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CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment is the first phase of the nursing process. It is a systematic collection of sufficient

accurate data acquired through interviews with the patient, his family and friends, and through

studying records, reports from diagnostic investigations as x-ray films, and other documents as

well as through observations, physical examination and the taking of the patient’s previous and

present medical history to arrive at the problems and possible causes which are written down in

order of priority to formulate a nursing diagnosis. However, this is not only limited to the first

encounter with family but is a continuous process, until the relationship between the nurse and

the family ends. This assessment comprises of client particulars, family medical and socio-

economic history, client’s developmental history, client’s lifestyle / hobbies, past medical

history, present medical history, admission of client, client’s concept of his illness, literature

review on disease condition and validation of data.

Patient’s Particulars

A fifty four (54) year old Mr. Samuel Ofori Daniels was born at Korle-Bu Teaching Hospital in

Accra to Mr. George Ofori Daniels and Madam Felicia Asantewaa on 19th August 1955. He is a

christian and currently worships with the Bethel of Prayer Ministry, Kumasi and a Ghanaian by

birth and nationality. Mr. Samuel Ofori Daniels is the first born of three children and the eldest

of his parents. He speaks English, Twi and Ga languages. He started his primary and junior

high school education at Anglican 1 Primary and JSS School, Nungua in Accra and continued to

Accra Academy, where he did his Advanced Level in Management. After his Advance Level, he

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then furthered his education at Accra Polytechnic where he had a Diploma in Marketing.

Currently, he is the Chief Inspector of Tax at the Internal Revenue Service in Kumasi. He is

married to Mrs. Agnes Ofori Daniels who is a private worker at Tema Community Four (4) and

they are blessed with four children. Mr. Daniels said that, he has lived most of his life in Accra,

the capital of Ghana but now lives in Buokrom, a surburb of Kumasi with house number Plot 20

Block 5.

Family Medical and Socio-Economic History

According to Mr. Samuel Ofori Daniels, his family members normally grow old. He added that,

his grandparents grew very old before they died. According to him there is no known mental

illness, diabetes, hypertension and diabetes mellitus or any contagious disease in their family.

However most of the family members do smoke, drink alcohol and tend to abuse drugs.

He claimed he is the breadwinner of the family even though sometimes supported by his lovely

wife. He uses the salary he earns as a Chief Inspector of Tax at the Internal Revenue Service for

the upkeep of his family. Mr. Daniels is insured under the National Health Insurance Scheme

(NHIS). This therefore made payment of the hospital bills affordable.

Client’s Developmental History

This entails how a person develops physically, mentally and socially; thus changing from one

state to a more mature state. Development takes place in various forms from the day of

conception until one dies.

According to client, he was told by his mother that, she went through a normal pregnancy,

carried him to full term and had a spontaneous vaginal delivery at the Labour Ward at Korle-Bu

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Teaching Hospital. His mother also told him that she had no complications such as vagina tear

or episiotomy. She had normal pueperium without any complications. Client was told that, he

was breastfed but not exclusively as he was given water alongside the breast milk and was also

weaned at the age of four months.

Mr. Daniels said, he was told by the mother that he was immunized against the six childhood

killer disease at the hospital where he was delivered. These immunization included polio vaccine

against poliomyelitis, Bacilli Calmette Guerin (BCG) vaccine against tuberculosis, Diphtheria,

pertusis and tetanus (DPT) vaccine against diphtheria, pertusis and tetanus, Yellow fever and

measles vaccines against yellow fever and measles respectively. Mr. Samuel Ofori Daniels

could not give detailed account of his developmental milestone. He was told that, he passed

through the normal developmental milestone and at age one he was able to walk without support.

He was told that, he had no serious illness during his infancy that could have impeded his

growth. He had his male secondary sexual characteristics at the age of fourteen years which

included deepening of the voice, hair growth at the genital area and armpit. He completed his

junior secondary school at the age of seventeen. Client lived with both parents until completion

of school at the Polytechnic.

Patient’s Lifestyle and Hobbies

Mr. Samuel Ofori Daniels wakes up as early as 4:30am in the morning. He observes his quite

time each morning followed by a glass of chilled water from the refrigeration even before

brushing his teeth with Pepsodent toothpaste. As a normal educated man, he maintains his

personal hygiene by bathing twice every morning and evening with cold water. Mr. Daniels has

always been busy as he is always seen around his office and therefore does not have much time

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to stay outside his job though enjoy watching football match only exclusively on television. He

likes reading the bible and listening to radio. His favourite food is fufu with palm nut soup.

Past Medical History

According to client, he was hospitalized when he was a child with malaria and since his

childhood sickness he has never been seriously sick and admitted, therefore does not visit the

hospital regularly. He said he has no known history of hypertension, diabetes, asthma or any

other infectious disease until two years ago when he was diagnosed of been prone to

hypertension. Since his entire family does not experienced any health problems none of his

family members have ever received any medical treatment against the above mentioned disease.

He said he sometimes experience slight headache and bodily pains but gets over it by purchasing

drugs (Ibuprofen) from the chemists shop (over the counter drugs).

Present Medical History

The client has a two year treatment of recurrent headaches and bouts of dizziness that usually last

for 2-3 days. He was in his usual state of health till 7 days ago when he began to experience

severe frontal headaches, non radiating, and associated with coryza. He simultaneously

experienced dizziness, making it difficult for him to walk and this was associated with blurred

vision. He went to hospital where he was treated on Out- Patient Department basis. Symptoms

however did not resolve. At 5:00 am on the morning of 6th January 2010, he had two episodes of

vomiting and the vomitus contained food particles. After sometime, he noticed a downward

deviation of his mouth on the left side. He thus rushed to Keffam Health Services where he was

further referred to Komfo Anokye Teaching Hospital’s Accident and Emergency Centre for

further management account of hypertensive crises with insipient Cerebrovascular Accident.

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Client was conscious with slurred speech and weakness at the right side of his body. The medical

officer on duty diagnosed client as having Right Hemispheric Cerebrovascular accident with left

hemiparesis. Client was then admitted at the Accident and Emergency Centre for a while and

referred to Ward D3.

Admission of Patient

The client was admitted on 6th January, 2010 at 9:20am. He was brought to Ward D3, a male

medical ward in a wheel chair by an admission team member and was accompanied by his wife

and children from the Accident and Emergency Centre. They were met at the entrance of the

ward and welcomed and were offered seats. The admission notes were collected from the

admission team by the student nurse (Prince Gyamfi) to confirm his admission to the ward. I

introduced myself to the relative and other nursing staffs also introduced themselves to the

relatives.

The admission team was dispatched and patient’s folder was looked through to gather some

information. Client was then admitted into a well prepared admission bed free from creases and

cramps with side rails to prevent client from falling.

The wife was reassured that client was in safe hands and everything possible will be done to

ensure his recovery. Client particulars such as name, date of admission, time, age, and next of

kin among others were taken and recorded in the ward state and admission and discharge book.

The client`s relatives were informed about the hospital policy on visiting hours, ward rules, the

items and clothing’s that were needed during the hospitalization.

A quick assessment of client’s general appearance was made and vital signs were checked and

recorded as follows;

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 Temperature: 38.1 degree celsius

 Pulse: 88 beats per minute

 Respiration: 22 cycles per minute

 Blood pressure: 170/100 millimetres of mercury

Client was conscious and alert. Client was reassured that with competent staff available

everything possible will be done to ensure his speedy recovery. The medical officer on duty at

the ward was informed of which he came to attend to him. Upon thorough examination on client,

the doctor confirmed the diagnosis as having Right Hemispheric Cerebrovascular Accident with

left hemiparesis.

Client was put on the following treatment;

1. Tablet Aspirin 500mg bd ×10 days

2. Tablet Amlodipine 10mg daily x30 days

3. Tablet Amoksiklav 625mg bd × 7 days

4. Tablet Lisinopril 10 mg daily x30 days

5. Tablet Multivite 200mg 3 times daily x 30 days

6. Tablet Diazepam 5mg nocte x 7

Drugs were collected from the dispensary, administered and recorded accordingly.

