/09 Paraceta- Adult tablet paracetamol Suppository Non narcotic To reduce Pain and Acetaminophen toxicity

mol 250-500mg x 4-6 hourly paracetamol analgesics/antipyretic pyrexia and fever with early signs such as

Children; 2months (6mg 250mg bd x 7 pain reduced anorexia, nausea and

stat) 3 months to 1 year Then gradually. generalized weakness within

(60-120mg/kg body weight) Syrup paracetamol the first 12-24 hours. Later

1-5 years (120-250mg) 6- 250mg tds x 5 signs include vomiting, liver

12 years (250-500mg) function test elevated within

which is repeated 4-6 hourly 48-72 hours after ingestion.

and a maximum of 24 hours None of them observed.

26/ 12/09 IV fluid IV dextrose saline 1000mls IV dextrose saline Intarvenous infusion To replace Clients Fluid overload, phlebitis,

dextrose in 24 hours 1 litre stat lost calories hydration tissue necrosis and

30
 saline and hydrate level and hypovolaemia

client calories

maintaine

26/ 12/09 Chloram- Adults;50mg/kg/day per 375 qid x 48 hours Potent broad To kill Infection Blood disorders including

phenicol oral or intravenous in intravenous spectrum antibiotics bacteria and was reversible and irreversible

divided doses q 6 hours up to reduce treated in aplastic anaemia, peripheral

to 100mg/kg/day in severe infection client neuritis, optic neuritis,

cases headache, depression,

Child; 50-75mg/kg/day per nausea vomiting, stomatitis.

oral or intravenous in Client did not experience

divided doses q 6 hours any.

26/ 12/09 Benzly- 0.5-0.6mu/kg 0.4mu qid x 48 Antibiotics To destroy Infections Urticaria, fever, joint pains,

penicillin hours (IV) bacteria and treated as rashas, angioedema,

to combat evidenced haemolytic anaemia etc.non

infection by client observed.

31
 free from

the

infections

through

investigati

ons

29 /12/09 Gentamy- Adult; 3mg/kg/day in 3 IV gentamycin Antibiotics To treat Bacteria Ototoxicity and

cin equal doses 8 hours 80mg daily x 2 infections by killed nephrotoxicity, phlebitis,

intravenously or killing after numbness, diarrhoea.

intramuscularly bacteria administra Noneobserved.

Child; 2-2.5mg/kg/day 8 tion of

hours intravenously or the drug

intramuscularly.

29/ 12 09 Cefuro- IM or IV route IV cefuroxine Antibiotics Treatment of Infections Urticaria, pruritus interstitial

xime Infants and children; 30- 450mg tds x 5 infections treated as nephritis thrombophlebitis

100mg/kg/day in 3-4 identified toxic epidermal necrolysis.

divided doses organism Non of them observed

32
Adult; 750mg 3 times daily has been

eliminated

33
PATIENT/FAMILY STRENGTHS

Not withstanding the fact that Mr. Kamel weak and unconscious, the family was able to carry out

the following:

1. They could carry out oral hygiene and bed bath on him

2. They could feed him orally.

3. Patient’s parents took care of his emotional needs by visiting him regularly during his

admission and were also able to settle his bills and other drugs involved in his hospitalization

through the national health insurance scheme.

HEALTH PROBLEMS

The following health problems were identified through the assessment of Master Kazor Kamel.

 High body temperature (fever)

 Headache

 Vomiting

 Immobility

 Sleeplessness

 Thick secretion and increase mucus production

 Client and mother has little knowledge on disease condition

34
NURSING DIAGNOSIS

The following health problems were developed into nursing diagnosis as follows;

1. Alteration in body temperature (pyrexia) related to infection process.

2. Alteration in comfort (headache) to disease (cerebral malaria).

3. Fluid volume deficit (potential) related to vomiting

4. Ineffective airway clearance related to copious thick secretions and mucous.

5. Sleeping pattern disturbance (insomnia) related to restlessness.

6. Impaired physical mobility related to cerebral malaria.

7. Knowledge deficit related to the disease condition (cerebral malaria).

35
 CHAPTER THREE

PLANNING FOR PATIENT/ FAMILY CARE

Nursing care plan serve as a tool to determine the patient’s state of health and to outline

measures to care for a client.

