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Correction Eric Kyere Ofosu_035754 a-1
Correction Eric Kyere Ofosu_035754 a-1
Correction Eric Kyere Ofosu_035754 a-1
BY
ID:( 41203120)
December 2023
i
PATIENT AND FAMILY CARE STUDY ON
WRITTEN BY:
(ID: 41203120)
SUBMITTED TO:
ACCRA- GHANA
December, 2023
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PREFACE
The patient and family care study is one of the tools used to assess a final year student for the
award of Registered General Nursing Certificate by the Nursing and Midwifery Council of
Ghana. The study helps the student nurse to combine classroom knowledge and clinical
experience in rendering nursing care to a patient from time of admission to the time of
The care study has therefore been written using the nursing process approach and offers the
student the opportunity to do much research into the causes, clinical manifestations,
diagnosis, complications, treatment and the prevention of congestive cardiac failure. The
study is also carried out to help the student nurse build a good relationship with patient and
family as well as the health team so as to meet the health needs of the patient. It affords the
student nurse the opportunity to put his broad theoretical knowledge acquired from the
The study also permits the student nurse to make follow-up visits to the patient’s community
to take a first hand and assessment of patient’s home and its surroundings. This helps in
establishing the possible cause of patient’s ill-health, state and it’s eventually to prevent
relapse of the condition through health education and recommendations as the cause may be.
It is recommended for final year students to carry out this study as an assessment tool to
determine student efficiency and theoretical as well as practical capabilities. The best practice
of nursing in its ethics entreats the practice of confidentiality. For confidentiality, the patient
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ACKNOWLEDGEMENT
I want to sincerely thank the Almighty God for providing me with the knowledge, insight,
courage, and understanding I needed to do this work effectively. May God exalt his name.
I would especially like to express my gratitude to my patient Mr. K.F. and his family for
their understanding and full cooperation during our therapy session. My sincere
appreciation also goes out to my parents for their financial and emotional assistance with
this work.
I would also like to thank the entire KAAF University College staff, particularly my supervisor,
Mrs. Delphina Abbey, who was able to read through the document with care and make the
My effort would be incomplete if I did not acknowledge the health team of the male medical
ward at Korle-Bu Teaching Hospital for their words of encouragement and support during this
investigation.
Finally, I would like to thank the writers and publishers of the textbooks used in this script.
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INTRODUCTION
A patient care study is a written document on the care rendered to a particular patient and the
family from the time of admission till he/she attains and maintains good health. The care
study uses the nursing process which is a modified scientific method anchored on assessment,
nursing diagnosis, planning, implementation and evaluation. Using the nursing process in the
care of the patient, an emphasis was placed on the health promotion, maintenance and
This patient care study is an account of effective nursing care rendered to Mr. K.F., a 61-
year-old man with the diagnosis of congestive cardiac failure was admitted into the male
medical ward of Korle-Bu Teaching Hospital through the male medical ward on the 5 th of
December, 2023. To render comprehensive care, the assessment was done and problems were
identified. These were resolved using the care plan. The nursing interventions range from
checking vital signs, ensuring proper ventilation, serving of nutritious diet, ensuring personal
hygiene and serving prescribed medications. The patient was hospitalized for five (5) days
and was discharged on the 10th of December, 2023 with much improvement in his condition.
One pre-discharge visit and two follow-up visits were made to the patient’s home to assess
his environment, identify predisposing factors of the patient’s condition, educate the patient’s
family on the condition, know how the patient is fairing and the right education given to
patient and family and to also ensure continuity of care. The patient was reviewed on
20/12/2023 which was scheduled by the doctor. This review was to assess the progression in
health or otherwise. Upon the review assessment, he was declared fit to go back home and
This script has been carefully organized into five chapters; chapter one covers the assessment
of the patient and family. Chapter two deals with data analysis, chapter three embraces the
nursing care plan instituted on the patient, chapter four consists of actual nursing care and
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preparation
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of patient and family towards discharge. Chapter five covers evaluation, termination of care,
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TABLE OF CONTENT
PREFACE.................................................................................................................................................i
ACKNOWLEDGEMENT.......................................................................................................................ii
INTRODUCTION..................................................................................................................................iii
TABLE OF CONTENT...........................................................................................................................v
CHAPTER ONE......................................................................................................................................1
1.0 ASSESSMENT OF PATIENT AND FAMILY.................................................................................1
CHAPTER TWO...................................................................................................................................16
2.0 ANALYSIS OF DATA...................................................................................................................16
2.1 COMPARISON OF DATA WITH STANDARDS.........................................................................16
2.2 CAUSE OF PATIENT’S ILLNESS................................................................................................18
2.3 PATIENT’S SPECIFIC TREATMENT..........................................................................................19
2.4 COMPLICATIONS.........................................................................................................................23
2.5 PATIENT HEALTH PROBLEMS..................................................................................................23
2.6 SPECIFIC STRENGTH..................................................................................................................23
2.7 GENERAL STRENGTH.................................................................................................................23
2.8 NURSING DIAGNOSES................................................................................................................24
CHAPTER THREE...............................................................................................................................25
CHAPTER FOUR..................................................................................................................................33
4.1 IMPLEMENENTATION CARE RENDERED TO PATIENT/FAMILY CARE PLAN...............33
4.2 SUMMARY OF ACTUAL NURSING CARE...............................................................................33
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4.3 PREPARATION OF PATIENT/FAMILY FOR DISCHARGE/REHABILITATION..................37
4.4 FOLLOW UPS/ HOME VISITS/CONTINUITY OF CARE..........................................................38
CHAPTER FIVE...................................................................................................................................41
5.0 EVALUTION OF CARE RENDERED TO PATIENT AND FAMILY........................................41
5.1 STATEMENT OF EVALUATION.................................................................................................41
5.2 AMENDMENT OF NURSING CARE...........................................................................................42
5.3 TERMINATION OF CARE............................................................................................................43
5.4 SUMMARY.....................................................................................................................................43
5.5 CONCLUSION................................................................................................................................43
5.6 RECOMMENDATIONS.................................................................................................................44
Bibliography..........................................................................................................................................45
Signatories.............................................................................................................................................46
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LIST OF TABLES
vi
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CHAPTER ONE
database. It includes the family history of illness, history of past illness, health history,
psychological history, signs and symptoms and the care goal of the patient.