Patient’s concept of his illness

According to client, he does not know the cause of his illness but he believes that it is an ailment

which has no connection with witchcraft. However, his expectation was that, he will feel healthy

very soon with the good medical treatment and nursing management.

LITERATURE REVIEW ON CEREBROVASCULAR ACCIDENT (STROKE)

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Cerebrovascular accident is a condition that produces sudden neurological symptoms such as

sudden loss of brain function, paralysis as a result of rupture of cerebral blood vessels or

occlusion by blood clot leading to disruption of blood supply to the brain tissue.

Incidence

Cerebrovascular accident affects males more than females. It is one of the major public health

problems in terms of both mortality and permanent disability. About 60%-70% of stroke occurs

in persons over 65 years of age. Young people occasionally sustain stroke because of trauma to

the cerebral vessels, inflammatory disorders of the arteries of the brain or congenital vascular

anomalies.

Aetiology

The main causes of stroke include;

1. Cerebral thrombosis;

The cerebral arteries are affected by atherosclerosis in which the lining of the arteries

becomes thickened and rough. The flow of blood becomes obstructed and clotting

occurs. This clot blocks the artery and deprives part of the brain of its blood supply.

2. Cerebral embolism;

An embolus could detach and lodge in one of the cerebral arteries and produce a

stroke. This variety of stroke is seen when a clot form on the left side of the heart and

is carried up in the blood stream to lodge in one of the cerebral arteries.

3. Cerebral haemorrhage;

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It is rupture of a blood vessel that produces haemorrhage into the brain tissue. This

event is common in cases of hypertension.

Predisposing factors/ risk factors

1) Hypertension

High blood pressure places abnormally high stress on the walls of blood vessels which

overtime weakens and damages the vessels.

2) Diabetes Mellitus; it leads to vascular changes in both the systemic and the cerebral

circulation and increase the risk of hypertension that could also lead to C.V.A

3) Obesity; excess fats in the body especially in the arteries narrows blood vessels, reducing

blood flow to vital organs especially the brain increasing the risk of stroke.

4) Heart diseases; especially in cardiac arrest where there is caessation of effective pumping

action of the heart, when not treated earlier can lead to stroke due to lack of adequate blood

pumped to the brain.

5) Elevated cholesterol;

When excess cholesterol is present in the bloodstream, it accumulates along the walls of

blood vessel, accelerating the progression of atherosclerosis and thereby increasing the risk

of stroke.

6) Cigarette smoking;

The nicotine in cigarette smoke damages blood vessel walls and make them susceptible to

atherosclerosis and also other chemicals in the smoke also affects the blood making it prone

to forming clots.

7) Carotid bruit; RBC disorders

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8) Trauma; This occurs when there is a head injury affecting the cerebral vessels. When this

happens there will be an impairment of blood supply to the brain and this leads to stroke.

9) Alcoholism; The injection of unpurified substances increases the risk for Cerebrovascular

accident, and abuse of alcohol can decrease cerebral blood flow and increase the risk of

intracranial haemorrhage.

10) Infection. Occlusions of cerebral vessels by a plaque impair or obstruct blood flow to

specific areas of the brain.

Pathophysiology

When the blood vessel supplying an area of the brain is blocked by an embolus, thrombus or due

to rupture of a blood vessel, ischemia of the brain tissues occur due to the loss of blood supply to

the brain leading to hypoxia, anoxia and hypoglycaemia. These situations subsequently cause

brain tissue death. The affected part of the brain produces neurological dysfunction and paralysis

such as blurred vision, loss of consciousness and disorientation.

Since the cerebral hemisphere controls the contra lateral side of the body, damage in the left

hemisphere produces paralysis of the right side of the body and vice versa.

TYPES OF CEREBROVASCULAR ACCIDENT

The types of stroke are;

1. ISCHAEMIC STROKE;

It occurs when there is a loss of function resulting from the destruction of blood supply to the

brain. It is caused by either an embolus or thrombus in the brain.

a. Embolytic stroke;

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It has a sudden onset and it is caused by large artery thrombosis.

b. Thrombotic stroke;

It has a gradual onset and it is caused by large artery thrombosis.

2. HAEMORRHAGIC STROKE;

This has a sudden onset and occurs from ruptured vessels such as secular aneurysm or as a result

of hypertension.

CLINICAL FEATURES

The clinical features can be grouped under the following headings;

(1) MOTOR LOSS;

a) Hemiplegic is present (paralysis of half of the body).

b) There is ataxia (failure of muscle co-ordination resulting in jerky movement)

c) Dysphagia (difficulty in swallowing).

d) There is dysarthria (inability to form words).

(2) COMMUNICATION LOSS;

a) There is dysphasia (defective speech).

b) Dysarthria (unclear pronounciation)

c) Dysphonia (difficulty in voice production)

(3) LOSS OF PERIPHERAL VISION;

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There is diplopia (double vision)

(4) SENSORY DEFICITS;

There is paraesthesia (numbness or tingling sensation of the affected part).

(5) IMPAIRMENT OF MENTAL ACTIVITY AND PSYCHOLOGICAL EFFECTS;

a) Impairment in learning capacity and memory is present.

b) Difficulty in comprehension.

c) Forgetfulnes.

d) Emotional disturbances.

e) Depression.

f) Lack of cooperation.

COMPLICATIONS

a) Pneumonia.

b) Paralysis.

c) Pulmonary Embolism.

d) Deep vein thrombosis.

e) Bedsore.

DIAGNOSTIC INVESTIGATIONS

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i. History and signs and symptoms shown by client confirmed the diagnosis.

ii. Computed tomography scan, It is done to indicate or isolate structural abnormalities,

infarction, edema and necrosis.

iii. Neuropsychological test; this helps to evaluate simple to complex verbal ability.

iv. Ophthalmoscopy; it may reveal arteriosclerosis and atherosclerotic changes in the retina

arteries.

v. Electroencephalogram (EEG); this may show low voltage, slow waves in ischemic

infarction. If it is caused by haemorrhage, it may have high voltage but slow waves.

vi. Cerebral blood flow studies; this will help to identify the blood flow pattern of the brain

and any abnormality.

vii. Lumbar puncture; this may indicate an increase of leucocytes in the cerebrospinal fluid.

Medical treatment

Medications that are useful in Cerebrovascular accident include;

i. Anticoagulants like heparin prevent further development of thrombosis and embolism.

ii. Corticosteroids like dexamethasone acts as anti- inflammatory agents thereby reducing

inflammatory reactions.

iii. Analgesics example paracetamol to reduce pain.

iv. Osmotic diuretic like mannitol helps to reduce cerebral edema.

v. Antihypertensive like nifedipine is given to treat or reduce hypertension.

vi. Anticonvulsants example phenytoin is given to prevent seizures.

vii. Antiplatelets like aspirin or clopidogrel is given to reduce the formation of clots

(thrombus and embolus).

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viii. Stool softeners example liquid paraffin to avoid constipation.

SPECIFIC SURGICAL INTERVENTION/TREATMENT

Based on the severity of the stroke and the extent of it; client may undergo craniotomy to remove

haematoma, endarterectomy to remove arteriosclerotic plaques from inner arterial wall or extra

cranial or intracranial bypass to prevent an artery that is blocked by an occlusion or stenosis.

Ventricular shunt may be necessary to drain cerebrospinal fluid.

NURSING MANAGEMENT

REASSURANCE

A calm and reassuring approach can be therapeutic to both the client and relatives. The client

was reassured that, there are competent nurses and doctors to enhance his speedy recovery.

Rapport with client and relatives should be established to help gain their trust and support in the

care given and also involve client and relatives in the care and treatment been provided. Client

and relatives should be encouraged to ask questions and answer them in straight and simple

terms. Each procedure to be performed on the client should be explained to help gain his

confidence. Client should be introduced to other clients on the ward. This will help relax client,

allay fears and anxiety and to gain client’s co- operation.