NURSING OBJECTIVES

 Client will have normal body temperature within 2 hours

 Client will be relieved of headache within 2 hours.

 Client will maintain normal fluid volume throughout his period of hospitalization.

 Client will maintain nutritional status within 4 days.

 Client will sleep comfortable within 24 hours

 Client will breathe normally without distress within 24 hours.

 Client will improve in mobility within 8 days.

 Client’s mother will have adequate education about disease condition (cerebral malaria)

36
 TABLE FOUR: NURSING CARE PLAN FOR MASTER KAMEL KAZOR

DATE NURSING NURSING NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS OBJECTIVE/ ORDERS INTERVENTIONS AND

TIME OUTCOME TIME

CRITERIA

26/12/0 Alteration in Client will be 1. Reassure 1. Client and mother were reassured of 26/12/09 Goal fully met as

9 at body relieved of client and competent nurses caring for him and their at client verbalize

10:00 temperature pyrexia mother preparedness to offer him the necessary 1:00pm absence of fever.

Am (pyrexia (39.4oC-37.3oC) assistance. This was done to gain client

39.4oC) within 4 hours cooperation and relieve anxiety.

related to as evidenced by

infection 2. Sponge 2. Client was sponged down with tepid

process 1. Clinical down client water (30.5oC) and wet towels were applied

(cerebral thermometer in the groin, axilla and forehead. This was

malaria) recording changed frequently to reduce the fever

normal body

temperature.

37
2. Client 3. Check 3. Client’s temperature was checked every

verbalizing the client 15 minutes after sponging with tepid water.

absence of temperature This was done to reduce temperature.

fever. every 15

minutes

4. Keep light 4. Clients clothing was removed and top

clothing on sheet was lifted to facilitate ventilation

client

5. Ensure 5. Adequate ventilation was ensured by

adequate opening nearby windows and raising the

ventilation window curtains.

6. Serve cold 6. Client was served with cold drink

drinks (orange juice) to bring the temperature to

38
 normal

7. Serve 7. Paracetamol suppository was given per

prescribed rectum to reduce pyrexia and recorded

antipyretics

NURSING

OBJECTIVE/

39
 OUTCOME

DATE NURSING CRITERIA NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS ORDERS INTERVENTIONS AND

TIME
TIME

29/12/0 Alteration in Client will be 1. Reassure 1. Client and mother were reassured that, 29/12/09 Goal fully met as

9 at comfort to relieve of client and measures will be put in place to relieve him at client verbalized

9:00am (headache) headache mother of pain. This was done to relieve anxiety 11:00am he has no pain.

related to within 4 hours and gain client cooperation.

disease as evidenced by

condition 1. Client 2. Ensure 2. Complete bed rest was provided by

(cerebral verbalizing he complete bed putting patient in a warm comfortable bed

malaria) has no pain rest. and noise was minimized on ward

2. nurse

observing that 3. Apply cold 3. Wet towel was put on the client forehead,

client is relaxed compress on and changed intermittently to reduce the

his head headache.

4. Put client 4. Client was assisted to assume a

40
 in a comfortable position that will provide

comfortable comfort with the help of the mother.

position

5. Give 5. Paracetamol suppository 250mg was

prescribed given per rectum to reduce pain.

analgesics.

NURSING NURSING

DATE NURSING NURSING

41
 AND DIAGNOSIS OBJECTIVE/ ORDERS INTERVETNIONS DATE EVALUATION SIGNATURE

TIME OUTCOME AND

CRITERIA TIME

1/01/10 Fluid volume Client will 1. Reassure 1. Client and mother were reassured that 15/01/10 Goal fully met as

at deficit maintain client and measures are will be put place to relieve client had good

8:00 (potential) normal body mother him from vomiting skin turgor.

Am related to fluid volume

vomiting throughout his 2. Provide 2. Client was provided with vomit bowl.

period of vomit bowl All vomitus were examined for content,

hospitalization amount and no abnormalities were detected.

as evidenced by
3. Remove all 3. Nauseating items that will stimulate
client having
nauseating vomiting were removed from the ward.
good skin
items on the
turgor
ward.

42
 4. Monitor 4. Prescribed intravenous fluids (dextrose

intravenous saline 1L) was set up and regulated to the

fluid prescribed rate to rehydrate client and

accurately maintain his nutritional requirement.