The data was collected from the patient, his relatives through communication and by
establishing a nurse-client relationship, and physical examination of the client, laboratory and
Mr. K.F is a 61-year-old guy who was born on September 10, 1962, to Mr. E.F and Madam
S.M (both deceased) in Agogo, the capital of Asante Akim North District. He is an Asante by
tribe and comes from Agogo. He speaks both Twi and English. He has a dark complexion,
weighs approximately 65 kilograms, and is about 152 centimeters tall. He currently resides in
Accra at the Abeka Adom junction at house number A453, a suburb of Accra metropolis.
He is married to Madam D.A. and has seven children: four males and three females. Mr. K.F.
is an educated, retired government worker who practices Christianity. His first daughter, age
According to Mr. K.F, there has not been a history of hereditary disease such as
hypertension, diabetes, and sickle cell disease in the family. However, his family members do
sometimes suffer from minor ailment such as abdominal pains, common cold, headache and
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minor injuries sustained in the course of their activities which they treat by purchasing over
Patient has seven children consisting of four males and three females. Six of the children are
married and are staying with their partners. Mr. K.F. is a retired civil servant, his pension pay
is their main source of livelihood for his nuclear family derived their daily bread. They are
living in their own house. He is able to provide the family with their basic needs.
Patient learnt from his mother that; he was born at home through spontaneous vaginal
delivery under the supervision of a Traditional Birth Attendant at Agogo in the Asante region
of Ghana. He is the first born of Mr. E.F. and Madam S.M. He was breastfed from the
day of delivery to the ninth month, with the introduction of weaning foods after six months
and was immunized against the six-killer disease. According to my patient, he does not know
when he started sitting unaided; crawling and walking but his mother told him he was one of
the most active children among his age mates. He started schooling in 1968 when he was six
years at Asenkyem D/A basic school and completed university at age 35. He was employed
into the civil service of Ghana. While perusing his education he also ventured into farming at
the age of 20 to support his parents in funding his education. Mr. K.F. also got married at the
age of 26.
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1.5 PATIENT’S LIFESTYLE/ HOBBIES
Mr. K.F goes to bed between the hours of 8:00pm-9:00pm and wakes up at 5:00am every
morning to say his morning prayers and take a morning walk. He then brushes his teeth, takes
his bath, eats breakfast and then goes to the news stand to read and sit for some time. Fufu
and groundnut soup is his favorite food. He takes breakfast around 7:00am, lunch at 12noon
and supper at 5:00pm. Patient is currently on retirement and does not like attending social
activities like wedding ceremonies but loves to read and listen to radio. He takes in alcohol
(Beer) and used to be a smoker but has now stopped smoking for the past years. He goes to
toilet twice a day but passes urine as many times as possible depending on the quantity of
Upon discussions, he said that he has never suffered from any serious illness until some
months ago, when he started feeling symptoms of fatigue, restlessness and pains in the
chest. It was then that he was diagnosed as having congestive cardiac failure at Korle-Bu
Teaching Hospital.
Patient was well until on the 30th November, 2023 he started experiencing heart pains,
coughing, tiredness and severe headache. According to him, he took tablet paracetamol for
three days and he could not bear the pain any longer so he was rushed to the emergency ward
of the Korle-Bu Teaching Hospital where he was diagnosed of Congestive Cardiac Failure
and then sent to the male medical unit for further treatment of his condition.
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1.8 ADMISSION OF PATIENT
On Tuesday, the 5th of December, 2023 at 11:00am, Mr. K.F. was admitted through the
Accident and Emergency unit of Korle- Bu Teaching Hospital by doctor J.A with the history
of coughing, breathlessness, headache and chest pain for three days. He was diagnosed as
having congestive cardiac failure. He was immediately put into a well laid bed and then
transferred to the male medical ward for further treatment. A nurse at Accident and
Emergency unit pre-informs the nurse in charge at the male medical ward of the patient’s
condition. An admission bed was prepared (cardiac bed) in readiness for his arrival. Later,
patient was brought into the ward in a wheel chair by the nurse at Accident and Emergency
unit accompanied by patient’s daughter, sister F.Z. They were warmly welcomed and patient
folder taken from the accompanying nurse. Patient was then put into the cardiac bed prepared
for him.
Temperature 36.00c
Pulse 107bpm
Respiration 26cpm
Weight 58kg.