REST AND SLEEP

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Adequate rest and sleep is necessary for the client since it conserves energy, relaxes the body and

mind, reduces stress on the affected part and promotes good circulation and good health. To

ensure this, the bed should be made comfortable, free from creases and cramps. All dirty and

soiled linen should be changed to promote sleep. Nearby windows should be opened to facilitate

good ventilation. Visitors should be restricted and also noise should be minimized by turning

down radio and television sets. Diuretics should be given to client during daytime to help him to

sleep well at night. Warm beverages and dim lights should be provided to induce sleep.

POSITION

The client’s position should be changed every 2 hours. To place a patient in a lateral (side-lying)

position, a pillow is placed between the legs before the patient is turned. To promote venous

return and prevent edema, the upper thigh should not be acutely flexed. The patient may be

turned from side to side, but the amount of time spent on the affected side should be limited if

sensation is impaired. If possible, the patient is placed in a prone position for 15 to30 minutes

several times a day. A small pillow or a support is placed under the pelvis, extending from the

level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the

hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures.

The prone position also helps to drain bronchial secretions and prevents contractual deformities

of the shoulders and knees. During positioning, it is important to reduce pressure and change

position frequently to prevent pressure ulcers.

OBSERVATION

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During the acute phase, a neurologic flow sheet is maintained to provide data about the following

important measures of the client’s clinical status:

• Change in the level of consciousness or responsiveness as evidenced by movement, resistance

to changes of position, and response to stimulation; orientation to time, place, and person

• Presence or absence of voluntary or involuntary movements of the extremities; muscle tone;

body posture; and position of the head

• Stiffness or flaccidity of the neck

• Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position

• Color of the face and extremities; temperature and moisture of the skin

• Quality and rates of pulse and respiration; arterial blood gas values as indicated, body

temperature, and arterial pressure

• Ability to speak

• Volume of fluids ingested or administered; volume of urine excreted each 24 hours

• Presence of bleeding

• Maintenance of blood pressure within the desired parameters

After the acute phase, the nurse assesses mental status (memory, attention span, perception,

orientation, affect, speech/language), sensation/perception (usually the patient has decreased

awareness of pain and temperature), motor control (upper and lower extremity movement),

swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel

and bladder function. Ongoing nursing assessment continues to focus on any impairment of

function in the patient’s daily activities, because the quality of life after stroke is closely related

to the client’s functional status.

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NUTRITION

A well balanced diet containing all the necessary food nutrients should be served to client.

Protein is given to repair worn out tissues, vitamins to boost the immune system, carbohydrates

for energy, fats and oils for energy and roughage to prevent constipation. The type of diet served

depends on the state of client.

Client will be on intravenous infusions to help maintain his fluid and electrolyte imbalance.

Nasogastric tube is passed when client is unconscious. If client is fed using Nasogastric tube,

feeding should be done every 2-4 hours and about 200-400ml of feed should be given, then add

about 30ml of water and rinse the tube. He should be given low sodium balanced diet containing

all the necessary nutrients to help prevent oedema. Client’s diet should be planned with the

dietician and client and sometimes the family members so as to know the type and quantity of

food to be served. Food should be served attractively to stimulate client’s appetite.

PERSONAL HYGIENE

As soon as the patient can sit up, personal hygiene activities are encouraged. The patient is

helped to set realistic goals; if feasible, a new task is added daily. The first step is to carry out all

self-care activities on the unaffected side. Such activities as combing the hair, brushing the teeth,

shaving with an electric razor, bathing, and eating can be carried out with one hand and are

suitable for self-care. Although the patient may feel awkward at first, the various motor skills can

be learned by repetition, and the unaffected side will become stronger with use. The nurse must

be sure that the patient does not neglect the affected side. Assistive devices will help make up for

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some of the patient’s deficits. A small towel is easier to control while drying after bathing, and

boxed paper tissues are easier to use than a roll of toilet tissue.

EXERCISE

The affected extremities are exercised passively and put through a full range of motion four or

five times a day to maintain joint mobility, regain motor control, prevent contractures in the

paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance

circulation. Exercise is helpful in preventing venous stasis, which may predispose the client to

thrombosis and pulmonary embolus. Repetition of an activity forms new pathways in the CNS

and therefore encourages new patterns of motion. At first, the extremities are usually flaccid. If

tightness occurs in any area, the range-of-motion exercises should be performed more frequently.

The client is observed for signs and symptoms that may indicate pulmonary embolus or

excessive cardiac workload during exercise; these include shortness of breath, chest pain,

cyanosis, and increasing pulse rate with exercise. Frequent short periods of exercise always are

preferable to longer periods at infrequent intervals. Regularity in exercise is most important.

Improvement in muscle strength and maintenance of range of motion can be achieved only

through daily exercise.

ELIMINATION

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During stroke attack, the patient may have transcient urinary incontinence due to confusion,

inability to communicate needs, and inability to use the urinal or bedpan because of impaired

motor and postural control. Occasionally after a stroke, the bladder becomes atonic, with

impaired sensation in response to bladder filling .Sometimes control of the external urinary

sphincter is lost or diminished. During this period, intermittent catheterization with sterile

technique is carried out. When muscle tone increases and deep tendon reflexes return, bladder

tone increases and spasticity of the bladder may develop. Because the client’s sense of awareness

is clouded, persistent urinary incontinence or urinary retention may be symptomatic of bilateral

brain damage. The voiding pattern is analyzed and the urinal or bedpan offered on this pattern or

schedule. The upright posture and standing position are helpful for male clients during this

aspect of rehabilitation. Client may also have problems with bowel control or constipation, with

constipation being more common. Unless contraindicated, a high-fiber diet and adequate fluid

intake (2 to 3 Litres per day) should be provided and a regular time established (usually after

breakfast) for toileting

PROTECTION FROM INJURY

Soft mattress is used in order to prevent sagging. Bed should be provided with pillows to help

elevate the affected part. Some of the pillows should also be put in between the legs to prevent

formation of pressure sores. Bed rails should be provided to prevent client from falling.

Sharp instruments should be taken away from client. Items needed by client should be placed

closer to him and there should be good lighting system to prevent client from falling. The floor

should be wiped to prevent client from slipping.

EDUCATION;
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Client and family education is a fundamental component of rehabilitation, and an ample

opportunity for learning about stroke, its causes and prevention, and the rehabilitation process

should be provided. In both care and rehabilitation facilities, the focus is on teaching client to

resume as much self care as possible. This may entail using assistive devices or modifying the

home environment to help the client live with a disability. The family is advised that the client

may tire easily, become irritable and upset by small events, and is likely to show less interest in

things. Because a stroke frequently occurs in the later stages of life, there is the possibility of

intellectual decline related to dementia. The nurse involved in home and continuing care also

needs to remind client and family members of the need for continuing health promotion and

screening practices. Clients who have not been involved in these practices in the past are

educated about their importance and are referred to appropriate health care providers, if

indicated.

Ca Experience

VALIDATION OF DATA

The information gathered from the relatives was cross checked with that given by client. The

purpose was to keep data from mistakes and misinterpretation. The signs and symptoms

presented by Mr. Samuel Ofori Daniels are the results of some physical examinations and

laboratory investigations that were done and the literature review confirmed the condition of

client as having Right Hemispheric Cerebrovascular accident with left hemiparesis.

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CHAPTER TWO

ANALYSIS OF DATA

This forms the second step in the nursing process. Information collected during client’s

assessment is compared with standard. It is further broken down to identify the patient’s actual

and potential problem. The nurse formulates the nursing diagnosis and renders the care

accordingly based on these problems.

COMPARISON OF DATA WITH STANDARDS

The table below indicates the comparison of diagnostic investigations, clinical features and

pharmacology of drugs conducted on client with standards.

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TABLE ONE DIAGNOSTIC INVESTIGATIONS

DATE SPECIMEN INVESTIGATION RESULTS NORMAL VALUE INTERPRET REMARKS

ATIONS

6/01/10 Blood Haemoglobin level estimation 12.8g/dL Males;12-18g/dL Normal No treatment given

Females;11-16g/dL

6/01/10 Blood Packed cell volume(PCV) 34.5% Males;40-54% Low No treatment given.