DATE NURSING NURSING DATE EVALUATION SIGNATURE

AND OBJECTIVE/ AND

43
TIME DIAGNOSIS OUTCOME NURSING NURSING TIME

CRITERIA ORDERS INTERVENTIONS

2/01/10 Sleep pattern Client will 1. Reassure 1. Client and mother were reassured that 2/01/10 Goal fully met as

at disturbance sleep at least 2 client and measures are put in place to help him sleep at client verbalized

9:00 (insomnia) hours during mother soundly. 4:00 that he was able

Am related to the day, 7-9 Pm to sleep.

restlessness hours at night 2. Reduce 2. Shoes with noisy sole were restricted on

as evidenced by noise at the the ward. Television and radio set volumes

1). Client ward were lowered to reduce noise on ward.

verbalizing that

he is able to 3. Restrict 3. All visitors were encouraged to come at

sleep. visitors visiting time and they were restricted to

2). Nurse during resting visiting while client is sleeping

observing that and sleeping

client sleeps time

uninterrupted

44
throughout the

night. 4. Schedule 4. Medication and monitoring of vital signs

most nursing were done at a time to ensure minimum

activities interruption.

together.

5. Put on dim 5. Bedside light was dimmed as client

light at client prefers sleeping in dim light.

cubicle

6. Serve 6. Warm Milo was served to induce sleep.

warm Tea and coffee were avoided to prevent

beverage and stimulation which can alter sleep.

avoid serving

stimulant

food

45
 7. Ensure 7. Bed was made comfortable, by

comfortable straightening it regularly. Client was

bed supported with pillows to ensure comfort

NURSING

DATE NURSING OBJECTIVE/ NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS INTERVENTIONS AND

CRITERIA

46
TIME TIME

7/01/10 Ineffective Client will 1. Reassure 1. Client and mother were reassured that all 7/01/10 Goal fully met as

at airway breathe client and measures that would help him breathe at client verbalized

8:00am clearance normally mother effectively would be put in place 12:00pm he could breath

related to without distress without

2. Assess the 2. Respiratory rate and depth were assessed
copious thick within 4 hours difficulty.
respiratory and recorded
secretions and as evidenced by
rate and depth
mucous 1). Client

verbalizing that
3. Assist the 3. Client was placed in the upright position
he can breath
client to supported by two pillows to enhance lungs
without
assume a expansion and help in breathing
difficulty
comfortable
2). Nurses
position
observing that
4. Loosen all 4. Tight clothing was removed to ensure
client have
tight clothes. comfort of the client.
clear breathe

47
 sound

5. Suction 5. Client was suctioned frequently to get rid

client. of secretions.

6. Teach 6. Client was taught deep breathing

client deep exercises to enhance airway clearance.

breathing

exercises

DATEAND NURSING NURSING NURSING NURSING DATE EVALUATION SIGNATURE

48
 TIME DIAGNOSIS OBJECTIVE/ ORDERS INTERVENTIONS AND

OUTCOME TIME

CRITERIA

9/01/10 at Impaired Patient will be 1. Reassure client 1. Client and mother were reassured 15/01/10 Goal fully met as

8:00am physical able to move, and mother. that, measures will be put in place to at client is able to

mobility walk and ensure movement of client. 8:00am move freely.

related to exercise the

cerebral body within 6 2. Assist client to 2. Client was assisted to move and

malaria days as move and change changed his position to a more

evidenced by ; to a more comfortable position.

comfortable

a. Client that position.

he is able to

move about 3. Change position 3. Client position was changed

freely. frequently. frequently to prevent him from

b. As developing pressure sores.

verbalized by

49
mother that

mobility has 4. Treat pressure 4. Pressure areas such as the

improved. areas and give buttocks, back, elbow etc were

back rub. treated to prevent ulcer at the bony

prominences.