1) Chest X-ray
2) Electrocardiogram
6) Sickling test
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He was put on the following treatments as prescribed:
All drugs were collected and administered as prescribed. Patient was reassured and made
comfortable in bed. Patient’s daughter was also informed of visiting hours as 4:00- 5:30am
and 4:00- 5:30pm daily and was asked to go and bring patient’s toiletries and other items
needed. Other hospital protocols were outlined to her. Patient was oriented to the ward later
when his condition was stable. It was during the admission process that I used the opportunity
to throw more light on my intention to involve patient and the rest of the family in my care
study which they agreed. Patients’ particulars such as his full name, age, sex, religion, date of
birth, address, and diagnosis were entered into the admission and discharge book.
Mr. K.F. does not attribute the cause of his illness to any evil spirits but believes his illness
came as a surprise to him. He believes that once he is in the hospital, he will be fine by the
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1.10 LITERATURE REVIEW
DEFINITION:
Congestive cardiac failure can be defined as an insufficient cardiac output to meet the
metabolic demands or needs of the body. The term congestive cardiac failure is most
commonly used when referring to both left sided and right sided heart failure. (Wash, 2002)
universityhealthnews.com
INCIDENCE
Globally, heart failure affects 1% of people aged 50 years, about 55 of those aged 75 years
and 25% of those aged 85 years or older. In U.S.A, near to 5million people have heart
failure, it is responsible for one million hospital admissions and 50000 deaths annually
(American Heart Association, 2007). The condition is more common among African
Americans than whites. The rate of death from heart failure is about 10% after 1year. About
half of those with congestive heart failure die within five years after diagnosis
(Smelter,&Bare,2018)
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AETIOLOGY OR CAUSE
According to Smelter, and Bare, (2010); congestive heart failure can result from any clinical
situation that alters the myocardial performance. They include the following:
mitral stenosis)
hemochromatosis)
Congestive heart failure may also occur in the presence of the following lifestyle habits:
1. Unhealthy habits such as smoking and excessive use of alcohol are often to blame.
2. Obesity and lack of activity may contribute to congestive cardiac failure, either
PATHOPHYSIOLOGY
Congestive cardiac failure manifests as organ hyper fusion and inadequate reserve as well as
including increased left ventricular volume and mass (hypertrophy). The myocardium
increased
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systemic vascular resistance secondary to enhanced activity of the sympathetic nervous
system and elevated levels of circulating catecholamine, the heart rate increases in order to
raise the cardiac output to meet the demands of the body. The renin–angiotensin mechanism
where renin is released from the cardiac output and anaerobic metabolism, when the cells get
little oxygen, metabolism decreases and there are alterations in the methods of energy
production in the body. This leads to production of adenosine triphosphate which causes
When all compensatory mechanisms then reach their critical levels, they begin to fail. The
right ventricle fails to function properly, the right atrium becomes distended and this leads to
stasis in the venous system. The pressure in the inferior and the superior vena cava increases.
The veins in the neck are distended, the liver become engorged, the legs become edematous
. The left side heart fails when blood returns to the left side of the heart more quickly than the
left ventricle can pump out, it leads to decrease stroke volume hence decrease in cardiac
output and also increase in left ventricular diastolic pressure and left atrium, then increase in
pressure of the pulmonary veins and capillaries. Some fluid will leak out causing edema of
the lungs and also pulmonary hypertension (Smelter, & Bare, 2018).
8
universityhealthnews.com
According to Smelter, and Bare, (2018), Heart failure can be described or classified in
several ways:
1. Left sided Failure: There is a reduction in the left ventricular output and/or an increase in
2. Right sided Failure: There is a reduction in right ventricular output for any given right atrial
pressure. Causes of isolated right heart failure include chronic lung disease (Cor-pulmonale).
3. Congestive heart failure (Involving both sides): Failure of the left and right heart may
develop because the disease process (e.g. dilated Cardiomyopathy or ischemic heart disease)
affects both ventricles or because disease of atrial pressure, pulmonary hypertension and
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CLASSIFICATION BASED ON THE SYMPTOMATOLOGY BY
According to Smelter, and Bare, (2010), the classifications based on the symptomatology by
1. NYHA I: Heart disease present but no undue breathlessness from ordinary activity.
3. NYHA III: Less than ordinary activity causes breathlessness, which is limiting
CLINICAL MANIFESTATIONS
According to Smelter, and Bare, (2018), the clinical manifestations of congestive heart failure
are:
2. Fatigue
3. Orthopnea
5. Dizziness
6. Pallor
7. Anxiety
8. Headache
9. Fever
11. There may be evidence of pleural effusion (especially on the right side)
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COMPLICATION OF CONGESTIVE CARDIAC FAILURE
According to Smelter, and Bare, (2018), the complications in congestive cardiac failure are as
follows:
1. Myocardial infarction
2. Cardiac arrhythmia
3. Pulmonary edema
4. Pneumonia
DIAGNOSTIC INVESTIGATION
According to Smelter, and Bare, (2018) the following diagnostic test can be done in
2. Chest x-ray
3. Electrocardiogram
4. Echocardiogram
5. Coronary angiogram
6. Myocardial biopsy
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MANAGEMENT
Medical management
decreases pulmonary venous pressure and reduce preload. Diuretics cause the
excretion of excess extracellular and this reduces the volume of blood returning to the
inhibitors (ACE inhibitors) are used in patients who cannot tolerate. ACE inhibitors
5. Supplemental oxygen therapy: This may become necessary as the heart failure
Lisinopril and captopril decreases left ventricular afterload with subsequent decrease
in heart rate thereby reducing the workload of the heart and increasing cardiac output.