Females;35-47%

6/01/10 Blood Mean corpuscular hemoglobin 34.3g/dL 32-36g/dL Normal No treatment given

concentration (MCHC)

6/01/10 Blood Mean corpuscular volume(MCV) 86.7mm³ 80-95mm³ Normal No treatment given

6/01/10 Blood Mean corpuscular hemoglobin 36.0pg Males;0-15pg High Treatment not

(MCH) Females;0-20pg given

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DATE SPECIMEN INVESTIGATION RESULTS NORMAL VALUES INTERPRET REMARKS

ATIONS

6/01/10 Blood White blood cell(WBC) 6.0×10⁹/L 4.0-11.0×10⁹/L Treatment not

Count 35.5% 20.0-45.0% Normal given.

Lymphocytes

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TABLE TWO: CLINICAL FEATURES

CLINICAL FEATURES IN LITERATURE CLINICAL FEATURES EXHIBITED BY

CLIENT

 Communication loss, there may be  Client did not exhibit dysarthria and

dysarthria, dysphasia and apraxia. apraxia but exhibited dysphasia

 Headache  Client exhibited mild headache.

 Motor loss, hemiplegia or hemiparesis  Client exhibited hemiplegia or

is exhibited, there may be ataxia and hemiparesis, ataxia but did not present

Dysphagia. Dysphagia.

 Anxiety  Client was anxious.

 Urinary incontinence  Client did not exhibit urinary

incontinence.

 There may be diplopia, perception  Client did not exhibit diplopia,

disturbance, hemianopia (partial hemianopia and paraesthesia.

blindness) and paraesthesia.

 Psychological effects and mental  Client did not present depression,

impairments, presence of depression, hostility, forgetfulness and lack of co-

presence of hostility, forgetfulness, and operation.

lack of co-operation are exhibited.

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CAUSES OF CLIENT’S ILLNESS

With reference to the literature review, the aetiology of cerebrovascular accident includes

cerebral thrombosis, cerebral embolism and cerebral haemorrhage. Obesity, excessive alcohol

intake, hypertension, diabetes mellitus, alcohol, smoking among others can predispose an

individual to stroke.

From various investigations it was proved that client’s condition was as result of hypertension

and predisposed by excessive alcoholism.

DRUG TREATMENT

The drugs listed below were prescribed for the client.

1. Tablet Aspirin 500mg bd × 10 days

2. Tablet Amoksiklav 625mg bdx7 days

3. Tablet Amlodipine 10mg daily x30

4. Tablet Lisinopril 10mg daily x 30 days

5. Tablet Multivite 200mg tds x 30

6. Tablet Diazepam 5mg nocte x 7

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TABLE THREE: PHARMACOLOGY OF DRUGS

DATE DRUG DOSAGE/ROUTE OF DOSAGE/ROUTE OF CLASSIFI ACTION ACTUAL SIDE EFFECTS

ADMINISTRATION( ADMINISTRATION CATION ACTION AND

LITERATURE) (CLIENT) OBSERVED REMEDIES

6/01/10 Tablet Dosage; 300mg bd × 10 days Non narcotic Blocks pain Client was Dizziness, hearing

Aspirin Adult;325-650mg analgesic. impulses in the relieved of loss, wheezing,

daily/bd Route; Orally CNS, reduce pain and the nausea, vomiting,

Children 65mg per 24 inflammation by temperature heartburn,

hour in four to six inhibition of reduced to gastrointestinal

divided doses not to prostaglandin normal range bleeding.

exceed 3.6g a day synthesis, and (36.2-37.2

reduce elevated degree celsius) Client did not

Route; oral, rectal body temperature. exhibit any of

these side effects.

DOSAGE/ROUTE OF DOSAGE/ROUTE OF
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DATE DRUG ADMINISTRATION ADMINISTRATION CLASSIFI ACTION ACTUAL SIDE EFFECTS

(LITERATURE) (CLIENT) CATION ACTION AND

OBSERVED REMEDIES

6/01/10 Tablet Dosage; 625mg bd × 7 days Broad It interferes with Client did not Nausea, vomiting,

Amoksikl Adult; 625mg bd spectrum cell wall replication exhibit any fever, severe

av Children; Depending on antibiotic. of susceptible signs of diarrhea,

the severity of infection Route; Orally organisms by infection. headache,

the daily dose will be binding to the urticaria, rash

between 25-45kg bacterial cell wall; Client did not

Route; oral the cell wall, exhibit any of

rendered these side effects.

osmotically

unstable, swells and

burst from osmotic

pressure.

DOSAGE/ROUTE OF DOSAGE/ROUTE OF
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DATE DRUG ADMINISTRATION ADMINIOSTRATION CLASSIFI ACTION ACTUAL SIDE EFFECTS

(LITERATURE) (CLIENT) CATION ACTION AND

OBSERVED REMEDIES

6/01/10 Tablet Dosage Calcium It inhibits calcium Client’s blood Dizziness,

Amlodipin Adult; 10mg daily ×30 days channel ion reflux across pressure was syncope,

e Initially, 10mg daily; blocker. cardiac and smooth returned to peripheral

dosage may be Route; Orally muscle cells normalcy oedema, nasal

gradually increased decreasing congestion,

over 10-14 days. contractility and pruritis, muscle

oxygen demand. It cramps.

may also dilate Client did not

Route; oral coronary arteries exhibit any of

and arterioles. these side effects.

DOSAGE/ROUTE OF DOSAGE/ROUTE OF
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DATE DRUG ADMINISTRATION ADMINISTRATION CLASSIFI ACTION ACTUAL SIDE EFFECTS

(LITERATURE) (CLIENT) CATION ACTION AND

OBSERVED REMEDIES

6/01/10 Tablet Dosage Angiotensin It may results Client’s blood Dizziness,

Lisinopril Adult; 10mg daily x 30 days Conventin primarily from pressure was headache, fatigue,

Initial dose, 10mg Enzyme suppression of reduced to paraesthesia,

daily. Adjust dosage Route; Orally (ACE) rennin- normal range. depression,

based on response. inhibitor angiontensin- hypotension,

Usual range is 20-40mg aldosterone system nausea dyspepsia.

daily. to lower blood Client did not

Route: oral pressure. experience any of

these side effects.

DOSAGE/ROUTE OF DOSAGE/ROUTE OF
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DATE DRUG ADMINISTRATION ADMINISTRATION CLASSIFI ACTION ACTUAL SIDE EFFECTS

(LITERATURE) (CLIENT) CATION ACTION AND

OBSERVED REMEDIES

7/01/10 Tablet Dosage Haematinics It stimulates Client‘s Nausea

Multivite 200-400mg three times 200mg tds x 30 days and appetite and appetite was abdominal

daily. multivitamin increase formation improved by discomfort.

supplement of haemoglobin. eating food Client showed

Route; orally Route; Orally served him. none of these side

effects.

DOSAGE/ROUTE OF DOSAGE/ROUTE OF
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DATE DRUG ADMINISTRATION ADMINISTRATION CLASSIFI ACTION ACTUAL SIDE EFFECTS

(LITERATURE) (CLIENT) CATION ACTION AND

OBSERVED REMEDIES

8/10/10 Tablet Dosage Skeletal Depresses CNS at Client was Depression

Diazepam Adults; 2mg-10mg 5mg nocte x 7 days muscle limbic and sub relieved of restlessness,

once or twice daily relaxant, cortical levels of anxiety and fainting,

Children;1mg-2.5mg anticonvulsa brain; suppresses calmness and anterogade

Route; Orally nt, sedative- spread of seizure sleep was amnesia,

Route: oral hypnotic activity in the promoted. psychosis,

intravenous, thalamus and headache,

intramuscular relieve anxiety, tremors.

muscle spasms and Client did not

seizures to promote experience these

calmness and sleep side effects.