5. Invite 5. Physiotherapist was invited to

physiotherapist to help client to move various body

do partial range of joints.

motion exercise on

the joint

50
DATE NURSING NURSING NURSING NURSING DATE EVALUATION SIGNATURE

AND DIAGNOSIS OBJECTIVE/ ORDERS INTERVENTIONS AND

TIME OUTCOME TIME

CRITERIA

51
14/01/10 at Knowledge Client mother 1. Reassure client 1. Client and mother were reassured 14/01/10 Goal fully met

9:00 deficit will be able and mother to allay by explaining procedures and telling at as the mother

am related to to answer their fears. them that, cerebral malaria had a good 12:00 identified the

the disease questions prognosis if detected early and treated. pm signs and

condition asked about symptoms of the

2. Provide privacy 2. Privacy was ensured and the mother
(cerebral the disease disease
offered a chair at the bedside.
malaria) condition condition.

within 24
3. Assess the level 3. The mother was allowed to ask
hours as
of the mother’s questions. All misconceptions were
evidenced by
knowledge on the corrected.
the mother
condition.
identifying

the signs and

4. Explain the 4. The causes, signs and symptoms,
symptoms of
condition to treatment and the need for follow up
the disease
mother. care were explained to the mother.
condition

52
5. Allow mother to 5. The mother was allowed to give

give feedback on feedback on what she has learnt from

whatever she has the education given.

learn

53
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT/FAMILY CARE PLAN

Implementation means the process of carrying out all the plans to meet client’s needs. It is the

fourth step in the nursing process. The purpose of the implementation is to ensure direct nursing

care, is delivered to the client in the most professionally and humanly beneficial way using the

care as a guide.

SUMMARY OF THE ACTUAL NURSING CARE

The nursing management of Master Kamel Kazor started on the day of admission, which was

the26th December, 2009 at 9:30 am to the time of discharge on the 15th January, 2010 until the

care was terminated.

The nursing care given throughout his stay at the children’s ward B5 was aimed at meeting the

client’s psychologically, physiological and spiritual needs.

FIRST WEEK OF ADMISSION (26th DECEMBER, 2009 – 1st JANUARY, 2010)

Master Kamel Kazor was brought to the children’s medical ward B 4 of Komfo Anokye

Teaching Hospital from Paediatric Emergency Unit on the 26th December, 2009.

Client was immediately put in bed, and because of the pyrexia, tepid sponging was done to help

stabilize the temperature to normal.

A tray was set and the doctor took blood sample for laboratory investigations like blood for

group and cross-matching, haemoglobin estimation, malaria parasite, full blood count and

packed cell volume. The vital signs were taken and recorded as follows:

54
  Temperature : 39.4 °C

 Pulse : 112 beat per minute

 Respiration : 36 cycle per minute

 The weight of the patient was also taken as, 10.9 kilogram.

The client was put on the following treatment (IM) Quinine 300mg stat then 150mg tid x 48

hours, intravenous dextrose saline 1 Litre stat, intravenous chloramphenicol 375 qid x 48 hours,

intravenous crystalline penicillin 0.4 mu qid x48 hours and suppository paracetamol 250mg bd

x 7. Drugs were served accordingly, and documented.

Client was tepid sponged due to the pyrexia he was having. Near by windows were also opened

to aid in fresh air entering the room to reduce client’s temperature. The vital signs were

monitored every two hourly. The prescribed drug paracetamol were served to decrease the pain

and reduce the high body temperature, and heavy clothing’s were removed.

Client and mother were assured that measures have been put in place to bring down the

temperature to normal. Client and mother were educated on the prevention and treatment of the

condition. The questions that she asked were answered accurately.

In the afternoon, prescribed drugs were served accordingly and documented in the nurse’s notes.

Intravenous line that was set was monitored for, swollen site, redness of area, kinking of the

infusion line and the rate of flow.

55
In the evening, client was given a warm bed bath and was served with rice and soup. His vital

signs were checked and recorded, after that; prescribed drugs were served and documented. At

about 7:30 pm client was found asleep.

On the 29th December, 2009, client was given routine care such as oral care with tooth brush and

tooth paste, bathed with warm water. During ward rounds in the morning, the doctor requested

that client should continue with treatment and drugs such as intravenous gentamycin 80mg daily

x 2 and cefuroxime 450mg tds x 5 were prescribed. The prescribed drugs were served. On that

day, client complained of headache on the morning. Client mother was assured that measures

would be implemented to relieve her son from headache. Wet towel was put on the client

forehead and changed intermittently to reduce the headache.