A positive inotropic agent such as digoxin increases the hearts’ ability to pump more
effectively by improving the contractility of the myocardium, it also decreases the left
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ventricular diastolic pressure and decreases systemic vascular resistance (Smelter, & Bare,
2010)
7. NURSING MANAGEMENT
According Smelter, and Bare, (2018), Nursing management of person with congestive heart
3. Anxiety
1. REST
Intermittent rest periods during the day and after activities are arranged
and the patient rest before and after meals and between procedures.
Nursing activities are planned such that they do not interfere with patient’s rest
period
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A gentle massage of the limbs is also helpful
The patient is also encouraged to take 5-10 deep breathe every 1-2 hours to
3. NUTRITION
The use of flavorings, spices, herbs and lemon juice are encouraged with salt
substitutes
Patient’s diet is planned together with the family taking into consideration
patient’s preferences and dislikes, patient and family are made aware of the
the condition).
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Limit salt intake to 2-3grams daily.
Administer diuretics as ordered in the morning for daily dose and the second
dose in the late afternoon if it’s twice to avoid frequent urinating in the night.
5. OBSERVATION
Monitor vital signs 4 hourly, assess for evidence of hypoxia (restlessness, tachycardia and
angina) give drugs ordered and observed for side effects, monitor client’s response to the
6. ELIMINATION
undue strain placed on the heart. A mild laxative may be given to keep the
stool soft.
Use of the bedpan requires more energy than getting out of bed and using a
Data obtained from client was verified from relatives and crossed checked from patient
folder, health workers, laboratory investigation, and physical assessment in order to get
correct information devoid of errors, biases and misinterpretations. The data were also
recorded as obtained and so there could be no gross distortion related to care giver
biases.
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CHAPTER TWO
Data analysis is the next step in the nursing process and involves the proper organization of the data collected from the client, family and the health
team. It involves breaking down of data collected during the period of assessment of the patient in order to arrive at conclusion about the patient
condition.
The table on the next page shows the comparison of results of various diagnostic investigations carried out on Mr. K.F. with literature values so
The following investigations were carried out to confirm the actual diagnosis of the patient’s condition:
1) Chest x-ray
5) Sickling test
6) Electrocardiogram
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TABLE 1: LABORATORY INVESTIGATIONS
05/12/2023 Chest Electrocardiogram Left ventricular Normal ventricles Left ventricle was Treatment was given.
hypertrophy enlarged
05/12/2023 Blood Blood film for Zero plasmodium Malaria parasites should Patient had no No anti-malaria drugs
malaria Parasites parasites not be seen malaria given
(MPs)
06/12/2023 Blood Blood urea nitrogen 15.5g/dl 7- 20 mg/dL (2.5- Results indicate that No treatment given
level estimate 7.1mmol/L) patient is in a normal
range
06/12/223 Blood Blood Creatinine 1.0mg/dL 0.84-1.21mg/dL (74.3- Results indicate No treatment given
estimate level 107mmol/L) patient is in normal
range
06/12/2023 Blood Sickling test Negative Negative RBC’S should be No sickling No treatment was given
circular biconcave and
nucleated
06/12/2023 Chest Electrocardiogram ECG showed subtle ST and T waves should be It is suggestive of IV Aminophylline 250mg
nonspecific ST and normal CCF administered to improve
T wave cardiac dialatation.
abnormalities.
Waves
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2.2 CAUSE OF PATIENT’S ILLNESS
With reference to the causes of congestive cardiac failure as indicated in the literature review,
Mr. K. F’s condition could be due to the smoking he engaged himself some years back.
TO LITERATURE PATIENT
4. Productive cough with pink frothy sputum Patient presented dry cough
11.Pleural effusion especially on the right Patient had pleural effusion on the side of the heart
During the course of treatment, client was put on the following medication:
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TABLE 3: PHARMACOLOGY OF DRUGS
STANDAR PRESCRIBED
D DOSAGE DOSAGE
5/12/2023 Furosemide 1-2mg/kg not 100mg start then Loop diuretic Inhibits sodium Patient had frequent No side effect
to exceed 80mg 1 2hourly and chloride urination, excessive observed
600mg per for 48hours reabsorption at sodium and
day proximal and subsiding the
distal tubules oedema especially
and the of the lower
ascending loop extremities.
of Henle of the
kidney.
5/12/2023 Acetaminophen 15mg/kg tid 1gram tds for Non-narcotic Relieve of pain Nausea and No side effect was
for 3days 3days and reduce fever vomiting, urticaria, observed.
jaundice and
hypoglycemia
DATE DRUG DOSAGE /ROUTE OF CLASSIFICATION DESIRED SIDE EFFECT REMARKS
ADMINISTRATION OF DRUG EFFECT
STANDARD PRESCRIBED
DOSAGE DOSAGE
5/12/2023 Lisinopril 5-10mg daily 5mg daily for 30 ACE inhibitors Blocks a Dry cough, fever, Patient blood
Days substance in the itching blur vision, pressure was
body that causes drowsiness, Decreased
the blood to headache and
tighten. This tiredness.
lowers blood
pressure and
increases the
supply of blood
and oxygen to
the heart
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DATE DRUG DOSAGE/ROUTE OF CLASSIFICATION DESIRED SIDE EFFECTS REMARKS
ADMINISTRATION OF DRUG EFFECT OF
DRUG
STANDARD PRESCRIBED
DRUG FOR
PATIENT
6/12/2023 Aminophylline 5-7mg/kg 250mg for Bronchodilator Relieve Arrhythmias’, No side effect
6/12/2023 Spironolactone 20-75mg daily 50mg Diuretic Relieve fluid Tingling No side effect
failure shortness of
breath.