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PATIENT / FAMILY STRENGTH

This the activity the client can do and what the family can also perform to aid in the recovery of

the patient.

The relatives assisted in the provision of drugs for the client. Relatives also helped by visiting

client regularly during which time they encouraged client, showed him love and they gave their

spiritual backing. The relatives also assisted in the feeding of client and also answered all

questions that were asked.

Client was also able to provide some answers to some of the questions by writing since he was

not able to speak.

HEALTH PROBLEMS

These are the conditions that affect the client physically, mentally and socially which can hinder

his recovery if special attention is not given to client. Through the data collected and assessment,

the following health problems were identified;

1. Pyrexia

2. Anxiety

3. Anorexia

4. Insomnia

5. Paralysis of the left side

6. Inadequate knowledge on the disease condition and its management.

7. Inability to maintain personal hygiene (bathing and hygiene)

8. Prolonged confinement to bed.

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NURSING DIAGNOSES

The under listed nursing diagnosis were made;

1. Alteration in body temperature (pyrexia) related to the Cerebrovascular accident.

2. Anxiety related to client’s hospitalization, treatment and the disease prognosis

3. Alteration in nutritional pattern (less than body requirement) related to impaired self

feeding, difficulty in chewing and difficulty in swallowing.

4. Sleeping pattern disturbance (insomnia) related to change in environment and abnormal

physiological status.

5. Impaired physical mobility related to hemiparesis.

6. Knowledge deficit related to lack of information and management of Cerebrovascular

accident.

7. Self care deficit (bathing and hygiene) related to paralysis.

8. High risk for impaired skin integrity related to prolonged confinement to bed.

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CHAPTER THREE

PLANNING FOR PATIENT/FAMILY CARE

This forms the next phase after the establishment of nursing diagnosis. In planning priorities are

set for short and long term objectives and finding appropriate nursing orders to implement on the

patient effectively to enhance recovery. Client, relatives and the health team are all included in

planning the nursing care.

The nursing care plan consist of nursing diagnosis, objective and outcome criteria, nursing

orders, interventions and evaluation of care given to patient and family.

NURSING OBJECTIVES /CRITERIAL OUTCOME

An objective is a desired outcome criteria towards which a special nursing intervention is carried

out. In planning for patient, family care, priorities are set in which problems of the client are

arranged in order of importance and to find solution to them.

The objectives set for client include;

1. Client will be relieved of fever within 24 hours as evidence by;

a. Body temperature falling within normal range (36.2-37.2 degree Celsius)

b. Client not warm to touch.

c. Client feeling comfortable in bed.

2. Client will express a relief in fear and anxiety within 24 hours as evidence by;

a. Nurse observing a cheerful facial expression of client.

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b. Client verbalizing the relief of fear.

3. Client will maintain normal nutritional status within 24 hours as evidence by nurse observing

client eat at least more than half of meal served.

4. Client will be able to sleep well within 24 hours as evidence by;

a. Nurse observing client having an uninterrupted and sound sleep for 6 hours at night and

during day time.

b. Client verbalizing that he can sleep very well at night and during daytime.

5. Client will be able to move paralyzed extremities with assistance during the period of

hospitalization as evidence by nurse observing client’s ability to change position of left upper

and lower limbs.

6. Client and family will have adequate knowledge about disease process and its effective

management within 24 hours as evidence by client and family providing correct feedback on the

disease condition and its management.

7 .Client’s personal hygiene will be maintained within 2 hours everyday as evidence by nurse

observing client looking neat, cheerful and comfortable in bed.

8. Client will not develop bed sores throughout his hospitalization period as evidence by nurse

observing no formation of bed sore at bony prominences of client during discharge.

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DATETABLE NURSING
FOUR: OBJECTIVE NURSING CARE
NURSING NURSING
PLAN TIME EVALUATION SIGNATURE

AND DIAGNOSIS OUTCOME ORDERS INTERVENTION AND

TIME CRITERIA DATE

06/01/2010 Alteration in Client will be 1. Reassure 1. Client was 07/01/10 Goal fully met

At body relieved of client. reassured that At as a .Nurse

10:00am temperature fever within 24 measures are put in 10:00am observed that

(pyrexia) related hours as place to bring the client’s body

to evidenced by body temperature temperature fell

Cerebrovascular a. Nurse to normal and all within normal

accident. observing procedures were ranges(36.2-37.2

client explained to him. degree Celsius)

temperature b. Client not

falling within 2. Tepid 2. Client was tepid warm to touch.

normal ranges sponge client. sponged to bring c. Client felt

(36.2-37.2 body temperature comfortable and

degree celsius) to normal. relaxed in bed.

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b. Client not 3. Remove heavy 3. Heavy clothing was

warm to touch. clothes from client. removed to aid in

c. Client feeling circulation of fresh air.

relaxed in bed.

4. Serve cold 4. Cold drinks were served

drinks. to reduce body temperature.

5. Open nearby 5. Nearby windows were

windows. opened to promote proper

ventilation.

6. Serve prescribed 6. Prescribed antipyretics

antipyretics. like aspirin was served.

DATE NURSING OBJECTIVE NURSING NURSING TIME EVALUATION SIGNATU

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AND DIAGNOSIS OUTCOME ORDERS INTERVENTION AND RE

TIME CRITERIA DATE

06/01/2010 Anxiety related Client will 1. Reassure client. 1. Client was reassured to 7/01/10 Goal fully met as

at 10:45 to experience a allay fears and anxiety. At a. Nurse observed

am hospitalization. relief in fear 10:45am that client had a

and anxiety 2. Allow client to 2. Client was allowed to cheerful facial

within 24 hours express his feelings voice his feelings about the expression.

as evidenced by about the admission and the period he b. Client

a. Nurse hospitalization. is going to be treated as a verbalized a relief

observing a patient to know his level of of fear and

cheerful facial understanding about the anxiety.

expression of hospitalization.

client.

b. Client 3. Introduce client 3. Client was introduced to

verbalizing a to other client’s other client’s recovering

relief of fear. recovering from from the same condition to

the same condition.

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make him confident.

4. Institute

diversional 4. Client was introduced to

therapy. diversional therapy such as

listening to music, reading

of story books in order for

him to keep his mind at rest.

5. Allow client to

ask questions. 5. Client was allowed to ask

questions and it was

answered in simple terms to

facilitate client’s

understanding about the

disease.

DATE NURSING OBJECTIVE NURSING NURSING TIME EVALUATION SIGNATU

AND DIAGNOSIS OUTCOME ORDERS INTERVENTION AND RE

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TIME CRITERIA DATE

07/01/2010 Alteration in Client will 1. Reassure client. 1. Client was reassured that 9/01/10 Goal fully met as

at 9:45 am nutritional maintain he will be able to eat very At nurse observed

pattern (less than optimal soon. 9:45am client consuming

body) nutritional more than half of

2. Help client to 2. Client was assisted to
requirement status within 24 the meal served.
perform oral perform oral hygiene in
related to hours as
hygiene. order to promote salivation
impaired self evidenced by
and stimulate appetite.
feeding, nurse observing

difficulty in client eat at 3. Discuss diet with 3. Client’s diet was

chewing and least more than client. discussed with him in order
swallowing half of meal to come out with the food
served. he likes.

4. A pleasant environment
4. Provide a
was provided to stimulate
pleasant

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environment. client’s appetite.

5. Serve meal in bit 5. Meal was served in bits

and attractively. and attractively in order to

stimulate client’s appetite.

6. Serve snacks in 6. Snacks such as fruit juice

between meals. were served in between

meals to stimulate client’s

appetite.

7. Serve prescribed
7. Prescribed haematinics
haematinics.
such as tablet multivite was

served to boost client’s

appetite.