Client was also assisted to assume a position that will provide comfort. Prescribed analgesics

like paracetamol was given and complete bed rest ensured. Vital signs checked and recorded as;

Temperature _ 36.8oC

Pulse _ 110 beats per minute

Respiration _ 34 cycle per minute

At about 8:00pm, client was asleep.

On the 1st January, 2010, during the first week of admission, client was given the routine

nursing care. During ward rounds in the morning, the doctor requested that client should

continue with treatment. The prescribed drugs were served. On this day, my client mother

complained that client has vomited once early this morning. Client’s mother was reassured that

measures are put in place to relieve him from vomiting. Client was provided with vomit bowl.

56
All vomitus were examined for content, amount and no abnormalities detected. Nauseating

items that will stimulate vomiting were moved from the ward. The doctor was notified and

prescribed intravenous fluid (dextrose saline 1L) and this was set up and regulated to the

prescribed rate to rehydrate client and maintain his nutritional requirements.

In the afternoon, I observed that client’s condition was improving and no complains was made.

In the evening, client ate his meal served after his vital signs were taken and prescribed drugs

served and documented.

Temperature - 36.7oC

Pulse - 112 beats per minute

Respiration - 30 cycles per minute

Client was made comfortable in bed. At about 7:30pm, client was asleep when I was leaving the

ward.

SECOND WEEK OF ADMISSION (2ND – 7TH JANUARY, 2010)

On the second week of admission, 2nd January, 2010, client was given routine nursing care such

as oral care with toothbrush and toothpaste, bathed with warm water. During the ward rounds,

the doctor asked to continue treatment. The prescribed drugs served and documented. Client’s

mother complained of his son’s inability to sleep during the day and night. Client and mother

were assured that measures will be put in place to help him sleep soundly. Noise was reduced

on the ward as shoes with noisy soles were restricted and television and radio set volume were

lowered. Visitors were restricted and encouraged to come at visiting time.

57
Most nursing activities were scheduled together to ensure minimum interruption. Bedside light

was dimmed and warm Milo served to induce sleep. Comfortable bed was ensured by

straightening it regularly. In the evening, client ate all meal served after vital sign has been

checked and recorded.

Temperature - 36.9oC

Pulse - 116 beats per minute

Respiration - 35 cycles per minute

Client was asleep at 8:00pm when I left the ward.

On the 7th January, 2010, client’s mother complains of her son breathing with difficulty. Client

was assessed and it was found out that, there were thick secretions and mucous in the throat.

Patient was put in a comfortable position and suctioned until he was able to breath without

difficulty. He was taught deep breathing exercise to enhance airway clearance. In the afternoon,

client was served lunch and prescribed medications was given. Vital signs was checked and

recorded after client has finished eating his super.

Temperature - 36.7oC

Pulse - 120 beats per minute

Respiration - 30 cycles per minute

Client was made comfortable in bed as he was deeply asleep in the evening when I was leaving

the ward.

58
THIRD WEEK OF ADMISSION (9TH – 15TH JANUARY, 2010)

On the third week of admission, Master Kamel Kazor was looking better but was not able to

walk properly. During ward rounds, client condition appeared improved and the doctor declared

his intervention to discharge him as soon as he walks without any difficulty. The mother was

reassured that, measures will be put in place to ensure movement of her son. Client was assisted

to move and change position to his comfort position. Client position changed frequently to

prevent him from developing pressure sores.

The physiotherapist was invited to help client to move various body joints everyday until client

was able to walk on the 14th January, 2010. The doctor declared his intention to discharge him

the next day. Parents were informed pre-assessment was carried out to know the amount to be

paid. In the afternoon, client bed was straightened regularly to ensure comfort. He was served

with rice and tomato stew with fish as his lunch. His medications were served and documented

and all vital signs checked and recorded in the nurses notes as;

Temperature - 36.4oC

Pulse - 108 beats per minute

Respiration - 32 cycles per minute

In the evening, he was given an assisted bathroom bath and all medications were served and

documented. Client ate at the meal served for supper. He was sleeping at the time I was leaving

the ward at 8:30pm.

On the 15th January, 2010, my client was discharged. In the morning, he was given warm bath to

improve his personal hygiene and mouth care was done to improve client’s appetite for food.