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2.4 COMPLICATIONS
With reference to the complications stated under the literature review, it was observed that
the patient did not have any complications during admission due to the excellent nursing care
rendered to him.
2. Patient was able to take warm bath to induce sleep for 2 hours
1. Dyspnea related to decrease cardiac output and low oxygen supply to the body.
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6. Activity intolerance(walking) related to fatigue
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CHAPTER THREE
This is the third stage of the nursing process in which the nurse, patient and the patient’s
family put heads together to see the possibility of rectifying the patient’s health problems. In
planning for the care of a patient, one has to draw a plan for short term needs and long-term
needs. The short-term goals are expected to be achieved within a short period of time whereas
In order to render a comprehensive nursing care to the client, it is important for the nurse to
develop objectives as a guide to determine when the nursing activities are expected to yield
results. These objectives can either be short term or long term. Short term objectives are those
that are set to be achieved within a relatively short period of time, whilst the long-term
OBJECTIVES
1. Patient will regain a normal breathing pattern within 48hours as evidenced by:
2. Patient will maintain a normal fluid and electrolyte balance throughout hospitalization as
evidenced by:
3. Patient will regain normal sleep pattern (6-8 hours) within 24hours as evidenced by:
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ii. verbalization by the patient that he slept well.
4. Patient will be relieved of pain in the chest within 24 hours as evidenced by patient
5. Patient will regain his normal eating pattern within 48hours as evidenced by:
6. Patient will gain optimal knowledge on cause, signs and symptoms, prevention and drug
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TABLE 4: PATIENT AND FAMILY CARE PLAN FOR MR. K.F
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION/ SIGN
TIME DIAGNOSIS OUTCOME TIME STATEMENT
CRITERIA
5/12/23 Dyspnea Patient will have 1. Put patient in a semi 1. Patient was put in a semi fowler position to 6/12/23 Goals fully met E.K.
O
@ related to a normal fowlers position ease in breathing. @ as evidenced by
11:00am decrease breathing 2. Remove tight 2. Tight garments around patient’s 11:00pm patient’s
cardiac pattern (18- garments around patient’s neck, waist, and chest were loosen. respiration rate
output and 20cycles per neck, waist and chest 3. Patient was taught deep breathing reduced to
low oxygen minute) within 3. Teach patient deep and coughing exercise 18cycle per
supply to the 24 hours as breathing exercise 4. Patient was told his condition will improve minute and
body. evidenced by the 4. Reassure patient 5. patient was given comfortable device to patient
and recording pillows or back rest. 6. Patient vital signs was checked of difficulty in
respiratory rate 7. Administer prescribed 7. Oxygen 3litre per minute was served as
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DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION/ SIGN
OUTCOME TIME STATEMENT
TIME DIAGNOSIS CRITERIA
5/12/23 Fluid volume Patient will 1. Reassure patient 1. Patient was told he would be relieved of the 10/12/23 Goal fully met as E.K.O.
@ excess maintain a 2. Elevate the feet swollen feet with the drugs given @ evidenced by
11:45am (pitting normal fluid side of the bed of 2. Foot end side of the bed was raised with 11:45am patient not
oedema of and electrolyte the patient patient’s feet elevated with pillows having pitting
feet) related balance 3. Monitor input and 3. Input and output chart was monitored oedema at his
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Ordered
29
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION/ SIGN
OUTCOME TIME STATEMENT
TIME DIAGNOSIS CRITERIA
6/12/23 Activity Patient will regain 1. Reassure patient 1. Patient was told that he would regain 7/12/23 Goal fully met E.K.O.
2. Place items close to
@ intolerance strength within 24 enough strength as the days went b, by @ as evidenced by
the bedside
8:00am (walking) to hours as evidenced the care rendered by the doctors and 8:00am patient
3. Alternate activities
fatigue by patient nurses. performing
with care
performing 2. Items needed by the patient were activities
4.Give high calorie diet
activity of daily put within reach to help conserve without
provide energy
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DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION/ SIGN
TIME DIAGNOSIS OUTCOME TIME STATEMENT
CRITERIA
6/12/23 Sleep pattern Patient will regain 1. Reassure patient 1. Patient was told he would have a 7/12/23 Goal fully met E.K.O
@ disturbances normal sleep 2. Prevent patient normal sleep with the nursing care @ as evidenced by
8:00am related to pattern (6-8 hours) from falling rendered. 8:00am patient
chest pain within 24 hours as 3. Provide a very 2. Side rails were provided verbalizing
evidenced by 1. quiet environment ability to sleep
night nurse report. 4. Perform all nursing 3. Nurses and relatives were told to 6-8 hours at
2. verbalization by activities together minimize their voices, lift chairs and night.
the patient that he 5. Restrict visitors not drag them. 2. night nurse
slept well. during periods of 4. Vital signs, serving of meals report
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DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION/ SIGN
OUTCOME TIME STATEMENT
TIME DIAGNOSIS CRITERIA
7/12/2023 Imbalance Patient will regain 1. Plan diet with patient 1. Diet was planned with patient 9/12/2023 Goal fully met as E.K.O
@ nutrition his normal eating 2. Provide mouth care for 2. Patient was assisted to do @ evidenced by 1.