DATE NURSING OBJECTIVE NURSING NURSING TIME EVALUATION SIGNATU

AND DIAGNOSIS OUTCOME ORDERS INTERVENTION AND RE

TIME CRITERIA DATE

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08/1/2010 Sleep pattern Client will be 1. Reassure client. 1. Client was reassured that 11/01/10 Goal fully met as

at 8:30 am disturbance able to sleep measured are put in place to At a. Nurse

related to change well within 24 ensure sound sleep. 8:30am observed client

in environment hours as having an

and abnormal evidenced by; 2. Make bed 2. A well prepared bed free uninterrupted and

physiological a. Nurse comfortable for from creases and cramps sound sleep for 6

status. observing client client. was made for client in order hours at night and

having an to enhance relaxation. during daytime.

uninterrupted b. Client

and sound sleep 3. Put off bright 3. Bright lights on the ward verbalized that he

for 6 hours at light. were switch off and dim can sleep at night

night and lights switch on to enhance and during

during daytime. sleep. daytime.

b. Client

verbalizing that 4. Minimize noise 4. Noise on the ward was

he can sleep at on the ward. minimized to promote

night and
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during daytime. sleeping.

5. Restrict visitors 5. Visitors were restricted

from entering the ward in

order to prevent them from

disturbing client.

6. Serve prescribed 6. Prescribed sedatives such

sedatives. as Diazepam were served to

induce sleep.

DATE NURSING OBJECTIVE NURSING NURSING TIME EVALUATION SIGNATU

AND DIAGNOSIS OUTCOME ORDERS INTERVENTION AND RE

TIME CRITERIA DATE

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09/01/2010 Impaired physical Client will be [Link] client 1. Client was reassured that 10/01/10 Goal fully met as

At 8:45am mobility related able to move he will be able to perform At client was able to

to hemiparesis. paralyzed majority of his daily 8:45am change positions

extremities activities on his own. of left upper and

with assistance lower extremities.

during the 2. Put client in a 2. Client was put in a

period of correct position. comfortable position to

hospitalization prevent contractures and

as evidenced by assist in maintaining good

client’s ability body alignment.

to change

position of left

upper and

3. Place all items 3. All items such as drinking

that will be needed cups and magazines needed

within reach of by client were placed on the

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client. unaffected side of the client

within his reach to reduce

the dependency on others.

4. Teach client 4. Client was taught the

skills for his various skills for his routine

routine activities. activities in order to

improve muscle tone and

strengthen bones.

5. Instruct client to 5. Client was instructed to

take note of safety take note of safety factors in

factors. order to prevent injury.

6. Teach client 6. Client was taught passive

passive exercise. exercises such as sitting up

in bed, turning from side to

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side and movement of the

limbs to improve upon his

muscle tone and strengthen

bones.

DATE NURSING OBJECTIVE NURSING NURSING DATE EVALUATION SIGNATU

AND DIAGNOSIS OUTCOME ORDERS INTERVENTION AND RE

TIME CRITERIA TIME

10/01/2010 Knowledge Client and 1. Reassure client 1. Client was reassured that 8/01/10 Goal fully met as

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at 9:00 am deficit related to family will have he will be given required At client and family

lack of adequate education on 9:00am were able to give

information on knowledge on cerebrovascular accident. correct feedback

the management disease process on disease

2. Make client and 2. Client was made
of and its effective condition and its
family comfortable and family
Cerebrovascular management management.
comfortable. members offered a seat.
accident. within 24 hours
3. Allow client to 3. Client was allowed to
as evidenced by
say what he knows share his view about the
client and
about the disease. disease in order to know his
family
knowledge about disease.
providing
4. Educate client 4. Client was educated on
correct
on disease condition by
feedback on the
Cerebrovascular defining and telling him its
disease process
accident. causes, types, signs,
and its effective
symptoms, treatment and
management.
the need for physiotherapy

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was also emphasised.

[Link] was given time to

5. Encourage ask questions in order to

client to ask know where client did not

questions. understand properly

6. Client was assessed on

6. Assess client on the education given in order

education given. to know client’s level of

understanding about disease

condition

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DATE NURSING OBJECTIVE/ NURSING NURSING DATE EVALUATIO SIGNATURE

AND TIME DIAGNOSIS OUTCOME CRITERIA ORDERS INTERVENTIONS AND TIME N

11/01/2010 Self care Client’s personal hygiene 1. Reassure 1. Client was 12/01/2010 Goal fully met

5:30 am deficit (bathing and grooming) will client reassured that he 6:30 am as client looked

(bathing and be maintained within 2 will be assisted neat, cheerful

hygiene) hours everyday as evidence to cater for his and comfortable

related to by client looking neat, hygiene needs in bed

paralysis. cheerful and comfortable in and achieve self

bed. sufficiency.

2. Assist 2. Client was

client to care assisted to care

for the mouth. for the mouth to

prevent

infections and

halitosis.

3. Assist 3. Client was

patient to bath assisted to bath and

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and groom. groom to make him

look neat and to

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DATE NURSING OBJECTIVE/ NURSING NURSING DATE EVALUATION SIGNATUR

AND TIME DIAGNOSIS OUTCOME CRITERIA ORDERS INTERVENTIONS AND TIME E

11/01/2010 High risk for Client will not develop 1. Reassure 1. Client was 13/01/2010 Goal fully met as

6:00 am impaired skin bed sores throughout his client and reassured that he 10:30 am client did not

integrity hospitalization period as explain will not develop develop bed

related to evidence by nurse procedure to pressure sores sores throughout

prolonged observing no formation of the client. throughout his his

confinement bed sore on the bony hospitalization and hospitalization

to bed. prominences of the client. procedure was period.

explained to him to

gain his confidence.

2. Treat client’s 2. Pressure areas

pressure areas such as the scapula,

and change his buttocks and occiput

position were treated and

frequently. client position

changed frequently

to prevent the

development of
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pressure sores and to

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CHAPTER FOUR

IMPLEMENTATING PATIENT/FAMILY CARE PLAN

Implementation is the fourth step in the nursing process. It deals with the actual nursing care

rendered to the patient. The primary focus of the implementation component is the provision of

individualized self nursing care with multifocal approach. It involves putting into practice all the

nursing care planned. During the process, the nurse bears in mind the individuality of the client,

his culture and socio-economic status.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT AND FAMILY

The care of Mr. Samuel Ofori Daniels started on the 6th of January 2010at 9:20am at the ward D3

from the Accident and Emergency Unit of the Komfo Anokye Teaching Hospital with the

diagnosis of Cerebrovascular Accident with left hemiparesis till he was discharged on the 11th

January 2010. Nursing care was aimed at relieving the client of his condition, to prevent

infection and maintain physiological function so that he could return home as healthy individual.

FIRST DAY OF ADMISSION (6TH JANUARY, 2010).

On the day of admission, client came to the ward on a wheel chair accompanied by his wife and

an admission team. On admitting the client, it was observed that, the temperature of client was

above the normal range (pyrexia). He was immediately reassured and informed about the care

that would be given to minimize the temperature to normal. The nursing management put in

place included the following; Client was tepid sponged with tepid water, his tight and heavy

clothing’s were removed to allow adequate circulation of air, Cold compresses were applied on

the forehead, groin, palm, feet and axilla to reduce the temperature, Client was also served with

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chilled drink to reduce the temperature to normal range (36.2-37.2 degree celsius), Prescribed

antipyretic such as Tablet Aspirin was also served. His vital signs was then checked 15 minutes

after and the temperature had reduced from 38.1 to 37.1 degree celsius.

Also due to hospitalization and unknown outcome of client’s condition, client and his relatives

were very anxious and afraid. They were reassured that hospitalization was a temporal measure

for effective treatment. Client and family were also encouraged to voice their fears, anxiety and

feelings about the outcome of the disease. Client and family asked questions and it was answered

in a simple and straight manner to facilitate understanding. Client was also introduced to other

patients recovering from similar condition to make him feel safe and comfortable. Diversional

therapy such as reading of story books, watching of television, listening to music and having

prayers with the hospital chaplain were instituted to keep his mind at rest.

SECOND DAY OF ADMISSION (7TH JANUARY, 2010).

On this day, client looked better but a little bit lethargic. It was observed that client cannot eat

well due to impaired self feeding and swallowing. Client and family were reassured that, the

problem will be catered for with the necessary medical and nursing management put in place.