59
The vital signs were checked, and recorded as;

Temperature - 37.0oC

Pulse - 109 beats per minute

Respiration - 34 cycles per minute

During the general ward rounds, client was examined thoroughly and discharged. The mother

was educated on the causes, signs and symptoms, prevention, treatment and management of

cerebral malaria because she has little knowledge about the condition. All misconception about

her son’s condition was corrected and accurate information provided.

The mother was informed to come for review on the 22nd of January 2010 at consulting room 1.

The need to adhere to drug regimen, come for review, report any identified health problems

even before the review date were explained to mother.

Client’s admission bills were covered by the national health insurance so they paid no amount.

At the ward, client and family were assisted to pack his belongings with the help of the mother.

When everything was in order, client’s mother thanked the health care givers on the ward.

Before the departure, client and relatives were reminded by the Nurse-in-charge, to honour the

appointment that has been made with him to come for review. I accompanied them to their

house and when we reached the house, other relatives in the house welcomed us. After about an

hour, I sought permission to leave for school.

60
PREPARATION OF PATIENT/FAMILY TOWARDS DISCHARGE

The preparation of my client and family towards discharge started on the day of admission with

the aim of helping client and family to take part in the care. It was also to make them aware of

the condition and how best, it can be controlled.

The day of client’s discharge, client and family, were taught the causes, signs and symptoms,

treatment and management of cerebral malaria. They were also advised to stop throwing

rubbish indiscriminately and to desist choked gutters in their vicinity that serve as a breeding

grounds for mosquitoes.

On client’s personal hygiene, the mother of the child was taught to bath and take proper care of

her son’s body.

Again, a nutritionist was called to teach client mother and her family about the type of food he

should eat. They were advised to combine drugs and diet effectively to client.

Client’s name was written into the admission and discharge book as well as the daily ward state.

Again client and mother were reminded to abide by the advises given to her for the child. She

was assisted to pack her belongings and dressed client nicely. Kamel and mother were

accompanied to Asuofua where they stay

Before accompanying them, the bed linen was sent to the laundry, whilst the mattress and

pillow were sent outside for airing. The bed stead and locker were cleaned with disinfectant

(Parazone 1:10).

61
FOLLOW UP/ HOME VISIT/CONTINUITY OF CARE

Home visit is a purposeful visit to the home of clients with the aim to find out their actual and

potential health problems at home. It is also to assess the use of available resources at the home

as well as in the community to maintain good health.

FIRST HOME VISIT

The first home visit was made whilst client was on admission, this was on the 28th December,

2009. On this day client’s father was accompanied to his house. The house is situated at

Asuofua a suburb of Kumasi. The visit was to help me know much about client’s habitat and to

know the prevailing environmental conditions. An inspection was made, and it was realized

that the compound was neat but the road linking to the house was very dusty and the gutters

were choked with huge and heaps of rubbish and stagnant water.

The father’s brother and sister who have visited them were very happy to see me and we

discussed issues concerning Kamel’s condition. Client’s father took me round the house to

enable me know much about the surroundings.

The house has its own toilet and bathrooms. The rooms were ventilated and there were no

mosquito-proof fitting doors and windows. They have access to good pipe borne water and

electricity. County Hospital is the nearest health facility to the family.

After staying and educating the family on environmental hygiene, I asked permission to leave

and I informed them that when client is discharged, I will visit them again.

62
SECOND HOME VISIT

The second home visit was on the 15th of January, 2010 on the day client was discharged.

Kamel Kazor and mother were accompanied home. On our way, I realized that, the gutters

were cleaned. We reached the house at 1:00 pm and we were warmly welcomed to the house by

the other members of the family.

I was offered a seat and communication begun through which more education was given to the

family about the need to administer the drug according to the prescription given and how to

prevent the condition from re-occurring. I made them aware that, care will be terminated and

handed over to a public health nurse within their vicinity on my next visit.

I took leave of them to go back to school with a promise to come back. I also reminded them of

the review date and its importance.

REVIEW OF PATIENT

The mother and patient came early as 8:00am on the 22nd of January, 2010 that was Friday, for

review. Folders of my patient was made available and made comfortable in a seat, before the

doctor. Upon thoroughly head to toe physical examination on the patient, no abnormality was

seen. The patient was sent to the haemotology laboratory for further laboratory investigation

with a requested laboratory form.