8:15am (less than pattern within patient Mouth care 8:15am patient eating ¾
body 48hours as 3. Serve food in bits 3. Food (salt free light soup) of served meal.
related to patient eating at 4. Serve patient with fruits attractively verbalized that
boost appetite.
loss of least ¾ of meals 4. Fruits such as oranges, apples, he has regained
2. Patient appetite
verbalizing that
appetite
32
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION/ SIGN
TIME DIAGNOSIS OUTCOME TIME STATEMENT
CRITERIA
8/12/2023 Knowledge Patient will gain 1. Assess the 1. Patient knowledge was assessed 8/12/2023 Goal fully met as E.K. O
@ deficit related optimal knowledge of patient on on the condition @ evidenced by 1.
8:20am to inadequate knowledge on condition 1:20pm patient
information cause, signs and 2. Explain the nature of 2. Nature of condition was explained verbalized his
about disease symptoms, condition to the patient to the patient and both written and understanding of
condition prevention and and provide written and oral information provided. the disease
drug regime oral information condition.
3. Rational of prescribed
within 5hours 3. Explain prescribed 2. Nurse
medications was explained to the
as evidenced by medication to patient Observed that
patient
1. patient along their rational i.e., patient was calm
4. Patient and family were given
discussing and purpose and side in bed.
opportunity to ask questions and
displaying in – effects
also express their concerns
depth 4. Provide opportunity
knowledge for patient and family
about the to ask questions,
condition. discuss concerns and
2. Nurse make necessary
observes patient lifestyle changes.
remain calm
33
bed
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CHAPTER FOUR
PLAN
This is the fourth stage of the nursing process. This includes the summary of the actual
nursing care rendered to the patient and family from the time of admission till the time of
The actual nursing care rendered to the patient and family in the management of the condition
on the day of admission, 05/12/2023 through to the time of discharge, (10/12/2023) and
continued into follow-up visits. He was nursed using the nursing care plan which was
Mr. K.F. was admitted into the male medical ward of the Korle-Bu Teaching Hospital on the
5th of December,2023 from Accident and Emergency unit in a wheel chair accompanied by a
nurse and his daughter into the ward. They were warmly welcomed to the ward and he was
made comfortable in a cardiac bed and all necessary information was collected from patient
and accompanying nurse. Patient and his relative were reassured of the competency of the
health team.
Patient’s vital signs were checked and recorded as Temperature; 36.0 0 c, Pulse; 107 bpm,
Respiration; 26cpm, and Blood pressure; 130/99mmhg. Prescribed medications were also
Upon assessing the patient, it was found out that patient had dyspnea and the objective was to
help patient have a normal breathing pattern (18-20cycles per minute) within 24 hours of
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nursing care. To achieve this goal, patient was put in a semi fowler position to ease in
breathing, patient tight clothing was loosened and prescribed oxygen administered. Patient’s
particulars were documented in the admission and discharge book and into the daily ward
state. Also, patient had oedema on the lower extremities as a result of sodium retention.
Patient was told he would be relieved of the swollen feet with the drugs given, end side of
the bed was raised with patient feet elevated with pillows, input and output chart was
monitored, patient was taught to take in low salt diet. Patient was also educated to do
moderate exercise such as walking around the bed to and fro of the ward as well as weighing
himself daily. Intravenous furosemide 80mg was served as ordered. Patient was then handed
Patient’s vital signs were checked and recorded and medication at 6:00am was served and
taken. From the report book, patient complained of waking up frequently to urinate at night
as such did not sleep adequately. Patient was greeted and enquired about his condition and he
said he was fairly well. Mr. K.F. was assisted to take his bath, oral hygiene, and his bed linen
was changed. Dusting of unit was done and a simple cardiac bed was made for her.
At 8:00am, he was reviewed by Dr. A.P during ward rounds and he complained of insomnia,
and headache. Mr. K.F was reassured he would have a normal sleep with the nursing care
rendered, side rails were provided to prevent him from falling, a very quiet environment was
provided for him, all nursing activities too were also performed together and visitors were
restricted during his period of sleep. Also, patient could not walk due to fatigue. Patients
was told he would regain strength as the days went by, by the care rendered by the doctors
and nurses, items needed by patient was put within his reach to conserve energy, he was also
made to rest with less performance of activities, and carbohydrate foods were given to
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provide energy. A towel was damped and placed on his forehead; windows opened for
ventilation; noise in the ward was reduced as much as possible. Dr. A.P asked for treatment
to be continued. Intravenous fluids were continued. Vital signs were checked at 10:00a.m and
124/100mmHg
Patient was made comfortable in bed and was also advised to have enough bed rest. All
prescribed medications were served and all procedures carried out were documented
appropriately.