Client’s diet was planned with him taking into consideration his likes and dislikes. Mouth care

was given to client before and after meals to help boost his appetite. Meals were also served

attractively to boost client’s appetite. All nauseating items were removed from the vicinity of the

client. Snacks such as fruit juices were served in between meals. All prescribed drugs were also

served.

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Client had all routine nursing care such as bathing, feeding, checking of vital signs and its

documentation as well as administration of drugs were all rendered to him.

THIRD DAY OF ADMISSION (8TH JANUARY2010)

Client looked better and cheerful. His personal hygiene such as care of hands and feet, given of

assisted bed bath and care of the mouth were rendered to him. Pressure areas were treated to

prevent any formation of bed sore. Vital signs were checked and prescribed medications served.

During conversation with client he said his only problem was his inability to sleep soundly

during the night due to change of environment and abnormal physiological status.

Measures were therefore put in place to enhance sound and uninterrupted sleep. Television and

radio sets on the ward were turned low and nearby windows were opened to enhance proper

ventilation. Client was given a warm bath to help improve circulation and also to relax him. Drug

administration and other procedures were done earlier to help client have enough time to sleep.

Client was also served with warm beverages to help induce sleep. All bright lights on their ward

were switched off to enhance sleep. Client’s bed was dressed properly to prevent creases and

cramps in order to enhance sleep.

FOURTH DAY OF ADMISSION (9TH JANUARY, 2010)

According to the night nurses report, client had a sound sleep with no complains and

interruptions. He was looking cheerful and healthier. Routine activities such as checking of vital

signs, administration of medications were carried out on client successfully this day. His

personal hygiene such as given of assisted bed bath and care of the mouth with toothbrush and

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Pepsodent were rendered to him. Pressure areas were treated to prevent any formation of bed

sore

Client was reassured that his condition will be stabilized through exercises and that he will be

taught how to perform these exercises. Client was also informed that these healthy exercises

performed each day will help him regain his strength.

A physiotherapist was consulted and more prescribed passive exercises were taught. Client was

also informed that he needed no vigorous exercises due to his condition. Client was taught to flex

and extend each limb six times with the unaffected limb supporting the affected limb to prevent

stiffness of the joint.

FIFTH DAY OF ADMISSION (10TH JANUARY, 2010)

Client’s condition was reviewed by Dr. Nkum on his ward rounds in the morning. He was happy

with client’s progress so far. He ordered that, treatment should continue and if all things been

equal client would be discharged soon.

Upon interaction with client and family, I observed that client and family had inadequate

knowledge about the disease condition and its effective management. Therefore, client and his

family were educated on the condition and they were encouraged to ask questions. Answers were

provided in simple forms to facilitate their understanding. Revision was done and client and

family gave an accurate feedback on the education given.

Client was given an assisted bed bath and was fed. In the afternoon, his friends visited him which

made him very happy. In the evening, client requested for a bed pan which was graciously

served. Client had his bath and mouth care with other routine nursing cares rendered. He had a

sound sleep that nigh.

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On this same day I made my first home visit to client’s residence at Buokrom, a suburb in

Kumasi.

SIX DAY OF ADMISSION (11TH JANUARY, 2010)

Client’s personal hygienic needs were taken care of such as assisted bed bath, assisted mouth

care, care of hands and feet with assistance from other night nurses. Efforts were made to help

client achieve self sufficiency such as combing his hair himself.

Also during bathing, clients pressure areas such as the scapula, elbow, buttocks and, occiput

were treated to enhance circulation. During the procedure the client’s skin was observed for

signs of abnormalities. Barrier creamsuch as Vaseline was applied on the pressure areas as well

as client’s bed made free from creases and cramps to enhance comfortability.

Vital signs were checked and recorded and prescribed medication administered. He was served

with porridge and bread.

During ward rounds on 11th January, 2010 at 10:35am, client was discharged after thorough and

careful assessment and review by the Head of physician of Team E. Assessment of client’s bill

was made and settled under the National Health Insurance Scheme. Client and family were

educated on the significance of continuing treatment and the need to come for review which was

25th January, 2010. He was advised to report any symptoms and also take physiotherapy

exercises very seriously.

Client expressed gratitude to the nursing and medical staff for their immense care rendered to

him and bid farewell to other clients. Bed linen was taken off, disinfected and the bed was

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prepared for the next admission. Client’s particulars were then signed off in the admission and

discharge book and also in the daily ward state.

The doctor discharged client on same prescription of medication. The prescribed medications

were;

1. Tablet Aspirin 300mg bd ×10 days

2. Tablet Amlodipine10mg daily x 30

3. Tablet Amoksiklav 625mg bd × 7 days

4. Tablet Lisinopril 10mg daily x 30

5. Tablet Multivite tds x30 days

Client and relatives were accompanied to lorry station and we fixed a date for a second

home visit (17th January, 2010) to check on client’s health.

PREPARATION OF CLIENT AND FAMILY FOR DISCHARGE AND

REHABILITATION

Preparation towards discharge of client started on the day of admission. Although client and

family were anxious and worried about client’s hospitalization and prognosis of the disease, they

were reassured that his admission was a temporary measure to give medical and nursing care to

the client. Client was also advised to report anytime there were unusual signs and symptoms such

as dizziness, headache and confusion. Client was also advised on risk factors such as smoking,

excessive intake of alcohol and overweight. Advice was also given to client on the need of a well

balanced diet to build his immunity and to provide essential elements to build up haemoglobin

level.

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Emphasis was made on the significance of exercising and the need to see the physiotherapist for

physiotherapy in order to help in restoring his strength and prevent complications like paralysis.

Client and relatives were educated on the need for follow up visit and also educated on the

dosage, action and adverse effects of prescribed medication.

Relatives were also educated on the need to protect client from injury by putting him on low bed

with side rails to prevent him from falling.

Client and relatives were told the review date, which was 25th January, 2010. Client was also

told to attend physiotherapy twice a week to rest the affected part.

FOLLOW UP/HOME VISIT/CONTINUITY OF CARE

A home visit is done before and after the client is discharged. It is a friendly but purposeful visit

to the home of the client with the aim of promoting and maintaining client and family at large so

as to prevent the further occurrence of disease.

FIRST HOME VISIT (10TH JANUARY, 2010)

The first home visit was on 10th January, 2010 while client was still on admission. The visit was

embarked to have more knowledge about client’s environment based on which education would

be given to client and relatives.

Client stays in a house with wife and four children. They have a hall and three bed rooms; one

for client and his wife and the other two for their children. Their kitchen is located besides the

living room. They have a good supply of water and a reservoir poly tank which they often

depend on in case of water shortage. They have electricity. Their refuse is collected into a dust

bin and is emptied every morning at the refuse damp. Client and relatives were educated to

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sweep their surroundings at least twice daily. They were also educated on the need to clean any

fluid-like substances on the floor to prevent client from slipping of client. They were also

advised to make items needed by client available or closer to client in order to prevent stress

when client is in search of them.

SECOND HOME VISIT (17TH JANUARY, 2010)

My second home visit was made on 17th January, 2010, after client has been discharged. The aim

was to find out how the client was doing, whether he was taken his drug and following

instructions given at the hospital and to remind them of the review date and the date of

termination of care.

I asked him of how he was doing after I had been welcomed by client and family. Based on

information collected from relatives and neighbours, I realized that client was doing well and

even walk with the aid of walking stick. I told them to continue with the drug treatment as well

as exercises which the physiotherapist had asked him to do.

I educated the client not to stress himself too much but to exercise moderately. I also re-echoed

on the need for him to make it a point to come for the review at the right time. I also made them

aware that, I will terminate my interaction officially with them on my next visit I then asked for

permission to leave after having scheduled to visit them again. The family thanked me for

coming to see them and I was finally seen off.