The doctor requested for haemoglobin estimation and malaria parasite in the blood. The result

was normal and no malaria parasite was present whiles haemoglobin level was 12gldl which

was within normal range; 12-18g/dl for males. The Doctor thanks the patient’s mother for the

63
proper care given or adherent to the advice and encouraged the mother to take very good care of

Kamel.

I accompanied them to the taxi station and went away at exactly 2:00pm after saying goodbye to

them.

THIRD HOME VISIT

The third home visit was on the 26th January, 2010. This visit was honoured, after client came

for review at the appointed date, 22nd January 2010. I arrived at the house at about 3:45 pm and

met client and other kids playing around. When they were questioned about the drugs

administration, I was told that he has been taking them as prescribed with the help of the mother

and sometimes father.

Client’s condition had improved very much and no complaints were presented. Client, mother

and relatives were educated about the need for them to give a well balanced diet to client and

also to keep the environment clean from mosquitoes, flies and choked gutters with stagnant

water. Emphasis was laid on the already education given. Client was officially introduced to the

Public Heath Nurse at County hospital who organizes child welfare clinics at Asuofua and was

already aware of child’s condition, to continue the special visits to the child’s home.

After a while, I asked for permission to leave. I bade them good bye and left for school.

64
 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

This phase involves critical consideration of how successful one was in terms of outcome of the

nursing orders given and the interventions carried out and meeting the set goals. Where

necessary, further investigations are done especially where goals are not met. This could be due

to wrong assessment, wrong orders given, inadequate intervention or limited time allowed to the

nursing diagnosis.

STATEMENT OF EVALUATION

With good nursing management, the objectives set were fully met and the health condition of

client improved tremendously.

On 26th December, 2010, client had pyrexia (39.4 °C). Goal was set to relieve client from

pyrexia. Nursing measures such as sponging client with tepid water (30.5), keeping light

clothing on client, serving of cold drinks (orange juice), and ensuring adequate ventilation were

carried out. Goal was fully achieved as client’s temperature dropped to 37.3oC.

On 29th December, 2009, at around 11:00 am client experienced headache. The objective set was

to relieve client of headache within 4 hours. Nursing measures such as complete bed rest,

application of cold compress on his head, putting him in a comfortable position and

administration of prescribed analgesics were carried out. Goal was fully met as client verbalized

he has no pain.

65
On the 1st January, 2010, client vomited. Goal set was to maintain normal fluid volume

throughout his period of hospitalization. Nursing measures such as providing vomit bowl,

removing all nauseating items from the ward, and monitoring of intravenous fluid were carried

on client. Goal was fully met as client had good skin turgor.

On 2nd of January, 2010, client complained of insomnia. The objective set was to help client to

have 2 hours sleep during the day and 7 – 9 hours at night. Nursing measures such as reduction

of noise at the ward, restriction of visitors, putting on dim light and serving of warm beverage

(Milo) were done for client. Goal was fully met as client verbalized that he was able to sleep.

On the 7th January, 2010, client presented with difficulty in breathing. The objective was to help

client breath normally without distress. Nursing interventions such as assisting client to assume

a comfortable position, loosening of all tight clothing’s, suctioning of client and teaching client

deep breathing exercises. Goal was fully met as client verbalized he could breath without

difficulty.

On the 9th January, 2010, client was not able to walk. The objective set was to help client to

move, walk and exercise the body within 6 days. Nursing measures such as assisting client to

move and change to a more comfortable position, treating pressure areas, changing position

frequently and inviting the physiotherapist to do partial range of motion exercises were carried

out. Goal was fully met as client was able to move freely.

On 15th of January 2010, client’s mother had little knowledge on the disease condition. The

objective set was to help client’s mother gain knowledge about the disease condition within 24

hours. Nursing measures such as assessing the level of the mother’s knowledge on the

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condition, explaining the condition and allowing her to give feedback on whatever she has

learned was carried out. Goal was fully met as the mother identified the signs and symptoms of

the disease condition.

AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET AND UNMET

OUTCOME CRITERIA

During client’s stay on the ward, effective and good nursing intervention coupled with the co-

operation and assistance from client, mother and family enabled all the goals set to be achieved.

Therefore no amendment was to be made.