My intention of paying a first visit to his home with his daughter who promised to take me to
The patient was said to have slept comfortably, which he verified following an exchange of
pleasantries. He had maintained his personal cleanliness and taken his prescriptions as
prescribed at 10:00 p.m. and 6:00 a.m. Mr. K.F. expressed the lack of headaches, insomnia, and
weariness. An evaluation of earlier days of admission was performed, and it was clear that the
goals had been fully met. The patient was evaluated, and it was discovered that he had
. Mr. K.F's diet was arranged with him, mouth care was provided, food was supplied in bite-
sized portions, and fruits such as oranges and apples were offered to stimulate his appetite. At
10:00am, his vital signs were 36.4◦C, 94bpm pulse, 20cpm respiratory rate, and
During our conversation, he expressed a desire to be with his family at home, and he was
urged to engage with other patients to alleviate boredom. The objective of his admission was
explained to him, as well as the fact that he would recover and return home soon.
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Care plan for the previous day was evaluated and it was realized that all goals were fully
met. Routine nursing care such as vital signs and serving of medications were done and
documented appropriately.
Much improvement was seen in patient’s condition on the fourth day of admission. After
reading through the report book, the patient reported to have slept soundly at night and
maintained his personal hygiene. Patient’s loss of appetite was ceased. He had taken
breakfast and lunch. He was assessed on knowledge of his condition and it was realized that
the patient had knowledge deficit related inadequate information about the disease condition.
He was reassured of competent nursing care and the nature of the disease condition, rational
of prescribed medication as well as prevention of the disease condition was explained to the
patient.
Blood pressure-120/70mmHg. His medication at 2:00pm was served and recorded. Patient
was observed to be communicating with others and looked calm and relaxed in bed. Patient`s
vital signs were checked at 6:00pm and recorded and medications were administered as
prescribed.
After greeting and asking patient of her condition he said he was doing well and hoped to be
discharged home. He had maintained his personal hygiene and other ward routine activities
carried out. His vital signs were checked at 6:00am as; blood pressure-120/70mmHg,
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At 8:30a.m, he lodged no complaint during the ward rounds. His medication was
continued by Dr. A.P and was told of possible discharge the next day. At 2:45pm, care
plan for 08/12/23 was evaluated and realized that goal was fully met.
Patient health was better on the sixth day of admission. After greeting and asking him
about his condition, he said he was doing well and hope to be discharged home. He
maintained his personal hygiene and other ward routine activities carried out. His vital
signs were checked at 6:00am as; temperature-36.5 0 C, pulse 94bpm, respiration 24cpm
At 8:30am, he was seen by Dr. A.P and discharged home with tablet Acetaminophen 1g
tds for 7days and tablet Lisinopril daily for 5days and he was told to come for review on
Drugs were collected and Mr. K. F’s knowledge was evaluated and he was able to give an
account on the causes, signs and symptoms and some preventive measures of her disease
condition. Patient was taken through the disease condition for some few minutes and he
was taught how to take the drugs. His discharge was entered into admission and discharge
book as well as the daily ward state form. Patient was assisted to pack his belongings and
he thanked me and said goodbye to the other patients in the ward and the staff. Mr. K.F
was accompanied to the car park where he boarded his son’s car to his house.
The preparation of Mr. K.F and family for discharge started on the day of admission during
the first interaction with him. Patient and family were reassured that his condition would
improve and soon be discharged home. The care took the form of reassurance, education on
diet, personal hygiene and drug regimen. Patient was made to understand that it was a
right
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choice he made by coming to the hospital to seek early treatment. They were encouraged to
continue with health care and avoid self-medication. They were also educated on the causes,
signs and symptoms of congestive heart failure. The needed cooperation from patient was
made known to him and the family pledged their maximum cooperation.
A visit to patient’s home was made on the 8 th of December, 2023, that is three days after the
patient was still on admission. This was done to assess and prepare the home setting. The
necessary information and education were given to the family for preparation of receiving the
patient back home. Patient and family were advised on the importance of follow-up visits by
the nurse.
Home visit is a planned visit a health care provider makes to the patient’s house to study,
identify and know the conditions of the client’s home that might contribute to the condition
The first home visit was made whilst patient was on admission. The patient’s home was
visited in the company of his daughter. Patient’s home is located at Abeka Adom junction
near the Harvest chapel. Upon reaching the house, a quick observation was made of the
environment and it was noticed that the environment was clean. The house was built with
cement blocks and roofed with aluminum sheets. The house is a four-bed room self-
contained. The doors and windows were well netted to prevent mosquitos from biting them.
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The source of drinking water was pipe-borne. Refuse was collected into dustbins with lid and
pick by a swage company weekly. Patient’s family members and other people in the house
were encouraged to maintain a healthy environment which would promote good health.
The family members showed appreciation for the visit and permission was sought to leave.
They were promised of my next visit after which they accompanied me to the taxi station
The second home visit was made on the said date. On reaching the house, the family
members were happy to see me again. After being offered a seat and pleasantries exchanged,
an enquiry into patient’s health was made and also to know if they had any new complaints.
No complaints were made and patient was found to be doing well. The need to reduce sodium
intake and the intake of a balanced diet was emphasized. They were also advised to give the
patient’s medications as prescribed. Patient’s wife was reminded of the date for review and
advised to adhere to it. The need to terminate the care on the next visit was also discussed. He
was also informed of the need for another health personnel close to his house to take over his
care. He was promised that a community health nurse, who will be doing this, will be
introduced to him during the next visit. Permission was sought to leave with a promise of a
third and final visit. They were thankful for the visit.