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DAY OF REVIEW

On the day of review which was on the 25th of January 2010, I met client and family early in the

morning at consulting room 1. After exchanging greetings with them, I helped them to collect the

client’s folder which was later handed to the nurse- in charge. When it reached his turn, client

was called into the consulting room and I went with him. Mr. Daniels made no complain and

after the review, the doctor expressed satisfaction with client’s remarkable improvement and

advise him to take good care of himself and report any problem if it should arise.

THIRD HOME VISIT (1st FREBRUARY, 2010)

The final home visit was conducted one week after review of client. Client’s condition had

improved and he had taken every bit of education given him very seriously. Client was educated

on nutrition, he was told to take in roughages to prevent constipation. He was again advised on

the need to avoid risk factors. Emphasis was again made on the need of client to seek medical

attention when sick. The public health nurse was informed about client’s condition and she

promised to render good care to the client.

Finally, client’s family and neighbours around were grateful and expressed their appreciation for

the care given to the client. They were thanked for their trust and co-operation. I bid them

farewell and departed.

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CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

Evaluation is the step in updating the plan of the patient care. It helps in the measuring of the

results or outcome of nursing actions against goals and objectives set.

STATEMENT OF EVALUATION

During the act of evaluating the nursing cares rendered to the client, all objectives set were fully

met and his condition improved. In the light of this, client developed no complications. The goals

set and evaluated are as follows;

On the 6th of January 2010, a goal was to set to reduce client’s high body temperature to normal

range (36.2-37.2 degree celsius) within 24 hours. Client was then tepid sponged with a wet towel

starting from the inner canthus of the eye to all parts of the body. All heavy clothing’s were also

removed to aid in proper circulation of fresh air to all parts of the body. Goal was fully met as

client’s body temperature reduced to normal range.

On the same day, goals were set to relief client and family of fear and anxiety within 24 hours.

They were reassured to allay fears and anxiety. Client was allowed to express his feelings about

hospitalization and was introduced to other client’s suffering from the same condition. Goal was

fully met as client expressed no feeling of fear and anxiety and had a relaxed and cheerful facial

expression

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On 7th January 2010, a goal was set to help patient obtain an optimal nutritional status within 24

hours. Diet was planned with client to his likes and dislikes and his favorite meal was served.

Goal was fully met as client was able to eat at least more than half of the meal served him.

On 8th January, 2010, client complained of his inability to sleep the previous night. A goal was

then set to help client to sleep well within 24 hours. A well prepared bed free from creases and

cramps was made for client to make him feel relaxed, visitors were also restricted from entering

the ward to prevent disturbance to client and dim lights were provided to enhance adequate sleep.

Goal was fully met as client was able to have an uninterrupted sleep for about 6 hours at night

and during daytime and patient verbalizing that he can sleep well.

On 9th January, 2010, a goal was set to make client able to move paralyzed extremities with

assistance during the period of hospitalization. Client was reassured and put into a correct

position to maintain good body alignment. Client was taught various skills for his routine

activities in order to improve his muscle tone and client was taught passive exercises to

strengthen his bones. Goals were fully met as client changed positions of left upper and lower

limbs.

On 10th January, 2010, client enquired about the cause of his ailment, a goal was then set to make

client have an insight about the disease process and its effective management within 24 hours.

Client was made comfortable and allowed to air his views about the disease and upon that he was

educated about the disease condition by defining it and telling him its causes, types, signs and

symptoms and the treatment in order to enhance his knowledge about the disease. Goal was fully

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met as client was able to provide correct feedback to the disease condition and its effective

management.

On 11th of January, 2010 an objective was set to maintain client’s personal hygiene everyday

throughout hospitalization period. Client’s mouth, hands and feet were cared for, and he was

given assisted bed bath throughout his stay at the ward. This goal was fully met as client looked

neat, cheerful and comfortable in bed.

On the same day objective was set to prevent client from developing pressure sores throughout

his stay at the ward as clients’ pressure areas were treated. There was also an application of

barrier cream on the bony prominences as well as client’s bed made free from creases and

cramps. This goal was fully met as client did not develop pressure sores throughout his stay at

the ward.

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AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OR UNMET

OBJECTIVE/OUTCOME CRITERIA

Upon careful evaluation of the nursing care rendered to Mr. Samuel Ofori Daniels and his

family, all goals and objectives set were fully met. Therefore, there was no need for amendment

of any of the objectives set during the care of the client.

TERMINATON OF CARE

Every nurse-patient relationship at the hospital needs to be terminated. However, this is a very

difficult step to take after a good rapport has been established. Because of this, the reality of

termination of care has to be made known to both client and family from the day of admission.

The termination of Mr. Samuel Ofori Daniels care started on the first day of interaction with him

and his family on the 6th of January 2010. To avoid separation of anxiety, I made known to them

that, our relationship was a therapeutic one and would last for a reasonable period. I also made it

known to them that, I would not be able to stay on the ward for 24 hours with him, hence the

need for their cooperation with other nurses and other paramedical staff on the ward.

They were therefore not surprised when I finally told them about the termination of care and

relationship with them during my last home visit which was on the 1st February 2010. On this

day I visited my client at Buokrom and told them that this will be my last official visit to them. I

handled my client to the public health nurse in charge of the community and advise client and

family to visit Manhyia Government Hospital if they fall sick.

I reassured my client and his family of my assistance within my capacity anytime they need my

help. I thanked client and his family sincerely for their co-operation.

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SUMMARY AND CONCLUSION

SUMMARY

Mr. Samuel Ofori Daniels, a 54 year old man was admitted at Ward D3 on the 6th January, 2010

with complains of weakness of the left side of his body and was unable to move his left hand or

walk. He was diagnosed of Right Hemispheric Cerebrovascular accident with left hemiparesis.

Some of the problems identified during observation on admission included, pyrexia, anxiety,

knowledge deficit, anorexia, paralysis of the left side, insomnia, lack of personal hygiene and

confinement to bed.

Objectives were set and nursing orders were implemented in order to solve client’s problems. All

objectives set for client were fully met at the time of discharge. During follow ups, client was

advised on the significance to maintain cleanliness in his environment. Client’s condition was

found to be satisfactory and improved with no complications.

Client was educated on the need to exercise regularly. He was again advised on the need to

report to the hospital if any sign or abnormality persisted and also the need to adhere to the drug

regimen prescribed.

Drugs prescribed for client on the day of admission were Aspirin, Amlodipine, Amoksiklav, and

Lisinopril were administered accordingly.

Client was very well without any complications at the time of discharge.

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CONCLUSION

In conclusion, the choice of Mr. Samuel Ofori Daniels as my client has helped me to obtain good

insight into Cerebrovascular Accident. It has given me more and vivid insight into the cause,

signs and symptoms, diagnosis, treatment and possible prevention of Cerebrovascular Accident.

This study has equally helped me to put the knowledge acquired in the three years of Nursing

Training College into practice.

Furthermore, client care study has enabled me to understand family attitude towards illness and

different behaviours of people when they are sick.

Lastly, I suggest that all things being equal, all clients are to be given an individualized care to

help reduce re-occurrence of disease conditions and mortality rate of clients admitted to the

hospital.

I hope and believe that the additional knowledge and experience I have acquired while nursing

Mr. Samuel Ofori Daniels and his family will help me offer a comprehensive nursing care to

other clients in the health set-up and the community as a whole.

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BIBLIOGRAPHY

Baer, C.L (1997), Nurses Drug Guide, 2nd Edition, Springhouse Corporation, Springhouse.

Cahill, M (1997), Handbook of Medical-Surgical Nursing, 2nd Edition, Springhouse

Corporation, Springhouse.

Houska A.T (2004), Drug Hand Book, 24th Edition, Springhouse Corporation, Springhouse.

Royle A. and Walsh M (1994), Watson’s Medical-Surgical Nursing and Related Physiology, 4th

Edition, Bailiere and Tindall, London.

Smeltzer, S.C and Bare GB (1992), Brunner and Saddarth’s Text Book of Medical-Surgical

Nursing, 7th Edition, J.B Lippincott Company Limited, Philadelphia.

Patient’s Folder Number, 130/10, Komfo Anokye Teaching Hospital.

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