TERMINATION OF CARE

Termination is the last phase of nurse-patient relationship. This activity is a very difficult step

to take after a good inter-personal relationship has been established between the nurse and the

patient, for this reason, the reality of the separation has to be explained on the first day of

admission.

Client and family were made to understand that hospitalization of client was temporal since he

could be discharge to go home after his condition had improved. The preparation for discharge

started on the day of admission until the day of discharge.

Interaction with Master Kamel Kazor and his family started from the day of admission, which

was 26th December, 2009and with good nursing management, client condition improved and

was discharged on the 15th January, 2010. Home visits were made on different occasions to the

client’s home to see how far he was progressing with the care given during admission. Series of

health education such as good personal and environmental hygiene, to take a well balanced diet,
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take prescribed drugs were given during such visits. He was finally handed over to the public

health nurse at County hospital at Asuofua.

SUMMARY OF CARE RENDERED TO PATIENT AND FAMILY

The care of client, Master Kamel Kazor started on 26th December, 2009. He was admitted with

the diagnosis of cerebral malaria. An effective nursing care was given to client.

Client health problems were identified, and goals and objectives were set to help solve the

problems. The health problems identified included pyrexia, headache, vomiting, immobility,

sleeplessness, thick secretions and increase mucus production and knowledge deficit. Client

was put on the following drugs; Intramuscular Quinine 300 mg stat then 150 mg three times

daily for 48 hours; syrup paracetamol 5 mls tds x 5, intravenous fluid dextrose saline 10%, 1L

stat, suppository paracetamol 250 mg bd x 7

All goals and objectives set to resolve identified health problems were fully met, due to good

and effective nursing care rendered to client. He was subsequently discharge on the 15th

January, 2010 and was reminded of the need to complete his treatment regimen and to maintain

personal hygiene and also the need for review. Client was visited during admission,

hospitalization and also after discharge. Observations were made during the home visit and

education was given to client and family members. He was handed over to a public health nurse

at the County Hospital at Asuofua and asked to continue care at the same place.

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CONCLUSION

The patient and family care study has helped me to obtain good insight about the disease

malaria. It has also helped me to understand comprehensive nursing care that has to be given to

individual patients.

The study has equally helped me to put the knowledge I have acquired from the three year

nursing programme into practice.

It has again, made me establish better interpersonal relationship with clients and his family and

the extent at which such relationship can enhance the recovery of my client.

Finally, I recommend that every student should endeavour to put the nursing process concept

into practice for it enables quality nursing care to be rendered to all clients, to enhance recovery.

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 BIBLIOGRAPHY

Boakye – Yiadom, R. (2007), Medical Nursing, 2nd Edition, Ghana: Richtech Print.

Pp 55-63.

Karch, Amy M. (2005), Lippincott’s Nursing Drug Guide, 4th Edition. Philadelphia: A

Wolter Kluwer Company. Pp 275, 276, 570-572, 947

Ministry of Health Ghana National Drugs Programme (G.N.D.P. 2004), Standard

Treatment Guidelines, 5th Edition, Accra-Ghana: Justice Press Limited. Pp 371 – 376.

Pp 55 – 63.

Smeltzer, S .C, and Bare, B. G. (2007) Brunner and Saddarth’s Textbook of Medical –

Surgical Nursing, 11th Edition, Philadelphia, J. B Lippincott Company. Pp 2129 –

2135

Waller, F .B (2001), Bailliere’s Nurses Dictionary. 23rd Edition. London: Bailliere’s

Tindal. Pp 67, 120.

Watson, J .E. (1972), Medical Surgical Nursing and Related Physiology. 4th Edition,

London: Churchill Livingstone Limited. Pp 1013-1017.

SIGNATORIES
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1. NAME OF CANDIDATE :…………………………………………….. …….

SIGNATURE :……………………………………………………

DATE :……………………………………………………

2. NAME OF WARD-IN-CHARGE :…………………………………………................

SIGNATURE :…………………………………………………….

DATE :……………………………………………………

3. NAME OF SUPERVISOR :……………………….............................................

SIGNATURE :……………………………………………………

DATE :……………………………………………………

4. NAME OF PRINCIPAL :…………………………………………………….

SIGNATURE :…………………………………………………….

DATE :…………………………………………………….

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