On the day of review, patient was assisted to go for his folder and accompanied to the
consulting room. Patient had no complaint and was advised to continue with his medications
and report any abnormality noticed. Patient was accompanied to the car and he was bid
goodbye.
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THIRD HOME VISIT (30th December, 2023)
The third home visit was made to assess the progress of patient’s condition and to finally
hand him over to a community health nurse to continue with the care. On reaching the house,
I was welcomed by the patient. After exchanging greetings, patient and family were thanked
for their cooperation throughout the care. The community health nurse who would continue
with the care was introduced to him. Patient was advised to continue to give his maximum
cooperation. Patient and family took time to express their appreciation for the care rendered
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CHAPTER FIVE
The last phase of the nursing process is evaluation; it gives insight into the effectiveness of
the care rendered to the patient. Evaluation runs through all the steps in the nursing process. It
From the day of admission (5/12/2023) to the day of discharge (10/12/2023), Mr. K.F. was
rendered individual care. Problems were identified and managed in order of priority. All
1. On the first day of admission (5th December, 2023), he complained of difficulty in breathing.
Objectives were set to relieve patient of the difficulty in breathing within 24 hours as
evidenced by the nurse checking and recording the normal respiratory rate of the patient The
2. On the 5th of December, 2023, an objective set at 11:45am to help patient have a
reduced oedema on the lower extremities as evidenced by the nurse observing pitting
oedema. The goals were fully met as evidenced by patient not having pitting oedema at
3. On the 6th of December, 2023 at 8:00am, an objective was set to help patient regain normal
sleep pattern (6-8 hours) within 48 hours as evidenced by the night nurse report. On that same
day at exactly 8:00am objectives were set for the patient to gain strength within 24 hours as
evidenced by patient performing activity of daily living with little assistance. Goal was fully
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met as evidenced by patient verbalizing ability to sleep 6-8 hours at night and patient
4. On the 7th of December, 2023 at 8:20am objectives were set to help patient regain his
normal eating pattern within 48hours as evidenced by patient eating at least ¾ of meals
5. On the 8th of December, 2023 at 8:00am an objective was set to help patient gain
optimal knowledge on cause, signs and symptoms, prevention and drug regime within
5hours. Goal fully met as evidenced by met as evidenced by patient verbalizing the
Mr. K.F. was nursed using the nursing process throughout his period of hospitalization.
Based on the various health problems identified on him, a nursing care plan was developed
and initiated under which objectives were set and the nursing interventions carried out
accordingly.
Mr. K. F’s condition improved and he was discharged home after six days of admission. Mr.
K.F and his family understood the disease condition and promised to take in necessary
measures to prevent the recurrence of the condition. Most of the health problems identified
were alleviated.
Amendment is drawn when set goals are not fully achieved. With effective nursing care
rendered to the patient and with support from the medical staff and patient’s family, all set
goals were successfully met within the stipulated time. There was no need for amendment
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5.3 TERMINATION OF CARE
It is the last stage of the relationship between the nurse and the patient. It is the most difficult
and important part of the cordial relationship that exist between the two parties. This is the
interactions between the nurse, patient and family is brought to a successful end. This aspect
was made known to Mr. K.F and family on the day of admission. As a result, they were not
worried about separation when it was made known to them during the last home visit. Patient
and family were reminded of the need to report any abnormalities to the hospital and not to
hesitate to call for help when the need arises. Patient looked healthy and his general condition
had improved. They were thanked for their maximum support and cooperation throughout the
hospitalization and writing of this case study. They also expressed their sincerest gratitude for
5.4 SUMMARY
The nursing care study is a documentary on the nursing care given to Mr. K.F, a 61years old
man. He was admitted to the male medical ward of the Korle-Bu Teaching Hospital on the
On admission, he looked ill but with a good management and effective nursing care together
with support from patient and relatives, his condition improved satisfactorily.
He was discharged on the 10th December 2023 without any complications. He looked healthy
and happy on the day of discharge. Three home visits were carried out during which patient
and family were educated. On the last visit, patient’s condition had improved tremendously.
5.5 CONCLUSION
In conclusion, the care study has been an educating and challenging experience. The study
has helped me gain insight into the condition congestive cardiac failure. It has also helped me
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to understand comprehensive nursing care especially to patients with this condition. It has
also given me the adequate practical knowledge to confidently take care of patients using the
5.6 RECOMMENDATIONS
Schools should allow students to start their care study early in order for students to spend
enough time on their work and also to do more than one, so that students will be well
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BIBLIOGRAPHY
Abrams, A.C (1995), Clinical drugs therapy rational for nursing practice (4th edition)
Bloom A. & Bloom S. (1986); Tooheys Medicine For Nurses (14th edition) Churchill
Livingstone , London
Smelter, S.C. & Bare, B.G. (2018). Brunner and Suddarth textbook of medical and surgical
Wilkins .
Standard Treatment Guidelines (2010). Ghana National Drug Programm.6th Edition. Accra:
Wash, M. (2002). Watson's Medical And Surgical Nursing And Related Science (7th ed).
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SIGNATORIES
SIGNATURE……………………………………………………………………………….
DATE……………………………………………………………………………………….
SIGNATURE………………………………………………………………………………
DATE……………………………………………………………………………………….
SIGNATURE …………………………………………………………...............................
DATE …………………………………………………………………………………........
4. NAME OF HOD
SIGNATURE ………………...…………………………………………………………...
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